PURPOSE: Urinary tract infection (UTI) is one of the common infectious diseases in children. Several imaging modalities can be used to confirm the presence of acute pyelonephritis (APN). Among them the 99mTcdimercaptosuccinic acid renal scan (DMSA scan) is used as a gold standard for diagnosis. Ultrasonography technology is evolving. Therefore, in this study, we investigated the sensitivity and specificity of Power Doppler ultrasonography (PDU) compared to the results from the previous study. METHODS: There were 260 patients included in this study, aged between 1 and 12 months old. The patients were admitted to the Yeungnam University Medical Center between January 2008 and December 2015. All patients underwent both DMSA scan and PDU within 5days of admission. Voiding cystourethrography (VCUG) was performed in 195 patients with abnormal DMSA scan or PDU. RESULTS: The diagnostic sensitivity of APN using PDU was 45.5% and specificity was 85.5% in 260 patients following detection of a defect on DMSA scan that was defined as APN. The diagnostic sensitivity and specificity of PDU for VUR were 65.5 % and 60.1%, respectively. The diagnostic sensitivity and specificity of DMSA scan for VUR were 95.7% and 14.1%, respectively. CONCLUSION: PDU has a high specificity but low sensitivity, so there are limitations in using it to replace a DMSA scan for the diagnosis of APN in children. DMSA scan and PDU have different sensitivity and specificity in diagnosis of VUR, respectively. Therefore, we suggest that the sensitivity and specificity of each test can be helpful in diagnosing APN and VUR when used in conjunction.
Academic Medical Centers ; Child ; Communicable Diseases ; Diagnosis ; Humans ; Pyelonephritis ; Sensitivity and Specificity ; Succimer ; Technetium Tc 99m Dimercaptosuccinic Acid ; Ultrasonography ; Ultrasonography, Doppler ; Urinary Tract Infections ; Vesico-Ureteral Reflux

PURPOSE: This study aimed to investigate clinical and radiological factors that may predict high-grade vesicoureteral reflux (VUR) in patients with febrile urinary tract infection (UTI). METHODS: We retrospectively analyzed medical records of 446 patients diagnosed with febrile UTI from March 2008 to February 2017. All patients underwent renal-bladder ultrasonography (RBUS), 99mTc dimercaptosuccinic acid (DMSA) renal scan, and voiding cystourethrography (VCUG), and were divided in to 3 groups: a high-grade VUR group (n=53), a low-grade VUR group (n=28), and a group without VUR (n=365). RESULTS: The recurrence and non-Escherichia coli infection rates in febrile UTI were significantly higher in the high-grade VUR group than in the other two groups (P<0.05). RBUS showed that hydronephrosis and ureter dilatation were more frequent in the high-grade VUR group than in the other groups (P<0.05). In the high-grade VUR group, a renal cortical defect was more likely to appear as multiple defects, and the difference in bilateral renal scan uptake between both kidneys was larger than in the other two groups (P<0.001). CONCLUSION: Recurrent UTI, non-E. coli UTI, abnormal findings on RBUS such as hydronephrosis and ureter dilatation, and abnormal findings in the DMSA renal scan such as multiple renal cortical defects and greater uptake difference were associated with high-grade VUR. VCUG should be selectively performed when RBUS and/or DMSA renal scan reveal significant abnormalities.
Child* ; Dilatation ; Humans ; Hydronephrosis ; Kidney ; Medical Records ; Recurrence ; Retrospective Studies ; Succimer ; Technetium Tc 99m Dimercaptosuccinic Acid ; Ultrasonography ; Ureter ; Urinary Tract Infections* ; Urinary Tract* ; Vesico-Ureteral Reflux*

PURPOSE: This study aimed to investigate clinical and radiological factors that may predict high-grade vesicoureteral reflux (VUR) in patients with febrile urinary tract infection (UTI). METHODS: We retrospectively analyzed medical records of 446 patients diagnosed with febrile UTI from March 2008 to February 2017. All patients underwent renal-bladder ultrasonography (RBUS), 99mTc dimercaptosuccinic acid (DMSA) renal scan, and voiding cystourethrography (VCUG), and were divided in to 3 groups: a high-grade VUR group (n=53), a low-grade VUR group (n=28), and a group without VUR (n=365). RESULTS: The recurrence and non-Escherichia coli infection rates in febrile UTI were significantly higher in the high-grade VUR group than in the other two groups (P<0.05). RBUS showed that hydronephrosis and ureter dilatation were more frequent in the high-grade VUR group than in the other groups (P<0.05). In the high-grade VUR group, a renal cortical defect was more likely to appear as multiple defects, and the difference in bilateral renal scan uptake between both kidneys was larger than in the other two groups (P<0.001). CONCLUSION: Recurrent UTI, non-E. coli UTI, abnormal findings on RBUS such as hydronephrosis and ureter dilatation, and abnormal findings in the DMSA renal scan such as multiple renal cortical defects and greater uptake difference were associated with high-grade VUR. VCUG should be selectively performed when RBUS and/or DMSA renal scan reveal significant abnormalities.
Child* ; Dilatation ; Humans ; Hydronephrosis ; Kidney ; Medical Records ; Recurrence ; Retrospective Studies ; Succimer ; Technetium Tc 99m Dimercaptosuccinic Acid ; Ultrasonography ; Ureter ; Urinary Tract Infections* ; Urinary Tract* ; Vesico-Ureteral Reflux*

PURPOSE: The aim of this study was to determine the clinical characteristics, frequency of renal abnormalities and benefits of a top-down approach in children with their first febrile urinary tract infection (UTI). METHODS: We reviewed 308 patients retrospectively who were admitted to Yeungnam University Hospital and were treated for their first febrile UTI from February 2006 to December 2013. We performed a comparative analysis of laboratory findings and results of imaging techniques including a Tc-99m dimercaptosuccinic acid (DMSA) renal scan. RESULTS: Among the patients, 69% (213/308) were males, and 90% (277/308) had their first UTI episode during infancy. A DMSA renal scan was performed on all patients, and showed positive findings in 60% (184/308) of cases. Laboratory indices of inflammation were significantly higher in the DMSA-positive group (P<0.05). There was a statistically significant difference in the age distribution between the two groups. In the DMSA-positive group, 165 patients underwent voiding cystourethrography (VCUG), and 58 (35%) cases demonstrated vesicoureteral reflux. In total, 110 patients in the DMSA-positive group, underwent repeat scanning at 6 months; 33 children (30%) demonstrated static scarring, but 77 (70%) had improved completely. The concordance of the ultrasonography (US) and VCUG was low. Older patients had more renal scarring. CONCLUSION: DMSA is a sensitive method for assessing the severity of inflammation and kidney injury. However, the ability of US to predict renal parenchymal damage was limited. A top-down approach in children with their first febrile UTI showed significant value.
Age Distribution ; Child* ; Cicatrix ; Humans ; Inflammation ; Kidney ; Male ; Methods ; Retrospective Studies ; Succimer ; Technetium Tc 99m Dimercaptosuccinic Acid ; Treatment Outcome* ; Ultrasonography ; Urinary Tract Infections* ; Urinary Tract* ; Vesico-Ureteral Reflux

PURPOSE: The aim of this study was to determine the clinical characteristics, frequency of renal abnormalities and benefits of a top-down approach in children with their first febrile urinary tract infection (UTI). METHODS: We reviewed 308 patients retrospectively who were admitted to Yeungnam University Hospital and were treated for their first febrile UTI from February 2006 to December 2013. We performed a comparative analysis of laboratory findings and results of imaging techniques including a Tc-99m dimercaptosuccinic acid (DMSA) renal scan. RESULTS: Among the patients, 69% (213/308) were males, and 90% (277/308) had their first UTI episode during infancy. A DMSA renal scan was performed on all patients, and showed positive findings in 60% (184/308) of cases. Laboratory indices of inflammation were significantly higher in the DMSA-positive group (P<0.05). There was a statistically significant difference in the age distribution between the two groups. In the DMSA-positive group, 165 patients underwent voiding cystourethrography (VCUG), and 58 (35%) cases demonstrated vesicoureteral reflux. In total, 110 patients in the DMSA-positive group, underwent repeat scanning at 6 months; 33 children (30%) demonstrated static scarring, but 77 (70%) had improved completely. The concordance of the ultrasonography (US) and VCUG was low. Older patients had more renal scarring. CONCLUSION: DMSA is a sensitive method for assessing the severity of inflammation and kidney injury. However, the ability of US to predict renal parenchymal damage was limited. A top-down approach in children with their first febrile UTI showed significant value.
Age Distribution ; Child* ; Cicatrix ; Humans ; Inflammation ; Kidney ; Male ; Methods ; Retrospective Studies ; Succimer ; Technetium Tc 99m Dimercaptosuccinic Acid ; Treatment Outcome* ; Ultrasonography ; Urinary Tract Infections* ; Urinary Tract* ; Vesico-Ureteral Reflux

PURPOSE: We used technetium-99m dimercaptosuccinic acid (DMSA) scintigraphy to identify factors predictive of renal cortical defects in infants <3 months of age with urinary tract infections (UTIs). METHODS: We retrospectively reviewed data on infants <3 months of age with culture-proven UTIs treated at a single center from March 2010 to February 2016. Blood samples were obtained for laboratory evaluation prior to commencement of antibiotic therapy. The therapeutic delay time (TDT) and therapeutic response time (TRT) were recorded. All patients were divided into two groups depending on features of their DMSA scans. We compared the demographic, clinical, and laboratory characteristics of the two groups. RESULTS: A total of 119 infants (94 males and 25 females; mean age, 56.9±21.3 days) were included. Cortical defects were evident in the DMSA scans of 47 cases (39.5%). In infants with such defects, the peak temperatures (38.9±0.57℃ vs. 38.4±0.81℃, P=0.001), the absolute neutrophil counts (8,920±4,460/mm vs. 7,290±4,090/mm, P=0.043), and the C-reactive protein (CRP) levels (6.49±4.33 mg/dL vs. 3.21±2.81 mg/dL, P=0.001) were significantly higher than those in infants without cortical defects. The TDT was also longer in those with cortical defects (P=0.037). CONCLUSION: We found that a TDT ≥8.5 hr (odds ratio [OR] 5.81), a peak temperature ≥38.3℃ (OR 6.19), and a CRP level ≥4.96 mg/dL (OR 7.26) predicted abnormal DMSA scan results in infants <3 months of age with UTIs.
C-Reactive Protein ; Female ; Humans ; Infant* ; Male ; Neutrophils ; Pyelonephritis ; Radionuclide Imaging ; Reaction Time ; Retrospective Studies ; Succimer ; Technetium Tc 99m Dimercaptosuccinic Acid ; Urinary Tract Infections* ; Urinary Tract*

PURPOSE: The previous reports regarding VUR resolution were not precise due to early frequent surgical intervention. We evaluated the spontaneous resolution (SR) rate and the incidence of new renal scars in primary VUR, focusing on severe reflux. METHODS: Medical records of 334 patients with primary VUR who were on medical prophylaxis without surgery for 1 to 9 years, were retrospectively reviewed. Medical prophylaxis was initiated with low-dose antibiotic prophylaxis or probiotics. Radioisotope cystourethrography was performed every 1 to 3 years until SR of reflux. New renal scar was evaluated with follow-up 99mTc DMSA renal scan. RESULTS: The SR rates decreased as VUR grades were getting higher (P=0.00). The overall and annual SR were 58.4% and 14.9%/yr in grade IV reflux and 37.5% and 9.3%/yr in grade V reflux. The median times of SR were 38 months in grade IV reflux and 66 months in grade V reflux. The probable SR rates in grade IV and V reflux were 7.8% and 8.9% in the 1st year, 46.0% and 30.8% in the 3rd year and 74.4% and 64.4% in the 5th year. The incidences of new renal scars between low to moderate reflux and severe reflux showed no significant difference (P=0.32). CONCLUSION: The SR rates of severe primary VUR were higher than previously reported and most new renal scars were focal and mild.
Antibiotic Prophylaxis ; Cicatrix* ; Follow-Up Studies ; Humans ; Incidence ; Medical Records ; Probiotics ; Retrospective Studies ; Technetium Tc 99m Dimercaptosuccinic Acid ; Vesico-Ureteral Reflux*

PURPOSE: We investigated whether C-reactive protein (CRP) levels, urine protein-creatinine ratio (uProt/Cr), and urine electrolytes can be useful for discriminating acute pyelonephritis (APN) from other febrile illnesses or the presence of a cortical defect on 99mTc dimercaptosuccinic acid (DMSA) scanning (true APN) from its absence in infants with febrile urinary tract infection (UTI). MATERIALS AND METHODS: We examined 150 infants experiencing their first febrile UTI and 100 controls with other febrile illnesses consecutively admitted to our hospital from January 2010 to December 2012. Blood (CRP, electrolytes, Cr) and urine tests [uProt/Cr, electrolytes, and sodium-potassium ratio (uNa/K)] were performed upon admission. All infants with UTI underwent DMSA scans during admission. All data were compared between infants with UTI and controls and between infants with or without a cortical defect on DMSA scans. Using multiple logistic regression analysis, the ability of the parameters to predict true APN was analyzed. RESULTS: CRP levels and uProt/Cr were significantly higher in infants with true APN than in controls. uNa levels and uNa/K were significantly lower in infants with true APN than in controls. CRP levels and uNa/K were relevant factors for predicting true APN. The method using CRP levels, u-Prot/Cr, u-Na levels, and uNa/K had a sensitivity of 94%, specificity of 65%, positive predictive value of 60%, and negative predictive value of 95% for predicting true APN. CONCLUSION: We conclude that these parameters are useful for discriminating APN from other febrile illnesses or discriminating true APN in infants with febrile UTI.
Acute Disease ; C-Reactive Protein/*analysis ; Case-Control Studies ; Fever/microbiology ; Humans ; Infant ; Male ; Potassium/*urine ; Predictive Value of Tests ; Prospective Studies ; Proteinuria/diagnosis ; Pyelonephritis/*diagnosis/radionuclide imaging ; Sensitivity and Specificity ; Sodium/*urine ; *Technetium Tc 99m Dimercaptosuccinic Acid ; Urinary Tract Infections/drug therapy/microbiology/*radionuclide imaging

To revise the clinical guideline for childhood urinary tract infections (UTIs) of the Korean Society of Pediatric Nephrology (2007), the recently updated guidelines and new data were reviewed. The major revisions are as follows. In diagnosis, the criterion for a positive culture of the catheterized or suprapubic aspirated urine is reduced to 50,000 colony forming uits (CFUs)/mL from 100,000 CFU/mL. Diagnosis is more confirmatory if the urinalysis is abnormal. In treating febrile UTI and pyelonephritis, oral antibiotics is considered to be as effective as parenteral antibiotics. In urologic imaging studies, the traditional aggressive approach to find primary vesicoureteral reflux (VUR) and renal scar is shifted to the targeted restrictive approach. A voiding cystourethrography is not routinely recommended and is indicated only in atypical or complex clinical conditions, abnormal ultrasonography and recurrent UTIs. 99mTc-DMSA renal scan is valuable in diagnosing pyelonephritis in children with negative culture or normal RBUS. Although it is not routinely recommended, normal scan can safely avoid VCUG. In prevention, a more natural approach is preferred. Antimicrobial prophylaxis is not supported any more even in children with VUR. Topical steroid (2-4 weeks) to non-retractile physiologic phimosis or labial adhesion is a reasonable first-line treatment. Urogenital hygiene is important and must be adequately performed. Breast milk, probiotics and cranberries are dietary factors to prevent UTIs. Voiding dysfunction and constipation should be properly treated and prevented by initiating toilet training at an appropriate age (18-24 months). The follow-up urine test on subsequent unexplained febrile illness is strongly recommended. Changes of this revision is not exclusive and appropriate variation still may be accepted.
Anti-Bacterial Agents ; Catheters ; Child ; Cicatrix ; Constipation ; Diagnosis ; Female ; Follow-Up Studies ; Humans ; Hygiene ; Milk, Human ; Nephrology ; Phimosis ; Probiotics ; Pyelonephritis ; Technetium Tc 99m Dimercaptosuccinic Acid ; Toilet Training ; Ultrasonography ; Urinalysis ; Urinary Tract Infections* ; Urinary Tract* ; Vaccinium macrocarpon ; Vesico-Ureteral Reflux

Technetium-99m dimercaptosuccinic acid (99mTc-DMSA) scan is performed when there is a need to visualize the renal cortex and not the ureters or the bladder as the latter two are not effectively imaged. Less than twenty cases of tracer accumulation in a dilated ureter during a 99mTc-DMSA scan have been reported worldwide. There is no published case of ureter visualization in a 99mTc-DMSA scan done in the Philippines. In the case at hand, visualization of the ureters prompted further investigation. The present study pointed to a consideration of obstructive hydroureter, which was eventually supported by VCUG findings. Ureteral visualization in a 99mTc-DMSA scan should therefore prompt the inclusion of megaureter in the differential diagnosis.