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

doi:10.1016/S0009-9260(98)80317-6

Clinical Radiology

Volume 53, Issue 10, October 1998, Pages 747-751

https://doi.org/10.1016/S0009-9260(98)80317-6 Get rights and content

A system for defining renal scarring on ultrasound is proposed and compared with DMSA scintigraphy. Renal scarring was assessed with ultrasound in children following urinary tract infection (UTI) using the following criteria: (1) proximity of sinus echoes to cortical surface; (2) loss of pyramids; (3) irregularity of outline; (4) loss of definition of capsular echo; and (5) calyceal dilatation. Three hundred and thirty-nine consecutive ultrasound scans (US) and DMSA scintigrams, comprising 648 kidneys, were performed and reported blindly and the results were compared. Using DMSA scintigraphy as the gold standard, ultrasound had a positive predictive value of 93% and a negative predictive value of 95%. Ultrasound disagreed with DMSA scintigraphy in 5.2% of kidneys. On review of the cases of disagreement where arbitration was possible by comparison with other imaging, ultrasound was incorrect in 10 kidneys and DMSA was incorrect in 13. We conclude that the sensitivity in the ultrasound detection of renal scarring can be greatly improved using this method. If no scars were detected at ultrasound an alternative explanation for an abnormal DMSA scintigram should be sought.

References (28)

TaskerAD et al.
Can ultrasound reliably detect renal scarring in children with urinary tract infection?
Clinical Radiology
(1993)
ScherzHC et al.
The selective use of dimercaptosuccinic acid renal scans in children with vesicoureteral reflux
Journal of Urology
(1994)
ShanonA et al.
Evaluation of renal scars by technetium-labeled dimercaptosuccinic acid scan, intravenous urography, and ultrasonography: a comparative study
Journal of Pediatrics
(1992)
WhiteRHR
Vescoureteric reflux and renal scarring
Archives of Diseases in Childhood
(1989)
JacobsonSH et al.
Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up
British Medical Journal
(1989)
GordonI et al.
The quantitation of 99m-Tc DMSA in paediatrics
Nuclear Medicine Communications
(1987)
PrestonAA
Imaging strategies and discussion of vesicoureteric reflux as a risk factor in the evaluation of urinary tract infection in children
Current Opinion in Pediatrics
(1994)
SmellieJM et al.
Urinary tract infection: a comparison of four methods of investigation
Archives of Disease in Childhood
(1995)
MacphersonRI et al.
Vesicoureteric reflux: radiologic aspects
Seminars in Urology
(1986)
StrifeJL et al.
Nuclear cystography and renal sonography: findings in girls with urinary tract infection
American Journal of Roentgenology
(1989)

HallerJO et al.

Paediatric urosonography: an update

Urologic Radiology

(1987)

KangarlooH et al.

Urinary tract infection in infants and children evaluated by ultrasound

Radiology

(1985)

SmellieJM et al.

Pitfalls in the investigation of children with urinary tract infection

Archives of Disease in Childhood

(1995)

LeonidasJC et al.

Sonography as a substitute for excretory urography in children with urinary tract infection

American Journal of Roentgenology

(1985)

Cited by (45)

The prevalence of kidney scarring due to urinary tract infection in Iranian children: a systematic review and meta-analysis
2019, Journal of Pediatric Urology
Citation Excerpt :
But in Howard et al. [53] study in Hong Kong, the overall prevalence of renal scars in male and female children with urinary tract infection aged less than 5 years was 18% and 11%, respectively, which is consistent with the results of the present study. In a study by Barry et al. [54], in 1998 in the UK, it was found that of 648 children with a mean age 3.89 years, 15.9% had kidney scarring due to urinary tract infection. In another study in England, Christian et al. [13] showed that of 990 children with urinary tract infections, 8.5% had renal scarring.
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.
The aim of this study was to investigate the prevalence of kidney scarring caused by urinary tract infection in Iranian children by meta-analysis.
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.
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).
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.
Cost and radiation exposure in the workup of febrile pediatric urinary tract infections
2016, Journal of Surgical Research
Citation Excerpt :
Radiologic images were reviewed by staff pediatric radiologists and pediatric urologists for evidence of renal cortical defects, renal scarring, global hypotrophy, atrophy, hydronephrosis, and size discrepancy. Renal cortical defects and scarring were identified on DMSA scans by the presence of areas of photopenia (Fig. 1) and on RUS by an irregular renal outline, loss of pyramids, or the proximity of sinus echoes to cortical surface (Fig. 2).9 Effective radiation doses, based on patient age and DMSA administered, was calculated using estimates of radiation dose equivalents from the Radiation Internal Dose Information Center (Oak Ridge Institute for Science and Education, Oak Ridge, TN).10
Technetium-99m dimercaptosuccinic acid (DMSA) scans are often used in the evaluation of pediatric patients with febrile urinary tract infections (UTIs). Given the prevalence of febrile UTIs, we sought to quantify the cost, radiation exposure, and clinical utility of DMSA scans when compared with dedicated pediatric renal ultrasounds (RUSs).
An institutional review board approved retrospective study of children under the age of 18 years evaluated at our institution for febrile UTIs between the years 2004-2013 was conducted. The patients had to meet all of the following inclusion criteria: a diagnosis of vesicoureteral reflux, a fever >38°C, a positive urine culture, and evaluation with a DMSA scan and RUS. A chart review was used to construct a cost analysis of technical and professional fees, radiographic results, and radiation dose equivalents.
Overall, 104 children met the inclusion criteria. A total of 122 RUS and 135 DMSA scans were performed. The technical costs of a DMSA scan incurred a 35% cost premium as compared to an RUS. The average effective radiation dose of a single DMSA scan was 2.84 mSv. New radiographic findings were only identified on 7% of those patients who underwent greater than 1 DMSA scan.
The utility of the unique information acquired from a DMSA scan as compared to a RUS in the evaluation of febrile UTI must be evaluated on an individual case-by-case basis given the increased direct costs and radiation exposure to the patient.
Recommended diagnostic imaging tests in urinary tract infections
2007, Anales de Pediatria
Se presenta una revisión de la evidencia científica disponible sobre las pruebas diagnósticas de imagen en la infección urinaria en la infancia. Contamos con suficiente información sobre la validez técnica de las distintas pruebas de imagen disponibles, que puede ser utilizada, mediante cálculo de probabilidades, en el proceso de toma de decisiones diagnósticas. Con todo, el rendimiento de los diagnósticos que estas pruebas nos ofrecen no está claro; algunas de las estimaciones de costes, eficacia y riesgos nos permiten asumir que ciertos diagnósticos tienen escasa trascendencia clínica. Es probable que la estrategia actual de uso habitual de pruebas de imagen deba ser sustituida por otra personalizada, en la que las pruebas sean indicadas tras considerar la información disponible en cada momento, la opinión de pacientes o familiares y nuestro juicio sobre la verosimilitud de los diagnósticos y los riesgos y beneficios de cada prueba.
The present article reviews the scientific evidence available on diagnostic imaging tests in urinary tract infections in childhood. There is sufficient information on the technical validity of the various imaging tests. Through calculating probabilities, this information can be used in the process of diagnostic decision making. Nevertheless, the diagnostic yield offered by these tests is unclear; some of the estimations of costs, efficacy and risks suggest that certain diagnoses have little clinical importance. The current strategy of routine use of imaging tests should probably be replaced by an individually-tailored approach, in which tests are indicated by taking into account the information available at each stage of the process, patients’ and relatives’ opinions, and clinicians’ judgment on the probability of the diagnoses and the risks and benefits of each test.
Investigation of urinary tract infection in children
2006, Current Paediatrics
Urinary tract infections are a common and sometimes troublesome problem for children, which in a minority may be associated with significant renal tract pathology and renal damage, yet there is little consensus amongst experts as to how they should be investigated. Correct diagnosis of UTI and prompt treatment of symptomatic infection are far more important than the subsequent investigation strategy. An investigation strategy should limit the use of invasive investigations involving ionizing radiation, to those where the information obtained is necessary to guide treatment. Children at high risk of pyelonephritic scarring or major underlying urinary tract anomalies should be identified and screened to identify renal scarring and urological disorders that require prompt treatment. These children are likely to be very young or have severe (pyelonephritis/septicaemia) or recurrent infection or positive findings on medical history and examination. Seemingly healthy, older children, with a negative medical history and physical examination who have a solitary minor or asymptomatic infection, which responded to treatment, do not require investigation as they are far less likely to have significant underlying disorders and the few who do so will be identified when they re-present with further infection.
Early Start to Therapy Preserves Kidney Function in Spina Bifida Patients
2006, European Urology
Citation Excerpt :
We strongly recommend a more proactive attitude to prevent any possible urological problems in children with spina bifida. Follow-up with ultrasound scans of the kidneys is a reliable monitoring method, and our data support those of other authors [21,22]. Spina bifida patients do not necessarily need to be subjected to DMSA scans if serum creatinin and ultrasound scans are normal, especially if UDS show low bladder pressure.
Renal scarring and renal failure remain life-threatening for children born with spinal dysraphism. We reviewed our data of spina bifida patients to evaluate whether optimal treatment of the neurogenic bladder from birth onwards can preserve kidney function.
We reviewed data on all newborns with spinal dysraphism who were referred to our hospital between January 1988 and June 2001. We looked at their situations at referral and at follow-up: the type of treatment, antimuscarinic agents, clean intermittent catheterisation (CIC), antibiotic prophylaxis, and operations (sling procedures, bladder augmentations, antireflux procedures). Renal function (ultrasound, DMSA scan, serum creatinin, creatinin clearance) and bladder function (urodynamic studies) were evaluated over time.
Data of 144 children of 176 could be evaluated by the end of the study: 5 patients had pre-existing renal abnormalities, 69 had an overactive sphincter, 27 had reflux, and six had renal scarring. None are currently developing end-stage renal disease. All patients with spina bifida aperta started CIC and antimuscarinic therapy shortly after birth. Five of the six patients with renal scarring were started on therapy with intermittent catheterisation and antimuscarinic therapy several months after birth. Sixty-three of 82 children with spina bifida were dry at school age (age six), although 37 of these had not had an operation.
We show that an early start to therapy helps to safeguard renal function for children born with spina bifida. Our data support other recent reports that children born with spina bifida can probably use their own kidneys for a lifetime, if they are given adequate urological treatment. To protect the upper urinary tract, we need to ensure low intravesical pressure by starting children early on CIC (the preferred treatment); antimuscarinic agents to counteract detrusor instability are indispensable in most cases. Proactive treatment of risks for upper tract deterioration results in a negligible loss of renal function, even when early urinary continence is included in the treatment protocol.
Pediatric urinary tract infection
2004, EAU Update Series
Urinary tract infection (UTI) in childhood affects many children but it can be difficult to diagnose, especially in infancy where it is believed that most renal damage occurs. UTI can point the way to underlying congenital abnormalities of the urinary tract which are uncommon, as are the long-term sequelae of renal scarring, hypertension and chronic renal failure. It is now appreciated that many infants have reflux associated damage before birth with associated renal dysplasia. Investigations in children with a UTI remain controversial with ultrasonography being sufficient in experienced hands and only selected patients undergoing cystography and radionuclide imaging. Gross vesicoureteric reflux (VUR) is rare and most mild to moderate VUR resolves spontaneously. Although there is no randomised controlled trial to date low dose prophylactic antibiotics are used in the majority of children in whom VUR is detected with surgery being reserved for those with problematical infections or anatomical abnormalities. Familial reflux is increasingly recognised.

View all citing articles on Scopus

View full text

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

Clinical Radiology

Journal of Urology

Journal of Pediatrics

Vescoureteric reflux and renal scarring

Archives of Diseases in Childhood

Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up

British Medical Journal

The quantitation of 99m-Tc DMSA in paediatrics

Nuclear Medicine Communications

Imaging strategies and discussion of vesicoureteric reflux as a risk factor in the evaluation of urinary tract infection in children

Current Opinion in Pediatrics

Urinary tract infection: a comparison of four methods of investigation

Archives of Disease in Childhood

Vesicoureteric reflux: radiologic aspects

Seminars in Urology

Nuclear cystography and renal sonography: findings in girls with urinary tract infection

American Journal of Roentgenology

Paediatric urosonography: an update

Urologic Radiology

Urinary tract infection in infants and children evaluated by ultrasound

Radiology

Pitfalls in the investigation of children with urinary tract infection

Archives of Disease in Childhood

Sonography as a substitute for excretory urography in children with urinary tract infection

American Journal of Roentgenology