Korean J Urol.  2012 Oct;53(10):716-720. 10.4111/kju.2012.53.10.716.

Abnormal Dimercaptosuccinic Acid Scan May Be Related to Persistence of Vesicoureteral Reflux in Children with Febrile Urinary Tract Infection

• Ki HC
• Kim SO
• Yoo DH
• Hwang IS
• Hwang EC
• Oh KJ
• Jung SI
• Kang TW
• Kwon D
• Park K
• Ryu SB

• KMID: 1856992
• DOI: http://doi.org/10.4111/kju.2012.53.10.716

Abstract

PURPOSE
This study assessed whether 99mtechnetium dimercaptosuccinic acid (DMSA) scintigraphy used for the assessment of renal sequelae after febrile urinary tract infection (UTI) has any prognostic value for outcome measurement of vesicoureteral reflux (VUR) by retrospectively evaluating the correlation between abnormal DMSA scintigraphy results and persistence of VUR in children with febrile UTI.
MATERIALS AND METHODS
The medical records of 142 children (57 boys, 85 girls) admitted with febrile UTI from January 2004 to December 2006 and who were followed up for more than 1 year were retrospectively reviewed. At the initial and follow-up visits, renal ultrasound and DMSA scans were performed within 7 days from the diagnosis and voiding cystourethrography (VCUG) was performed within 1 month in all case and follow-up evaluations.
RESULTS
The children's mean age was 4.8+/-3.6 years (range, 0.3 to 14 years). The mean follow-up was 28.2+/-4.8 months. At the initial examination, VUR was more often associated with an abnormal DMSA scan result (83.3%) than with a normal DMSA scan result (16.7%, p=0.02). The frequency of VUR with an abnormal DMSA scan during acute UTI was significantly higher than the frequency of VUR with a normal DMSA scan (38.8% vs, 25.8%, respectively, p=0.004). Also, high-grade VUR was associated with an abnormal DMSA scan result (32.5%) more often than with a normal DMSA scan result (0%, p=0.01). Children with an abnormal DMSA scan had a lower resolution rate of VUR (17.5%) than did children with a normal DMSA scan (75.0%) at the follow-up VCUG (p=0.02).
CONCLUSIONS
An abnormal result on a DMSA scan during febrile UTI is associated with high-grade and persistent VUR. DMSA scans performed during febrile UTI are useful in reflux resolution in childhood.

Keyword

Technetium Tc 99m dimercaptosuccinic acid; Urinary tract infections; Vesico-ureteral reflux

MeSH Terms

Child
Follow-Up Studies
Humans
Medical Records
Retrospective Studies
Succimer
Technetium Tc 99m Dimercaptosuccinic Acid
Urinary Tract
Urinary Tract Infections
Vesico-Ureteral Reflux
Succimer
Technetium Tc 99m Dimercaptosuccinic Acid

Reference

1. Rushton HG. Urinary tract infections in children. Epidemiology, evaluation, and management. Pediatr Clin North Am. 1997; 44:1133–1169. PMID: 9326956.

2. Gleeson FV, Gordon I. Imaging in urinary tract infection. Arch Dis Child. 1991; 66:1282–1283. PMID: 1661570.

3. Smellie JM, Ransley PG, Normand IC, Prescod N, Edwards D. Development of new renal scars: a collaborative study. Br Med J (Clin Res Ed). 1985; 290:1957–1960.

4. Bellinger MF, Duckett JW. Vesicoureteral reflux: a comparison of non-surgical and surgical management. Contrib Nephrol. 1984; 39:81–93. PMID: 6744882.

5. Merrick MV, Notghi A, Chalmers N, Wilkinson AG, Uttley WS. Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 1: Reflux. Arch Dis Child. 1995; 72:388–392. PMID: 7618902.

6. Merrick MV, Notghi A, Chalmers N, Wilkinson AG, Uttley WS. Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 2: Scarring. Arch Dis Child. 1995; 72:393–396. PMID: 7618903.

7. 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–e109. PMID: 22040289.

8. Camacho V, Estorch M, Fraga G, Mena E, Fuertes J, Hernandez MA, et al. DMSA study performed during febrile urinary tract infection: a predictor of patient outcome? Eur J Nucl Med Mol Imaging. 2004; 31:862–866. PMID: 14758509.

9. Preda I, Jodal U, Sixt R, Stokland E, Hansson S. Normal dimercaptosuccinic acid scintigraphy makes voiding cystourethrography unnecessary after urinary tract infection. J Pediatr. 2007; 151:581–584. 584.e1PMID: 18035134.

10. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Möbius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol. 1985; 15:105–109. PMID: 3975102.

11. Gordon I, Piepsz A, Sixt R. Auspices of Paediatric Committee of European Association of Nuclear Medicine. Guidelines for standard and diuretic renogram in children. Eur J Nucl Med Mol Imaging. 2011; 38:1175–1188. PMID: 21503762.

12. Piepsz A, Hahn K, Roca I, Ciofetta G, Toth G, Gordon I, et al. Paediatric Task Group European Association Nuclear Medicine. A radiopharmaceuticals schedule for imaging in paediatrics. Eur J Nucl Med. 1990; 17:127–129. PMID: 2279492.

13. Majd M, Nussbaum Blask AR, Markle BM, Shalaby-Rana E, Pohl HG, Park JS, et al. Acute pyelonephritis: comparison of diagnosis with 99mTc-DMSA, SPECT, spiral CT, MR imaging, and power Doppler US in an experimental pig model. Radiology. 2001; 218:101–108. PMID: 11152787.

14. Jakobsson B, Nolstedt L, Svensson L, Soderlundh S, Berg U. 99mTechnetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings. Pediatr Nephrol. 1992; 6:328–334. PMID: 1343562.

15. Ditchfield MR, de Campo JF, Nolan TM, Cook DJ, Grimwood K, Powell HR, et al. Risk factors in the development of early renal cortical defects in children with urinary tract infection. AJR Am J Roentgenol. 1994; 162:1393–1397. PMID: 8192006.

16. Lomberg H, Hanson LA, Jacobsson B, Jodal U, Leffler H, Eden CS. Correlation of P blood group, vesicoureteral reflux, and bacterial attachment in patients with recurrent pyelonephritis. N Engl J Med. 1983; 308:1189–1192. PMID: 6341837.

17. Temiz Y, Tarcan T, Onol FF, Alpay H, Simşek F. The efficacy of Tc99m dimercaptosuccinic acid (Tc-DMSA) scintigraphy and ultrasonography in detecting renal scars in children with primary vesicoureteral reflux (VUR). Int Urol Nephrol. 2006; 38:149–152. PMID: 16502071.

18. Tseng MH, Lin WJ, Lo WT, Wang SR, Chu ML, Wang CC. Does a normal DMSA obviate the performance of voiding cystourethrography in evaluation of young children after their first urinary tract infection? J Pediatr. 2007; 150:96–99. PMID: 17188624.

19. Sillen U. Vesicoureteral reflux in infants. Pediatr Nephrol. 1999; 13:355–361. PMID: 10454790.

20. Wennerstrom M, Hansson S, Jodal U, Stokland E. Disappearance of vesicoureteral reflux in children. Arch Pediatr Adolesc Med. 1998; 152:879–883. PMID: 9743033.

21. Schwab CW Jr, Wu HY, Selman H, Smith GH, Snyder HM 3rd, Canning DA. Spontaneous resolution of vesicoureteral reflux: a 15-year perspective. J Urol. 2002; 168:2594–2599. PMID: 12441993.

22. Nepple KG, Knudson MJ, Austin JC, Cooper CS. Abnormal renal scans and decreased early resolution of low grade vesicoureteral reflux. J Urol. 2008; 180(4 Suppl):1643–1647. PMID: 18715588.

23. Merguerian PA, Jamal MA, Agarwal SK, McLorie GA, Bagli DJ, Shuckett B, et al. Utility of SPECT DMSA renal scanning in the evaluation of children with primary vesicoureteral reflux. Urology. 1999; 53:1024–1028. PMID: 10223500.

24. Stokland E, Hellstrom M, Jacobsson B, Jodal U, Sixt R. Renal damage one year after first urinary tract infection: role of dimercaptosuccinic acid scintigraphy. J Pediatr. 1996; 129:815–820. PMID: 8969722.

25. Goldman M, Bistritzer T, Horne T, Zoareft I, Aladjem M. The etiology of renal scars in infants with pyelonephritis and vesicoureteral reflux. Pediatr Nephrol. 2000; 14:385–388. PMID: 10805465.

26. 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; 187:1032–1036. PMID: 22264451.