Renal Ultrasound Scan Research Articles

A prospective observational study of associated anomalies in Hirschsprung's disease.

BackgroundAssociated anomalies have been reported in around 20% of Hirschsprung patients but many Authors suggested a measure of underestimation. We therefore implemented a prospective observational study on 106 consecutive HSCR patients aimed at defining the percentage of associated anomalies and implementing a personalized and up-to-date diagnostic algorithm.MethodsAfter Institutional Ethical Committee approval, 106 consecutive Hirschsprung patients admitted to our Institution between January 2010 and December 2012 were included. All families were asked to sign a specific Informed Consent form and in case of acceptance each patient underwent an advanced diagnostic algorithm, including renal ultrasound scan (US), cardiologic assessment with cardiac US, cerebral US, audiometry, ENT and ophthalmologic assessments plus further specialist evaluations based on specific clinical features.ResultsMale to female ratio of our series of patients was 3,4:1. Aganglionosis was confined to the rectosigmoid colon (classic forms) in 74,5% of cases. We detected 112 associated anomalies in 61 (57,5%) patients. The percentage did not significantly differ according to gender or length of aganglionosis. Overall, 43,4% of patients complained ophthalmologic issues (mostly refraction anomalies), 9,4% visual impairment, 20,7% congenital anomalies of the kidney and urinary tract, 4,7% congenital heart disease, 4,7% hearing impairment or deafness, 2,3% central nervous system anomalies, 8,5% chromosomal abnormalities or syndromes and 12,3% other associated anomalies.ConclusionsOur study confirmed the underestimation of certain associated anomalies in Hirschsprung patients, such as hearing impairment and congenital anomalies of the kidney and urinary tract. Subsequently, based on our results we strongly suggest performing renal US and audiometry in all patients. Conversely, ophthalmologic assessment and cerebral and heart US can be performed according to guidelines applied to the general population or in case of patients with suspected clinical features or chromosomal abnormalities. This updated diagnostic algorithm aims at improving overall outcome thanks to better prognostic expectations, prevention strategies and early rehabilitation modalities. The investigation of genetic background of patients with associated anomalies might be the next step to explore this intriguing multifactorial congenital disease.

A clinical and molecular review of ubiquitous glucose-6-phosphatase deficiency caused by G6PC3 mutations

The G6PC3 gene encodes the ubiquitously expressed glucose-6-phosphatase enzyme (G-6-Pase β or G-6-Pase 3 or G6PC3). Bi-allelic G6PC3 mutations cause a multi-system autosomal recessive disorder of G6PC3 deficiency (also called severe congenital neutropenia type 4, MIM 612541). To date, at least 57 patients with G6PC3 deficiency have been described in the literature.G6PC3 deficiency is characterized by severe congenital neutropenia, recurrent bacterial infections, intermittent thrombocytopenia in many patients, a prominent superficial venous pattern and a high incidence of congenital cardiac defects and uro-genital anomalies. The phenotypic spectrum of the condition is wide and includes rare manifestations such as maturation arrest of the myeloid lineage, a normocellular bone marrow, myelokathexis, lymphopaenia, thymic hypoplasia, inflammatory bowel disease, primary pulmonary hypertension, endocrine abnormalities, growth retardation, minor facial dysmorphism, skeletal and integument anomalies amongst others. Dursun syndrome is part of this extended spectrum. G6PC3 deficiency can also result in isolated non-syndromic severe neutropenia. G6PC3 mutations in result in reduced enzyme activity, endoplasmic reticulum stress response, increased rates of apoptosis of affected cells and dysfunction of neutrophil activity.In this review we demonstrate that loss of function in missense G6PC3 mutations likely results from decreased enzyme stability. The condition can be diagnosed by sequencing the G6PC3 gene. A number of G6PC3 founder mutations are known in various populations and a possible genotype-phenotype relationship also exists. G6PC3 deficiency should be considered as part of the differential diagnoses in any patient with unexplained congenital neutropenia.Treatment with G-CSF leads to improvement in neutrophil numbers, prevents infections and improves quality of life. Mildly affected patients can be managed with prophylactic antibiotics. Untreated G6PC3 deficiency can be fatal. Echocardiogram, renal and pelvic ultrasound scans should be performed in all cases of suspected or confirmed G6PC3 deficiency. Routine assessment should include biochemical profile, growth profile and monitoring for development of varicose veins or venous ulcers.

Pregnancy in reflux nephropathy - our experience

Reflux nephropathy, a leading cause of chronic renal failure in women of childbearing age, leads to pregnancy and neonatal complications and poses risk to babies due to autosomal dominant inheritance....

Abnormal Dimercaptosuccinic Acid Scan May Be Related to Persistence of Vesicoureteral Reflux in Children with Febrile Urinary Tract Infection

PurposeThis study assessed whether 99mtechnetium dimercaptosuccinic acid (DMSA) scintigraphy used for the assessment of renal sequelae after febrile urinary tract infection (UTI) has any prognostic value for outcome measurement of vesicoureteral reflux (VUR) by retrospectively evaluating the correlation between abnormal DMSA scintigraphy results and persistence of VUR in children with febrile UTI.Materials and MethodsThe medical records of 142 children (57 boys, 85 girls) admitted with febrile UTI from January 2004 to December 2006 and who were followed up for more than 1 year were retrospectively reviewed. At the initial and follow-up visits, renal ultrasound and DMSA scans were performed within 7 days from the diagnosis and voiding cystourethrography (VCUG) was performed within 1 month in all case and follow-up evaluations.ResultsThe children's mean age was 4.8±3.6 years (range, 0.3 to 14 years). The mean follow-up was 28.2±4.8 months. At the initial examination, VUR was more often associated with an abnormal DMSA scan result (83.3%) than with a normal DMSA scan result (16.7%, p=0.02). The frequency of VUR with an abnormal DMSA scan during acute UTI was significantly higher than the frequency of VUR with a normal DMSA scan (38.8% vs, 25.8%, respectively, p=0.004). Also, high-grade VUR was associated with an abnormal DMSA scan result (32.5%) more often than with a normal DMSA scan result (0%, p=0.01). Children with an abnormal DMSA scan had a lower resolution rate of VUR (17.5%) than did children with a normal DMSA scan (75.0%) at the follow-up VCUG (p=0.02).ConclusionsAn abnormal result on a DMSA scan during febrile UTI is associated with high-grade and persistent VUR. DMSA scans performed during febrile UTI are useful in reflux resolution in childhood.

Granulomatous interstitial nephritis causing acute renal failure: a rare presenting feature of sarcoidosis

A 56-year-old Caucasian woman presented to a peripheral hospital with 8 months history of abdominal discomfort, nausea, night sweats and lethargy. She had lost 10 kg weight and had recovered from an episode of painless bilateral cheek swelling ∼2 months prior to presentation. There was no history of rash, red eyes, dry mouth, joint pains, cough, breathlessness or chest pain. Her only medication at presentation was omeprazole. On admission, she was dehydrated, and had pain and tenderness in the right hypochondrium of the abdomen. Vital signs and physical examination were otherwise normal. Initial blood tests were as follows: creatinine 266 μmol/l, urea 12.3 mmol/l, albumin 49 g/l, corrected calcium 2.61 mmol/l, C-reactive protein 7 mg/l, erythrocyte sedimentation rate (ESR) 11 mm/h, haemoglobin 15.1 g/dl and white blood cell count 5.4 × 109/l. Liver function tests and urine microscopy examination were normal. Twenty-four hour urine protein excretion was 0.24 g. Chest X-ray was interpreted as normal by the admitting team. Renal tract ultrasound scan showed normal appearance of kidneys and urinary bladder. Despite rehydration therapy, serum creatinine rose to 411 μmol/l and she was transferred to our centre. Anti-nuclear antibodies, anti-neutrophil cytoplasmic antibodies, complement C3 and C4 levels and myeloma screen were normal or negative. A further review of the initial chest X-ray suggested bilateral hilar enlargement, and …

Gross hematuria in a case of Wilson disease: Questions

An eight-year-old boy with the primary diagnosis of Wilson disease and maintained on penicillamine was referred to pediatric nephrology for recurrent episodes of gross hematuria. There was no history of vomiting or diarrhea, and physical examination was unremarkable apart from a slightly enlarged liver. Initial urine examination confirmed significant red blood cells (40–50 /hpf) even during periods when he was not having gross haematuria. Renal parameters were as follows: serum sodium (136 mmol/L), potassium (3.3 mmol/L), chloride (111 mmol/L), calcium (8.1 mg/dl), bicarbonate (16 mmo/L), albumin (4.1 g/dl), and creatinine (0.6 mg/dl). Serum complements (C3 and C4) were normal, and phase-contrast microscopy of the urine showed no significant dysmorphic red blood cell. His renal ultrasound scan was also reported as normal. Twenty-fourhour urine collection showed insignificant proteinuria (185 mg) but grossly elevated urinary calcium of 215 mg (normal 4 mg /kg/ 24 h=88 mg). The rest of his urinary electrolytes were as follows: sodium 50 mmol/L, potassium 61.3 mmol/L, and chloride 74.7 mmol /L.

When is it necessary to perform nuclear renogram in patients with a unilateral neonatal hydronephrosis?

To examine whether anteroposterior(AP) pelvic diameter on postnatal renal ultrasound scan (US) can predict both initial differential renal function (DRF) and deterioration in DRF in patients with prenatally diagnosed hydronephrosis. One hundred and thirty-three patients diagnosed with a unilateral prenatal hydronephrosis, confirmed postnatally, were evaluated. We tried to find the cutoff values for initial AP diameter and change in AP diameter based on initial DRF and renal outcome. Reduction of 5% or more was considered as deterioration in function. All patients had an initial US scan at a mean age of 1.62weeks (1-4) and nuclear renogram at 13.24weeks (7-21). All patients had a second US at a mean age of 10.58weeks (6-19). 119 patients had a second renogram. Initial mean pelvic diameter was 20.86 (11-49)mm. When AP pelvic diameter was less than 20mm, 98.6% of all renal units had a function of ≥40%. The cutoff point for AP pelvic diameter was 19.05 when DRF was ≥45% (P<0.001). When the reduction in hydronephrosis in pelvic diameter was analyzed to predict the initial renal function, a cutoff point of 1.3mm decrease was found when initial renal function was ≥40% (P<0.001). The reduction in AP pelvic diameter was 2.1mm when initial DRF was ≥45% (P=0.009). For all patients except 3 individuals, if there was a reduction in AP diameter or the AP diameter was stable, then no reduction in function was observed. When the AP pelvic diameter is less than 20mm at presentation, DRF is normal. If the AP diameter is stable or decreases, there is unlikely to be a significant deterioration in renal function. Consequently, in selected patients, congenital unilateral hydronephrosis can be followed with serial ultrasounds.

Pregnancy in reflux nephropathy – our experience

Reflux nephropathy, a leading cause of chronic renal failure in women of childbearing age, leads to pregnancy and neonatal complications and poses risk to babies due to autosomal dominant inheritance....

Practical Guidelines for Managing Patients with 22q11.2 Deletion Syndrome

A 12-year-old boy currently is followed by multiple sub-specialists for problems caused by the chromosome 22q11.2 deletion syndrome (22q11DS) (Figure). He was born via spontaneous vaginal delivery, weighing 3033 g, to a 31-year-old G3P3 mother after a full-term pregnancy complicated only by mild polyhydramnios. Family history was non-contributory. Apgar scores were 8 at 1 minute and 9 at 5 minutes. With the exception of a weak cry, the results of the infant’s initial examination were unremarkable, and he was moved to the well-baby nursery. Shortly thereafter, a cardiac murmur was noted, the cardiology department was consulted, and the child was transferred to a local tertiary care facility with a diagnosis of tetralogy of Fallot. Stable, he was discharged home at 3 days of life. Figure Mild dysmorphic facial features of a boy aged 11 years with 22q11.2DS, including a short forehead, hooded eyelids with upslanting palpebral fissures, malar flatness, bulbous nasal tip with hypoplastic alae nasi, and protuberant ears. At 5 days of life, he had jerky movements. On presentation to the local emergency department, his total calcium level was 4.7 mg/dL, and later partial hypoparathyroidism was diagnosed. At that time, a consulting geneticist suggested the diagnosis of chromosome 22q11DS. Weeks later, the family received a telephone call confirming the diagnosis with fluorescence in situ hybridization (FISH). No additional information about the diagnosis, prognosis, etiology, or recurrence risk was provided until the child was 5 months of age, when he underwent cardiac repair at a third hospital, where a comprehensive 22q11DS program was in operation. In the interim, the child had feeding difficulties requiring supplemental nasogastric tube feeds, nasal regurgitation, and gastroesophageal reflux, while the parents searched the internet for reliable information about their son’s diagnosis. Subsequent notable abnormalities and interventions included: recurrent otitis media with bilateral myringotomy tube placement at 6 months; angioplasty with left pulmonary artery stent placement after the identification of pulmonary artery stenosis with bilateral pleural effusions at age 6 years; chronic upper respiratory infections with significant T cell dysfunction requiring live viral vaccines to be held until age 7 years; velopharyngeal incompetence necessitating posterior pharyngeal flap surgery at 7 years; enamel hypoplasia and numerous caries resulting in 3 separate dental procedures under general cardiac anesthesia beginning at age 7 years; multiple cervical and thoracic vertebral anomalies with thoracic levoconvex scoliosis and upper lumbar dextroscoliosis requiring growing rod placement at age 11 years with subsequent rod extension at ages 11.5 and 12 years; postoperative hypocalcemia; short stature; constipation; and persistent idiopathic thrombocytopenia. Pertinent negative test results included normal renal ultrasound scanning and parental 22q11.2 deletion studies. On physical examination, the boy’s height and weight have consistently tracked just below the fifth percentile, with no evidence of growth hormone deficiency. His head circumference is within reference range at the 25th percentile. Dysmorphic features include: a low anterior hairline; hooded eyelids; malar flatness; normally formed but protuberant ears with attached lobes; a mildly deviated nose with a bulbous nasal tip and hypoplastic alae nasi; asymmetric crying facies with a thin upper lip; mild micrognathia; a sacral dimple; and soft tissue syndactyly of the second and third toes. Developmentally, the boy had mild delays in achieving motor milestones, sitting at 11 months and walking at 18 months. However, he exhibited significant delays in the emergence of language: he never babbled, spoke his first words at age 3 years, and only achieved full conversational speech at 7 years. However, he had relative strengths in receptive language and communicated appropriately by the use of sign language. Now quite conversant, he is mainstreamed in the seventh grade with resource room supports. Moreover, he is affable, but exhibits anxiety and perseverations. Lastly, despite numerous medical, academic, and social challenges, he participates in assisted athletics, is an avid wrestling fan, and enjoys travel. However, his exceptionally supportive parents, siblings, and extended family continue to worry about his long-term outcome and transition of care as he approaches adulthood. As demonstrated by this boy’s complicated course, practical multi-system guidelines are needed to assist the general practitioner and specialists in caring for patients with 22q11DS. Although still under-recognized, detection, including in the prenatal setting, is increasing. Moreover, the phenotypic spectrum is highly variable, and patients may present at any age. Thus, initial guidelines developed by an international panel of experts present the best practice recommendations currently available across the lifespan, with a major focus on the changing issues through childhood development.

Renal Calcification in Very Low Birth Weight Infants

Renal calcification in preterm infants has been described frequently. The etiologic factors have not yet been fully clarified. The objective of this study was to evaluate the incidence of and risk factors for renal calcification in our population. We retrospectively reviewed the charts of very low birth weight preterm infants during a 1-year period. Renal ultrasound scans were performed at term or before discharge and at a corrected age of 1 year. Six infants (6%) had renal calcification at term or before discharge compared with 96 who did not. Factors significantly associated with renal calcification included gestational age (26 weeks vs. 29 weeks, p=0.006), birth weight (851 g vs. 1141 g, p=0.004), duration of mechanical ventilation (69 days vs. 29 days, p=0.002), length of intensive care (72 days vs. 41 days, p=0.013), furosemide therapy (33% vs. 3%, p=0.027), and dexamethasone therapy (50% vs. 2% p=0.001). Birth weight and dexamethasone therapy had significant independent association after stepwise logistic regression analysis. Sex, oliguria, acidosis, duration of oxygen therapy, length of hospital stay, nutrition status, and nephrotoxic drugs did not differ between the two groups. Three of the six infants had spontaneous remission of renal calcification, whereas two patients without the finding in neonatal stage had renal calcification at a corrected age of 1 year. The incidence of renal calcification in very low birth weight infants in this study was relatively low, and the calcification was transient in one-half of the infants. Extremely premature, sick infants requiring long-term ventilation, and those receiving furosemide or dexamethasone were more likely to have renal calcification. Clinicians should be aware that renal calcification may develop beyond the neonatal stage.

Detection of renal scars by transplant renal ultrasounds and DMSA scans after urinary tract infections in paediatric renal transplant recipients

AimsTo study the clinical features and compare the accuracy of transplant renal ultrasound (TRUS) and dimercaptosuccinic acid (DMSA) scans in the detection of scars following urinary tract infection (UTI) in...

Commentary to “The prognostic impact of an abnormal initial renal ultrasound on early reflux resolution”

This study follows on the heels of a similar recent publication [1]. Sjostrom and colleagues analysed the predictive factors for the resolution of congenital high-grade vesicoureteric reflux (VUR). It was a prospective well-constructed study, and it was concluded that, on multivariate analysis, bladder dysfunction, breakthrough urine infection (UTI) and renal abnormality were all strong negative predictive indicators for the resolution of VUR. This current study had the laudable aim of investigating whether a much simpler predictive indicator of early VUR resolution, the initial renal ultrasound scan (US), could be identified.Thesame institutionhadpreviously reported thatan abnormal renal isotopescanwasanegativepredictive indicator of VUR resolution, and thus had experience and a track record in this area [2]. It was a logical progression to investigate the predictive impact of US, as it is the commonest investigation in children presenting with urinary tract pathology. Despite identifying many limitations to the study it was stated that: ‘Our data can be utilized when counselling patients with grade II and III reflux. In this setting, an abnormal renal ultrasound may have an incrementally lower resolution rate than would be expected by grade alone’. I have considerable concern about this, as I do not believe the data support this statement, and it is possible that such published conclusions could lead to the inappropriate surgical treatment of large numbers of children.

A guideline for the inpatient care of children with pyelonephritis

BACKGROUND AND OBJECTIVES:Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care.METHODS:We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis.RESULTS:Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence.CONCLUSION:Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.

Febrile Urinary Tract Infections in 0- to 3-Month-Old Infants: A Prospective Follow-Up Study

To track the clinical evolution of febrile urinary tract infection (UTI) diagnosed in 0- to 3-month-old infants and characterize uropathogen frequencies, antimicrobial resistance rates, renal abnormalities, and differences in the sexes in this age group. We observed prospectively 46 infants identified in a cohort of 209 children with first UTI diagnosed between July 2006 and July 2008 at the age of 0 to 3 months. Renal ultrasound scanning and voiding cystourethrography examinations were performed in all infants. Infants < 3 months old represented 21% of all children with first UTI. Of these children, 26% were female and 74% were male. Escherichia coli was isolated in 88% of cases and had a high rate of resistance to ampicillin (71%) and to trimethoprim/sulfamethoxazole (47%); 21% of children had vesicoureteral reflux, which was of low-grade in 67% of cases, with spontaneous resolution before 2 years in all cases. In infants with normal ultrasound scanning results, a low-grade vesicoureteral reflux was subsequently found in 10% of cases. Infants aged 0 to 3 months represent 21% of children treated for febrile UTI. Boys represent 74% of these cases. E coli is responsible for 88% of UTIs, with a high rate of resistance to antibiotics. When ultrasound scanning examination results are normal, the risk of missing a significant renal abnormality is expected to be extremely low.

One-stage correction of intermediate imperforate anus in males: preliminary results

Background: This prospective study was designed to assess the safety, cost effectiveness, and advantages of performing posterior sagittal anorectoplasty without colostomy on males with intermediate imperforate anus.Method: Five consecutive males with intermediate imperforate anus were entered into the study. Chest and abdominal x-rays, skeletal surveys, renal ultrasound scans, and invertograms were done. Patients were resuscitated, and Pena’s posterior sagittal anorectoplasty (PSARP) done in prone positions. Two-ml syringe vents were inserted into the new anus for 10 days. Cephalosporin and metronidazole were given as peri-operative antibiotics.Results: All patients had intermediate anomalies. There were no other major associated congenital anomalies. Urethral catheter could not be inserted in one patient. One patient presented with septicaemia and jaundice. He was deemed too ill to withstand a major operation. These 2 patients therefore had diverting colostomies. There were no problems with posterior sagittal anorectoplasty in the other 3 patients. The father of one patient discharged him against medical advice on the 5th postoperative day. The mother had post-partum haemorrhage and they went for traditional treatment because they could not provide blood donors. The skin wound of 2 patients healed completely at removal of stitches. Both are having monthly dilatations 9months and 1 year post-operatively.Conclusion: This preliminary study shows that it is feasible for males with intermediate imperforate anus to have safe posterior sagittal anorectoplasty without colostomy. The advantages of one, instead of 3 major operations, are many, especially in developing countries. If this result can be reproduced in high anomalies colostomy may be unnecessary in many cases of anorectal malformations with a lot of benefits to these unfortunate children and their poor families.

Abnormal Urinary Steroid Profiles in Four Hypertensive Obese Children

There is a poorly understood association between obesity and hypertension. We demonstrated abnormalities of adrenal androgen and cortisol metabolites in four hypertensive obese children. Four males (aged 10 to 15 years) were evaluated for systolic blood pressures consistently above the 99.6th percentile. All were overweight with BMI ranging from 27-35. Clinical examinations, renal ultrasound and DMSA scans were normal. Plasma electrolytes, renin, aldosterone, cortisol, testosterone, ACTH and TSH were normal. 24-Hour urinary steroid profiles showed a generalised excess of adrenal androgen and cortisol metabolites in all cases. Relevant recognised disorders of adrenal androgen and cortisol metabolism were excluded. There is no clinical condition explaining these abnormal urinary steroid profiles. These results support previous findings and provide new data on abnormal urinary adrenal androgen excretion in obese hypertensive patients. Further studies may determine the relationship between obesity, hypertension and the observed abnormalities of urinary steroid excretion.

Renal Scarring and Urinary Tract Infection After Successful Endoscopic Correction of Vesicoureteral Reflux

We evaluated renal function and the incidence of urinary tract infection after successful endoscopic correction of vesicoureteral reflux. From 1988 to 2007, 169 male and 338 female patients (696 refluxing renal units) with a median age of 3.7 years underwent successful endoscopic correction of primary vesicoureteral reflux using polytetrafluoroethylene and dextranomer/hyaluronic acid copolymer. Reflux was grades I to V in 36 (5.2%), 178 (25.6%), 298 (42.7%), 163 (23.4%) and 21 refluxing renal units (3.1%), respectively. Renal ultrasound and (99m)technetium-dimercaptosuccinic acid scan were performed in all patients preoperatively, and in all patients and in 509 of 696 refluxing renal units (73%) postoperatively, respectively. All patients were followed 1 to 20 years (median 13). Preoperatively (99m)technetium-dimercaptosuccinic acid scan revealed scarring in 543 of 696 refluxing renal units (78%). Reflux resolved after 1 injection in 473 refluxing renal units (68%), in 161 (23%) after 2 and in 25 ureters (3.6%) after 3. In 37 refluxing renal units (5.4%) reflux improved to grade I, which required no further treatment. Renal deterioration was noted in 11 of 26 refluxing renal units with initially severe renal scarring (less than 20% uptake on (99m)technetium-dimercaptosuccinic acid scan). The remaining refluxing renal units in this group showed an insignificant 2.3% change in relative function after successful reflux correction (p >0.005). Patients with vesicoureteral reflux downgrading did not show new renal scars. Of the remaining 446 refluxing renal units 27 (6.1%) showed a greater than 5% decrease in relative function without new scarring. Eight children in the polytetrafluoroethylene group and 3 in the dextranomer/hyaluronic acid copolymer group (overall 2.2%) had febrile urinary tract infection after successful endoscopic correction, leading to reevaluation that resulted in the diagnosis of recurrent reflux in 8 (72.7%). A total of 28 children (5.6%) had afebrile urinary tract infection without recurrent vesicoureteral reflux. Our data show that successful endoscopic correction of vesicoureteral reflux is accompanied by a low incidence of new renal scarring and febrile urinary tract infection. Patients who initially have corrected reflux but who have a febrile urinary tract infection at long-term followup require prompt revaluation to rule out recurrent reflux.

Radiological investigations following urinary tract infection: changes in Australian practice

Objective:To examine practice changes in the conduct of radiological investigations in Australia following urinary tract infection (UTI).Design:Observational study using data from the national Medicare database over the 15-year period July...

Torsion of Renal Transplant 10 Years After Simultaneous Kidney-Pancreas Transplantation: Imaging as a Diagnostic Tool

Renal transplant torsion around its pedicle is a rare technical complication of intraperitoneal renal transplantation. Intraperitoneal placement allows more transplant mobility, which increases the risk of torsion. The length of the vascular pedicle, excess ureteral length, and paucity of adhesion secondary to steroid administration are factors that also contribute to the abnormal mobility of the kidney (1). One of the diagnostic difficulties of renal torsion is its lack of specific clinical features. A high level of suspicion is needed to diagnose renal transplant torsion because it may mimic rejection and venous thrombosis. Therefore, imaging studies play a crucial role in renal torsion diagnosis. We report a case of a 48-year-old woman, with simultaneous kidney-pancreas transplant (SKPT), who developed torsion of the transplanted kidney 10 years after transplantation. She had SKPT in 1997 after developing end-stage renal disease secondary to type 1 diabetes mellitus. She was on prednisone, cyclosporine, and mycophenolic acid. Her baseline serum creatinine level was 1.1 mg/dL. Ten years later, she presented with a 3 days history of nausea, vomiting, loose stool, and anuria. On physical examination, she was markedly hypotensive and severely dehydrated, and she had mild left lower quadrant abdominal tenderness. On admission, her serum creatinine level was 6.2 mg/dL, blood glucose 93 mg/dL, serum amylase 38 mg/dL, and a trough cyclosporine was 81 ng/mL. A renal ultrasound scan showed mild pelvicaliectasis with no apparent change from a study 2 years prior. Doppler sonography showed normal arterial waveforms. Patient was aggressively resuscitated with crystalloids with no improvement in her urine output or serum creatinine level. A renal biopsy was performed, which did not show any significant pathologic changes. There was no evidence of rejection on the biopsy. A computed tomography (CT) scan of the transplanted kidney showed moderate degree of hydronephrosis and swelling around the transplanted kidney (Fig. 1b vs. a). An antegrade nephrostogram demonstrated a corkscrew-like configuration of the proximal ureter with neither opacification of the more distal ureter nor the urinary bladder. A percutaneous nephrostomy tube was placed and a copious amount of urine returned.FIGURE 1.: Pelvic renal transplant (b) shows moderate changes of hydronephrosis and dilatation of the renal collecting system compared with prior computed tomography scan (a).The patient was taken to the operating room. At laparotomy, the kidney was found twisted 180° around its pedicle with no compromise to the vascular structures. However, it was apparent that the “volvulized” transplant kidney had induced a rotational obstruction of the transplant ureter at the insertion of the bladder. The torsion was straightened, and a nephropexy of the kidney to the left colon and the anterior abdominal wall was performed. Postoperatively her serum creatinine level decreased to 0.9 mg/dL, and she was discharged home in stable condition. CT scan is more sensitive than renal ultrasound in detecting torsion of the transplanted kidney. CT imaging may show changes in renal orientation as well as secondary changes such as swelling, hydronephrosis, or abnormal enhancement (2). The most suggestive imaging sign of renal transplant torsion is the change in the axis of the transplanted kidney, which can be facilitated by comparison with baseline scans as demonstrated in our case. To our knowledge, this is the first case report of SKPT recipient who developed torsion of the transplanted kidney 10 years after transplantation. Samir Nangia Department of Internal Medicine Medical College of Wisconsin Milwaukee, WI Ehab R. Saad Division of Nephrology Medical College of Wisconsin Milwaukee, WI

Screening Young Children with a First Febrile Urinary Tract Infection for High-grade Vesicoureteral Reflux with Renal Ultrasound Scanning and Technetium-99m-labeled Dimercaptosuccinic Acid Scanning

To evaluate the predictive value of renal ultrasound scanning and 99m-Technetium-dimercaptosuccinic acid (DMSA) scintigraphy for high-grade vesicoureteral reflux (VUR) in young children with a first urinary tract infection (UTI). The medical records of children who had been examined with renal ultrasound scanning, DMSA scanning, and voiding cystourethrography (VCUG) were reviewed. The findings of renal ultrasound scanning, DMSA scanning, and their predictive values were evaluated. Of 699 children, high-grade VUR (grades III-V) was diagnosed in 119 (17.0%). Signs of renal hypodysplasia (OR, 16.15), cyclic dilatation of pelvicaliceal system (OR, 11.73), hydroureter (OR, 4.00) with renal ultrasound scanning, and renal hypodysplasia (OR, 8.78), acute pyelonephritis (OR, 2.76) with DMSA scanning were associated with high-grade VUR. The sensitivities for high-grade VUR of ultrasound scanning alone (67.2%) or DMSA scanning alone (65.5%) were not as good as that of a both-test strategy, which had a sensitivity rate of 83.2%. The negative predictive value of the both-test strategy was 91.5%. Renal ultrasound scanning and DMSA scanning both should be routinely performed in children with a first febrile UTI. VCUG is only indicated when abnormalities are apparent on either ultrasound scanning or DMSA scanning or both.