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Published on: February 4, 2015
Top-down approach is possible strategy for predicting breakthrough fUTIs and renal scars in infants
Shina Kawai1, Takahiro Kanai2, Taiju Hyuga1
1Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
Insights
Acute-phase dimercaptosuccinic acid (DMSA) scintigraphy may not be necessary for predicting recurrent febrile urinary tract infections (fUTI) in infants. Chronic-phase DMSA can help detect renal scars, potentially making acute-phase imaging redundant when combined with other preventative measures.
Area of Science:
- Pediatric Nephrology
- Diagnostic Imaging
- Infectious Diseases
Background:
- Febrile urinary tract infections (fUTI) are common in infants.
- Identifying infants at risk for recurrent fUTI (r-fUTI) is crucial.
- Acute-phase technetium-99m dimercaptosuccinic acid (DMSA) scintigraphy is a standard initial imaging test.
Purpose of the Study:
- To evaluate the effectiveness of DMSA scintigraphy in predicting r-fUTI in infants.
- To determine the relationship between DMSA scintigraphy findings and r-fUTI development.
Main Methods:
- Seventy-nine infants with fUTI underwent acute-phase DMSA scintigraphy.
- Patients with defects had follow-up voiding cystourethrography and chronic-phase DMSA (6 months later).
- All patients received continuous antibiotic prophylaxis (CAP) and were followed for r-fUTI.
Main Results:
- Acute-phase DMSA defects were found in 40.5% of infants.
- The overall incidence of r-fUTI was 5% during a mean follow-up of 17 months.
- r-fUTI occurred in infants both with and without acute-phase DMSA defects; some with r-fUTI had significant vesicoureteral reflux (VUR), while others did not.
Conclusions:
- A 'top-down' approach using chronic-phase DMSA may predict r-fUTI and identify significant VUR.
- Acute-phase DMSA may be unnecessary for predicting r-fUTI when chronic-phase DMSA is used for renal scar detection.
- Combined with genital hygiene and CAP, chronic-phase DMSA may suffice for managing infants with fUTI.
Background:
Acute-phase technetium-99 m dimercaptosuccinic acid (DMSA) scintigraphy is recommended for initial imaging in children with febrile urinary tract infection (fUTI). Recently, the importance of identifying patients at risk of recurrent fUTI (r-fUTI) has been emphasized. To clarify the effectiveness of DMSA scintigraphy for predicting r-fUTI in infants, we investigated the relationship between defects on DMSA scintigraphy and r-fUTI.
Methods:
Seventy-nine consecutive infants (male: female, 60:19) with fUTI were enrolled in this study. DMSA scintigraphy was performed in the acute phase, and patients with defect underwent voiding cystourethrography and chronic-phase (6 months later) DMSA scintigraphy. Patients were followed on continuous antibiotic prophylaxis (CAP).
Results:
Defects on acute-phase DMSA scintigraphy were observed in 32 children (40.5%) of 79. The mean follow-up observation period was 17.0 ± 10.1 months. Four patients had r-fUTI (5%). Two of them had defects on DMSA scintigraphy in both the acute phase and chronic phase, and had bilateral vesicoureteral reflux (VUR) grade IV. Two others had r-fUTI without defects on DMSA and did not have VUR. Twelve patients had defect on chronic-phase DMSA scintigraphy and four of them had no VUR.
Conclusions:
The top-down approach is a possible method for predicting r-fUTI in infants and does not miss clinically significant VUR. Also, given that the prevalence of r-fUTI was 5% regardless of the presence of defects on acute-phase DMSA, then, in conjunction with genital hygiene and CAP, acute-phase DMSA might be unnecessary if chronic-phase DMSA is performed for all patients to detect renal scar.
