DMSA Scan Research Articles

Procalcitonin, C-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children.

In children with urinary tract infection (UTI), only those with pyelonephritis (and not cystitis) are at risk for developing long-term renal sequelae. If non-invasive biomarkers could accurately differentiate children with cystitis from children with pyelonephritis, treatment and follow-up could potentially be individualized. This is an update of a review first published in 2015. The objectives of this review were to 1) determine whether procalcitonin (PCT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) can replace the acute DMSA scan in the diagnostic evaluation of children with UTI; 2) assess the influence of patient and study characteristics on the diagnostic accuracy of these tests, and 3) compare the performance of the three tests to each other. We searched MEDLINE, EMBASE, DARE, Web of Science, and BIOSIS Previews through to 17th December 2019 for this review. The reference lists of all included articles and relevant systematic reviews were searched to identify additional studies not found through the electronic search. We only considered published studies that evaluated the results of an index test (PCT, CRP, ESR) against the results of an acute-phase 99Tc-dimercaptosuccinic acid (DMSA) scan (conducted within 30 days of the UTI) in children aged 0 to 18 years with a culture-confirmed episode of UTI. The following cut-off values were used for the primary analysis: 0.5 ng/mL for procalcitonin, 20 mg/L for CRP and 30 mm/hour for ESR. Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate pooled random-effects pooled sensitivity and specificity values. A total of 36 studies met our inclusion criteria. Twenty-five studies provided data for the primary analysis: 12 studies (1000 children) included data on PCT, 16 studies (1895 children) included data on CRP, and eight studies (1910 children) included data on ESR (some studies had data on more than one test). The summary sensitivity estimates (95% CI) for the PCT, CRP, ESR tests at the aforementioned cut-offs were 0.81 (0.67 to 0.90), 0.93 (0.86 to 0.96), and 0.83 (0.71 to 0.91), respectively. The summary specificity values for PCT, CRP, and ESR tests at these cut-offs were 0.76 (0.66 to 0.84), 0.37 (0.24 to 0.53), and 0.57 (0.41 to 0.72), respectively. The ESR test does not appear to be sufficiently accurate to be helpful in differentiating children with cystitis from children with pyelonephritis. A low CRP value (< 20 mg/L) appears to be somewhat useful in ruling out pyelonephritis (decreasing the probability of pyelonephritis to < 20%), but unexplained heterogeneity in the data prevents us from making recommendations at this time. The procalcitonin test seems better suited for ruling in pyelonephritis, but the limited number of studies and the marked heterogeneity between studies prevents us from reaching definitive conclusions. Thus, at present, we do not find any compelling evidence to recommend the routine use of any of these tests in clinical practice.

Renal Cortical 68Ga-PSMA-11 PET and 99mTc-DMSA Images.

68Ga-prostate-specific membrane antigen (PSMA) ligands are novel PET radiotracers for prostate cancer. These radiotracers also localize in the normal renal cortex to a high degree and can demonstrate parenchymal defects. We recently started a prospective research study to compare 68Ga-PSMA-11 PET/CT with 99mTc-dimercaptosuccinic acid (DMSA) scan in adults with pyelonephritis. Here, we present a side-by-side comparison of renal cortical PSMA PET/CT and DMSA images of an adult patient with chronic recurring pyelonephritis. Methods: Our prospective study was approved by the Ethical Committees. DMSA images (multiple planar and SPECT) were obtained 3 h after intravenous injection of 111 MBq (3 mCi) of 99mTc-DMSA. On a separate day, we obtained PET/CT images of the kidneys 60 min after intravenous injection of 74 MBq (2 mCi) of 68Ga-PSMA-11 after the patient provided written informed consent. Results: The patient was a 46-y-old woman with history of chronic recurring pyelonephritis. Both DMSA scan and PSMA PET/CT demonstrated slight cortical thinning with mildly reduced uptake in the upper pole of the right kidney, with no significant cortical defects. There was an excellent distribution of activity in the renal cortex and better image resolution with PSMA PET than with DMSA scan. Non-attenuation-corrected PSMA PET images also showed the same findings, with reasonable image quality. Conclusion: In our first case, 68Ga-PSMA-11 PET imaging provided promising results in an adult patient with pyelonephritis. The results of our prospective study on a larger number of adult patients will provide a more accurate comparison of 68Ga-PSMA-11 PET to 99mTc-DMSA scanning in pyelonephritis.

99mTc-dimercaptosuccinic acid scan versus MRI in pyelonephritis: a meta-analysis

Tc-dimercaptosuccinic acid (DMSA) scan is the current gold standard in detecting parenchymal changes, particularly scarring, in pyelonephritis. Recently, magnetic resonance imaging (MRI) is gaining popularity in the diagnosis of pyelonephritis. The aim of this study is to perform a meta-analysis on studies directly comparing MRI to DMSA scan in patients with pyelonephritis. Systematic searches of PUBMED and EMBASE databases were performed to extract studies comparing MRI and DMSA scan in patients with pyelonephritis. The relevance of articles was assessed by two authors according to predefined inclusion and exclusion criteria. The pooled estimates of the sensitivities of MRI and DMSA scan were computed using random-effects meta-analysis model following DerSimonian and Laird's method. Subgroup analysis and publication bias were performed. Seven studies were included (164 patients). Using random effect model, the pooled estimate of the sensitivities of MRI and DMSA scan were 0.62 (95%CI: 0.44 - 0.77) and 0.59 (95%CI: 0.48 - 0.70), respectively. The pooled estimates of sensitivities of MRI and DMSA scan for acute pyelonephritis were 0.73 (95%CI: 0.49- 0.89) and 0.66 (95%CI: 0.56 - 0.75), respectively, and for scar detection were 0.48 (95%CI: 0.31- 0.66), and 0.50 (95%CI: 0.30 - 0.71), respectively. The overall sensitivities of MRI and DMSA scan were equivalent in detecting parenchymal changes in pyelonephritis. MRI and DMSA scan appeared to be equivalent to scar detection. In a small number of studies, MRI appeared to be better than the DMSA scan in acute pyelonephritis but this should be further studied in a larger number of patients.

Real-Time DMSA-SPECT/US Fusion Imaging Revealing Nonscarring Loss of Function After Pyelonephritis.

Using real-time SPECT/US fusion imaging, the localization of an uptake defect in DMSA scan could be identified unambiguously after being uncertain in ultrasound alone. Thereby, a localized functional loss, due to history of pyelonephritis, without scarring, but reduced cortical thickness could be verified. DMSA-SPECT/US primarily demonstrates its utility in depiction of renal pathologies and may be a descriptive tool in equivocal constellation of findings.

The value of quantitative pentavalent 99mTc-dimercaptosuccinic acid scan in predicting progression-free survival and overall survival in patients with glioblastoma multiforme

AbstractAim:Glioblastoma multiforme (GBM) is the commonest and the most aggressive primary brain tumour. Pentavalent 99mTc-dimercaptosuccinic acid (99mTc (V)-DMSA) has been found to be a tumour-seeking agent. Pre-radiotherapy 99mTc (V)-DMSA positive scan was found to be significantly correlated with poor progression-free survival (PFS) and overall survival (OS). This study aims at evaluating the impact of quantitative 99mTc (V)-DMSA tumour uptake before and after radiotherapy on PFS and OS in patients with GBM.Methods:A prospective study included 40 patients with GBM. Single-photon emission computed tomography studies were done before and after adjuvant radiotherapy and were qualitatively and quantitatively evaluated. The retention index (RI) of the viable tumour was correlated with PFS and OS.Results:The qualitative enhancement of 99mTc (V)-DMSA uptake either positive or negative was significantly correlated with PFS at both early and late images (p-values 0·04 and 0·026, respectively) and OS only in the late image (p-value 0·036). The calculated ion/non-lesion ratios at late images were statistically correlated with PFS and OS (p-values 0·021 and 0·025, respectively). The baseline RI had significant correlation with PFS only (p-value 0·01).Conclusion:The degree of 99mTc (V)-DMSA scan positivity is a poor prognostic factor for PFS and OS in GBM patients.

MP27-01 TIME-DRIVEN ACTIVITY-BASED COST ANALYSIS OF MANAGEMENT PATHWAYS FOR VESICOURETERAL REFLEX

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures (MP27)1 Apr 2020MP27-01 TIME-DRIVEN ACTIVITY-BASED COST ANALYSIS OF MANAGEMENT PATHWAYS FOR VESICOURETERAL REFLEX Lucshman Raveendran*, Robert Di Cesare, Kornelia Twardowski, David During, Darius Bagli, Myla Moretti, and Martin Koyle Lucshman Raveendran*Lucshman Raveendran* More articles by this author , Robert Di CesareRobert Di Cesare More articles by this author , Kornelia TwardowskiKornelia Twardowski More articles by this author , David DuringDavid During More articles by this author , Darius BagliDarius Bagli More articles by this author , Myla MorettiMyla Moretti More articles by this author , and Martin KoyleMartin Koyle More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000866.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The evaluation, management, and clinical guidelines surrounding vesicoureteral reflux (VUR) remain highly variable despite being a common pediatric diagnosis, all of which make costing unpredictable. Time-Driven Activity-Based Costing (TDABC) is a novel costing methodology that is purported to provide a rapid and more accurate calculation of total costs vs. traditional costing methods. It also frames granular insights into cost drivers and savings opportunities for a given diagnosis. The aim of the study is to employ TDABC to characterize institutional costs for three management pathways for VUR. METHODS: We developed detailed process maps for VUR management based on practice guidelines applicable to a hypothetical female VUR index patient with grade 3 unilateral reflux without bowel-bladder dysfunction at our tertiary-care center institution. The cost of three management pathways were described: observation with continuous antibiotic prophylaxis (OCAP); minimally-invasive endoscopic surgery (EDP) with dextranomer/hyaluronic acid; and open re-implantation surgery (ORP). Costs for each pathway were calculated using the capacity cost rate ($/minute) for institutional resources and time estimates of resource utilization captured through direct observation and EMR data. The three pathways engaged the full spectrum of possible follow-up visits, diagnostic imaging, and interventions in VUR management. RESULTS: A substantial range of total costs was observed for all pathways: OCAP ($1,683.58 - $2,041.12), EDP ($2,262.37 - $4,012.89), and ORP ($3,317.76 - $3,924.82). On average, variation in diagnostic imaging accounted for an average of $558.81 to the cost of management pathways. Moreover, total costs for a single DMSA scan accounted for 8%-15% of any pathway’s overall costs. Material costs for VCUG imaging and endoscopic surgery were high at 59% and 64%-76% of their individual total costs, respectively. For open-reimplantation surgery, higher costs were attributable to the longer use of operating room space (vs. EDP) and inpatient post-operative stay, the latter accounting for 21.7% of total costs of ORP. CONCLUSIONS: To our knowledge, this is the first application of TDABC to describe the cost of services delivered in pediatric urology. TDABC demonstrates significant cost variability in VUR treatment modalities and identified local cost drivers to target. This type of analysis can be useful for other potential patients with various grades, laterality, age and sex of VUR, as well as in other complex management situations. Source of Funding: This project was supported by the AUA Medical Student Fellowship © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e409-e409 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lucshman Raveendran* More articles by this author Robert Di Cesare More articles by this author Kornelia Twardowski More articles by this author David During More articles by this author Darius Bagli More articles by this author Myla Moretti More articles by this author Martin Koyle More articles by this author Expand All Advertisement PDF downloadLoading ...

Accuracy of Ultrasound in Identifying Renal Scarring as Compared to DMSA Scan

ObjectiveTo assess the accuracy of renal ultrasound (RUS) in detecting renal scarring (RS). MethodsAll initial DMSA scans performed from 2006 to 2009 for history of urinary tract infection (UTI) or vesicoureteral reflux (VUR) in patients under 14 years old were identified, and clinical history obtained via chart review. Patients who had RUS within 4 months of DMSA scan and no documented UTI during that interval were included. Decreased uptake of tracer associated with loss of contours or cortical thinning defined a positive DMSA study. Increased echogenicity/dysplasia, cortical thinning, atrophic kidney and/or abnormal corticomedullary differentiation defined a positive RUS. The sensitivity and specificity of RUS in identifying RS were calculated using DMSA scan as the gold standard. ResultsA total of 144 patients had initial DMSA scans performed for UTI or VUR, with a RUS within 4 months, and no UTI between the 2 studies. Ninety-five of 144 (66%) had RS on DMSA and 49/144 (34%) did not. Patients with or without RS on DMSA were not different in gender (P = .073), age (P = .432), insurance (P = 1.000) or VUR grade (P = .132). Only 39/144 (27.1%) patients had positive RUS. The sensitivity of RUS for RS was 35.8% and the specificity was 89.8%, leading to an accuracy of 54.2% (95%CI; 45.7-62.5%, P = .999). ConclusionRUS demonstrated poor sensitivity for RS visualized on DMSA scan. This suggests that RUS is a poor screening test for RS or indicators of future renal scar. A normal ultrasound does not rule out RS or risk of future renal scar. Specificity of RUS was excellent.

The role of Thallium-201 scintigraphy and Tc-99m pentavalent dimercaptosuccinic acid in diagnosis and grading of chondrosarcoma

PurposeDistinguishing between enchondromas and low-grade (grade 1) chondrosarcomas can be challenging. The aim of this study was to investigate the role of Thallium-201 scintigraphy and Technetium-99 m pentavalent dimercaptosuccinic acid (Tc-99 m DMSA (V)) in the diagnosis and grading of chondrosarcomas. Methods232 consecutive patients with pathologically proven cartilaginous tumours between the years 2000 and 2018 were evaluated. We included 197 patients (101 males and 96 females; median age 50 years; range 15–86 years) who underwent Thallium-201(n = 193) and/or Tc-99 m DMSA (V) scanning (n = 67). Increased uptake was defined as uptake greater than background. The reference standard was the histopathological assessment based on a grading system (grade 1–3). Data was analysed using multivariate modelling. ResultsThere were 46 patients with enchondromas and 151 with chondrosarcomas. Of those, 64 (enchondroma n = 21, chondrosarcoma n = 43) underwent both Thallium-201 and Tc-99 m DMSA (V). Thallium-201 uptake had 7.92 times greater odds of grade 1 chondrosarcomas than enchondromas. Thallium-201 uptake was significantly associated with the odds of a higher grade chondrosarcoma (grade 2–3). DMSA (V) positivity was associated with 4.75 times the odds of a chondrosarcoma diagnosis over enchondroma (p = 0.024). DMSA (V) uptake revealed no association with chondrosarcoma grading. ConclusionLow-grade chondrosarcomas continue to pose a diagnostic dilemma. Thallium-201 scans may identify malignancy in benign appearing tumours as well as differentiate between low-grade and high-grade chondrosarcomas in said malignancies. DMSA (V) may be useful in distinguishing between benign and malignant entities as a whole.

Clinical value of late DMSA scan in predicting vesicoureteral reflux in children with febrile urinary tract infection

Clinical value of late DMSA scan in predicting vesicoureteral reflux in children with febrile urinary tract infection

Validity of urine neutrophile gelatinase-associated lipocalin in children with primary vesicoureteral reflux.

Vesicoureteral reflux (VUR) is the most common congenital urinary tract abnormality in children. The objective of this study was to evaluate the diagnostic value of urine neutrophil gelatinase-associated lipocalin (NGAL) in children with primary vesicoureteral reflux (VUR). A total of 69 patients were evaluated in 2 groups with (32) and without (37) VUR. Patients with secondary VUR, infectious or inflammatory disorders, obstructive uropathies, and acute or chronic kidney disease were excluded. Urine NGAL level was measured by ELISA kit. Mean age of children with VUR was 36.84 ± 28.16, compared to those without VUR 32.32 ± 29.08, with no significant difference (p = 0.51). Mean urine NGAL (p = 0.012) and urine NGAL/Cr (p = 0.003) were higher in patients with VUR. In addition, urine NGAL/Cr increased significantly in patients with decreased parenchymal function, compared to those with normal DMSA scan. Using the cutoff value of 0.888, urine NGAL had 84% sensitivity and 81% specificity for diagnosis of VUR. Based on AUC (0.86), urine NGAL had acceptable diagnostic accuracy in children with VUR. The results of this study support the evidence that urine NGAL/Cr is a sensitive, specific and accurate biomarker for diagnosis of children with primary VUR.

Xanthogranulomatous pyelonephritis: The conundrum of a calcified kidney

Abstract Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic destructive granulomatous inflammation of the kidney that can sometimes mimic other renal pathologies like tumours or infections. For this reason, it is also called “the great imitator”. This is the case of a 7-year old girl that presented to the hospital with right hip pain and a suspicious right sided abdominal lesion, thought initially to be a Wilms’ tumour and then an appendiceal mass with a psoas abscess. The abscess was percutaneously drained and the patient was treated with intravenous antibiotics. At 6 weeks interval, the interval appendicectomy was negative. On subsequent follow-up imaging, an abnormally structured kidney was shown, surrounded by a calcified rim and a remnant psoas abscess, which suggested XGP or tuberculous (TB) pyelonephritis as differentials. A DMSA scan showed no function in the affected kidney and the patient underwent a nephroureterectomy. The histopathology showed features that prompted consideration of tuberculosis but ultimately allowed a diagnosis of XGP. XGP can be a confounding pathology as in the present case, where there remained multiple clinical, radiological and histological differentials throughout the course of the patients care, right up to the final diagnosis.

Children with vesicoureteric reflux have joint hypermobility and occasional tenascin XB sequence variants.

To consider alternative mechanisms that give rise to a refluxing ureterovesical junction (UVJ), we hypothesized that children with a common heritable urinary tract defect, vesicoureteric reflux (VUR), may have a defect in the extracellular matrix composition of the UVJ and other tissues that would be revealed by assessment of the peripheral joints. Hypermobile joints can arise from defects in the extracellular matrix within the joint capsule that affect proteins, including tenascin XB (TNXB). We performed an observational study of children with familial and non-familial VUR to determine the prevalence of joint hypermobility, renal scarring, and DNA sequence variants in TNXB. Most children (27/44) exhibited joint hypermobility using the Beighton scoring system. This included 15/26 girls (57.7%) and 12/18 boys (66.7%), which is a significantly higher prevalence for both sexes when compared to population controls (p<0.005). We found no association between joint hypermobility and renal scarring. Seven of 49 children harbored rare pathogenic sequence variants in TNXB, and two also exhibited joint hypermobility. No sequence variants in TNXB were identified in 25/27 children with VUR and joint hypermobility. Due to the observational design of the study, there was missing data for joint hypermobility scores in six children and for dimercaptosuccinic acid (DMSA) scans in 17 children. We observed a high prevalence of VUR and joint hypermobility in children followed within a tertiary care pediatric urology clinic. While mutations in TNXB have been reported in families with VUR and joint hypermobility, we identified only two children with these phenotypes and pathogenic variants in TNXB. We, therefore, speculate that VUR and joint hypermobility may be due to mutations in other extracellular matrix genes.

Evaluation of cyclic direct radionuclide cystography findings with DMSA scintigraphy results in children with a prior diagnosis of vesicoureteral reflux.

Direct radionuclide cystography (DRC) with cyclic imaging is a sensitive method used for the detection of vesicoureteral reflux (VUR). Radionuclide cystography is generally recommended for follow-up evaluation of VUR. The aim of this study was to evaluate cyclic DRC with DMSA scan results during the follow-up period in children with a prior diagnosis of VUR. DRC findings of 85 children with VUR were evaluated together with DMSA findings during follow-up. VUR grade was classified anatomically as grades I, II, and III reflux. Reflux grades of II and III were regarded as high-grade reflux. Reflux was also graded functionally as transient and continuous on the basis of the presence of reflux on either filling or voiding phases (transient) or both phases (continuous) of at least one cycle. Among 85 children, 32 (38%) exhibited reflux. In five patients, reflux was observed on both sides, and a total of 37 refluxing units (RUs) were evaluated. According to the highest grade attained in either cycle, 31 (84%) units had grade II, five had grade I and one had grade III reflux. Reflux was continuous in 23 (62%) and transient in 14 (38%) RUs. The incidence of an abnormal scan result was higher in continuous reflux group (78%) than in high-grade anatomic reflux group (59%). The addition of a second cycle resulted in the diagnosis of continuous reflux in six (26%) more RUs. DMSA scan findings correlated significantly with functional reflux classification (P<0.05), but not with anatomic reflux classification (P>0.05). Functional classification of VUR into continuous and transient reflux resulted in higher correlation with DMSA scan findings compared with anatomic reflux grading in follow-up patients with VUR. Cyclic imaging contributed to continuous reflux diagnosis. The significance of functional information obtained from cyclic DRC in initial diagnostic workup, management, and follow-up of children with urinary tract infection needs to be determined with further studies.

Changes in Serum Levels of Interleukin-8 in Upper and Lower Urinary Tract Infections in 3 months to 12 years' children in Semnan

Background: Urinary tract infection (UTI) is one of the most common bacterial diseases in children. This infection can lead to serious complications, such as chronic kidney injury, chronic renal failure, and even hypertension. The aim of this study was to investigate changes in serum levels of interleukin-8 in upper and lower urinary tract infections, and to investigate its association with the type of urinary tract involvement. Methods: This was a cross-sectional and prospective study. The study population consisted of all children aged 3 months to 12 years' old who referred to Amiralmomenin Hospital in Semnan city. By convenience sampling, 57 children were enrolled and received either oral or injectable treatment. Interleukin-8 serum levels were measured before and 3 days after treatment, by ELISA method and using available kits. DMSA scan was performed one week after admission to assess the severity of kidney parenchymal involvement in order to determine and distinguish between lower and upper urinary tract infections. Results: Totally 57 subjects with mean age 21.2 ± 20.76 months were enrolled. Children aged more than 20 months were more likely to have upper urinary tract infection than the other group (P=0.005). In males, the prevalence of upper urinary tract infection was significantly lower (P = 0.049). Children with upper urinary tract infection had a higher interleukin-8 concentration (P=0.001) than the lower urinary tract infection. Conclusion: IL-8 had higher serum concentrations in upper urinary tract infections compared to lower urinary tract infections. As a result, this test can be used as a suitable substitute for DMSA scan, to predict the type of urinary tract infection.

Interventions for primary vesicoureteric reflux.

Interventions for primary vesicoureteric reflux.

Serum neutrophil gelatinase-associated lipocalin for predicting acute pyelonephritis in infants with urinary tract infection.

IntroductionFever and elevated inflammatory markers have been used for diagnosis of acute pyelonephritis (APN) in infants with urinary tract infection (UTI).The aim of the study was to compare the usefulness of serum neutrophil gelatinase-associated lipocalin (sNGAL) with inflammatory markers for predicting APN in infants with UTI.Material and methodsThe prospective study included 46 infants with a first episode of UTI, divided into two groups (APN 23, lower UTI 23), according to the DMSA scan results. The following laboratory tests were performed: sNGAL, PCT, CRP, WBC, and ESR.ResultsSignificantly elevated levels of sNGAL, PCT, CRP, and ESR were observed in infants with APN compared to those with lower UTI. Higher sNGAL, CRP, and ESR values, presence of fever, and longer duration of fever before antibiotic treatment were associated with APN [odds ratio (OR) 1.02, 1.27, 1.03, 13.46, 2.12, respectively]. Receiver operating characteristic (ROC) analysis showed better diagnostic profiles for sNGAL, PCT, and CRP than for ESR for predicting APN [area under the curve (AUC) 0.808, 0.819, 0.841, and 0.750, respectively]. The appropriate cut-off values of sNGAL, PCT and CRP were 100.8 ng/ml, 0.15 ng/ml, 5.3 mg/dl (all sensitivity and specificity 82.6%), and that of ESR was 40 mm/h (sensitivity 78.3%, specificity 60.9%).ConclusionssNGAL shows similar usefulness as PCT and CRP for predicting APN in infants with UTI, the diagnostic value of ESR is smaller, and WBC is not useful at all. The presence of fever and longer duration of fever are important predictors of APN in infants with UTI.

Early start of clean intermittent catheterization versus expectant management in children with spina bifida

PurposeWe instituted early clean intermittent catheterization (CIC) in 1997 for all newborn infants with spina bifida (SB). We compared this group to a historical group managed expectantly to see if early catheterization was associated with a reduction in renal scar rate as determined by DMSA scanning. MethodsData were studied retrospectively on all infants with SB over a recent 13-year period who were treated with early universal CIC in a regional pediatric urology department. These were compared to our previously published outcomes in a historical group (1985–1994) that was managed expectantly [Brown et al. Chronic pyelonephritis in association with neuropathic bladder. Eur J Pediatr Surg 1999;9 Suppl 1:29–30.] Results114 infants were born with SB from 1997 to 2010, of which 13 were excluded from this analysis. Mean follow-up was 11.4 years. In the historical cohort there were 126 infants born from 1985 to 1994, with 26 exclusions; follow-up then ranged from 4 to 13 years. DMSA scan showed renal scarring in 19/101 (18.8%) of the recent cohort versus 39/100 (39%) of the previous group (P = 0.002). Renal scarring at a later age also appeared to be a feature of the recent group, with first detection occuring by 4 years in only 9/19 (47%) in the latest cohort compared to 28/39 (72%) in the historical cohort. ConclusionBased on these renal protective data, we recommend indwelling and then intermittent catheterization from birth in all patients with SB. Level of evidenceLevel III. Type of studyRetrospective, cohort comparison study.

Antinatriuretic phenomena seen in children with acute pyelonephritis may be related to the activation of intrarenal RAAS

We investigated whether antinatriuretic phenomena [decreases in urinary sodium (uNa) and fractional excretion of sodium (FENa)] seen in children with acute pyelonephritis (APN) are associated with the renin–angiotensin–aldosterone system (RAAS).We examined 114 children experiencing their first episode of febrile urinary tract infection (fUTI) consecutively admitted to our hospital from July 2012 to June 2014. Blood tests [C-reactive protein, white blood cell count, erythrocyte sedimentation rate, and aldosterone (Aldo)] and urine tests [uNa, urine potassium (uK) and FENa] were performed upon admission. All enrolled children underwent a 99m-dimercaptosuccinic acid renal scanning (DMSA) at admission. Areas with cortical defects (AreaCD) and uptake counts (UptakeCD) on their DMSA scans were calculated. Data were compared between children with positive DMSA results (APN), lower urinary tract infection (L-UTI), and controls; and between children with high and low Aldo levels.uNa, uNa/K, and FENa negatively correlated with AreaCD%, UptakeCD, and Aldo; were significantly lower in APN patients than in LUTIs and controls regardless of Aldo level; were lower in the high Aldo group than in the low Aldo group. However, there is no difference in AreaCD% and UptakeCD between APN children with the high and low Aldo level.Decreases in uNa, uNa/K, and FENa in children with APN may result from an antinatriuretic effect of RAAS and be related to the activation of the intrarenal RAAS.

鈍的腎茎部損傷の治療法の変遷(Transition of treatment for blunt renal pedicle injury: through our 12 cases)

要旨鈍的腎茎部損傷（以下，本症）は，多発外傷を伴うことが多く，迅速な治療の選択を迫られる。しかし治療法が確立しているわけではない。自験例を検討し，本症の治療法を考える。沖縄県立中部病院の33年間と，沖縄県立北部病院の27年間に経験した12例に対して，診療録を後方視的に検討した。男女比は男9例，女3例。年齢中央値は31歳（9–58）。受傷機転は交通外傷10例，木材による圧挫傷1例，転落1例。多発外傷は5例で，他臓器損傷は全例に認めた。治療は腎摘6例，再建4例，未治療2例であった。再建腎の腎機能回復例は，1例のみであった。未治療の1例に高血圧を発症した。血液透析を要する症例はなかった。死亡例は2例で，原因は大量出血による凝固障害と敗血症であった。本症の治療では，救命が最優先であり，そのための腎摘や未治療は，許容される。再建群では不完全閉塞型腎動脈損傷の1例に術後腎機能が回復した。完全閉塞型に対する再建の成功率は非常に低いと考える。

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.