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SNMMI procedure standard/EANM practice guideline on pediatric [99mTc]Tc-DMSA renal cortical scintigraphy: an update. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-022-00484-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AbstractThe Society of Nuclear Medicine and Molecular Imaging (SNMMI), founded in 1954, is an international scientific and professional organization with a purpose to promote the science, technology, and practical application of nuclear medicine. The European Association of Nuclear Medicine (EANM), founded in 1985, is a nonprofit professional medical association with a purpose to facilitate international communication among individuals in nuclear medicine pursuing clinical and academic excellence. Members of the SNMMI and EANM are physicians, technologists, and scientists who specialize in the research and practice of nuclear medicine. The SNMMI and EANM will periodically publish new guidelines for nuclear medicine practice to further advance the science of nuclear medicine and improve patient care. Existing standards/guidelines will be reviewed for revision or renewal, as appropriate. Each standard/guideline, representing a policy statement by the SNMMI/EANM, has undergone a thorough review, and represents an expert consensus. The SNMMI and EANM recognize that the safe and effective use of diagnostic nuclear medicine imaging requires specific training and skills, as described in each document. These standards/guidelines are educational resources designed to assist practitioners in providing appropriate nuclear medicine care for patients. They are consensus documents, and are not mandatory provisions or requirements of practice. They are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the SNMMI and the EANM cautions against the use of these standards/guidelines in litigation procedures that call into question the clinical decisions of a practitioner. The ultimate judgment regarding the appropriateness and propriety of any specific procedure or course of action must be made by medical professionals, taking into account the unique context of each case. Thus, there is no implication that action differing from what is detailed in these standards/guidelines, on its own, is below the standard of care. On the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the standards/guidelines when, based on the reasonable judgment of the practitioner, such course of action is warranted based on the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the standards/guidelines. Practicing medicine involves not only the science, but also the art of dealing with the prevention, detection, diagnosis, and treatment of disease. The variety and complexity of human conditions make it impossible for general guidelines to consistently allow for an accurate diagnosis to be reached or a specific treatment response to be predicted. Therefore, it should be recognized that adhering to these standards/guidelines does not ensure a successful outcome. All that should be expected is that a practitioner follows a reasonable course of action based on their level of training, the current landscape of knowledge, the resources at their disposal, and the needs/context of the particular patient being treated. The purpose of this document is to provide nuclear medicine physicians, radiologists, and other clinicians with guidelines for the recommendation, performance and interpretation of 99mTc-dimercaptosuccinic acid renal cortical scintigraphy ([99mTc] Tc-DMSA scintigraphy) in pediatric patients. These recommendations represent the expert opinions of experienced leaders in this field, and these recommendations are not all supported by a high level of evidence. Further studies are required to have evidence-based recommendations for the application of [99mTc] Tc-DMSA renal cortical scintigraphy in pediatrics. This guideline summarizes the views of the SNMMI Renal Cortical Scintigraphy in Children Working Group and the EANM Pediatrics Committee. It reflects recommendations for which the SNMMI and EANM cannot be held responsible. The recommendations should be taken into context of good practice of nuclear medicine and do not substitute for national and international legal or regulatory provisions.
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Bar-Sever Z, Shammas A, Gheisari F, Vali R. Pediatric Nephro-Urology: Overview and Updates in Diuretic Renal Scans and Renal Cortical Scintigraphy. Semin Nucl Med 2022; 52:419-431. [PMID: 35031115 DOI: 10.1053/j.semnuclmed.2021.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 11/11/2022]
Abstract
Nuclear medicine offers several diagnostic scans for the evaluation of congenital and acquired conditions of the kidneys and urinary track in children. Tc-99m-MAG 3 diuretic renal scans are most commonly used in the evaluation and follow up of urinary track dilatations. They provide functional information on the differential renal function and on drainage quality which is allows distinction between obstructed and non-obstructed kidneys and the need for surgical correction vs conservative management in kidneys with impaired drainage. Standardized imaging and processing protocols are essential for correct interpretation and for meaningful comparisons between follow up scans. Different approaches and conceptions led to some contradicting recommendations between SNMMI and EANM guidelines on diuretic renography in children which caused confusion and to the emergence of self-made institutional protocols. In Late 2018 the two societies published joint procedural guidelines on diuretic renography in infants and children which hopefully will end the confusion. Tc-99m DMSA scans provide important information about the function of the renal cortex allowing detection of acute pyelonephritis, renal scars dysplasia and ectopy as well as accurate determination of the differential renal function. They are commonly used in the evaluation of children with urinary tract infections and affect clinical management. A standardized imaging and processing protocol improves the diagnostic accuracy of these studies. SPECT or pinhole images should be a routine part of the imaging protocol. This is one of the recommendations in the new EANM and SNMMI procedural guidelines for renal cortical scintigraphy in children available online on the SNMMI website and is under publication. This article provides an overview on the clinical role of diuretic renography and cortical scintigraphy in children and describes the imaging protocols focusing on the new recommendations in the procedural guidelines.
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Affiliation(s)
- Zvi Bar-Sever
- Department of Nuclear Medicine, Schneider Children's Medical Center, Petach Tikva, Tel-Aviv University, Israel.
| | - Amer Shammas
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Farshid Gheisari
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Reza Vali
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
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YÜKSEL S, BECERİR T, SEYHAN B. The evaluation of the relationship of clinical and laboratory evidence with renal damage in the pediatric patients that had urinary tract infections. PAMUKKALE MEDICAL JOURNAL 2021:908-915. [DOI: 10.31362/patd.990677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
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Najafi F, Sarokhani D, Hasanpour Dehkordi A. The prevalence of kidney scarring due to urinary tract infection in Iranian children: a systematic review and meta-analysis. J Pediatr Urol 2019; 15:300-308. [PMID: 31229416 DOI: 10.1016/j.jpurol.2019.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 05/13/2019] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- F Najafi
- Research Center For Environmental Determinants of Health (RCEDH), School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - D Sarokhani
- Research Center For Environmental Determinants of Health (RCEDH), School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - A Hasanpour Dehkordi
- Social Determinants of Health Research Center, Shahrekord University of Medical sciences, Shahrekord, Iran.
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Widening the lens to childhood: relevance and lifetime risk of kidney failure. Curr Opin Nephrol Hypertens 2019; 28:233-237. [PMID: 30844883 DOI: 10.1097/mnh.0000000000000494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Lifetime risk of outcomes is emerging as a highly relevant health indicator, even in the context of low absolute risk of disease progression in short time frames. Evidence to support this concept for kidney failure is increasing, with growing emphasis on the long-term impact of risk factors occurring early in life. RECENT FINDINGS Proteinuria and stage of chronic kidney disease (CKD) are now established predictors of CKD progression in children, and youth with type 2 diabetes are emerging as a group at significant risk. Recent population-based studies have also examined the lifetime risk of end-stage renal disease in individuals with any childhood CKD. A recent study found that even in the absence of biomarkers of renal injury, childhood CKD can increase the lifetime risk of end-stage renal disease four-fold, and up to 10-fold in adults less than 40 years of age. SUMMARY Children with CKD are at high lifetime risk of kidney failure and require follow-up. Identifying children at highest lifetime risk through the use of biomarkers and risk equations, and determining the optimal duration and intensity of follow-up requires further research.
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Kim SW, Lee YS, Han SW. Endoscopic injection therapy. Investig Clin Urol 2017; 58:S38-S45. [PMID: 28612059 PMCID: PMC5468263 DOI: 10.4111/icu.2017.58.s1.s38] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/18/2017] [Indexed: 11/18/2022] Open
Abstract
Since the U.S. Food and Drug Administration approved dextranomer/hyaluronic acid copolymer (Deflux) for the treatment of vesicoureteral reflux, endoscopic injection therapy using Deflux has become a popular alternative to open surgery and continuous antibiotic prophylaxis. Endoscopic correction with Deflux is minimally invasive, well tolerated, and provides cure rates approaching those of open surgery (i.e., approximately 80% in several studies). However, in recent years a less stringent approach to evaluating urinary tract infections (UTIs) and concerns about long-term efficacy and complications associated with endoscopic injection have limited the use of this therapy. In addition, there is little evidence supporting the efficacy of endoscopic injection therapy in preventing UTIs and vesicoureteral reflux-related renal scarring. In this report, we reviewed the current literature regarding endoscopic injection therapy and provided an updated overview of this topic.
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Affiliation(s)
- Sang Woon Kim
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seung Lee
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Won Han
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
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Abdelhalim A, Khoury AE. Critical appraisal of the top-down approach for vesicoureteral reflux. Investig Clin Urol 2017; 58:S14-S22. [PMID: 28612056 PMCID: PMC5468260 DOI: 10.4111/icu.2017.58.s1.s14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/14/2017] [Indexed: 11/18/2022] Open
Abstract
Vesicoureteral reflux (VUR) has been linked to recurrent urinary tract infections (UTIs), renal scarring, hypertension, renal insufficiency and end-stage kidney disease. Different imaging strategies have been proposed to approach children presenting with UTI to sort out patients with significant VUR while minimizing patient morbidity, radiation exposure and financial burden. None of these imaging strategies is universally accepted. The“top-down approach” (TDA) aims at restricting the number of voiding cystourethrograms (VCUGs) and its associated morbidity while identifying patients with clinically-significant reflux. In this approach, children presenting with febrile UTIs are acutely investigated with dimercapto-succinic acid (DMSA) renal scans to identify patients with renal parenchymal inflammation. Those with evidence of renal affection are offered VCUG and late DMSA scan to identify VUR and permanent renal scarring, respectively. Although TDA could identify clinically-significant VUR with high sensitivity, it is not without limitations. The approach segregates patients based on the presence of DMSA cortical lesions omitting the morbidity and the economic burden of UTI. Additionally, some of DMSA lesions are attributed to congenital dysplasia and unrelated to UTI. Ionizing radiation exposure, financial costs, limited availability of DMSA scans in the acute setting, variability in interpreting the results and low yield of actionable findings on DMSA scans are some other limitations. In this review, we tried to address the drawbacks of the TDA and reinforce the value of patient-centered approach for VUR.
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Affiliation(s)
- Ahmed Abdelhalim
- Department of Urology, University of California, Irvine, Children's Hospital of Orange County, Orange, CA, USA.,Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Antoine E Khoury
- Department of Urology, University of California, Irvine, Children's Hospital of Orange County, Orange, CA, USA
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Sauer A, Wirth C, Platzer I, Neubauer H, Veldhoen S, Dierks A, Kaiser R, Kunz A, Beer M, Bley T. Off-label-use of sulfur-hexafluoride in voiding urosonography for diagnosis of vesicoureteral reflux in children: A survey on adverse events. World J Clin Pediatr 2017; 6:52-59. [PMID: 28224096 PMCID: PMC5296630 DOI: 10.5409/wjcp.v6.i1.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/30/2016] [Accepted: 11/17/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the risk profile of sulfur hexafluoride in voiding urosonography (VUS) based on a large cohort of children.
METHODS Since 2011 sulfur hexafluoride (SH, SonoVue®, Bracco, Italy) is the only ultrasound contrast available in the European Union and its use in children has not been approved. Within a 4-year-period, 531 children with suspected or proven vesicoureteral reflux (f/m = 478/53; mean age 4.9 years; 1 mo-25.2 years) following parental informed consent underwent VUS with administration of 2.6 ± 1.2 mL SH in a two-center study. A standardized telephone survey on adverse events was conducted three days later.
RESULTS No acute adverse reactions were observed. The survey revealed subacute, mostly self-limited adverse events in 4.1% (22/531). The majority of observed adverse events (17/22) was not suspected to be caused by an allergic reaction: Five were related to catheter placement, three to reactivated urinary tract infections, five were associated with perineal disinfection before voiding urosonography or perineal dermatitis and four with a common cold. In five patients (0.9%) hints to a potential allergic cause were noted: Perineal urticaria was reported in three interviews and isolated, mild fever in two. These were minor self-limited adverse events with a subacute onset and no hospital admittance was necessary. Ninety-six point two percent of the parents would prefer future VUS examinations with use of SH.
CONCLUSION No severe adverse events were observed and indications of self-limited minor allergic reactions related to intravesical administration of SH were reported in less than 1%.
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Role of Renal Ultrasonography in Predicting Vesicoureteral Reflux and Renal Scarring in Children Hospitalized with a First Febrile Urinary Tract Infection. Pediatr Neonatol 2016; 57:113-9. [PMID: 26163341 DOI: 10.1016/j.pedneo.2015.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/21/2015] [Accepted: 06/05/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND This study was designed to examine the capability of renal ultrasonography (US) for predicting vesicoureteral reflux (VUR) and renal scarring (RS), and to assess, using initial US, the significant urologic abnormalities that impact on management of children hospitalized with a first febrile urinary tract infection (UTI). METHODS Hospitalized children aged ≤ 2 years with a first febrile UTI were prospectively evaluated using imaging studies, including (99m)Tc dimercaptosuccinic acid (DMSA) scan, US, and voiding cystourethrography. RESULTS Of the 310 children analyzed (195 boys and 115 girls), 105 (33.9%) had abnormal US. Acute DMSA scans were abnormal in 194 children (62.6%), including 89 (45.9%) with concomitant abnormal US. There was VUR in 107 children (34.5%), including 79 (25.5%) with Grades III-V VUR. The sensitivity and negative predictive values of US were 52.3% and 75.1%, respectively, for Grades I-V VUR and 68.4% and 87.8%, respectively, for Grades III-V VUR. Eighty-five children (27.4%) had RS, including 55 (64.7%) with abnormal US. Of the 105 children with abnormal US, 33 (31.4%) needed subsequent management (surgical intervention, parental counseling, or follow up of renal function). Nephromegaly on initial US and Grades III-V VUR were risk factors of RS. CONCLUSION Abnormal US may carry a higher probability of Grades III-V VUR and RS, and can affect subsequent management in a significant number of children. Nephromegaly on initial US and Grades III-V VUR are strongly associated with an increased risk for RS. Thus, US should be performed on children after a first febrile UTI and children with normal US may not require voiding cystourethrography.
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Yılmaz S, Özçakar ZB, Kurt Şükür ED, Bulum B, Kavaz A, Elhan AH, Yalçınkaya F. Vesicoureteral Reflux and Renal Scarring Risk in Children after the First Febrile Urinary Tract Infection. Nephron Clin Pract 2016; 132:175-80. [DOI: 10.1159/000443536] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 12/19/2015] [Indexed: 11/19/2022] Open
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Insignificant impact of VUR on the progression of CKD in children with CAKUT. Pediatr Nephrol 2016; 31:105-12. [PMID: 26404649 DOI: 10.1007/s00467-015-3196-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 08/13/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) is associated with an increased risk of kidney disorders. It is unclear whether VUR is associated with progression from chronic kidney disease (CKD) to end-stage kidney disease (ESKD) in children with congenital anomalies of the kidney and urinary tract (CAKUT). METHODS We conducted a 3-year follow-up survey of a cohort of 447 children with CKD (stage 3-5). Rates of and risk factors for progression to ESKD were determined using the Kaplan-Meier method and Cox regression respectively. RESULTS Congenital anomaly of the kidney and urinary tract was the primary etiology in 278 out of 447 children; 118 (42.4 %) had a history of VUR at the start of the cohort study. There were significantly more boys than girls with VUR, whereas the proportions were similar in children without VUR. The types of urinary anomalies/complications of the two groups were significantly different. Three-year renal survival rates of the groups were not significantly different, irrespective of CKD stage. Age < 2 years and age after puberty, stage 4 or 5 CKD, and heavy proteinuria, but not history of VUR, were significantly associated with progression to ESKD. CONCLUSIONS History of VUR at the start of follow-up was not associated with the progression of stage 3-5 CKD in children with CAKUT.
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Kilborn T, Moodley H, Brink A, Nourse P. A case-based approach to UTI imaging – making sense of the guidelines. SA J Radiol 2015. [DOI: 10.4102/sajr.v19i2.877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Urinary tract infections (UTIs) are common amongst children and invariably result in imaging tests to look for correctable causes that may predispose the child to infection. The objective of imaging is to identify those children at risk of long-term renal damage. The ideal imaging algorithm is extensively debated in the literature owing to the lack of evidence-based data, evolving theories on the pathophysiology of UTI and vesicoureteric reflux (VUR). The present article provides a case-based approach to the imaging of UTIs and proposes guidelines relevant to the South African setting.
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Riccabona M. Imaging in childhood urinary tract infection. Radiol Med 2015; 121:391-401. [DOI: 10.1007/s11547-015-0594-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/08/2015] [Indexed: 10/22/2022]
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Demir S, Tokmak N, Cengiz N, Noyan A. Value of sonographic anterior-posterior renal pelvis measurements before and after voiding for predicting vesicoureteral reflux in children. JOURNAL OF CLINICAL ULTRASOUND : JCU 2015; 43:490-494. [PMID: 25545034 DOI: 10.1002/jcu.22260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 10/03/2014] [Accepted: 11/16/2014] [Indexed: 06/04/2023]
Abstract
PURPOSE Voiding cystourethrography (VCUG) is the gold standard for diagnosing vesicoureteral reflux (VUR), but it is important to minimize the use of VCUG because of the urinary catheterization and radiation exposure required. Ultrasound (US) observations suggest that pelvicalyceal dilatation varies according to the degree of bladder fullness in children with urinary tract infection. The aim of this study was to assess whether anterior-posterior (AP) measurements of the renal pelvis on US before and after voiding can be used as a screening tool while predicting the presence of VUR in children. METHODS The subjects were toilet-trained children older than 4 years who required VCUG. Two groups were established based on the VCUG results: a VUR group of 40 kidney units (each unit defined as calyces and ureter) that exhibited different severities of reflux, and a control group of 68 kidney units unaffected by VUR. Prior to VCUG, US AP measurements of the renal pelvis of each kidney unit were recorded when the urinary bladder was full and again after bladder emptying. The change in AP measurement from before to after voiding was compared between the two groups. RESULTS The mean change in AP measurements from before to after voiding in the VUR group was significantly greater than that in the control group (p = 0.003). CONCLUSIONS Comparing US AP measurements of the renal pelvis before and after voiding is useful for identifying children who are suspected to have VUR and thus require immediate VCUG.
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Affiliation(s)
- Senay Demir
- Baskent University Faculty of Medicine, Radiology, Adana, Turkey
| | - Naime Tokmak
- Baskent University Faculty of Medicine, Radiology, Adana, Turkey
| | - Nurcan Cengiz
- Baskent University Faculty of Medicine, Pediatric Nephrology, Adana, Turkey
| | - Aytul Noyan
- Baskent University Faculty of Medicine, Pediatric Nephrology, Adana, Turkey
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Narchi H, Marah M, Khan AA, Al-Amri A, Al-Shibli A. Renal tract abnormalities missed in a historical cohort of young children with UTI if the NICE and AAP imaging guidelines were applied. J Pediatr Urol 2015; 11:252.e1-7. [PMID: 25979215 DOI: 10.1016/j.jpurol.2015.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/09/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In a historical cohort of children with a urinary tract infection (UTI) who had already undergone all the imaging procedures, the aim was to determine renal tract abnormalities which would have been missed had we implemented the new guidelines from the National Institute for Health and Care Excellence in the United Kingdom (NICE) or the American Academy of Pediatrics (AAP). MATERIAL AND METHODS After a UTI episode, forty-three children (28 females, 65%) aged between 2 months and 2 years presenting at two general hospitals with a febrile UTI before 2008 underwent all the recommended imaging studies predating the new guidelines. Hydronephrosis was defined and graded according to the Society for Fetal Urology (SFU) classification. Hydronephrosis grade II (mild pelvicalyceal dilatation), grade III (moderate dilatation), and grade IV (gross dilatation with thinning of the renal cortex), duplication, vesicoureteral reflux (VUR) grade II and above, renal scarring and reduced renal uptake (<45%) on technetium-99m-labeled dimercaptosuccinic acid (DMSA) scintigraphy were considered significant abnormalities. We calculated the proportion of abnormalities which would have been missed had the new guidelines been used instead. RESULTS The median of age was 7.6 months (mean 8.7, range 2-24 months), with the majority (n = 37, 86%) being under 1 year of age. Ultrasound (US) showed hydronephrosis in 14 (32%), all grade II. A voiding cystourethrogram (VCUG) was performed in all and showed VUR ≥ grade II in 16 (37%), including eight children (19%) where it was bilateral. DMSA scan showed scarring in 25 children (58%) of whom 11 (26%) had bilateral scars. Reduced differential renal uptake was present in 10 children (23%). Of the 29 children with normal US, 18 (62%) had renal scarring and nine (31%) had VUR ≥ grade II. The NICE guidelines would have missed 63% of the children with VUR ≥ grade II, including a high proportion of grades IV and V VUR, 44% of the children with renal scarring, and 20% of the children with decreased renal uptake, including some children with bilateral renal scarring and with decreased renal uptake. The AAP guidelines would have missed 56% of the children with VUR ≥ grade II, including a high proportion of grades IV and V VUR, and all children with renal scarring as well as those with decreased renal uptake. CONCLUSION The prevalence of renal tract abnormalities missed by the new guidelines is high. They should be used with full awareness of their limitations.
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Affiliation(s)
- Hassib Narchi
- Department of Pediatrics, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.
| | - Muhaned Marah
- Department of Pediatrics, Al Ain Hospital, Al Ain, United Arab Emirates
| | - Asad Aziz Khan
- Department of Pediatrics, Al Ain Hospital, Al Ain, United Arab Emirates
| | - Abdulla Al-Amri
- Department of Pediatrics, Tawam Hospital, Al Ain, United Arab Emirates
| | - Amar Al-Shibli
- Department of Pediatrics, Tawam Hospital, Al Ain, United Arab Emirates
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Bocquet N, Biebuyck N, Lortat Jacob S, Aigrain Y, Salomon R, Chéron G. Explorations morphologiques après un premier épisode de pyélonéphrite chez l’enfant. Arch Pediatr 2015; 22:547-53. [DOI: 10.1016/j.arcped.2015.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 11/12/2014] [Accepted: 02/03/2015] [Indexed: 10/23/2022]
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Hadjipanayis A, Grossman Z, Del Torso S, van Esso D, Dornbusch HJ, Mazur A, Drabik A, Montini G. Current primary care management of children aged 1-36 months with urinary tract infections in Europe: large scale survey of paediatric practice. Arch Dis Child 2015; 100:341-7. [PMID: 25378379 DOI: 10.1136/archdischild-2014-306119] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe current practice among European paediatricians regarding diagnosis and management of urinary tract infections in children aged 1-36 months and to compare these practices with recently published guidelines. DESIGN Web-based large scale survey evaluating knowledge of, attitudes towards and the methods for diagnosing, treating and managing urinary tract infections in children. SETTING Primary and secondary care practices in Europe. SAMPLE 1129 paediatricians. RESULTS A diagnosis of urinary tract infection is considered by 62% of the respondents in children aged 1-36 months with unexplained fever. The preferred method of urine collection is use of a bag (53% for infants <3 months and 59% for children 4-36 months of age). 60% of paediatricians agree that oral and parenteral antibiotics have equal efficacy. Co-amoxiclav is the antibiotic of choice for 41% of participants, while 9% prescribe amoxicillin. 80% of respondents prescribe ultrasound in all children with a confirmed urinary tract infection. 63% of respondents prescribe a cystography when abnormalities are revealed during ultrasound evaluation. A quarter of respondents recommend antibiotic prophylaxis for all children with any vesicoureteral reflux. The data among European countries are very heterogeneous. The three most recent urinary tract infection guidelines (the National Institute for Health and Care Excellence (NICE), the American Academy of Paediatrics and the Italian Society of Paediatric Nephrology) are not followed properly. CONCLUSIONS Management of febrile urinary tract infections remains controversial and heterogeneous in Europe. Simple, short, practical and easy-to-remember guidelines and educational strategies to ensure their implementation should be developed.
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Affiliation(s)
- Adamos Hadjipanayis
- Faculty of Medicine, European University Cyprus, Larnaca General Hospital, Derynia, Cyprus
| | - Zachi Grossman
- Pediatric Clinic, Maccabi Health Services, Tel Aviv, Israel
| | - Stefano Del Torso
- Pediatra di Famiglia ULSS 16, Studio Pediatrico Vecellio 33, Padova, Italy
| | - Diego van Esso
- Primary Care Health Centre 'Pare Claret', Catalan Institute of Health, Barcelona, Spain
| | | | - Artur Mazur
- Medical Faculty, University of Rzeszów, Rzeszów, Poland
| | - Anna Drabik
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giovanni Montini
- Nephrology and Dialysis Unit, Department of Paediatrics, Azienda Ospedaliero Universitaria Sant'Orsola-Malpighi, Bologna, Italy
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Abstract
Vesicoureteric reflux is defined as the retrograde passage of urine from the bladder into one or both ureters and often up to the kidneys, and mainly affects babies and infants. In severe cases dilatation of the ureter, renal pelvis, and calyces might be seen. Traditionally it was thought that only a low percentage of children have vesicoureteric reflux, but studies have suggested as many as 25-40% are affected. Guidelines recommend that the number of investigations for vesicoureteric reflux in children who have had a febrile urinary tract infection be reduced, but this approach is controversial. The recommendations also suggest that prophylactic antibiotics and surgery should be avoided in children with non-severe vesicoureteric reflux. In this Seminar I present data on the management of children with vesicoureteric reflux and give suggestions on how to navigate this difficult area.
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Affiliation(s)
- Kjell Tullus
- Department of Nephrology, Great Ormond Street Hospital for Children, London, UK.
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Shih BF, Tsai JD, Tsao CH, Huang FY. Reappraisal of the effectiveness of 99mTc-dimercaptosuccinic acid scans for selective voiding cystourethrography in children with a first febrile urinary tract infection. Kaohsiung J Med Sci 2014; 30:608-12. [DOI: 10.1016/j.kjms.2014.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 10/05/2014] [Accepted: 10/13/2014] [Indexed: 11/30/2022] Open
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Roupakias S, Sinopidis X, Karatza A, Varvarigou A. Predictive risk factors in childhood urinary tract infection, vesicoureteral reflux, and renal scarring management. Clin Pediatr (Phila) 2014; 53:1119-33. [PMID: 24366998 DOI: 10.1177/0009922813515744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Approaches to the management of children with urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scars have been challenged and have become controversial over the past decade. It is difficult to determine when, how, and which patients will benefit from the diagnosis and management of this condition. Therefore, the issues of diagnostic imaging, observation, follow-up, and intervention tend to be decided more on a case-by-case basis, rather than by using an algorithm. Over the past few years, there have been advances in the identification of risk factors that predispose patients with UTI to present with VUR, to develop recurrent UTIs and renal scars, to have deteriorating renal function, to show VUR improvement and/or spontaneous resolution, and to be candidates for and benefit from early surgical intervention.
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Affiliation(s)
- Stylianos Roupakias
- Department of Pediatric Surgery, University of Patras Medical School, Patras, Greece
| | - Xenophon Sinopidis
- Department of Pediatric Surgery, University of Patras Medical School, Patras, Greece
| | - Ageliki Karatza
- Department of Pediatrics, University of Patras Medical School, Patras, Greece
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Liao PF, Ku MS, Tsai JD, Choa YH, Hung TW, Lue KH, Sheu JN. Comparison of procalcitonin and different guidelines for first febrile urinary tract infection in children by imaging. Pediatr Nephrol 2014; 29:1567-74. [PMID: 24648130 DOI: 10.1007/s00467-014-2801-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND We examined the ability of a procalcitonin (PCT) protocol to detect vesicoureteral reflux (VUR) and renal scarring (RS), evaluated procedural costs and radiation burden, and compared four representative guidelines for children with their first febrile urinary tract infection (UTI). METHODS Children aged ≤2 years with their first febrile UTI who underwent renal ultrasonography (US), acute and late technetium-99m ((99m)Tc)-dimercaptosuccinic acid scan, and voiding cystourethrography were prospectively studied. The representative guidelines applied in a retrospective simulation included the American Academy of Pediatrics (AAP), National Institute of Clinical Excellence, top-down approach (TDA), and Italian Society of Pediatric Nephrology (ISPN). These were compared in terms of ability to detect abnormalities, procedural costs and radiation. RESULTS Of 278 children analyzed, 172 (61.9%) had acute pyelonephritis. There was VUR in 101 (36.3%) children, including 73 (26.3%) with grades III-V VUR. RS was identified in 75 (27.0%) children. To detect VUR, TDA and PCT had the highest sensitivity for grades I-V VUR (80.2%) and III-V VUR (94.5%), respectively, whereas AAP had the highest specificity for I-V VUR (77.4%) and III-V VUR (78.0%), respectively. TDA and PCT had the highest sensitivity (100%) for detecting RS. The highest cost and radiation dose was associated with TDA, whereas AAP had the least expenditure and radiation exposure. By multivariate analysis, PCT and VUR, especially grades III-V, were independent predictors of RS. CONCLUSIONS There is no perfect guideline for first febrile UTI children. The PCT protocol has good ability for detecting high-grade VUR and RS. If based on available imaging modalities and reducing cost and radiation burden, clinical suggestions in the AAP guidelines represent a considerable protocol.
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Affiliation(s)
- Pei-Fen Liao
- Department of Pediatrics, Chung Shan Medical University Hospital, No. 110, Section 1, Jianguo North Road, Taichung, 402, Taiwan
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Herbst KW, Corbett ST, Lendvay TS, Caldamone AA. Recent Trends in the Surgical Management of Primary Vesicoureteral Reflux in the Era of Dextranomer/Hyaluronic Acid. J Urol 2014; 191:1628-33. [DOI: 10.1016/j.juro.2013.09.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Katherine W. Herbst
- Departments of Urology and Research, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Sean T. Corbett
- Department of Urology, University of Virginia Children's Hospital, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Thomas S. Lendvay
- Department of Urology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Anthony A. Caldamone
- Division of Urology, Hasbro Children's Hospital, Brown University School of Medicine, Providence, Rhode Island
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Role of procalcitonin in predicting dilating vesicoureteral reflux in young children hospitalized with a first febrile urinary tract infection. Pediatr Infect Dis J 2013; 32:e348-54. [PMID: 23584577 DOI: 10.1097/inf.0b013e3182905d83] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this article was to assess the usefulness of procalcitonin (PCT) as a marker for predicting dilating (grades III-V) vesicoureteral reflux (VUR) in young children with a first febrile urinary tract infection. METHODS Children ≤2 years of age with a first febrile urinary tract infection were prospectively evaluated. Serum samples were tested for PCT at the time of admission to a tertiary hospital. All children underwent renal ultrasonography (US), Tc-dimercaptosuccinic acid renal scan, and voiding cystourethrography. The diagnostic characteristics of PCT test for acute pyelonephritis and dilating VUR were calculated. RESULTS Of 272 children analyzed (168 boys and 104 girls; median age, 5 months), 169 (62.1%) had acute pyelonephritis. There was VUR demonstrated in 97 (35.7%), including 70 (25.7%) with dilating VUR. The median PCT value was significantly higher in children with VUR than in those without (P < 0.001). Using a PCT cutoff value of ≥1.0 ng/mL, the sensitivity and negative predictive value for predicting dilating VUR were 94.3% and 95.4%, respectively, for PCT, and 97.1% and 97.8%, respectively, for the combined PCT and US studies, whereas the positive and negative likelihood ratios were 2.03 and 0.107, respectively, for PCT, and 1.72 and 0.067, respectively, for the combined studies. By multivariate analysis, high PCT values and abnormalities on US were independent predictors of dilating VUR. CONCLUSIONS PCT is useful for diagnosing acute pyelonephritis and predicting dilating VUR in young children with a first febrile urinary tract infection. A voiding cystourethrography is indicated only in children with high PCT values (≥1.0 ng/mL) and/or abnormalities found on a US.
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Friedman AA, Wolfe-Christensen C, Toffoli A, Hochsztein DE, Elder JS, Lakshmanan Y. History of recurrent urinary tract infection is not predictive of abnormality on voiding cystourethrogram. Pediatr Surg Int 2013; 29:639-43. [PMID: 23535965 DOI: 10.1007/s00383-013-3301-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE The American Academy of Pediatrics recently recommended against routine voiding cystourethrograms (VCUGs) in children 2 to 24 months with initial febrile UTI, raising concern for delayed diagnosis and increased risk of UTI-related renal damage from vesicoureteral reflux (VUR). We assessed factors potentially associated with higher likelihood of abnormal VCUG, including UTI recurrence, which could allow for more judicious test utilization. METHODS We retrospectively reviewed all initial VCUGs performed at Children's Hospital of Michigan between January and June, 2010. History of recurrent UTI was ascertained by evidence of two or more prior positive cultures or history of "recurrent UTI" on VCUG requisition. Outcomes assessed included rates of VUR or any urologic abnormality on VCUG. RESULTS Two hundred and sixty-two patients met inclusion criteria. VUR was detected in 21.3 %, urologic abnormality including VUR in 27.4 %. Degree of bladder distension, department of referring physician, study indication, positive documented urine culture, and history of recurrent UTI or UTI and other abnormality were all not associated with increased likelihood of VUR or any urologic abnormality on VCUG. CONCLUSION VUR and VCUG abnormality are no more likely when performed after recurrent UTI or for UTI plus other abnormality. This reasons against postponing VCUG until after UTI recurrence, as positive findings are no more likely in this setting.
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Affiliation(s)
- Ariella A Friedman
- Department of Urology, Henry Ford Hospital, 2799 W. Grand Blvd, K-9 Urology, Detroit, MI 48202, USA.
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NICE guidelines for imaging studies in children with UTI adequate only in boys under the age of 6 months. Pediatr Surg Int 2013; 29:215-22. [PMID: 23314790 DOI: 10.1007/s00383-012-3257-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the applicability of the National Institute for Health and Clinical Excellence (NICE) guidelines for imaging studies in children under the age of three with first urinary tract infection (UTI). METHODS In our cohort of 112 patients, we gathered data regarding the occurrence of indications for ultrasonography (US) and voiding cystourethrography (VCUG) according to the NICE guidelines, dimercaptosuccinic acid (DMSA) scintigraphy examinations, UTI recurrence, antimicrobial prophylaxis (AMP), anti-reflux procedures, and other urological procedures. RESULTS If the NICE guidelines had been applied, 13 of the 25 patients (52 %) with vesicoureteral reflux (VUR), including 6 of the 12 patients (50 %) with dilating VUR and 3 of the 4 patients who underwent endoscopic anti-reflux treatment, would have been missed, and a negative VCUG would have been avoided in 25 of the 42 patients (60 %) with no VUR. None of the missed diagnoses occurred in the younger boys' group. CONCLUSION Based on these preliminary analyses, we feel that the NICE guidelines for imaging studies in children under 3 years old with UTI may be applicable to clinical use only in boys under 6 months of age. For other patients the guidelines were unsuccessful.
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Acute 99mTc DMSA Scan Predicts Dilating Vesicoureteral Reflux in Young Children With a First Febrile Urinary Tract Infection. Clin Nucl Med 2013; 38:163-8. [DOI: 10.1097/rlu.0b013e318279f112] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The role of DMSA renal scintigraphy in the first episode of urinary tract infection in childhood. Ann Nucl Med 2012. [PMID: 23203209 DOI: 10.1007/s12149-012-0671-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The role of dimercaptosuccinic acid (DMSA) renal scintigraphy in the first episode of urinary tract infection (UTI) has been the subject of debate for many years. The aim of this study was to evaluate the relationship of voiding cystourethrography (VCUG), renal ultrasonography and DMSA renal scintigraphy and to detect renal parenchymal changes by performing DMSA renal scintigraphy at 6 months after the first episode of UTI. METHODS A prospective study was conducted in 67 hospitalized children (46 boys, 21 girls). Mean age of the patients was 0.97 ± 1.57 years (0.02-7.26 years). All children received VCUG, renal ultrasonography and DMSA renal scintigraphy. DMSA renal scintigraphy was performed at 1 and 6 months after UTI. RESULTS Of 67 children, 17 (25.4%), 23 (34.3%) and 20 (29.9%) had vesicoureteral reflux (VUR), abnormal renal ultrasonography and abnormal DMSA renal scintigraphy, respectively. Unilateral hydronephrosis had a significant correlation with VUR at p value 0.024. In renal units, abnormal renal ultrasonography and hydronephrosis had significant correlations with VUR at p values 0.039 and 0.021, respectively. In patients and renal units, hydronephrosis had no significant correlation with abnormal DMSA renal scintigraphy at 1 month after UTI. However, abnormal renal ultrasonography and VUR had significant correlations with abnormal DMSA renal scintigraphy at p values 0.022 and < 0.001 in patients and at p values 0.024 and < 0.001 in renal units, respectively. Both in patients and renal units, VUR (Grade I-III) had no significant correlation with abnormal DMSA renal scintigraphy. However, severe VUR (Grade IV-V) had significant correlations with abnormal DMSA renal scintigraphy at p values < 0.001 and < 0.001, respectively. Seventeen patients underwent DMSA renal scintigraphy at 6 months after UTI. In addition, 15 (88.2%) developed persistent renal scarring. CONCLUSION Abnormal renal ultrasonography and severe VUR identify renal parenchymal changes. DMSA renal scintigraphy in the first episode of UTI should be carried out in those patients. Abnormal DMSA renal scintigraphy at 1 month after UTI has a tendency to persist.
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Ammenti A, Cataldi L, Chimenz R, Fanos V, La Manna A, Marra G, Materassi M, Pecile P, Pennesi M, Pisanello L, Sica F, Toffolo A, Montini G. Febrile urinary tract infections in young children: recommendations for the diagnosis, treatment and follow-up. Acta Paediatr 2012; 101:451-7. [PMID: 22122295 DOI: 10.1111/j.1651-2227.2011.02549.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
UNLABELLED We report the recommendations for the diagnosis, treatment, imaging evaluation and use of antibiotic prophylaxis in children with the first febrile urinary tract infection, aged 2 months to 3 years. They were prepared by a working group of the Italian Society of Pediatric Nephrology after careful review of the available literature and a consensus decision, when clear evidence was not available. CONCLUSION These recommendations are endorsed by the Italian Society of Pediatric Nephrology. They can also be a tool of comparison with other existing guidelines in issues in which much controversy still exists.
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Affiliation(s)
- Anita Ammenti
- Department of Pediatrics, University of Parma, Parma, Italy
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Ključevšek D, Battelino N, Tomažič M, Kersnik Levart T. A comparison of echo-enhanced voiding urosonography with X-ray voiding cystourethrography in the first year of life. Acta Paediatr 2012; 101:e235-9. [PMID: 22211993 DOI: 10.1111/j.1651-2227.2011.02588.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Second-generation echo-enhanced voiding urosonography (VUS) with improved contrast-specific ultrasound (US) techniques is increasingly being used for vesicoureteric reflux (VUR) detection. AIM To compare VUS with X-ray voiding cystourethrography (VCUG) and to evaluate the predictive value of pelvicalyceal dilatation for detecting VUR in the first year of life. MATERIALS AND METHODS Sixty-six children younger than one were investigated by US, VUS and VCUG. VCUG represented the reference method for VUR detection. RESULTS According to VCUG, VUR was present in 16/132 (12%) renal units. VUS confirmed all these and additionally revealed VUR in 26 renal units (all together 42/132 (32%) renal units with VUR). It should be noted that all VUR detected only with VUS and missed by VCUG were of grades II and III. In 27/92 (29%) US normal and in 15/40 (37%) renal units with pelvicalyceal dilatation, VUR was detected by VUS. CONCLUSION We believe that VUS could safely replace VCUG in VUR detection in infants, with no regard to the degree of abnormality of the upper urinary tract seen on US. VCUG should be limited only to cases where bladder and/or urethra pathology are suspected.
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Affiliation(s)
- Damjana Ključevšek
- Paediatric Radiology Unit, University Medical Centre, Ljubljana, Slovenia
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Lee JH, Kim MK, Park SE. Is a routine voiding cystourethrogram necessary in children after the first febrile urinary tract infection? Acta Paediatr 2012; 101:e105-9. [PMID: 22040289 DOI: 10.1111/j.1651-2227.2011.02507.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIM The aim of this study was to estimate the value of identifying vesicoureteral reflux (VUR) on a voiding cystourethrogram (VCUG) and the benefit of VUR management according to imaging strategies at the first febrile urinary tract infection (UTI). METHODS Children aged 1-144 months (n = 618) with the first febrile UTI admitted at our hospital from 2000 to 2009 were enrolled. In all patients, renal sonogram (US), (99m) Tc-dimercaptosuccinic acid (DMSA) renal scanning and VCUG were performed. Retrospective analyses per patient and per renal unit were performed. RESULTS Abnormal US or DMSA scans had a sensitivity of 100% and a negative predictive value (NPV) of 100% to detect high-grade reflux. In hydronephrotic kidneys, DMSA scanning had a sensitivity of 88.2% and a NPV of 97.1% to detect high-grade reflux. CONCLUSION Routine VCUG is not required after the first febrile UTI in patients with normal US or normal DMSA scan. Even if the US reveals hydronephrosis, routine VCUG is not necessary if the DMSA findings are normal. It is recommended that children who did not receive both a DMSA scan and VCUG after the first febrile UTI should be followed up over the long term.
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Affiliation(s)
- Jun Ho Lee
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
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Prediction of vesicoureteral reflux in children with first urinary tract infection by dimercaptosuccinic Acid and ultrasonography. IRANIAN JOURNAL OF PEDIATRICS 2012; 22:57-62. [PMID: 23056860 PMCID: PMC3448216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 09/06/2011] [Accepted: 11/06/2011] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Urinary tract infection (UTI) is one of the most common causes of febrile pediatric diseases. Also, vesicoureteral reflux (VUR) is a significant risk factor for UTI. Voiding cystourethrography (VCUG) is the method of choice for evaluation of VUR. This study was done to predict VUR by DMSA scan (technetium 99 m-labeled dimercaptosuccinic acid) and ultrasonography (US). METHODS In a prospective study, all children with first time acute pyelonephritis were selected and evaluated by DMSA scan and US. Then VCUG was done with negative urine culture. All children with final diagnosis of obstructive congenital anomaly were excluded. The sensitivity, specifity, positive predictive values, negative predictive values, Confidence Interval of DMSA scan and US were calculated for prediction or exclusion of VUR. FINDINGS Among 100 children with UTI diagnosis, VUR was detected in 39 children and 63 (31.5%) kidneys. DMSA scan was abnormal in 103 (51.5%) units, 45 units had VUR (PPV=44%), 79 units with normal DMSA scan had no VUR (NPV=81%). Of kidney units that were abnormal by DMSA or US, 51 units had VUR. PPV and NPV were 44% and 56%, respectively. CONCLUSION DMSA scan alone or with US cannot predict VUR (especially low grade VUR). But according to NPV, it seems that absence of VUR can be predicted. So, more studies are needed to determine the usefulness of DMSA scan and US instead of VCUG for detection of VUR.
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Lee YJ, Lee JH, Park YS. Risk factors for renal scar formation in infants with first episode of acute pyelonephritis: a prospective clinical study. J Urol 2012; 187:1032-6. [PMID: 22264451 DOI: 10.1016/j.juro.2011.10.164] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Indexed: 02/05/2023]
Abstract
PURPOSE We prospectively determined the risk factors for renal scar formation after the first episode of acute pyelonephritis as confirmed on dimercapto-succinic acid scintigraphy in children younger than 1 year. MATERIALS AND METHODS A total of 213 infants with acute pyelonephritis were enrolled in the study. Infants with urological abnormalities other than vesicoureteral reflux were excluded from analysis. Followup scanning was performed 6 months after acute pyelonephritis and voiding cystourethrography was performed after the acute phase of infection. Possible risk factors were evaluated including gender, peak fever, duration of fever before and after treatment with antibiotics, white blood cell count, C-reactive protein concentration, presence of vesicoureteral reflux and reflux grade. RESULTS Six months after acute pyelonephritis 37 of 213 (17.4%) infants and 41 of 248 (16.5%) renal units with acute photon defects on initial dimercapto-succinic acid scintigraphy had renal scars. The rates of scar formation were significantly higher in infants with vesicoureteral reflux than in those without (39.4% vs 7.5%, p <0.001, OR 9.433) and in renal units with vesicoureteral reflux than in those without (39.4% vs 8.2%, p <0.001, OR 7.237). Renal scar formation was related to reflux grade (none-8.2%, grade I-20%, grade II-22.7%, grade III-40%, grade IV-70%, grade V-55.6%, p <0.001) but not to any other clinical or laboratory variables. CONCLUSIONS The presence of vesicoureteral reflux was the only independent risk factor for renal scar formation after acute pyelonephritis in infants. The prevalence of renal scarring was significantly correlated with reflux grade. Voiding cystourethrography is necessary in infants after the first acute pyelonephritis episode is confirmed on dimercapto-succinic acid renal scintigraphy.
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Affiliation(s)
- Yoon Jung Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Routh JC, Grant FD, Kokorowski PJ, Nelson CP, Fahey FH, Treves ST, Lee RS. Economic and radiation costs of initial imaging approaches after a child's first febrile urinary tract infection. Clin Pediatr (Phila) 2012; 51:23-30. [PMID: 21868595 PMCID: PMC3792796 DOI: 10.1177/0009922811417294] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND. The traditional initial imaging approach following pediatric urinary tract infection is the "bottom-up" approach (cystogram and renal ultrasound). Recently, the "top-down" approach (nuclear renal scan followed by cystogram for abnormal scans only) has gained increasing attention. The relative cost and radiation doses of these are unknown METHODS. The authors used a decision model to evaluate these imaging approaches. Cost and effective radiation dose estimates, including sensitivity analyses, were based on one-time imaging only. RESULTS. Comparing hypothetical cohorts of 100 000 children, the top-down imaging approach cost $82.9 million versus $59.2 million for the bottom-up approach. Per-capita effective radiation dose was 0.72 mSv for top-down compared with 0.06 mSv for bottom-up. CONCLUSIONS. Routine use of nuclear renal scans in children following initial urinary tract infection diagnosis would result in increased imaging costs and radiation doses as compared to initial cystogram and ultrasound. Further data are required to clarify the long-term clinical implications of this increase.
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Affiliation(s)
| | | | | | - Caleb P. Nelson
- Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA
| | | | - S. Ted Treves
- Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA
| | - Richard S. Lee
- Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA
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Kidney Ultrasonography and Dimercaptosuccinic Acid Scans for Revealing Vesicoureteral Reflux in Children With Pyelonephritis: A 7-Year Prospective Cohort Study of 1500 Pyelonephritic Patients and 2986 Renal Units. Nephrourol Mon 2011. [DOI: 10.5812/numonthly.1972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hannula A, Venhola M, Perhomaa M, Pokka T, Renko M, Uhari M. Imaging the urinary tract in children with urinary tract infection. Acta Paediatr 2011; 100:e253-9. [PMID: 21711394 DOI: 10.1111/j.1651-2227.2011.02391.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To evaluate whether ultrasonography (US) alone is sufficient in imaging the urinary tract in 1185 children with urinary tract infection (UTI). METHODS The reports on US and voiding cystourethrography (VCUG) were reviewed. RESULTS Initial US was normal in 861/1185 patients (73%). VCUG revealed abnormal findings in 285/861 (33%), of which grade III-V vesicoureteral reflux (VUR) comprised 97 cases (11%). During follow-up, VUR had resolved in 88/97 (91%) patients: in 50/57 (88%) patients without active treatment for VUR, in 27/29 (93%) with endoscopic and in 11/11 (100%) with open surgery for VUR. During follow-up, 11/97 patients (11%) had developed new renal scarring detectable in US, but no renal impairment occurred. Except for VUR, VCUG showed nonobstructive urethral valves in two infant boys with normal initial US. Thus, in 861 children with normal initial US, 40 patients with grade III-V VUR and two patients with significant nonreflux pathology may have benefited from surgical treatment, giving the total number of possibly missed pathological finding in 42/861 (4.9%) cases if VCUG had not been performed. CONCLUSION We suggest that children with UTI could be examined using US alone and to use VCUG only after additional indications.
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Affiliation(s)
- Annukka Hannula
- Department of Paediatrics, University of Oulu, Oulu, Finland.
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Radiographic evaluation of children with febrile urinary tract infection: bottom-up, top-down, or none of the above? Adv Urol 2011; 2012:716739. [PMID: 21860620 PMCID: PMC3155794 DOI: 10.1155/2012/716739] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/14/2011] [Indexed: 11/18/2022] Open
Abstract
The proper algorithm for the radiographic evaluation of children with febrile urinary tract infection (FUTI) is hotly debated. Three studies are commonly administered: renal-bladder ultrasound (RUS), voiding cystourethrogram (VCUG), and dimercapto-succinic acid (DMSA) scan. However, the order in which these tests are obtained depends on the methodology followed: bottom-up or top-down. Each strategy carries advantages and disadvantages, and some groups now advocate even less of a workup (none of the above) due to the current controversies about treatment when abnormalities are diagnosed. New technology is available and still under investigation, but it may help to clarify the interplay between vesicoureteral reflux, renal scarring, and dysfunctional elimination in the future.
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Blanchais T, Legrand A, Allain Launay E, Leclair MD, Caillon J, Roussey-Kesler G. [Comparison of two protocols of febrile urinary tract infection management in children]. Arch Pediatr 2011; 18:955-61. [PMID: 21795028 DOI: 10.1016/j.arcped.2011.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 05/19/2011] [Accepted: 06/10/2011] [Indexed: 01/27/2023]
Abstract
PURPOSE To compare two first febrile urinary tract infection (UTI) management protocols with regards to the diagnosis of high-grade vesicoureteral reflux (VUR) and cost. METHODS This study compared two cohorts of children under 16 years of age, admitted for a first episode of febrile UTI. The first group (in 2005) was managed according to previous recommendations (IV treatment and cystography performed for all children under 3 years of age). The second group (in 2006) was managed according to age and procalcitonin level. High-grade VUR frequency, UTI recurrence, hospitalization rate, and cost were compared between the two cohorts. RESULTS A total of 225 children were included in 2005 and 116 in 2006. High-grade VUR was found in 6.2 and 9.5% of the patients in 2005 and 2006, respectively (P=0.274). There was no statistically significant difference in the UTI recurrence rate between the two cohorts (5.3% in 2005 and 8.6% in 2006; P=0.237). The mean cost of an episode of febrile UTI was not significantly different in 2005 and 2006 (€2235 in 2005, €2256 in 2006; P=0.902), but was lower for children older than 6 months in 2006 (€1292 versus €1882 in 2005; P=0.0042). CONCLUSION Our management protocol for a first febrile UTI episode in children based on procalcitonin levels seems to be suitable for the diagnosis of high-grade VUR. The hospitalization rate and the mean cost of management for children older than 6 months of age was significantly reduced in 2006. The management guidelines for a first occurrence of febrile UTI in children should be reconsidered.
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Affiliation(s)
- T Blanchais
- Clinique médicale pédiatrique, hôpital Mère-Enfant, CHU de Nantes, 7, Quai-Moncousu, 44093 Nantes cedex, France
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Characteristics of first urinary tract infection with fever in children: a prospective clinical and imaging study. Pediatr Infect Dis J 2011; 30:371-4. [PMID: 21502928 DOI: 10.1097/inf.0b013e318204dcf3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Our objective is to provide the clinical characteristics, uropathogen frequencies, and antimicrobial resistance rates of first urinary tract infection (UTI) diagnosed in febrile Belgian children. The ability of noninvasive ultrasound to detect renal abnormalities and vesicoureteral reflux (VUR) in these patients was also assessed. METHODS We prospectively followed (median, 20 months) 209 children treated for first febrile UTI. Renal ultrasound (US) and voiding cystourethrography examinations were performed in all patients. RESULTS Among these children, 63% were females and 37% were males, and 75% of them had their first UTI before the age of 2 years. The most common causative agent was Escherichia coli (91% of cases) with high rate resistance to ampicillin (58%) and trimethoprim/sulfamethoxazole (38%). Of these children, 25% had evidence of VUR (15 boys and 38 girls). VUR was of low grade in 85% of cases. The overall performance of renal US as a diagnostic test to detect significant uropathies excluding low-grade VUR was excellent; the sensitivity attained 97% and the specificity 94%. CONCLUSION Girls represent 63% of cases with first UTI. For 91% of UTIs, Escherichia coli is held responsible with a high rate of resistance to ampicillin and trimethoprim/sulfamethoxazole. US is an excellent screening tool that allows avoidance of unjustified voiding cystourethrography studies.
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Yim HE, Choi BM, Rhie YJ, Yoo KH, Hong YS, Lee JW. Hepatic and pulmonary nodular lesions in pediatric urinary tract infections. Pediatr Nephrol 2011; 26:425-31. [PMID: 21170664 DOI: 10.1007/s00467-010-1706-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 11/02/2010] [Accepted: 11/04/2010] [Indexed: 11/30/2022]
Abstract
One of the major goals in investigating children with urinary tract infection (UTI) is to recognize patients at risk of further UTI-related problems. This study reports the clinical features of 19 pediatric patients with UTIs in whom associated hepatic and/or pulmonary nodules were incidentally diagnosed by the imaging tests performed for the UTI. Hepatic nodules in five patients were detected on ultrasound scans, and pulmonary nodules and both hepatic and pulmonary nodules were detected in 12 and two children by dimercaptosuccinic acid scintigraphy. The mean age of the patients was 24.5 months. Vesicoureteral reflux (VUR) was detected in nine of 17 patients (52.9%), acute pyelonephritis was identified in nine of 18 patients, and renal scarring was found in 57.1% patients with pyelonephritis. On follow-up, the hepatic and/or pulmonary nodules regressed in all patients. About 85.7% of patients experienced a recurrence of UTI within 1 year. In comparison with age- and sex-matched controls with UTIs without pulmonary or hepatic nodules, the presence of VUR and the recurrence of UTI within 1 year were higher in patients with UTIs and nodules (P<0.05). The hepatic and/or pulmonary nodules identified on the ultrasound scan and by dimercaptosuccinic acid scintigraphy may provide a valuable diagnostic marker for the proper management of patients with an UTI.
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Affiliation(s)
- Hyung Eun Yim
- Department of Pediatrics, College of Medicine, Korea University, Seoul, 152-703, Korea
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Preda I, Jodal U, Sixt R, Stokland E, Hansson S. Imaging strategy for infants with urinary tract infection: a new algorithm. J Urol 2011; 185:1046-52. [PMID: 21247606 DOI: 10.1016/j.juro.2010.10.043] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE We analyzed clinical data for prediction of permanent renal damage in infants with first time urinary tract infection. MATERIALS AND METHODS This population based, prospective, 3-year study included 161 male and 129 female consecutive infants with first time urinary tract infection. Ultrasonography and dimercapto-succinic acid scintigraphy were performed as acute investigations and voiding cystourethrography within 2 months. Late scintigraphy was performed after 1 year in infants with abnormality on the first dimercapto-succinic acid scan or recurrent febrile urinary tract infections. End point was renal damage on the late scan. RESULTS A total of 270 patients had end point data available, of whom 70 had renal damage and 200 did not. Final kidney status was associated with C-reactive protein, serum creatinine, temperature, leukocyturia, non-Escherichia coli bacteria, anteroposterior diameter on ultrasound and recurrent febrile urinary tract infections. In stepwise multiple regression analysis C-reactive protein, creatinine, leukocyturia, anteroposterior diameter and non-E.coli bacteria were independent predictors of permanent renal damage. C-reactive protein 70 mg/l or greater combined with anteroposterior diameter 10 mm or greater had sensitivity of 87% and specificity of 59% for renal damage. An algorithm for imaging of infants with first time urinary tract infection based on these results would have eliminated 126 acute dimercapto-succinic acid scans compared to our study protocol, while missing 9 patients with permanent renal damage. CONCLUSIONS C-reactive protein can be used as a predictor of permanent renal damage in infants with urinary tract infection and together with anteroposterior diameter serves as a basis for an imaging algorithm.
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Affiliation(s)
- Iulian Preda
- Department of Pediatrics, Queen Silvia Children's Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
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Lazarus J. Have we overtreated children with vesicoureteric reflux? AFRICAN JOURNAL OF UROLOGY 2010. [DOI: 10.1007/s12301-010-0023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Diagnostic role of initial renal cortical scintigraphy in children with the first episode of acute pyelonephritis. Ann Nucl Med 2010; 25:37-43. [DOI: 10.1007/s12149-010-0431-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/13/2010] [Indexed: 11/30/2022]
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5-Year Prospective Results of Dimercapto-Succinic Acid Imaging in Children With Febrile Urinary Tract Infection: Proof That the Top-Down Approach Works. J Urol 2010; 184:1703-9. [DOI: 10.1016/j.juro.2010.04.050] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Indexed: 11/21/2022]
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Fouzas S, Krikelli E, Vassilakos P, Gkentzi D, Papanastasiou DA, Salakos C. DMSA scan for revealing vesicoureteral reflux in young children with urinary tract infection. Pediatrics 2010; 126:e513-9. [PMID: 20679300 DOI: 10.1542/peds.2009-3635] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objective of this study was to assess the ability of acute dimercaptosuccinic acid (DMSA) scintigraphy for revealing vesicoureteral reflux (VUR) in young children after a first febrile urinary tract infection (UTI). METHODS Children aged<or=24 months and were admitted with a first febrile UTI during a 5-year period were evaluated. The ability of acute DMSA scintigraphy to reveal dilating (grades 3-5) or severe (grades 4-5) VUR was assessed by comparing DMSA scan findings with those of voiding cystourethrography. RESULTS Of the 296 children included, 46 had dilating and 25 severe VUR. Abnormal DMSA scan results were associated with an odds ratio of 4.36 for dilating and 5.50 for severe VUR. For detecting dilating VUR, the area under the curve (AUC) was 0.68, the positive likelihood ratio (LR) was 2.00, and the negative LR was 0.46; for severe VUR, those values were 0.69, 2.10, and 0.38, respectively. Children with abnormal DMSA scan results combined with abnormal ultrasonography had an odds ratio of 3.60 for dilating and 6.32 for severe VUR. Despite normal findings on both investigations, 12 children had dilating and 4 severe VUR. For dilating VUR, the area under the (AUC) was 0.65, the positive LR was 1.70, and the negative LR was 0.47; for severe VUR, the values were 0.69, 1.90, and 0.29, respectively. CONCLUSIONS Our data suggest that acute DMSA scintigraphy has limited overall ability in identifying VUR and should not be endorsed as replacement for voiding cystourethrography in the evaluation of young children with a first febrile UTI.
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Affiliation(s)
- Sotirios Fouzas
- University Hospital of Patras, Department of Pediatrics, Rio, Patras, 265 04, Greece.
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Chishti AS, Maul EC, Nazario RJ, Bennett JS, Kiessling SG. A guideline for the inpatient care of children with pyelonephritis. Ann Saudi Med 2010; 30:341-9. [PMID: 20716830 PMCID: PMC2941245 DOI: 10.4103/0256-4947.68549] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care. METHODS We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis. RESULTS Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence. CONCLUSION Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.
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Affiliation(s)
- Aftab S Chishti
- Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA.
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Kljucevsek D, Kljucevsek T, Kersnik Levart T, Novljan G, Kenda RB. Catheter-free methods for vesicoureteric reflux detection: our experience and a critical appraisal of existing data. Pediatr Nephrol 2010; 25:1201-6. [PMID: 20069314 DOI: 10.1007/s00467-009-1391-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 10/29/2009] [Accepted: 11/05/2009] [Indexed: 11/26/2022]
Abstract
In recent years, the exact role of vesicoureteric reflux (VUR) in general has become controversial, though in some groups of children the knowledge of the existence or non-existence of VUR is still a very important issue. The number of techniques available for the assessment of VUR is increasing, and a new classification taking into account their real characteristics (direct/indirect, catheter-using/catheter-free, radiation-giving/radiation-free) has been proposed. The purpose of the following review is to evaluate the currently available evidence supporting the use of various catheter-free methods for VUR detection. We believe that as the clinical role of VUR has been questioned, it is even more important for the method of its detection to be user-friendly as regards catheterisation, radiation and availability. There is still no evidence supporting the assertion that any of the catheter-free methods of VUR detection might be the optimal one for any child. However, there are some groups of children who would benefit from using them. New studies using new, catheter-free methods of VUR detection or a combination of two or more of the methods described may prove useful in improving sensitivity and providing additional data on this important issue.
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Affiliation(s)
- Damjana Kljucevsek
- Paediatric Radiology Unit, University Medical Centre, Bohoriceva 20, 1000, Ljubljana, Slovenia.
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Acute lobar nephronia is associated with a high incidence of renal scarring in childhood urinary tract infections. Pediatr Infect Dis J 2010; 29:624-8. [PMID: 20234330 DOI: 10.1097/inf.0b013e3181d8631a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute lobar nephronia (ALN) is a severe nonliquefactive inflammatory renal bacterial infection, and requires a longer duration of treatment. The aim of this prospective study was to investigate renal scarring after ALN and to examine the risk factors for renal scarring in children with ALN compared with those with acute pyelonephritis (APN). METHODS Patients with computed tomography-diagnosed ALN were enrolled and randomly allocated, with serial entry, to either a 2- or 3-week antibiotic treatment regimen. Age- and gender-matched APN patients served as comparators. Patients underwent dimercaptosuccinic acid scintigraphy at least 6 months later to assess renal scarring. RESULTS A total of 218 children (109 ALN, 109 APN) were enrolled. The incidence of renal scarring was similar between 2- and 3-week treatment groups and was higher in ALN patients than in APN patients (89.0% vs. 34.9%, P < 0.001). Renal scarring was prone to occur in children with higher inflammatory indices and longer duration of fever before and after treatment. Multiple regression analysis on independent variables showed that only ALN was significantly associated with a higher incidence of renal scarring. CONCLUSIONS Our results showed a new finding that ALN is associated with a very high incidence of renal scarring, in comparison to APN, irrespective of the duration of antibiotic treatment.
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Urinary Tract Infections in Children: Recommendations for Antibiotic Prophylaxis and Evaluation. An Evidence-Based Approach. Curr Urol Rep 2010; 11:98-108. [DOI: 10.1007/s11934-010-0095-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yang EM, Kim SJ, Kim CJ, Woo YJ. Clinical Usefulness of Ultrasonography and 99mTechnetium Dimercaptosuccinic Acid Scan for Predicting the Vesicoureteral Reflux in Children with Urinary Tract Infection. Chonnam Med J 2010. [DOI: 10.4068/cmj.2010.46.1.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Eun Mi Yang
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Sang Jeong Kim
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Chan Jong Kim
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Young Jong Woo
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
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Predictors of abnormal renal cortical scintigraphy in children with first urinary tract infection: the importance of time factor. Int Urol Nephrol 2009; 42:1041-7. [PMID: 19798584 DOI: 10.1007/s11255-009-9650-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 09/10/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION We evaluated different factors predicting the development of acute pyelonephritis in Iranian children, with special attention to time factor. METHODS One hundred nineteen patients (93 females and 26 males; age = 32.6 ± 30.8 months) with first urinary tract infection (UTI) were evaluated. None had previous urological problems. Prior to antibiotic therapy blood samples were gathered for laboratory evaluation. Vital signs on admission were measured. Clinical and laboratory indices, including therapeutic delay time (TDT) and therapeutic response time (TRT), were measured. Most patients were evaluated with renal ultrasound in the first three days following admission. All patients underwent dimercaptosuccinic acid (DMSA) renal scintigraphy and 71 were assessed for vesicoureteral reflux (VUR). RESULTS DMSA scans were abnormal in 77 cases, of which 11 cases had bilateral renal involvement. Mean values for TDT, TRT, leukocyte count (LC), absolute neutrophil count (ANC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were 74.1 h, 39.6 h, 15725 ± 6682 mm(-3), 10772 ± 6458 mm(-3), 51.9 ± 32.5 mm, and 27.3 ± 25.1 mg l(-1), respectively. VUR was present in 29 of 142 evaluated renal units. CONCLUSION TDT ≥ 48 h, TRT ≥ 24 h, axillary temperature ≥ 39°C, LC ≥ 13500 mm(-3), and age ≥ 18 months predicted abnormal DMSA scan in patients with first episode of UTI. Considerably higher TDT and TRT values of the current study compared to previous ones suggests the more important role of time factor in predicting abnormal DMSA findings in a developing country than in developed ones.
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