Practical approach to screen vesicoureteral reflux after a first urinary tract infection

Abstract

Introduction:Vesicoureteral reflux (VUR) is a common pediatric urologic disorder. After the first urinary tract infection (UTI), imaging studies are recommended, starting with a renal ultrasound (RUS). Voiding cystourethrography (VCUG) and dimercaptosuccinic acid (DMSA) scan are the other main radiologic studies used to detect VUR. We evaluated the use of RUS as a screening method for VUR in children below 2 years of age, in order to avoid unnecessary VCUG.Materials and Methods:Medical records and imaging studies of infants (<2 years) who had their first UTI in a 6 year period were retrospectively reviewed. We evaluated the sensitivity, specificity, and negative predictive values of RUS and DMSA for diagnosing VUR.Results:Among 155 children (51% males) with their first UTI, 148 RUS were performed, 128 VCUG and 29 DMSA. VUR was detected in 21% patients; 14.5% low grade and 6.5% high grade. One hundred and twenty-one patients underwent both RUS and VCUG, 101 RUS were normal and 20 abnormal. Of the normal RUS 98% had no or low grade VUR. Among those with an abnormality on RUS 30% had high grade VUR (P < 0.001).Conclusions:After the first UTI in infants (<2 years) RUS is a good screening method for VUR. Among such shildren with a normal RUS, we do not recommend VCUG or DMSA. In our opinion, VCUG should be performed only in patients with abnormal findings in RUS or in recurrent UTI.

Ureter Visualization on Tc-99m DMSA Scintigraphy in Pediatric Patients

“…Several other studies have pointed out the same finding and have concluded that cystourethrography is indicated in only patients with DMSA abnormalities [2]. This methodology has high sensitivity and negative predictive value in the detection of high grade VUR (86% and 93% respectively) [2,3]. The Visualization of the dilated collecting system in DMSA scintigraphy has never been analyzed previously.…”

“…Recent studies have indicated another potential benefit of DMSA scan to pick patients who need further imaging by voiding for diagnosis of VUR [2,3]. None of the patients with normal DMSA scintigraphy had high grade VUR according to these reports.…”

Predictive score for vesicoureteral reflux in children with a first febrile urinary tract infection

“…Abnormal renal US results also showed a statistically significant association with VUR after a first febrile UTI in children. 26,27 Fuente et al 28 reported that 98% of children with normal renal US results after a first febrile UTI had no or low-grade VUR (grades I and II VUR), and VCUG should be considered only in children with abnormal findings on renal US. The negative predictive value of renal US for identifying VUR was 90% in the present study.…”

Risk factors for kidney damage in pediatric patients with recurrent urinary tract infections

“…La cistoutretrografía miccional (CUGM), es el método de oro para detectar RVU, pero requiere cateterización uretral que es dolorosa, conlleva un (17) riesgo de infección y produce irradiación. La Academia Americana de Pediatría no recomienda la prescripción de CUGM en forma rutinaria después de la primera ITU, excepto en caso de detección ecográfica de hidronefrosis, uropatía obstructiva, u otros tipos de anomalías como (18) cicatrices renales o en ITU atípica , a pesar de que la ecografía no es un buen método para detectar RVU porque ésta puede ser normal en RVU debajo grado, y en los de alto grado puede demostrar signos indirectos como dilatación ureteral o hidronefrosis.…”