Clinical study and management of genitourinary tuberculosis

Background: Tuberculosis can affect any organ system of the body, including the genitourinary tract. Genitourinary TB is the most common form of extra pulmonary TB accounting for 27% (14- 41%) worldwide. Aim and objectives: To study distribution of GU TB in relation to age, sex, anatomical site, signs and symptoms and to study various diagnostic modalities, treatment and role of surgery in GU TB. Materials and methods: This study was a cross sectional study done at department of Urology, King George hospital, Visakhapatnam. The study was done over a period of 30 months, which was from September 2014 to February 2017. All the patients reporting to the hospital with proven genitourinary tuberculosis or diagnosed after coming to the hospital were included in the study. Total number of cases was 35. 10 were males and 25 were females. History, physical examination, laboratory and radiological investigations were done on the patients and the primary focus of the disease and organs involved are determined. All the patients received treatment as indicated. Results: Most of the patients (33 out of 35) belonged to low socio-economic status and came from rural settings. Of them 10(28.57%) were males and 25(71.43%) were females. The mean age of patients was 36 years (range 16-60years). 2 patients were <20 years, 11 patients were between 21-30 years, 11 patients were between 31-40 years, 8 patients were between 41-50 years and 3 were above 50 years. In this study, kidney was involved in 19 cases and was the most common organ involved, followed by bladder (14 cases) and ureter(10 cases). Irritative voiding symptoms were the most common symptom seen in 23 cases. Flank pain was noted in 20 cases, sterile pyuria in 22 cases and hematuria in 7 cases. Six(17.14%) out of thirty five patients had renal failure at the time of presentation and diagnosis. Nephrectomy was done in 12 cases. Nephrectomy with augmentation Immadi Chandrasekhar, Pasalapudi Anurag Jose. Clinical study and management of genitourinary tuberculosis. IAIM, 2019; 6(1): 48-57. Page 49 cystoplasty and ureteric reimplantation was done in another 6 cases. Ileal conduit was done in 6 cases. Ureteric reimplantation with psoas hitch was done in 3 cases. Conclusion: Genitourinary tuberculosis is often silent and has nonspecific clinical features. Irritative voiding symptoms are the common presentation. Kidney is the most commonly affected organ in GU TB. GU TB is a disease of young adults, with majority affected in the 3rd and 4th decades. CT scan is replacing IVU as an imaging modality of choice in GU TB. Diagnosis of GU TB can be baffling, compelling a high index of suspicion owing to paucibacillary load in the biological specimens and the difficulty to isolate or grow TB bacilli. Hence a strong clinical suspicion is necessary for correct diagnosis. Anti-tubercular therapy is the mainstay of treatment. Genitourinary tuberculosis results in sequel which may require major organ removing and reconstructive surgeries

A Renal Size Discrepancy among the Findings of Renal Sonogram in Children with Their First Episode of Pyelonephritis is One of the Useful Parameters to Predict the Presence of Cortical Defects on the Acute DMSA Renal Scan

PURPOSE: We investigated whether a renal size discrepancy on a renal sonogram (US) in children with febrile urinary tract infection (UTI) was correlated with the presence of cortical defects on their dimercaptosuccinic acid (DMSA) renal scan. METHODS: We examined 911 children who were admitted consecutively to our hospital with their first episode of febrile UTI from March 2001 to September 2014. All enrolled children underwent a US and DMSA scan during admission. According to the US findings, including the renal size discrepancy, data were compared between children with positive and negative DMSA scan results. A positive DMSA scan result was defined as reduced or absent tracer localization and indistinct margins that did not deform the renal contour. RESULTS: Mean renal lengths of the right and left kidneys were larger in children with positive DMSA scan results than in children with negative DMSA scan results (63.2±11.3 mm vs. 58.4±7.8 mm, P<0.001; 64.9±11.2 mm vs. 59.9±7.9 mm, P<0.001; respectively). A significant difference was observed in both renal lengths between children with positive and negative DMSA scan results (4.6±3.8 mm vs. 3.3±2.6 mm, P<0.001). A multiple logistic regression analysis, revealed that a small kidney, cortical thinning, and a renal length discrepancy on US findings were significant factors for predicting the presence of cortical defects on an acute DMSA scan [P=0.028, 95% confidence interval (CI) 1.054–2.547; P=0.004, 95% CI 1.354–4.810; P<0.001, 95% CI 1.077–1.190, respectively]. CONCLUSION: In conclusion, a renal size discrepancy on US findings in children with their first episode of febrile UTI was a helpful tool for predicting the presence of cortical defects on an acute DMSA scan.

Nuclear Imaging in Pediatric Kidney Diseases

Renal scintigraphy is a useful tool in diagnosis and management of various nephro-urological conditions. Tc-99m dimercaptosuccinicacid renal scintigraphy (Tc-99m-DMSA), Tc-99m mercaptoacetyltriglycine (Tc-99m-MAG3) or Tc-99m diethylenetriaminepentaaceticacid (Tc-99m-DTPA) dynamic renal scintigraphy, and Radionuclide micturating cystography are the common scans used in children withkidney diseases. These studies are minimally invasive, easily available, and offer both anatomic details and functional informationrequired for thorough evaluation. At the same time, it is essential to have appropriate knowledge to interpret these studies and be awareof their limitations and pitfalls. The advent of Positron emission tomography-computed tomography/magnetic resonance imaging (PET-CT/MRI) has broadened the scope of nuclear medicine. This article focuses on the technique, interpretation, indication and recentpractice guidelines of renal scintigraphy in children with kidney diseases.

Paediatric Urinary Tract Infection: Microbiologic Profile and Antibiotics Sensitivity in Children Presenting with UTI

Background: This study was designed to determine the microbiologic profile and Antibiotics Sensitivity in Children presenting with UTI. Materials & Methods: This hospital based prospective study was conducted in 28 patients Patients from 2 months to 12 years were admitted to the pediatric ward and visited in outpatient department (OPD) with diagnosis of UTI based on history with routine and microscopic examination of urine were considered for this study. The UTI investigation protocol recommended ultrasound, voiding cystourethrography (VCUG), and DMSA scan. Clinical and laboratory parameters at the index infection, including highest measured temperature, highest C-reactive protein (CRP), bacterial findings, and the number of febrile recurrences, were recorded. Results: Fever was the most common symptom accounting for 76.4% of patients with nausea and vomiting (42.8%), dysuria (53.6%), abdominal pain (57.1%) and anorexia (46.4%). Urine analysis was done in all suspected cases of UTI. Among all urine samples 60.7% had WBC >10/hpf, followed by 87 (28.6%) which had WBC between 6-10/hpf. Only 6 (10.7%) had WBC 5 or less. Among all urine analyses 68 (57.1%) Conclusion: E. coli (82%) was the most common organism found followed by Klebsiella pneumonia (12%), Proteus mirabilis (5%)and 1% were other pathogens like Enterococcus species (Table 4, Fig 1). All isolated E. coli was sensitive to Imipenem, Nalidixic acid, Netilmicin and Vancomycin. E. coli were 80-90% sensitive to Amikacin, Ceftriaxone, Cefuroxime, Ofloxacin, Gentamicin and Nitrofurantoin.

Comparison of 99mTc-DMSA Renal Scan and Power Doppler Ultrasonography for the Detection of Acute Pyelonephritis and Vesicoureteral Reflux

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.

Clinical Characteristics and Outcomes of the First Episode of Urinary Tract Infection in Neonates and Infants Younger than 2 Months of Age

PURPOSE: The American Academy of Pediatrics provides guidelines for managing febrile urinary tract infection (UTI) in infants and children 2-24 months old, but little guidance is offered regarding UTIs in those younger than 8 weeks of age. The definition of UTI is unclear and whether to proceed with micturating cystourethrography (MCUG) or 99mtechnetium-dimercaptosuccinic acid (DMSA) scintigraphy scan in this age group is controversial. METHODS: We retrospectively analyzed 29 neonates and infants younger than 2 months of age who underwent late DMSA scans 9 months following the first episode of febrile or symptomatic UTI between July 2009 and June 2016. RESULTS: In total, 192 children aged 0-24 months underwent ultrasound and DMSA scans (MCUG in 174/192). Neonates and infants younger than 2 months of age were significantly less likely to develop fever, and had a lower fever peak, shorter duration of fever before admission and after starting antibiotics, longer hospitalization period, lower C-reactive protein, and greater incidence of non-Escherichia coli infection. There was no difference in pyuria response at diagnosis. The prevalence rates of an ultrasound abnormality (28%), vesicoureteral reflux (28%), UTI recurrence (38%), and renal scarring (10%) in infants younger than 8 weeks of age were similar to those in children 2-24 months old. CONCLUSION: Neonates and infants younger than 2 months of age with UTI warrant special consideration because the fever response used for diagnosis in older children may be absent or blunted. Clinical guideline is needed for the diagnosis and management of UTI in this age group.

Clinical Characteristics and Outcomes of the First Episode of Urinary Tract Infection in Neonates and Infants Younger than 2 Months of Age

PURPOSE: The American Academy of Pediatrics provides guidelines for managing febrile urinary tract infection (UTI) in infants and children 2-24 months old, but little guidance is offered regarding UTIs in those younger than 8 weeks of age. The definition of UTI is unclear and whether to proceed with micturating cystourethrography (MCUG) or 99mtechnetium-dimercaptosuccinic acid (DMSA) scintigraphy scan in this age group is controversial. METHODS: We retrospectively analyzed 29 neonates and infants younger than 2 months of age who underwent late DMSA scans 9 months following the first episode of febrile or symptomatic UTI between July 2009 and June 2016. RESULTS: In total, 192 children aged 0-24 months underwent ultrasound and DMSA scans (MCUG in 174/192). Neonates and infants younger than 2 months of age were significantly less likely to develop fever, and had a lower fever peak, shorter duration of fever before admission and after starting antibiotics, longer hospitalization period, lower C-reactive protein, and greater incidence of non-Escherichia coli infection. There was no difference in pyuria response at diagnosis. The prevalence rates of an ultrasound abnormality (28%), vesicoureteral reflux (28%), UTI recurrence (38%), and renal scarring (10%) in infants younger than 8 weeks of age were similar to those in children 2-24 months old. CONCLUSION: Neonates and infants younger than 2 months of age with UTI warrant special consideration because the fever response used for diagnosis in older children may be absent or blunted. Clinical guideline is needed for the diagnosis and management of UTI in this age group.

Clinical Efficacy of a Top-down Approach for Children with a First Febrile Urinary Tract Infection

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.

Clinical Efficacy of a Top-down Approach for Children with a First Febrile Urinary Tract Infection

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.

Clinical Significance of Uptake Difference on DMSA Scintigraphy in Pediatric Urinary Tract Infection

PURPOSE: Disruption of normal renal development can lead to congenital anomalies of the kidney and urinary tract, including renal hypodysplasia. We aimed to clarify whether small kidney size affects clinical manifestations in children with urinary tract infection (UTI). METHODS: One hundred fifty-four patients who had their first symptomatic UTI between January 2014 and June 2015 were enrolled in this study. Differences in kidney size were estimated based on percent uptake of (99m)Tc-dimercaptosuccinic acid (DMSA) in scintigraphy. The patients who showed more than 10% difference in kidney size on DMSA scintigraphy with none or minimal cortical defects were included in group A. (group A, n=17). Laboratory, clinical, and imaging results were compared with those of the other patients (group B, n=137). RESULTS: Group A had a relatively higher incidence of vesicoureteral reflux than group B (44% vs 20%, P<0.05). The levels of plasma neutrophil gelatinase-associated lipocalin (NGAL) and serum C-reactive protein were significantly higher in group A (193 [64-337] vs 91 [59-211] ng/mL and 4.1 [0.5-11.9] vs 2.1 [0.7-5.3] ng/mL, respectively; all P<0.05). Linear regression analysis revealed that plasma NGAL level strongly correlated with the difference in renal uptake in DMSA scintigraphy in group A (R²=0.505). CONCLUSION: The difference in kidney size could influence the clinical course and severity of pediatric UTI.

Comparison of Chelating Agents DMPS, DMSA and EDTA for the Diagnosis and Treatment of Chronic Metal Exposure.

Aims: Several chelating agents are presently used among environmental physicians to diagnose and treat a chronic metal overexposure. We evaluated and compared the binding capacity of the most common chelating agents DMPS (2, 3-dimercapto-1- propanesulfonic acid), DMSA (dimercaptosuccinic acid), also called Succimer) and EDTA (ethylene diamine tetraacetic acid) for the potentially toxic metals Antimony (Sb), Arsenic (As), Cadmium (Cd), Lead (Pb) and Mercury (Hg). Secondly, we evaluated how the nutrient elements Calcium (Ca), Copper (Cu) and Zinc (Zn) are affected by the chelating agents tested. Study Design: Through ICP-MS (Inductively Coupled Plasma Mass Spectroscopy) analysis of urine from environmentally burdened patients, we determined which chelating agent in oral or injectable form has the best potential to be used as a provocation test for the diagnosis of multiple metal over exposure, and which chelating agent is best used for the detoxification treatment of a single metal exposure. Place and Duration of Study: Micro Trace Minerals and Friedle Laboratories, Hersbruck/Regensburg, Germany, between January 2011 and February 2013. Methodology: Data utilized is based on urine samples from chronically exposed patients, male and female adults, received from chelation therapists. Acutely intoxicated patients were not included. Results: The intravenous application of DMPS is most suitable for the diagnosis and treatment of a single or multiple metal exposure, involving the metals Sb, As and Hg. Both EDTAs (NaCaEDTA and NaEDTA), administered intravenously, are the agents of choice for Cd, while Pb can be chelated using DMSA, DMPS, or the EDTAs. Both EDTAs have a strong Zn binding ability, but only NaEDTA is suitable for binding appreciable amounts of Ca. DMPS best binds Cu. Conclusion: The intravenous application of DMPS is most useful for the diagnosis of multiple metal overexposure. It is also the treatment of choice for Sb, As and Hg and has the strongest Cu binding ability of the chelators tested.

Clinical features and renal morphological changes of the patients with urinary tract infection associated ureteral stent / 中华泌尿外科杂志

Objective To evaluate the clinical features and renal morphological changes of the patients with urinary tract infection associated ureteral stent.Methods From Oct.2012 to May.2013,21 patients were divided into three groups depending on the different conditions:Group A (n=7):patients who had febrile urinary tract infections associated with ureteral stents; Group B (n =7):patients with ureteral stents but no fever; Group C (n=7):patients who had febrile urinary tract infections but no ureteral stent.The clinical data,laboratory data and 99Tcm-dimercaptosuccinic acid (DMSA) renal scintigraphy results were recorded prospectively and analyzed.Results In Group A,there were two patients had flank pain and positive costovertebral angle percussion tcnderness.The mean value of white blood cells and Hs-CRP of Group A and Group C were obviously higher than Group B (P＜0.05).The ratios of pyuria were 100.0％,71.4％ and 100.0％ in Group A,B and C.The ratios of positive urine bacteuria culture were 100.0％,42.9％ and 100.0％ in Group A,B and C.The results of 99Tcm-DMSA renal scintigraphy demonstrated the decreased uptake in the different portion of the kidneys on the sides of ureteral stents inserted in all the patients in Group A but no such changes in Group B and Group C.Conclusions 99Tcm-DMSA renal scintigraphy can be used to judge the status of urinary tract infection associated ureteral stent.The febrile urinary tract infection associated with ureteral stents always means pyelonephritis occurs and prompt treatment must be given.

Prevalência de pielonefrite aguda e incidência de cicatriz renal em crianças menores de dois anos de idade com infecção do trato urinário avaliadas por cintilografia renal com 99mTc-DMSA: a experiência de um hospital universitário / Prevalence of acute pyelonephritis and incidence of renal scarring in children under the age of two with urinary tract infection evaluated by 99mTc-DMSA renal scintigraphy: the experience of a university hospital

OBJECTIVE: To calculate the frequencies of acute pyelonephritis and renal scarring in patients under the age of two, with first episode of urinary tract infection in a Brazilian university hospital, comparing with data reported in the international literature. MATERIALS AND METHODS: Scintigraphic reports of children less than two years old submitted to 99mTc-DMSA renal scintigraphy in a university hospital in Rio Grande do Sul between 2006 and 2009 were reviewed to investigate acute pyelonephritis/renal scarring. Additionally, the presence of vesicoureteral reflux, early use of antibiotics, and comorbidities were investigated on electronic records. The sample size calculation was based on a systematic review study and obtained a minimum of 147 patients. Patients whose electronic records were not available were excluded. RESULTS: One hundred and fifty-seven children met the inclusion criteria; among them 48 had acute pyelonephritis and 8 of these had renal scars. Neither age nor sex presented any significant association with acute pyelonephritis (p = 0.405 and p = 0.124, respectively). No statistical significance was observed in the association between vesicoureteral reflux and acute pyelonephritis (p = 1.0) and other comorbidities (p = 0.470), and in relation to early use of antibiotics with acute pyelonephritis (p = 0.130) and renal scarring (p = 0.720). CONCLUSION: The frequencies found in the present study for acute pyelonephritis/renal scarring are in agreement with the results reported by most studies in the literature.

OBJETIVO: Calcular as frequências de pielonefrite aguda e cicatriz renal em pacientes menores de dois anos com cintilografia renal com 99mTc-DMSA com primeiro quadro de infecção do trato urinário em hospital universitário brasileiro, comparando com dados da literatura internacional. MATERIAIS E MÉTODOS: Foram revisados laudos cintilográficos de crianças menores de dois anos de idade que realizaram cintilografia renal com 99mTc-DMSA em um hospital universitário no Rio Grande do Sul, entre 2006 e 2009, para pesquisa de pielonefrite aguda/cicatriz renal. Revisaram-se a presença de refluxo vesicoureteral, o uso precoce de antibiótico, e a presença de comorbidades que constassem nos prontuários eletrônicos. Calculou-se a amostra com base num estudo de revisão sistemática e obteve-se um mínimo de 147 pacientes. Excluíram-se pacientes sem registro eletrônico. RESULTADOS: Cento e cinquenta e sete crianças preencheram critérios de inclusão do estudo, 48 tiveram pielonefrite aguda e 8 destas apresentaram cicatriz renal. Nem a idade nem o gênero dos pacientes apresentaram associação significativa com pielonefrite aguda (p = 0,405 e p = 0,124, respectivamente). Não houve diferença estatística nas associações de refluxo vesicoureteral e pielonefrite aguda (p = 1,0) e outras comorbidades (p = 0,470) e em relação ao uso precoce de antibiótico com pielonefrite aguda (p = 0,130) e cicatriz renal (p = 0,720). CONCLUSÃO: As frequências de pielonefrite aguda e cicatriz renal obtidas concordam com os resultados da maioria dos estudos publicados.

Renal Manifestations and Imaging Studies of Kawasaki Disease

PURPOSE: The aim of this study was to verify renal inflammation following Kawasaki disease (KD) using single photon emission computed tomography along with Technetium-99m dimercaptosuccinic acid scintigraphy (DMSA renal SPECT). METHODS: From March 2011 to October 2011, 15 patients diagnosed with KD at the National Health Insurance System Ilsan Hospital were enrolled in the study. All patients underwent DMSA renal SPECT to evaluate renal involvement during the acute phase of KD. Urine beta2-microglobulin (beta2-MG), a marker of renal proximal tubular dysfunction, was also measured to assess renal damage. RESULTS: All 15 patients had normal renal function test results. However, microscopic hematuria and pyuria were observed in 13% and 33% of the patients, respectively. Moreover, urine beta2-MG was elevated in 46% of the patients. In addition, patients were divided into two groups based on beta2-MG level: those with an increased beta2-MG level, and those with a normal beta2-MG level. No significant differences were found between these two groups in clinical characteristics, laboratory, sonography, and echocardiography findings. All patients' DMSA renal SPECT scans were normal. CONCLUSION: Our study showed that mild abnormalities in the urinalysis and elevated urine beta2-MG were the only findings of renal involvement in KD. However, no aggressive renal manifestations were detected on DMSA renal SPECT.

Differences in the Clinical Characteristics of Children with Urinary Tract Infections Based on the Results of 99mTc-Dimercaptosuccinic Acid Renal Scanning

PURPOSE: The 99mTc-Dimercaptosuccinic acid (DMSA) renal scan is used primarily for the diagnosis of renal scarring and acute pyelonephritis in children with urinary tract infections (UTI). This study aimed to evaluate clinical differences based on the positive or negative results of DMSA scans and kidney ultrasonography (US) in pediatric UTI. METHODS: We retrospectively reviewed 142 pediatric patients with UTI who were admitted to Myongji Hospital from January 2004 to December 2012. We performed a comparative analysis of clinical parameters such as age, sex, white blood cell (WBC) count, neutrophil count, blood urea nitrogen (BUN) level, creatinine (Cr) level, C-reactive protein (CRP) level, and durations of hospitalization and fever, grouped by the results of the DMSA scans and kidney US. RESULTS: The mean age of the patients was 33.8+/-48.3 months, and 78 (55%) were male. Fifty-two patients had abnormal DMSA findings, and 71 patients had abormal kidney US findings (test positive groups). In the DMSA scan positive group, there were significant differences in age, WBC counts, neutrophil counts, CRP level, BUN level, Cr level, hospitalization duration, number of abnormal findings on kidney US, and incidence of vesicoureteral reflux (VUR) compared with the scan negative group. The kidney US positive group had significant differences in age, neutrophil count, CRP level, BUN level, Cr level, hospitalization duration, number of abnormal findings on the DMSA scans, and more frequent VUR compared with the US negative group. CONCLUSION: Our data suggest that there were no major differences in clinical parameters based on the results of the DMSA scans compared with kidney US in pediatric UTI. However, as kidney US and DMSA scan were performed to predict VUR, the sensitivity and negative predictive value was increased.

Daño renal cortical en niños con primera infección del tracto urinario alto / Cortical renal damage in children with a first infection of the high urinary tract

Introducción: entre el 5 y 22 % de los niños que padecen pielonefritis aguda desarrollarán cicatriz renal. Objetivo: describir los aspectos clínico-epidemiológicos del daño renal cortical en niños con la primera infección del tracto urinario alto. Métodos: estudio observacional prospectivo y longitudinal sobre el daño renal cicatricial en niños con la primera infección urinaria alta, ingresados en el servicio de nefrología del Hospital Pediátrico Universitario "William Soler", entre el 1º de enero de 2008 y diciembre 31 de 2009. Se diagnosticaron 50 pacientes, y 38 reunieron criterios para incluirlos en el estudio. Los pacientes tenían una edad media de 18 meses. A los 38 pacientes se les realizó ultrasonido renal durante la fase aguda de la enfermedad, y gammagrafía renal estática entre 6 y 12 meses después del cuadro agudo, para precisar la lesión renal cortical. En los casos con cicatriz renal, ausencia o disminución de captación del radiofármaco (99mTc-DMSA), se les realizó uretrocistografía miccional para precisar la existencia de reflujo vesicoureteral. Resultados: 28 pacientes (73,7 %) son del sexo femenino, 17 (44,7 %) menores de 6 meses, 17 (44,7 %) tienen entre 6 y 36 meses, y 4 (10,6 %) > 3 años. La infección urinaria fue atípica en 23 (60,5 %), y el germen aislado, la Escherichia coli en 33 (86,8 %). El ultrasonido de la fase aguda demostró dilatación pélvica renal en 3 (7,9 %) y asimetría renal en 1 (2,6 %). En 2 pacientes (5,2 %) se demostró cicatriz renal y en 11 (28,4 %) hipofunción de la corteza renal. La uretrocistografía miccional demostró reflujo vesicoureteral grado III en una niña, que además, tenía cicatriz renal. No existió relación entre el inicio de los síntomas, comienzo de la terapeútica y lesión cortical. Conclusiones: los factores de riesgo para desarrollar cicatriz renal pospielonefrítica fueron: sexo femenino, edad menor de 3 años y reflujo vesicoureteral grado III.

Introduction: between the 5 and the 22 % of children suffering acute pyelonephritis will develop a renal scar. Objective: to describe the clinical-epidemiological features of the cortical renal damage in children with a first infection of high urinary tract. Methods: a longitudinal, prospective and observational study was conducted on the cicatricial renal damage admitted in the Nephrology services of the "William Soler" University Children Hospital from January 1, 2008 to December 31, 2009. Fifty patients were diagnosed and 38 fulfilled the inclusion criteria to study. Patients had a mean age of 18 months and underwent renal ultrasound during the acute phase of disease and static renal scintigraphy between 6 and 12 months after the acute picture, to specify exactly the cortical renal injury. In cases of renal scar, lack or decrease of the radioactive drug capture (99mTc-DMSA) authors carried out miction uretrocystography to specify exactly the presence of vesicoureteral reflux. Results: twenty six patients (73.7 %) are females, 17 (44.7 %) aged under 6 months, 17 (44.7 %) have between 6 and 36 months and 4 (10.6 %) > 3 years old. The urinary infection was atypical in 23 (60.5 %) and as a isolated germ the Escherichia coli in 33 (86.8 %). Ultrasound of acute phase demonstrated a renal pelvis dilation in 3 (7.9 %) and renal asymmetry in 1 (2.6 %). In 2 patients (5.2 %) there was renal scar and in 11 (28.4 %) an decreased function of the renal cortex. The miction uretrocystography demonstrated the presence of grade III vesicoureteral reflux in a girl, who also had a renal scar. There was not relation between the onset of symptoms, the onset of therapeutics and the cortical injury. Conclusions: the risk factors to develop a post-pyelonephritis renal scar were: female sex, be aged under 3 and grade III vesicoureteral reflux.

Función renal relativa normalizada por volumen en la gamagrafía con 99mTc-DMSA: estudio basado en una población pediátrica / Volume normalized relative renal function in 99mTc-DMSA scintigraphy: study in a paediatric population

Objetivo Evaluar las diferentes características diagnósticas de la función renal relativa (FRR) y de la función renal relativa normalizada por volumen renal relativo (FRRN), con el fin de analizar la posible mejora diagnóstica que implicaría su uso conjunto. Métodos Hemos estudiado con 99mTc-DMSA 952 unidades renales (riñones individuales), que pertenecían a 476 pacientes pediátricos (269 niñas) de edades comprendidas entre 0 y 11 años. De ellas, 355 unidades renales se consideraron patológicas a partir del análisis visual gammagráfico. Se determinaron los puntos de corte más apropiados para establecer los valores normales de las funciones FRR y FRRN, considerando como patrón de referencia al análisis visual gammagráfico. Se realizaron curvas ROC y se calculó el índice “J de Youden” y la exactitud para diferentes puntos de corte desde 42 por ciento hasta 50 por ciento, tanto para la FRR como para la FRRN. Se realizó también un análisis bayesiano (global y parcial clasificando las unidades renales por indicaciones clínicas) de la FRR y la FRRN. Resultados Para la FRR el mejor punto de corte fue 45 por ciento y para la FRRN fue 47 por ciento. El análisis bayesiano global mostró mejores resultados de los diferentes parámetros estadísticos para la FRRN. El análisis bayesiano parcial indicaba un importante incremento de la sensibilidad en pacientes con patología de dilatación de vía: de 10 por ciento (FRR) a 74.6 por ciento (FRRN); y con pielonefritis aguda: de 29.2 por ciento (FRR) a 66.2 por ciento (FRRN) mientras que en pacientes con nefropatías crónicas la sensibilidad fue similar (70.1 por ciento). Conclusión El cálculo de la FRRN (punto de corte 47 por ciento) proporciona información útil y complementaria a la FRR, ya que cuantifica la calidad relativa del riñón independientemente del volumen renal y refleja mejor los hallazgos gammagráficos.

Purpose To assess the different diagnostic features of relative renal function (RRF) and volume normalized relative renal function (NRRF) with the aim of analysing the possible diagnostic improvement that would imply their joint use. Methods We studied 952 kidneys with 99mTc-DMSA, belonging to 476 paediatric patients (269 girls) aged 0-11 years. 355 out of total were considered pathologic (visual analysis). The most appropriate cut-off points for establishing normality of RRF and NRRF were determined, considering as gold standard the visual scintigraphic analysis. R.O.C. curves were performed, J Youden index and accuracy were calculated for the different cut-off points from 42 percent to 50 percent for RRF and NRRF. A bayesian analysis (global and partial according to clinical indications) of RRF and NRRF was also performed. Results For RRF the better cut-off point was 45 percent and for NRRF 47 percent. The global bayesian analysis showed better values of the different statistical parameters for NRRF. Partial bayesian analysis indicated an important increment of sensitivity in patients with dilated pyelocalicial system: from 10 percent (RRF) to 74.6 percent (NRRF); and acute pyelonephritis: from 29.2 percent (RRF) to 66.2 percent (NRRF) while the sensitivity in patients with chronic nephropathy remained stable (70.1 percent). Conclusion NRRF calculation (cut-off 47 percent) provides useful and additional information to RRF, as it quantifies the relative quality of kidney tissue regardless of renal volume and better reflects better the scintigraphic findings.

Asimetría en la función relativa en CR DMSA en riñones con doble sistema excretor no complicado: variante normal / Asymmetry in the relative function in CR DMSA in kidneys weith double non complicated excretor system: normal Variant

Introducción: El doble sistema excretor (DS) al Cintigrama Renal (CR) DMSA, con asimetría en la función relativa es un hallazgo relativamente frecuente. Evaluamos su incidencia, correlación con ecografía y valores de función relativa. Material y Método: Se seleccionaron los CR DMSA con diagnóstico cintigráfico de DS sin otras alteraciones. Ecografías sin otros hallazgos. Se comparó la función relativa entre riñones con y sin DS y entre riñones con y sin asimetría de tamaño. T-Test para muestras independientes. Se correlacionó el DMSA con la ecografía. Resultados: 79 pacientes en que se dispuso ecografía fueron estudiados. 17 con DS bilateral (21,5 por ciento). 72 por ciento mujeres, promedio de edad: 54,4 meses (1–204). Función relativa promedio en riñones con DS unilateral: 51,8 por ciento (43-61 por ciento) y 48,19 por ciento (39-57por ciento) en riñones sin DS. p<0,0001. En riñones con DS y aumentados de tamaño la diferencia con el contralateral fue mayor que en los de igual tamaño. Ecografía concordante con el CR DMSA en 52,63 por ciento. Conclusiones: 1.- La función relativa en riñones con Doble Sistema fue significativamente mayor que en riñones sin Doble Sistema, especialmente cuando existió asimetría en el tamaño renal. Esta condición debe considerarse variante normal para evitar la interpretación errada de riñones contralaterales hipofuncionantes. 2.- En la mitad de los pacientes hubo concordancia con la ecografía en diagnóstico de DS, hallazgo esperable.

Aim: Duplex system in DMSA with asymmetry in relative function it’s a frequent finding. We evaluated the incidence, correlation with sonography and the relative functions in these kidneys. Method: We selected patients with scintigraphic diagnosis of duplex system in the DMSA, without any other scintigraphic lesions and had a normal ultrasound. We compared the relative renal function in kidneys with and without duplex system and in kidney with and without size asymmetry. Independent samples t test was applied. DMSA results were compared with ultrasound. Results: 79 patients had ultrasound. 17 with bilateral DS (21.5 percent). 72 percent women; median age: 54.4 months (1–204). Relative function in unilateral DS kidney was 51.8 percent (43-61 percent) and 48.19 percent in kidneys without DS (39-57 percent), p< 0.0001. In kidneys larger and DS the difference in relative function with the contralateral kidney was more important than kidney with similar size. The ultrasound was concordant with DMSA in 52.63 percent of the patients. Conclusions: 1.- The relative function values were significantly higher in kidneys with Duplex System than kidneys without it, especially with asymmetry of the renal size .This condition should be consider a normal variant for to avoid the wrong interpretation of hipofunctioning contralateral kidney. 2.- Half of the patients had duplex system in DMSA scintigraphy and ultrasound, which was predictable.

Prevalence of Vesicoureteral Reflux According to the Timing of Voiding Cystourethrography in Infantile Urinary Tract Infection

PURPOSE: To evaluate the prevalence of vesicoureteral reflux (VUR) according to the timing of voiding cystourethrography (VCUG) in infantile urinary tract infection (UTI). METHODS: The data of 134 infants (1-12 months) with renal cortical defect in 99mTc-2, 3-dimercaptosuccinic acid (99mTc-DMSA) scan with a diagnosis of UTI in two hospitals from 2000 to 2010 were retrospectively analyzed. The VCUG was performed after 2 weeks from the diagnosis of UTI in Group I (n=68), and the VCUG was performed within 2 weeks from the diagnosis of UTI in Group II (n=66). RESULTS: There were no significant differences between the two groups in the duration of fever, white blood cell count, C-reactive protein levels, and abnormalities in ultrasonography (P>0.05). There was no significant difference between the two groups in the prevelence of VUR, bilateral VUR, and severe VUR. VCUG-induced UTI was detected 16 (23.5%) of patients in whom the procedure was performed 2 weeks after the diagnosis, and none of VCUG-induced UTI occurred in those in whom the procedure was performed 2 weeks within the diagnosis. CONCLUSION: We conclude that the prevalence of VUR according to the timing of VCUG did not differ between the two groups in infantile UTI with renal cortical defect in DMSA scan. We also found that performing VCUG with antibiotics can decrease risk of VCUG-induced UTI.

Limitations of 99mTc-DMSA scan in diagnosing acute pyelonephritis in children / 소아과

PURPOSE: We aimed to prove the relative limitation of 99mTc-DMSA scintigraphy (DMSA) compared to computed tomography (CT) in diagnosing acute pyelonephritis (APN) in children. METHODS: Since September 2006, after a 64-channel CT was imported, 10 DMSA false-negative patients have been identified: these patients underwent a CT scan for acute abdomen or acute febrile symptoms and were diagnosed as having APN; however, their DMSA scans were clear. We focused on these 10 DMSA false-negative patients and analyzed their clinical findings and CT results. We used Philips Brilliance Power 64-channel CT scanner for the CT scan and Siemens Orbitor Nuclear Camera 60 Hz for the DMSA scan. RESULTS: The 10 DMSA false-negative patients were mostly males (80%) and infants (80%). They had fever for a mean of 1.1-day duration before admission and showed increase in acute reactants: leukocyte, erythrocyte sedimentation rate, and C-reactive protein. The CT findings of renal lesions were focal in 6 (60%) cases and diffuse in 4 (40%) cases, and most of the lesions were unilateral in 80% of patients. CT proved that 22 renal lesions were neglected by DMSA. Differential renal function test by DMSA was also of no use in the evaluation of renal lesions. CONCLUSION: In this study, DMSA scan showed limitation in finding renal cortical lesions of CT-proven APN patients. DMSA false-negative results seem to occur at early-phase disease of infantile age, but more prospective studies are needed to determine the reasons and their prevalence.