Improved ultrasound detection of renal scarring in children following urinary tract infection

Renal Cortical Imaging with Tc-99m DMSA in Children: An Institutional Review

Background  Urinary tract infection (UTI) is one of the commonly encountered conditions in children. Dimercaptosuccinic acid (DMSA) scintigraphy is widely advocated for functional and morphological evaluation of the renal cortex including parenchymal defect. Moreover, only a small percentage of renal defects are detected by ultrasound. We aimed to examine DMSA scintigraphy of children and identify factors associated with cortical defect. Methods  Patients aged ≤ 18 years old who underwent DMSA scintigraphy (November 18, 2019-February 2, 2023, 30 children) were included. All children received intravenous injections of 99m Tc-DMSA followed by static planar and single-photon-emission computed tomography imaging at 3 hours. Cortical findings and differential functions of the worst affected kidney were graded accordingly. Grade I has no more than two cortical defects, grade II has more than two cortical defects with normal parenchyma between the defects, while grade III is when generalized damage is noted, and grade IV is when a shrunken kidney is seen with no DMSA uptake. Normal functioning kidney is when the relative function at 45 to 55%, mildly reduced function at 40 to 44%, and substantially impaired function at 10 to 39%, while nonfunctioning is when the differential split renal function < 10%. All data were then statistically analyzed. Results  Majority was female (53%). The mean age was 5.85 years. UTI episodes were 73%. Twenty-two children had congenital urinary tract anomalies. All patients with vesicoureteric refluxes (VURs) had positive defects. Scintigraphy showed abnormalities in 17 children affecting unilateral (64%) or both kidneys (36%). There were 17 children (57%) respectively in the abnormal DMSA scan findings category with normal until significant impairment of the functioning kidney category. VURs were significantly associated with abnormal scintigraphy ( p  < 0.05). A significant association was found between abnormal DMSA scan findings and differential renal function ( p  < 0.05). Conclusion  Significant association was noted between VURs and abnormal DMSA scintigraphy, abnormal DMSA scan findings, and impaired differential renal function. Special consideration should be given to these cases.

Risk factors and implications associated with ultrasound-diagnosed nephrocalcinosis in cats with chronic kidney disease

BACKGROUND

Microscopic nephrocalcinosis is a common pathological feature of chronic kidney disease (CKD) in cats. Detection of macroscopic nephrocalcinosis using ultrasonography and its implications remain unexplored.

OBJECTIVES

Identify risk factors associated with ultrasound-diagnosed nephrocalcinosis and evaluate the influence of nephrocalcinosis on CKD progression.

ANIMALS

Thirty-six euthyroid client-owned cats with CKD.

METHODS

Prospective cohort study. Cats with CKD with and without ionized hypercalcemia were enrolled for renal ultrasonography. Cats were categorized according to the presence or absence of ultrasound-diagnosed nephrocalcinosis. Binary logistic regression was performed to identify nephrocalcinosis risk factors. The influence of nephrocalcinosis on CKD progression was assessed using linear mixed models.

RESULTS

Ultrasound-diagnosed nephrocalcinosis was evident in 61% of CKD cats overall, with increased prevalence (81%) in those with hypercalcemia. At enrollment, higher blood ionized calcium concentration (odds ratio [OR], 1.27 per 0.1 mg/dL; P = .01), plasma phosphate concentration (OR, 1.16 per 0.1 mg/dL; P = .05), plasma creatinine concentration (OR, 1.29 per 0.1 mg/dL; P = .02) and alanine aminotransferase activity (OR, 2.08 per 10 U/L; P = .04) were independent nephrocalcinosis risk factors. The rate of change in log-transformed fibroblast growth factor-23 differed significantly between groups (P = .04). Cats with CKD and nephrocalcinosis had increasing plasma creatinine concentrations (.03 ± .01 mg/dL/month; P = .04) and phosphate concentrations (.06 ± .02 mg/dL/month; P < .001) and decreasing body weight (.02 ± .01 kg/month; P < .001) over time.

CONCLUSIONS AND CLINICAL IMPORTANCE

Nephrocalcinosis is prevalent in cats with CKD, especially in those with hypercalcemia. This pathological feature appears to be associated with CKD progression in cats.

Dynamic and static ultrasound features predictive of vesicoureteral reflux and renal damage in children and adolescents with neurogenic bladder

PURPOSE

This study aimed to analyze the diagnostic accuracy of dynamic and static ultrasound (DSUS) in detecting vesicoureteral reflux (VUR) and renal scarring in a cohort of children with neurogenic bladder (NB).

MATERIALS AND METHODS

A retrospective, longitudinal, observational study was conducted using the Reporting Diagnostic Accuracy Studies guideline. The DSUS (index test) data were compared with voiding cystourethrography (VCUG) and renal scintigraphy 99mTc-dimercaptosuccinic (reference tests). Overall performance for predicting VUR and renal scarring was assessed using renal pelvic diameter (RPD)/distal ureteral diameter and renal parenchymal thinning on DSUS, respectively.

RESULTS

A total of 107 patients (66 girls, median age 9.6 years) participated. Seventeen patients (15.9%) presented VUR, eight bilateral. For overall reflux grade, the AUC was 0.624 for RPD and 0.630 for distal ureteral diameter. The diagnostic performance for detecting high-grade VUR was slightly better for DSUS parameters. The AUC was 0.666 for RPD and 0.691 for distal ureteral diameter. The cut-offs of 5 mm for RPD and 6.5 mm for distal ureteral diameter presented the best diagnostic odds ratio (DOR) to identify high-grade VUR. The increase of RPD during detrusor contractions showed an accuracy of 89.2%. The thinness of renal parenchyma presented an accuracy of 88% for renal scarring.

CONCLUSION

DSUS predicts VUR and renal scarring in children with NB with fair to good accuracy, and all measurements exhibited a high negative predictive value (NPV). The increase in RPD during voiding or detrusor contractions proved to be the most accurate parameter for indicating the presence of VUR in this study.

The prevalence of kidney scarring due to urinary tract infection in Iranian children: a systematic review and meta-analysis

INTRODUCTION

Urinary tract infection is one of the most common diseases in childhood, and can lead to severe complications such as renal scarring in case of lack of diagnosis and timely treatment.

OBJECTIVE

The aim of this study was to investigate the prevalence of kidney scarring caused by urinary tract infection in Iranian children by meta-analysis.

STUDY DESIGN

English -language databases including Science Direct, PubMed, Scopus, Web of Science, and Springer, and Persian -language sites including SID, Magiran, Iranmedex, and Medlib, and the Google Scholar search engine were searched by in March 2018 using MeSH keywords. The heterogeneity of studies was studied using the I2 index. Data were analyzed using STATA software, version 15.1.

RESULTS

In 18 studies, the prevalence of kidney scarring from urinary tract infections in Iranian children was 31% (95% confidence intervalCI: 22%-39%), (which was 14% in girls and 23% in boys. Also, the prevalence of kidney scar in children with urinary reflux was 47% and in children without urinary reflux was 12%. The most common symptom of the renal scar was fever in 61%, followed by urinary reflux in 45% (unilateral in 42% and bilateral in 30%). Also, the prevalence of mild, moderate, and severe reflux, respectively, was 31%, 27%, and 13%. Meta-regression also showed that the prevalence of kidney scar due to urinary tract infections had no significant relationship with the number of samples and years of research (P > 0.05).

DISCUSSION AND CONCLUSION

About one-third of Iranian children suffering from urinary tract infections had kidney scarring, so that the prevalence is lower in girls than in boys. Also, the prevalence of renal scarring in children with urinary reflux is about four times higher than that in children without urinary reflux.

3D CT of renal pathology: initial experience with cinematic rendering

3D computed tomography (CT) visualizations of volumetric data have become an important aspect of diagnostic imaging. The utility of 3D CT has been well described for the imaging of a number of renal pathologies. Recently, a new 3D visualization technique known as cinematic rendering (CR) has become available and provides photorealistic images derived from standard CT acquisitions by use of a complex global lighting model. Herein, we describe a number of normal variant and pathologic conditions of the kidney visualized with CR. We provide comparisons of findings with CR to traditional methods of 3D imaging and comment on the potential applications of this new method of 3D CT rendering.

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.

Prospective evaluation of healthy Ragdoll cats for chronic kidney disease by routine laboratory parameters and ultrasonography

Ragdoll breeder organisations often forewarn Ragdoll cat owners that renal problems may develop as a result of polycystic kidney disease (PKD), chronic interstitial nephritis, familial renal dysplasia or nephrocalcinosis. Healthy Ragdoll and non-Ragdoll cats were prospectively evaluated by measuring serum creatinine and urea concentrations, routine urinalysis and abdominal ultrasonography. All Ragdoll cats also underwent genetic PKD testing. One hundred and thirty-three Ragdoll and 62 control cats were included. Ragdoll cats had significantly lower serum urea concentrations and higher urinary specific gravity. However, median creatinine concentration, median urinary protein-to-creatinine ratio, and the proportion of cats with serum creatinine or urea concentration exceeding the reference interval did not differ. One or more renal ultrasonographical changes were detected in 66/133 (49.6%) Ragdoll and in 25/62 (40%) control cats. Ragdoll cats showed significantly more frequent segmental cortical lesions (7.5% versus 0%), abnormal renal capsule (19.5% versus 8%) and echogenic urine (51.9% versus 25.8%). Chronic kidney disease (CKD) was ultrasonographically suspected in 7/133 (5.3%) Ragdoll and in none of the control cats, which approached significance. Laboratory parameters confirmed kidney dysfunction only in 1/7 of these Ragdoll cats. All Ragdoll cats were PKD negative. In conclusion, first, breed-specific serum creatinine reference intervals are not likely required for Ragdoll cats. Second, renal ultrasonographical abnormalities are common, both in Ragdoll and non-Ragdoll cats. Third, healthy young Ragdoll cats are uncommonly affected by PKD and CKD, but an increased susceptibility of Ragdoll cats to develop CKD cannot be excluded. Finally, Ragdoll cats are predisposed to segmental cortical lesions, which may indicate renal infarction or cortical scarring.

Spinal dysraphism

To review the clinical features and current understanding of spina bifida with an emphasis on the Indian Scenario. Selected articles and current English language texts were reviewed. The authors experience was also reviewed and analysed. Spina bifida is a common congenital anomaly encompassing a wide spectrum of neural tube defects.It is broadly classified as spina bifida aperta and occulta. With the prenatal screening, the incidence of aperta is gradually declining, whereas the detection of occulta has increased with the advent of magnetic resonance imaging. Over the years, the understanding of pathophysiology has made a significant changein the management of these anomalies. Early detection and complete correction can significantly reduce the neurological disability. This article is an overview of spina bifida with a special emphasis on Indian scenario.

Technical report—Diagnosis and management of an initial UTI in febrile infants and young children

OBJECTIVES

The diagnosis and management of urinary tract infections (UTIs) in young children are clinically challenging. This report was developed to inform the revised, evidence-based, clinical guideline regarding the diagnosis and management of initial UTIs in febrile infants and young children, 2 to 24 months of age, from the American Academy of Pediatrics Subcommittee on Urinary Tract Infection.

METHODS

The conceptual model presented in the 1999 technical report was updated after a comprehensive review of published literature. Studies with potentially new information or with evidence that reinforced the 1999 technical report were retained. Meta-analyses on the effectiveness of antimicrobial prophylaxis to prevent recurrent UTI were performed.

RESULTS

Review of recent literature revealed new evidence in the following areas. Certain clinical findings and new urinalysis methods can help clinicians identify febrile children at very low risk of UTI. Oral antimicrobial therapy is as effective as parenteral therapy in treating UTI. Data from published, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI when vesicoureteral reflux is found through voiding cystourethrography. Ultrasonography of the urinary tract after the first UTI has poor sensitivity. Early antimicrobial treatment may decrease the risk of renal damage from UTI.

CONCLUSIONS

Recent literature agrees with most of the evidence presented in the 1999 technical report, but meta-analyses of data from recent, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI. This finding argues against voiding cystourethrography after the first UTI.

Sensitivity of ultrasonography in detecting renal parenchymal defects: 6 years' follow-up

While (99m)Tc-dimercaptosuccinic acid (DMSA) scanning is still considered the most accurate method for the assessment of renal parenchymal defects (RPDs), our study 6 years previously suggested that ultrasonography (US) could be a safe and efficient substitute for this purpose, provided that it is reliably performed and that renal function parameters are followed. By comparison of the original and follow-up study data from 67 children, the accuracy of our recommendations was re-evaluated. US was performed and renal function parameters investigated and correlated to the DMSA scans from the original study. US identified all six patients with clinically significant RPD and 52/61 with clinically insignificant RPDs, seen on the DMSA scans. Twenty two out of 22 severe RPDs, 21/23 moderate RPDs and 20/40 mild RPDs seen on the DMSA scans were detected by US. In ten cases normal US findings from the original study were rendered abnormal, correlating well with the DMSA scans with respect to RPD localization and kidney size. These results further support our previous suggestion that US is a safe and harmless alternative to DMSA scanning in the detection and follow-up of RPDs. While it cannot be excluded that small RPDs missed on the initial US might 'develop' clinical significance in later life, children with normal findings on initial US should have another sonogram done, at the shortest a year later, together with an investigation of renal function parameters.

Resolution of cortical lesions on serial renal scans in children with acute pyelonephritis

BACKGROUND

The ideal time for distinguishing a renal scar from acute inflammatory lesions by renal DMSA scintigraphy remains controversial.

OBJECTIVE

To determine the time needed for resolution of lesions after acute pyelonephritis.

MATERIALS AND METHODS

A total of 105 children with acute pyelonephritis underwent renal sonography, voiding cystourethrography and baseline DMSA scintigraphy. Two subsequent scans were performed during the 6th and 12th months in patients with abnormal findings on the previous scan.

RESULTS

The baseline DMSA scintigraphy revealed cortical lesions in 37 patients. At 6 months, 13 patients (38.2%) were found to have cortical lesions. At 12 months, 6 patients (17.6%) were found to have persistent renal cortical lesions. The resolution rates for lesions detected on the first scan were 61.8% and 82.4% on the 6- and 12-month scans, respectively. Vesicoureteric reflux, and bilaterality or multifocality were not relevant for resolution of lesions. Female gender seemed to be associated with a higher persistence rate.

CONCLUSIONS

The renal cortical defects present at 6 months have a high rate of resolution later during follow-up. DMSA scintigraphy performed 12 months after the infection provides more reliable data regarding persistence of renal cortical lesions.

Urological follow-up of adult spina bifida patients

AIMS

The vast majority of the current urological literature understandably has concentrated on the management of children with spina bifida, because in the past the majority did not survive into adulthood. With improvements in the understanding and multidisciplinary care of spina bifida patients it has become a disease of adults. Our aim was to evaluate the current literature to attempt to formulate evidence based guidelines for the management of this difficult group of patients.

METHODS

We reviewed the literature on adult urological management of spina bifida, all relevant articles which concentrated on adults and long-term management were studied in full.

RESULTS

Renal function may begin/continue to deteriorate into adulthood, becoming the leading cause of adult death. This is thought to occur because of changes in the adult bladder, with increases in storage pressure. Medical and surgical management should aim to preserve renal function as well as the maintenance of continence in the face of the growing and changing urinary tract. Follow-up should be regular and in the context of a specialist multidisciplinary clinic. Despite being unvalidated in the follow-up of adult spina bifida patient's annual serum creatinine, ultrasound and urodynamics are currently the best tools available.

CONCLUSIONS

There is no reason why the majority of spina bifida sufferers cannot use their own kidneys for the rest of their lives. This however relies on urological treatment being instigated soon after birth and continuing into adulthood.

Unilateral multicystic dysplastic kidney: long term outcomes

AIMS

To report the long term follow up of children with antenatally detected unilateral multicystic dysplastic kidney (MCDK) with documentation of complications, involution rate with time, and renal function at 10 years.

METHODS

Data were retrieved from a prospective regional registry of patients with MCDK between 1985 and 2004. Children were followed using a common protocol of investigation with follow up ultrasound scans (USS) at 2 (165 patients), 5 (117 patients), and 10 years (43 patients).

RESULTS

Serial USS showed that 33% of the MCDK kidneys had completely involuted at 2 years of age, 47% at 5 years, and 59% at 10 years. No patients developed hypertension, significant proteinuria, or malignancy, but two developed pelviureteric junction obstruction in the contralateral kidney. Twenty seven of 143 children (19%) had vesicoureteric reflux (VUR) (96% mild to moderate VUR) into the contralateral kidney with no difference in the incidence of urinary tract infections or renal scarring between those with or without VUR. The mean estimated glomerular filtration rate (GFR) was 86.4 ml/min/1.73 m2 (range 48-125) in 31 of 43 patients followed to 10 years.

CONCLUSIONS

Conservative management of unilateral MCDK is justified with clinical review and infrequent USS but longer term follow up continues in the 41% still with renal remnants at 10 years and those with impaired GFR. It is suggested that the initial micturating cystogram is deferred unless abnormal USS features are present in the contralateral kidney or ureter.

Early Start to Therapy Preserves Kidney Function in Spina Bifida Patients

OBJECTIVE

Renal scarring and renal failure remain life-threatening for children born with spinal dysraphism. We reviewed our data of spina bifida patients to evaluate whether optimal treatment of the neurogenic bladder from birth onwards can preserve kidney function.

METHODS

We reviewed data on all newborns with spinal dysraphism who were referred to our hospital between January 1988 and June 2001. We looked at their situations at referral and at follow-up: the type of treatment, antimuscarinic agents, clean intermittent catheterisation (CIC), antibiotic prophylaxis, and operations (sling procedures, bladder augmentations, antireflux procedures). Renal function (ultrasound, DMSA scan, serum creatinin, creatinin clearance) and bladder function (urodynamic studies) were evaluated over time.

RESULTS

Data of 144 children of 176 could be evaluated by the end of the study: 5 patients had pre-existing renal abnormalities, 69 had an overactive sphincter, 27 had reflux, and six had renal scarring. None are currently developing end-stage renal disease. All patients with spina bifida aperta started CIC and antimuscarinic therapy shortly after birth. Five of the six patients with renal scarring were started on therapy with intermittent catheterisation and antimuscarinic therapy several months after birth. Sixty-three of 82 children with spina bifida were dry at school age (age six), although 37 of these had not had an operation.

CONCLUSION

We show that an early start to therapy helps to safeguard renal function for children born with spina bifida. Our data support other recent reports that children born with spina bifida can probably use their own kidneys for a lifetime, if they are given adequate urological treatment. To protect the upper urinary tract, we need to ensure low intravesical pressure by starting children early on CIC (the preferred treatment); antimuscarinic agents to counteract detrusor instability are indispensable in most cases. Proactive treatment of risks for upper tract deterioration results in a negligible loss of renal function, even when early urinary continence is included in the treatment protocol.

How does study quality affect the results of a diagnostic meta-analysis?

BACKGROUND

The use of systematic literature review to inform evidence based practice in diagnostics is rapidly expanding. Although the primary diagnostic literature is extensive, studies are often of low methodological quality or poorly reported. There has been no rigorously evaluated, evidence based tool to assess the methodological quality of diagnostic studies. The primary objective of this study was to determine the extent to which variations in the quality of primary studies impact the results of a diagnostic meta-analysis and whether this differs with diagnostic test type. A secondary objective was to contribute to the evaluation of QUADAS, an evidence-based tool for the assessment of quality in diagnostic accuracy studies.

METHODS

This study was conducted as part of large systematic review of tests used in the diagnosis and further investigation of urinary tract infection (UTI) in children. All studies included in this review were assessed using QUADAS, an evidence-based tool for the assessment of quality in systematic reviews of diagnostic accuracy studies. The impact of individual components of QUADAS on a summary measure of diagnostic accuracy was investigated using regression analysis. The review divided the diagnosis and further investigation of UTI into the following three clinical stages: diagnosis of UTI, localisation of infection, and further investigation of the UTI. Each stage used different types of diagnostic test, which were considered to involve different quality concerns.

RESULTS

Many of the studies included in our review were poorly reported. The proportion of QUADAS items fulfilled was similar for studies in different sections of the review. However, as might be expected, the individual items fulfilled differed between the three clinical stages. Regression analysis found that different items showed a strong association with test performance for the different tests evaluated. These differences were observed both within and between the three clinical stages assessed by the review. The results of regression analyses were also affected by whether or not a weighting (by sample size) was applied. Our analysis was severely limited by the completeness of reporting and the differences between the index tests evaluated and the reference standards used to confirm diagnoses in the primary studies. Few tests were evaluated by sufficient studies to allow meaningful use of meta-analytic pooling and investigation of heterogeneity. This meant that further analysis to investigate heterogeneity could only be undertaken using a subset of studies, and that the findings are open to various interpretations.

CONCLUSION

Further work is needed to investigate the influence of methodological quality on the results of diagnostic meta-analyses. Large data sets of well-reported primary studies are needed to address this question. Without significant improvements in the completeness of reporting of primary studies, progress in this area will be limited.

Further investigation of confirmed urinary tract infection (UTI) in children under five years: a systematic review

BACKGROUND

Further investigation of confirmed UTI in children aims to prevent renal scarring and future complications.

METHODS

We conducted a systematic review to determine the most effective approach to the further investigation of confirmed urinary tract infection (UTI) in children under five years of age.

RESULTS

73 studies were included. Many studies had methodological limitations or were poorly reported. Effectiveness of further investigations: One study found that routine imaging did not lead to a reduction in recurrent UTIs or renal scarring. Diagnostic accuracy: The studies do not support the use of less invasive tests such as ultrasound as an alternative to renal scintigraphy, either to rule out infection of the upper urinary tract (LR- = 0.57, 95%CI: 0.47, 0.68) and thus to exclude patients from further investigation or to detect renal scarring (LR+ = 3.5, 95% CI: 2.5, 4.8). None of the tests investigated can accurately predict the development of renal scarring. The available evidence supports the consideration of contrast-enhanced ultrasound techniques for detecting vesico-ureteric reflux (VUR), as an alternative to micturating cystourethrography (MCUG) (LR+ = 14.1, 95% CI: 9.5, 20.8; LR- = 0.20, 95%CI: 0.13, 0.29); these techniques have the advantage of not requiring exposure to ionising radiation.

CONCLUSION

There is no evidence to support the clinical effectiveness of routine investigation of children with confirmed UTI. Primary research on the effectiveness, in terms of improved patient outcome, of testing at all stages in the investigation of confirmed urinary tract infection is urgently required.

Freqüência de desaparecimento do refluxo vésico-ureteral de graus I a III em pacientes pediátricos

OBJETIVOS: avaliar a freqüência do desaparecimento do refluxo vésico-ureteral (RVU) primário de graus I a III em crianças e correlacionar com idade no diagnóstico, sexo, grau e lateralidade. MÉTODOS: estudo retrospectivo de 34 crianças com RVU diagnosticado por uretrocistografia miccional (UCM). Cinco pacientes eram meninos (mediana: um ano e seis meses) e 29 meninas (mediana: três anos) O exame controle pela UCM ou cistografia foi realizado em intervalos de 12 a 24 meses. Na análise das variáveis utilizou-se a curva de sobrevida de Kaplan-Meier. RESULTADOS: o desaparecimento do RVU ocorreu em 52,9% dos pacientes. Comparando faixas etárias não houve diferença estatística. Nos meninos o desaparecimento do RVU ocorreu na mediana de 24 meses e nas meninas, de 60 meses. Houve diferença estatística entre os sexos (p = 0,02). Houve desaparecimento do RVU em 80% dos pacientes com RVU de grau I (mediana: 25,5 meses), 66,6% de grau II (mediana: 48 meses) 40% de grau III (mediana: 60 meses); em 21% no bilateral (mediana: 48 meses) e 75% no unilateral (mediana: 28,5 meses). Houve diferença estatística entre os graus de RVU (0,02) e lateralidade (p = 0,05). CONCLUSÕES: o desaparecimento do RVU ocorreu no sexo masculino, nos graus I ou II e unilateral.

Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard

Dimercaptosuccinic acid (DMSA) renal scan is presently the technique of choice for assessing renal scars. Recent advances suggest that ultrasonography could replace DMSA scan for this purpose. This paper describes the experience of a tertiary pediatric referral hospital performing ultrasonography and DMSA scans in the assessment of renal scarring. Investigations were conducted 3-6 months after patients presented with urinary tract infection (UTI). Results were extracted from the radiology information system and recorded for analysis. All children with a UTI who had undergone DMSA and ultrasound examination on the same day between January 1995 and December 1999 were included; 930 kidneys were compared. DMSA scan was utilized as the reference method. When used to detect focal renal scarring, ultrasonography had a sensitivity of 5.2%, specificity of 98.3%, a positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 75.8%. When used to detect diffuse renal scarring, ultrasonography had a sensitivity of 47.2%, specificity of 91.8%, PPV of 60.8% and NPV of 86.6%. Our results demonstrate that although ultrasonography has a good specificity for the detection of renal scarring compared with DMSA, it has low sensitivity, PPV and NPV. Ultrasonography cannot be substituted for DMSA scan in the evaluation of focal renal scarring.

Work-up of urinary tract infection in infants and children

Urinary tract infection (UTI) in infants and children demands rapid differentiation between upper UTI (pyelonephritis) and lower UTI (cystitis) for prompt treatment to be initiated so that renal damage is minimized. This pictorial review presents a wide gamut of structural and functional abnormalities of the urinary tract that may predispose infants and children to UTI, including vesicoureteral reflux, upper urinary tract obstruction (ureteropelvic junction obstruction), lower urinary tract obstruction (primary megaureter, ureterovesical junction obstruction, posterior urethral valve, ectopic ureterocele with or without associated duplex collecting system), neurogenic problems (dysfunctional voiding), calculi, and parenchymal scars. Sonography (ultrasound [US]) is the imaging modality of choice for assessment of renal size, growth (serial sonograms), texture, and blood flow. Other modalities used to work-up UTI in the pediatric patient include fluoroscopic voiding cystourethrogram, nuclear voiding cystourethrogram, and nuclear renal scintigraphy (NRS). Excretory urography is no longer recommended in the routine evaluation of childhood UTI because information regarding anatomy and function (qualitative and quantitative) can be better assessed with US and NRS, respectively. Computed tomography and magnetic resonance imaging are primarily reserved for complex cases in which a definitive diagnosis cannot be made with routine imaging. Algorithms for work-up of UTI in various pediatric age groups are presented.

Vesicoureteral reflux and urinary tract infections

Urinary tract infection is a common problem in children. The combination of vesico-ureteric reflux (VUR) and urinary tract infection may predispose children to pyelonephritis and subsequent complications. This review outlines the modifications suggested in the recent literature in the protocol for investigations and diagnosing VUR. Recent interest has been expressed in studying certain molecular markers to measure non-invasively renal damage in children with VUR. Long term results of comparative trials between medical and surgical management have been published recently.

Risk assessment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography

AIMS

To address some of the issues in the ongoing debate over the optimal diagnostic imaging following childhood urinary tract infection (UTI), by determining the risk of missing renal cortical scarring which would be detected on a technetium-99m dimercaptosuccinic acid (DMSA) gold standard if ultrasound alone were used, factoring for clinical features (upper or lower tract), UTI recurrence, and age group (infants, preschool, or school age).

METHODS

Details of UTI clinical features and recurrence were recorded for 990 children with a proven UTI, and their DMSA and ultrasound results were compared for each kidney.

RESULTS

The risks of missing DMSA scarring varied between 0.4% (school age children with solitary lower tract UTI) and 11.1% (infants with recurrent upper tract UTI).

CONCLUSIONS

UTI clinical features are important in assessing the need for DMSA imaging. Current UK imaging guidelines are endorsed, although preschool children with solitary lower tract UTI remain a controversial group and more attention needs to focused on children with recurrent UTI.

Management of recurrent urinary tract infection and vesicoureteral reflux in children

The management of recurrent urinary tract infections and vesicoureteral reflux in neonates and children is still a challenging problem. This review critically summarizes the highlights and current innovations in diagnosis and therapy, focusing on the peer-reviewed literature of the past year. Future developments and research efforts are briefly discussed.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection

These authors review four areas of office pediatric practice: office laboratory procedures, office economics, parenting and parent education, and urinary tract infections. Thomas Ball reviews the literature published this past year on physician office laboratories, with updates on the Clinical Laboratories Improvement Amendments, laboratory utilization, and office diagnosis of infectious mononucleosis. Eve Shapiro offers an update on office economics, discussing physician organizations and managed care, and a medical ethics evaluation of medical economics. Burris Duncan provides an update on parenting and parent education, with emphasis on defining "the best interests of the child." Richard Wahl summarizes the past year's publications on pediatric urinary tract infections, reviewing the circumcision debate, dysfunctional voiding, vesicoureteral reflux, and the diagnosis and follow-up of acute pyelonephritis.

Evaluation and management of pediatric urinary tract infections

Urinary tract infections (UTIs) are relatively common in children. We describe the evaluation and management of children with UTIs, as well as the risks and consequences related to the UTI. This article describes a rational approach to the evaluation and management of childhood UTIs with the relation to the natural history and risk factors.