Journal review

Renal damage detected by DMSA, despite

normal renal ultrasound, in children with febrile
UTI
Published in Journal of Pediatric Urology (2015)
11, 126.e1e126.e7
By

N.C. Bush, M. Keays, C. Adams, K. Mizener, K. Pritzker c, W. Smith,

J. Traylor, C. Villanueva, W.T. Snodgrass

1999 American Academy of

Pediatrics guidelines

renal-bladder ultrasound (RBUS) and VCUG

after the first FUTI in children younger than 2
years of age

2011 American Academy of

Pediatrics guidelines

do not support the use of antimicrobial prophylaxis to prevent

febrile recurrent UTI in infants without vesicoureteral reflux
(VUR) or with grade I to IV VUR.
Therefore, a voiding cystourethrography (VCUG) is not
recommended routinely after the first UTI
VCUG is indicated if renal and bladder ultrasonography reveals
hydronephrosis, scarring, or other findings that would suggest
either highgrade VUR or obstructive uropathy and in other
atypical or complex clinical circumstances.
VCUG should also be performed if there is a recurrence of a
febrile UTI

Question

previous reports have demonstrated poor correlation

between RBUS and renal scarring, compared to the gold
standard DMSA scintigraphy, with sensitivity ranging from
5 to 47%
Accordingly, RBUS alone may fail to identify patients with
underlying renal damage who may benefit from
cystography to identify VUR.
purpose of the study was to determine how well RBUS
performed in detecting renal damage that was identified
by DMSA performed 3 months after FUTI.

Methods

Cross-sectional study
multi-provider pediatric urology group evaluated the children for UTI and/or
VUR between October 2008 and December 2012 using a standardized
protocol
All children aged 018 years, with at least one FUTI, who underwent RBUS
and DMSA were evaluated.
Those with a solitary kidney, ectopic ureter, ureterocele, PUV, prune belly
syndrome, and/or neurogenic bladder were excluded.

Definitions

Renal-bladder ultrasound was defined as abnormal, with the

presence of any of the following:

hydronephrosis grades IIV by Society of Fetal Urology

criteria (including pelviectasis without caliectasis);

hydroureter 7 mm in transverse diameter;

renal scar defined by abnormal focal renal contour with

parenchymal thinning; and/or size discrepancy 1 cm
between kidneys.

Children with suspected renal duplication anomalies were

classified as normal, unless the renal size discrepancy was
1 cm between the kidneys and/or hydro(uretero)nephrosis
was present.

Definitions

DMSA scans were independently reviewed by two pediatric

radiologists
Results were graded using the grading scale adapted from the
Randomized Intervention for Children with Vesicoureteral Reflux
(RIVUR) trial

Definitions

Because this protocol began before the 2011

AAP guidelines on UTI, the definition of UTI
was according to prior guidelines
a symptomatic child with >50,000 colonyforming units (CFU)/ml on catheterized
specimens or >100,000 CFU/ml in bag or
voided specimens.

Data analysis

The primary outcome was abnormal DMSA. Sensitivity,

specificity, positive predictive value, negative predictive value,
and false negative rates were calculated for normal and
abnormal RBUS
Multiple logistic regression was used to estimate the odds of
abnormal DMSA with pre-determined risk factors

RBUS (normal/abnormal),

number of FUTI (1, 2, 3),

age (months)

Gender

Grade of VUR

On average, DMSA was performed

3.5m after baseline RBUS.
In view of RBUS in identifying children
with renal damage on DMSA:
Sensitivity 34% (95% CI 2642%),
specificity 88% (95% CI 8591%)
positive predictive value (true positive)
of 47% (95% CI 3757%)
negative predictive value (true
negative) of 81% (95% CI 7784%)
(Table 3).
false negative rate of 19% (95% CI
1623%), with nearly one in every five
children demonstrating focal cortical
defects and/or diminished renal
function on DMSA despite a normal
RBUS after FUTI

Among the 149 children with abnormal DMSA, 47 (32%) had

diminished ipsilateral renal function of less than 44%

Out of those 47 children, 35(35/99 35%) of those with normal

RBUS and 12(12/50 24%) of those with abnormal RBUS (P =
0.22)

VUR was similarly present in children with normal

RBUS/abnormal DMSA, compared to those with abnormal
RBUS/abnormal DMSA (76% vs 74%, P = 0.90)

VCUG was performed on abnormal DMSA, VUR was identified in

76%, including grades IV in 5 (4%), 26 (18%), 35 (24%), 26
(18%), and 16 (11%), respectively, and no VUR identified in 35
(24%).

Among the 149 children with abnormal DMSA, 47 (32%) had

diminished ipsilateral renal function of less than 44%

Out of those 47 children, 35(35/99 35%) of those with normal

RBUS and 12(12/50 24%) of those with abnormal RBUS (P =
0.22)

VUR was similarly present in children with normal

RBUS/abnormal DMSA, compared to those with abnormal
RBUS/abnormal DMSA (76% vs 74%, P = 0.90)

VCUG was performed on abnormal DMSA, VUR was identified in

76%, including grades IV in 5 (4%), 26 (18%), 35 (24%), 26
(18%), and 16 (11%), respectively, and no VUR identified in 35
(24%).

Odds of risk factor for abnormal DMSA

Discussion

On detecting renal damage, ie abnormal DMSA, RBUS had poor sensitivity

(34%) and a low positive predictive value (47%)
Also, it had a false negative rate ranging from 14% in children aged 24
months to 23% in children aged 2 years and older
Thus, a substantial portion of children had abnormal DMSA, despite normal
RBUS, which suggests that renal damage will not be detected if only RBUS is
performed.
Of the children younger than 2 years of age and who were referred after one
FUTI with a normal RBUS, 10% had an abnormal DMSA , all were additionally
found to have VUR ranging from grades IV
Of all age with one FUTI with a normal RBUS, 19% had an abnormal DMSA,
80% had VUR grade I-V.
VCUG was performed on abnormal DMSA, VUR was identified in 76%,
including grades IV in 5 (4%), 26 (18%), 35 (24%), 26 (18%), and 16 (11%)
Close correlation between abnormal DMSA and VUR, thus RBUS alone failed
to detect substantial portion of high grade VUR

Conclusion

Normal RBUS failed to detect any renal function loss and/or

cortical renal defects found on DMSA that were obtained 3
months after initial FUTI in 10% of children <2 years old and
19% >2 years old, and in 25% of children of all ages with two or
more FUTI. Of these children, 76% were found to have VUR
and were therefore considered to have continued risk for
recurrent FUTI and additional renal damage. Imaging after
initial FUTI should include acute RBUS and delayed DMSA,
reserving cystography for those with abnormal DMSA and/or
recurrent FUTI.

Commentary to the article

Approximately 3% of girls and 1% of boys develop a

symptomatic UTI in childhood, yet 85% of children with a first
symptomatic or febrile UTI do not develop a recurrent UTI.
Thus, large number of children who would be exposed to
radiation during a costly and lengthy test, but would never
develop a recurrent UTI.
Consider prevalence of renal abnormality on DMSA scan, and if
VCUG was done if DMSA abnormal, risk reduction of recurrent
UTI in giving antibiotic prophylaxis number need to treat is 275

While if VCUG was done in RECURRENT UTI, and give antibiotic

prophylaxis accordingly, number need to treat is 20