Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections

Prediction model for severe vesicoureteral reflux in children with urinary tract infection and/or hydronephrosis

BACKGROUND

As voiding cystourethrography is invasive and exposes to radiation and urinary tract infection (UTI), identifying only high-grade reflux is important. We aimed to identify clinical, laboratory and imaging variables associated with high-grade primary reflux in children presenting with UTIs and/or urinary tract dilatation and develop a prediction model for severe reflux.

METHODS

Data of children who underwent voiding cystourethrography due to UTI and/or urinary tract dilatation were retrospectively analyzed for demographic, clinical and imaging findings. Patients with severe (grades 4-5) reflux were compared with the rest for these parameters and a prediction model was developed for severe reflux.

RESULTS

The study included 1044 patients (574 female). Severe reflux was present in 86 (8.2%) patients. Age < 2 years, male sex, non-E. coli uropathogens, UTD-P3 dilatation and multiple kidney scars on DMSA scintigraphy were associated with severe reflux. Using these variables a prediction model for severe reflux with a score ranging from 0-7 and accuracy rate of 93.4% was developed. A score ≥ 5 had sensitivity 44.2%, specificity 97.4%, PPV 60.3%, NPV 95.1% and OR 29.5 for severe reflux. Scores ≥ 5 and ≥ 4 catch 44% and 73% of severe reflux, while prevent invasive voiding cystourethrography in 94.0% and 83.6% of patients, respectively.

CONCLUSION

Age < 2 years, male sex, non-E. coli uropathogen growth, presence of UTD-P3 dilatation on ultrasonography and multiple scars on DMSA scintigraphy are risk factors for severe reflux. A scoring system based on these variables appears to be effective in predicting the presence of severe reflux and eliminating unnecessary voiding cystourethrography.

Guidelines for the Prevention, Diagnosis, and Management of Urinary Tract Infections in Pediatrics and Adults: A WikiGuidelines Group Consensus Statement

Importance

Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence.

Objective

To create a clinical guideline for the diagnosis and management of urinary tract infections that addresses the gap between the evidence and recommendation strength.

Evidence Review

This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In May 2023, new and existing members were solicited for questions on urinary tract infection prevention, diagnosis, and management. For each topic, literature searches were conducted up until early 2024 in any language. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were developed discussing the available literature and associated risks and benefits of various approaches.

Findings

A total of 54 members representing 12 countries reviewed 914 articles and submitted information relevant to 5 sections: prophylaxis and prevention (7 questions), diagnosis and diagnostic stewardship (7 questions), empirical treatment (3 questions), definitive treatment and antimicrobial stewardship (10 questions), and special populations and genitourinary syndromes (10 questions). Of 37 unique questions, a clear recommendation could be provided for 6 questions. In 3 of the remaining questions, a clear recommendation could only be provided for certain aspects of the question. Clinical reviews were generated for the remaining questions and aspects of questions not meeting criteria for a clear recommendation.

Conclusions and Relevance

In this consensus statement that applied the WikiGuidelines method for clinical guideline development, the majority of topics relating to prevention, diagnosis, and treatment of urinary tract infections lack high-quality prospective data and clear recommendations could not be made. Randomized clinical trials are underway to address some of these gaps; however further research is of utmost importance to inform true evidence-based, rather than eminence-based practice.

Vesicoureteral Reflux in Children with Urinary Tract Infections in the Inpatient Setting in Taiwan

Purpose

Children with vesicoureteral reflux (VUR) are at an increased risk of recurrent urinary tract infections (UTIs). Early detection and treatment of VUR are important to prevent renal function impairment. Therefore, the aims of this study were to determine the epidemiology of VUR and to identify clinical factors associated with VUR in Taiwanese children with a first documented UTI.

Patients and Methods

We conducted this nationwide retrospective study using the Longitudinal Health Insurance Database 2010. Children ≤6 years of age who were admitted and received intravenous antibiotics for a newly diagnosed UTI were included. Multivariate logistic regression analysis was used to identify independent factors associated with VUR.

Results

Overall, 388 (10.2%) of the children had VUR. The median (interquartile range) age at diagnosis of VUR was 0.5 (0.3–1.3) years. Among the children with VUR, the age at first UTI and the age at diagnosis of VUR were significant lower in the males than in the females. Age ≤1 year at the first UTI (odds ratio (OR), 1.3; 95% confidence interval (CI): 1.0–1.7), renal agenesis and dysgenesis (OR, 4.1; 95% CI: 1.3–13.1), hydronephrosis (OR, 2.2; 95% CI: 1.7–2.9), duplex collecting system/ectopic kidney/ectopic ureter (OR, 13.0; 95% CI: 8.1–20.8), neuropathic bladder (OR, 4.7; 95% CI: 2.0–11.1) and spina bifida (OR, 5.9; 95% CI: 1.3–27.8) were independent factors for VUR.

Conclusion

The children with VUR were more likely to have small kidneys and progression to end-stage renal disease. VUR was common in the children with a UTI and who were ≤1 year of age. Clinicians should arrange ultrasound to diagnose urinary tract anomalies. Infants with urinary tract anomalies, neuropathic bladder and spina bifida should receive further voiding cystourethrography to diagnose VUR early, as this may help to prevent renal damage.

Management of the congenital solitary kidney: consensus recommendations of the Italian Society of Pediatric Nephrology

In recent years, several studies have been published on the prognosis of children with congenital solitary kidney (CSK), with controversial results, and a worldwide consensus on management and follow-up is lacking. In this consensus statement, the Italian Society of Pediatric Nephrology summarizes the current knowledge on CSK and presents recommendations for its management, including diagnostic approach, nutritional and lifestyle habits, and follow-up. We recommend that any antenatal suspicion/diagnosis of CSK be confirmed by neonatal ultrasound (US), avoiding the routine use of further imaging if no other anomalies of kidney/urinary tract are detected. A CSK without additional abnormalities is expected to undergo compensatory enlargement, which should be assessed by US. We recommend that urinalysis, but not blood tests or genetic analysis, be routinely performed at diagnosis in infants and children showing compensatory enlargement of the CSK. Extrarenal malformations should be searched for, particularly genital tract malformations in females. An excessive protein and salt intake should be avoided, while sport participation should not be restricted. We recommend a lifelong follow-up, which should be tailored on risk stratification, as follows: low risk: CSK with compensatory enlargement, medium risk: CSK without compensatory enlargement and/or additional CAKUT, and high risk: decreased GFR and/or proteinuria, and/or hypertension. We recommend that in children at low-risk periodic US, urinalysis and BP measurement be performed; in those at medium risk, we recommend that serum creatinine also be measured; in high-risk children, the schedule has to be tailored according to kidney function and clinical data.

Risk factors for kidney scarring and vesicoureteral reflux in 421 children after their first acute pyelonephritis, and appraisal of international guidelines

BACKGROUND

Acute pyelonephritis (AP) is a common bacterial infection in childhood. Follow-up guidelines on these children are controversial. This study aimed to identify risk factors for kidney scarring and vesicoureteral reflux (VUR). Furthermore, international follow-up guidelines were used for simulation to evaluate sensitivity and specificity.

METHODS

Urinary culture-confirmed first-time AP patients (aged 0-14 years) were enrolled (n = 421) from review of patient charts. All underwent kidney ultrasound (US) and a technetium-99m-dimercaptosuccinic acid (DMSA) scan or technetium-99m-mercaptoacetyltriglycine scinti-renography (MAG3) at 4-6 months of follow-up. The international guidelines used for simulation were from the National Institute of Health UK (NICE), the American Association of Paediatrics (AAP) and the Swedish Paediatric Society (SPS).

RESULTS

17.8% presented with an abnormal DMSA/MAG3 at follow-up, 7.1% were diagnosed with VUR grades III-V and 4.7% were admitted for surgery. Non-Escherichia coli infections, abnormal kidney US, elevated creatinine and delayed response to treatment (>48 h) were risk factors for abnormal DMSA findings and VUR grades III-V. NICE and SPS guidelines showed best sensitivity in diagnosing VUR grades III-V (75%) compared with AAP (56%).

CONCLUSIONS

Risk factors are helpful in identifying the children in need of further investigations and minimizing invasive work-up for the rest. International guidelines on follow-up detect a varying number of children with kidney damage and/or significant VUR. Future work must focus on identifying more specific risk factors, better imaging, or specific biomarkers, to enhance sensitivity and specificity in detecting the children at high risk for developing recurrent infections and/or nephropathy.

The prevalence of vesicoureteral reflux in infants with first urinary tract infection following circumcision is similar to infants with UTI not following circumcision

PURPOSE

Urinary tract infections (UTIs) are common serious bacterial infections in early infancy. Ritual circumcision in neonates may increase the risk of UTI within 2 weeks of the procedure. The aims of this study were to assess the prevalence and risk factors for vesicoureteral reflux (VUR) among young infants with first UTI following circumcision, and compare it with the prevalence of VUR among young infants with first UTI not related to circumcision.

METHODS

In this retrospective cohort study, the medical records of all children aged 0-100 days who were diagnosed with UTI at Shaare Zedek Medical Center between 2005 and 2012 were reviewed for demographic, clinical and laboratory data and for the presence of VUR in voiding cystourethrography (VCUG).

RESULTS

Four hundred and sixty eight cases of UTI were included. Infants with post-circumcision UTI in our study were more likely to have associated bacteremia and abnormal renal function tests. VCUG was done for 166 infants (35%). There was no statistically significant difference in the prevalence of abnormal VCUG between infants with UTI following circumcision, in comparison to infants with UTI not following circumcision (30% vs. 36%, p = NS).

CONCLUSIONS

The decision regarding the need for radiographic evaluation and prophylactic antibiotic treatment following UTI should be made regardless if infection was related to circumcision.

Managing vesicoureteral reflux in children: making sense of all the data

Current management of vesicoureteral reflux (VUR) in children is the result of a steady albeit controversial evolution of data and thinking related to the clinical impact of VUR and urinary tract infection (UTI) in children, the value of clinical screening, and the relative impact of testing and interventions for VUR. While controversy continues, there is consensus on the importance of bladder dysfunction on VUR outcomes, the likelihood of VUR resolution, and the fact that not all children with VUR require active treatment. Early efforts to define risk stratification hold the most promise to provide more patient-specific treatment of UTI and VUR in children.

Detection of Vesicoureteral Reflux Using Electrical Impedance Tomography

OBJECTIVE

The purpose of this study is to detect vesicoureteral reflux (VUR) noninvasively using an electrical impedance tomography (EIT). VUR is characterized by the backflow of urine from the bladder to the kidneys.

METHODS

Using porcine models, small quantities of a solution mimicking the electrical properties of urine were infused into each ureter. EIT measurements were taken before, during and after the infusion using electrodes positioned around the abdomen. The collected data from 116 experiments were then processed and time-difference images reconstructed. Objective VUR detection was determined through statistical analysis of the mean change in the voltage signals and EIT image pixel intensities.

RESULTS

Unilateral VUR was successfully detected in 94.83% of all mean voltage signals and in over 98.28% of the reconstructed images. The images showed strong visual contrast between the region of interest and the background.

CONCLUSION

In animal models, EIT has the capability to detect reflux in the kidneys with high accuracy. The results show promise for EIT to be used for screening of VUR in children.

SIGNIFICANCE

VUR is the most common congenital urinary tract abnormality in children. The condition predisposes children to urinary tract infections and kidney damage. The current gold standard diagnostic test, a voiding cystourethrogram, is invasive and uses ionizing radiation; therefore, there is a need for new tools for identifying VUR in children. This study presents a noninvasive method to detect VUR in animal models, illustrating the potential for EIT as a screening tool in clinical scenarios.

Delayed diagnosis of primary vesicoureteral reflux in children with recurrent urinary tract infections: Diagnostic approach and renal outcomes

OBJECTIVE

In this study, we aimed to assess renal outcomes of delayed diagnosis of dilating primary vesicoureteral reflux (VUR) following recurrent febrile urinary tract infections (fUTIs) and its diagnostic imaging procedures.

MATERIAL AND METHODS

The medical records of patients who underwent ultrasonography (US), non- acute dimercaptosuccinic acid (Tc-99mDMSA) scintigraphy and voiding cystourethrography (VCUG), and who were older than 2 years at the time of VUR diagnosis were retrospectively reviewed.

RESULTS

A total of 32 children (female, n=27: 84.4%) with a mean age of 7.67±3.34 years at the time of diagnosis of VUR were included in the study. Grade III, IV, V VUR were found in 22%, 69%, and 9% of the patients, respectively. At the time of VUR diagnosis, abnormal US findings were detected in 75% of the cases. Tc-99mDMSA detected abnormalities in 83.9% (7 with a single scar, 7 with multiple lesions, 12 with reduced kidney function) of the patients. Estimated glomerular filtration rate of 3 patients with bilateral grade IV VUR was <75 mL/min/1.73 m². In 5 patients (16%), VUR could not be predicted by US+DMSA scintigraphy (Grade IV VUR in 3 and Grade III in 2 cases ). The sensitivity in predicting VUR was 75.00% (95% CI: 56.60-88.54) and 83.87% (95% CI: 66.27-94.55), respectively, for US alone and combined US+DMSA.

CONCLUSION

VCUG should be performed routinely in addition to US and non-acute DMSA in all children referred with recurrent fUTIs. Awareness of childhood UTI in public and healthcare personnels should be increased in order to refer these patients at a early stage to pediatric urology and nephrology units.

Dimercaptosuccinic acid scintigraphy vs. ultrasound for renal parenchymal defects in children

INTRODUCTION

Dimercaptosuccinic acid (DMSA) scintigraphy is the gold standard in the evaluation of renal parenchymal defects and is widely used in the pediatric population. As more recent ultrasound equipment was purchased at our tertiary pediatric centre, our objective was to evaluate if renal ultrasound (US) results are equivalent or sufficient when compared to DMSA scintigraphy in the assessment of renal anomalies.

METHODS

The charts of all 463 patients who underwent DMSA scintigraphy between January 2009 and May 2014 at our pediatric tertiary centre were reviewed. The objective was to look for correlation between US and DMSA scan results for renal scars/dysplasia. A hundred and sixty pediatric patients followed with US and DMSA scan for a total of 285 renal units remained for evaluation after exclusions. Timing of the exams, urinary tract infection (UTI), and indication for imaging were reviewed. Results with older (105 patients) and newer (55 patients) US equipment were compared.

RESULTS

Among the 285 renal units evaluated, 39 (14%) had renal parenchymal defects shown by US and 87 (31%) by DMSA scintigraphy (sensitivity 36%, specificity 96%). The DMSA scan was normal for eight abnormal kidneys (3%) on US. The results were not statistically significant when compared to exams performed with newer or older US machines.

CONCLUSIONS

At our institution, US data are not sensitive enough to give reliable information about renal parenchymal defects, even with newer equipment. DMSA scintigraphy still remains mandatory for the evaluation of renal anomalies, but could be optional if the US exam indicates parenchymal defects.

Imaging studies and biomarkers to detect clinically meaningful vesicoureteral reflux

The work-up of a febrile urinary tract infection is generally performed to detect vesicoureteral reflux (VUR) and its possible complications. The imaging modalities most commonly used for this purpose are renal-bladder ultrasound, voiding cystourethrogram and dimercapto-succinic acid scan. These studies each contribute valuable information, but carry individual benefits and limitations that may impact their efficacy. Biochemical markers are not commonly used in pediatric urology to diagnose or differentiate high-risk disease, but this is the emerging frontier, which will hopefully change our approach to VUR in the future. As it becomes more apparent that there is tremendous clinical variation within grades of VUR, the need to distinguish clinically significant from insignificant disease grows. The unfortunate truth about VUR is that recommendations for treatment may be inconsistent. Nuances in clinical decision-making will always exist, but opinions for medical versus surgical intervention should be more standardized, based on risk of injury to the kidney.

Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections

BACKGROUND

There is considerable interest in detecting vesicoureteral reflux (VUR) because its presence, especially when severe, has been linked to an increased risk of urinary tract infections and renal scarring. Voiding cystourethrography (VCUG), also known as micturating cystourethrography, is the gold standard for the diagnosis of VUR, and the grading of its severity. Because VCUG requires bladder catheterisation and exposes children to radiation, there has been a growing interest in other screening strategies that could identify at-risk children without the risks and discomfort associated with VCUG.

OBJECTIVES

The objective of this review is to evaluate the accuracy of two alternative imaging tests - the dimercaptosuccinic acid renal scan (DMSA) and renal-bladder ultrasound (RBUS) - in diagnosing VUR and high-grade VUR (Grade III-V VUR).

SEARCH METHODS

We searched MEDLINE, EMBASE, BIOSIS, and the Cochrane Register of Diagnostic Test Accuracy Studies from 1985 to 31 March 2016. The reference lists of relevant review articles were searched to identify additional studies not found through the electronic search.

SELECTION CRITERIA

We considered published cross-sectional or cohort studies that compared the results of the index tests (DMSA scan or RBUS) with the results of radiographic VCUG in children less than 19 years of age with a culture-confirmed urinary tract infection.

DATA COLLECTION AND ANALYSIS

Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate summary sensitivity and specificity values.

MAIN RESULTS

A total of 42 studies met our inclusion criteria. Twenty studies reported data on the test performance of RBUS in detecting VUR; the summary sensitivity and specificity estimates were 0.44 (95% CI 0.34 to 0.54) and 0.78 (95% CI 0.68 to 0.86), respectively. A total of 11 studies reported data on the test performance of RBUS in detecting high-grade VUR; the summary sensitivity and specificity estimates were 0.59 (95% CI 0.45 to 0.72) and 0.79 (95% CI 0.65 to 0.87), respectively. A total of 19 studies reported data on the test performance of DMSA in detecting VUR; the summary sensitivity and specificity estimates were 0.75 (95% CI 0.67 to 0.81) and 0.48 (95% CI 0.38 to 0.57), respectively. A total of 10 studies reported data on the accuracy of DMSA in detecting high-grade VUR. The summary sensitivity and specificity estimates were 0.93 (95% CI 0.77 to 0.98) and 0.44 (95% CI 0.33 to 0.56), respectively.

AUTHORS' CONCLUSIONS

Neither the renal ultrasound nor the DMSA scan is accurate enough to detect VUR (of all grades). Although a child with a negative DMSA test has an < 1% probability of having high-grade VUR, performing a screening DMSA will result in a large number of children falsely labelled as being at risk for high-grade VUR. Accordingly, the usefulness of the DMSA as a screening test for high-grade VUR should be questioned.