DMSA renal scanning versus urography for detecting renal scars in vesicoureteral reflux

32 children admitted to Hacettepe University Hospital for surgical treatment of vesicoureteral reflux (VUR) between 1987 and 1988 were included in this prospective double-blind study. All patients underwent intravenous urography (IVU), voiding cystouretrography and 99mTc DMSA renal scanning. The sensitivity and specificity of the DMSA scan and IVU for detecting renal scarring were investigated. With regard to the presence of renal scarring, the sensitivity and specificity of IVU and DMSA were not found to be statistically different. But when the scars were scored, DMSA was found to have a higher scoring index compared to IVU. In patients who were candidates for surgical management of VUR, renal scars could be detected both by IVU and DMSA scan but, for the follow-up, the DMSA scan was found to be the investigation of choice.     

Abnormal DMSA renal scan findings and associated factors in older children with vesicoureteral reflux

International Urology and Nephrology - There are scanty data on the rate of abnormal Tc-99 m dimercaptosuccinic acid (DMSA) renal scintigraphy and associated factors in children older than...     

Cystitis follicularis in children with primary vesicoureteral reflux

In an attempt to determine whether cystitis follicularis affects the spontaneous resolution of primary vesicoureteral reflux we reviewed the records of 65 children with reflux and cystitis follicularis. A group of children with primary vesicoureteral reflux but without cystitis follicularis was included as controls. The data did not reveal a statistically significant difference in either the rate of spontaneous resolution of reflux or the need for surgical correction between these 2 groups of children.     

Management of primary vesicoureteral reflux in children

The management of primary vesicoureteral reflux (VUR) in child suffered major changes by focusing on the medical treatment in order to prevent the urinary tract infections and the occurrence of postinfectious renal scars. Continuous antibiotic prophylaxis and the follow-up by serial cystography of the spontaneous resolution of the reflux are considered nowadays the best choice in most of the cases. Surgery is recommended only in selected cases. Sub-ureteral injection of bulking agents to correct the reflux holds promise as an alternative to open surgery, but presents the challenge of identifying the ideal bulking agent.     

Probiotics prophylaxis in children with persistent primary vesicoureteral reflux

Probiotics, beneficial living microorganisms, have been proven to be effective in preventing gastrointestinal infections, but their effect in preventing urinary tract infection (UTI) is inconclusive. A prospective randomized controlled study was done to compare the preventive effect of probiotics with conventional antibiotics in children with persistent primary vesicoureteral reflux (VUR). One hundred twenty children who had had persistent primary VUR after antibiotic prophylaxis for 1 year were randomly allocated into a probiotics (Lactobacillus acidophilus 10⁸ CFU/g 1 g b.i.d., n = 60) or an antibiotics (trimethoprim/sulfamethoxazole 2/10 mg/kg h.s., n = 60) prophylaxis group during the second year of follow-up. The incidence of recurrent UTI was 18.3% (11/60) in the probiotics group, which was not different from 21.6%(13/60) in the antibiotic group (P = 0.926). The causative organisms of recurrent UTI were not significantly different between the two groups (P = 0.938). Even after stratification by VUR grade, age, gender, phimosis, voiding dysfunction and renal scar, the incidence of recurrent UTI did not differ significantly between the two groups (P > 0.05). The development of new renal scar was not significantly different between the two groups (P > 0.05). In conclusion, probiotics prophylaxis was as effective as antibiotic prophylaxis in children with persistent primary VUR.     

Remission of primary vesicoureteral reflux in children with medical management

We studied the spontaneous resolution rate in children with primary vesicoureteral reflux (VUR) and the interference of some specific factors. We reviewed the records of 110 children (14 days - 16 years) admitted in the 4th Pediatric Clinic Ia?i with primary VUR, between 1994 - 2003, which had exclusive medical management and minimum one follow-up cystogram. We used Kaplan-Meier curves to analyze the resolution rate of VUR during the follow-up in relation with initial grade, age at diagnosis, gender, recurrent urinary tract infections (UTIs) and the presence of renal scarring. The remission rate for all the cases was 70%, with differences based on the reflux grade: 100% for grade I and 45% for grade IV. The cases diagnosed during infancy recovered faster than those diagnosed after this period. The presence of renal scarring and breakthrough UTIs increased the remission time. In conclusion the majority of patients with VUR resolved during medical management, the remission rate being influenced by the reflux grade, presence of renal scarring and breakthrough UTIs.     

Clinical analysis of primary vesicoureteral reflux in children

The retrospective analysis of 64 patients between 1 month and 14 years old with 87 primary vesicoureteral units with reflux was reviewed. They were followed-up for a period of 3 to 60 months. Thirty one patients were managed conservatively by chemotherapy (group A) and 28 patients were treated surgically. As the anti-reflux operation the Politano-Leadbetter procedure was used in 27 patients and the modified Politano-Leadbetter procedure in 1 patient (group B). Five patients were not treated (group C). In 13 of the 30 renal units of group A, the vesico-ureteral reflux disappeared spontaneously and in group B the post-operative cystourethrography revealed cure of reflux in all the renal units. In 2 of the 21 renal units of group A excretory urography (IVP) revealed improvement and in 3 deterioration. Post-operative IVP revealed improvement in 13 of 39 renal units of group B and in 2 deterioration. In 3 of the 22 renal units of group A the renogram revealed improvement and in 3 deterioration. The post-operative renogram revealed improvement in 8 of the 28 renal units of group B and deterioration in renal units. Analysis was also made according to the vesicoureteral reflux grade.     

Screening for vesicoureteral reflux and renal scars in siblings of children with known reflux

The incidence of vesicoureteral reflux (VUR) in the general population is less than 1%, but it is high in families with reflux. The reported prevalence of VUR among siblings of index patients with reflux has ranged from 4.7% to 51%. Reflux carries an increased risk of pyelonephritis and long-term renal impairment. The purpose of this study was to identify the age-related incidence and severity of reflux, and the frequency of associated renal parenchymal damage in siblings of children with reflux in order to assess the use of screening at different ages. Between October 1994 and February 2003, 40 siblings of 34 index patients were screened with direct voiding cystography. 99( m ) technetium (Tc)-dimercaptosuccinic acid (DMSA) nuclear renal scans were performed in siblings with VUR to detect renal scarring. The cystograms were interpreted as showing the presence or absence of VUR and the DMSA scan as symmetrical or asymmetrical differential function, with or without renal scarring. Of 40 siblings, 17 had VUR, representing an incidence of 42.5%. The mean age at study entry of the 15 boys and 25 girls was 63 months (range 6 months to 12 years). The majority of siblings with abnormal DMSA scans were asymptomatic. Reflux was unilateral in 12 siblings and bilateral in 5. Of the 17 refluxing siblings (22 refluxing ureters), 7 (41.17%) had a history of symptomatic urinary tract infection (UTI). The frequency of VUR was nearly equal in siblings over 6 years and those younger than 6 years. Of the 17 siblings with VUR, 16 had DMSA scintigraphy. Of these, 5 were normal and 11 (68.75%) showed abnormalities (7 asymmetrical differential function and 4 parenchymal defect), which was bilateral in 7 and unilateral in 4. In conclusion, this study confirms a significant overall incidence of VUR and renal parenchymal damage in the siblings of patients with known reflux. The prevalence of reflux in older siblings is similar to that in younger siblings. Our review suggests that all siblings over 6 years should undergo a screening cystogram, even in the absence of urinary tract infection. DMSA scintigraphy of asymptomatic siblings appears to be beneficial in preventing renal injury.     

Intrarenal reflux in children with vesicoureteral reflux]

Voiding cystourethrography (VCU) of 407 children with vesicoureteral reflux (VUR) at our hospital during 1969-1990 was reviewed and 7 cases (8 ureters) of intrarenal reflux (IRR) were found. All the children were male and had had an episode of febrile urinary infection under one year of age. One child had a left flank mass, which was later proven a urinoma. VUR was moderate (grade III) in 3 and massive (grade IV and V) in 5. VUR was estimated as primary in one child and as secondary in 6 (anterior urethral ring 2, posterior urethral valve 2, neurogenic bladder 2). IRR was localized to the upper area in 3, to the lower area in 2, and to the whole kidney in 3. Sixty percent of those with IRR in the polar areas was associated with moderate VUR, whereas all of those in the whole kidney was with massive one. Renal scarring was assessed by excretory urography (IVP) and/or 99mTc-DMSA renoscintigraphy. Seven kidneys were evaluable; polar scars in 5, dwarf with polar scar in 1 and dwarf with poor function (suspected hypodysplasia) in 1. In 4 kidneys new scar formation was observed. It was noted, however, that IRR did not necessarily accompany renal scars of the corresponding areas and IRR to the whole kidney did not always lead to multiple scars in the whole kidney. The nature and problems of IRR, renal scars and 99mTc-DMSA renoscintigraphy were discussed. It was suggested that urinary infection played a greater part in renal scar formation.     

Microalbuminuria in children with vesicoureteral reflux

Vesicoureteral reflux (VUR) is a common congenital anomaly of the urinary tract that may be inherited. Reflux of infected urine may cause scarring in susceptible kidneys with the potential to compromise renal function. The aim of the study was to evaluate the possible influence of different grades of VUR on glomerular damage using microalbuminuria as a parameter. Children with VUR detected by voiding cystourethrography (VCUG) were investigated. According to the grade of VUR, patients were separated into three groups. The first group included 12 children with VUR grade I-II. The second group consisted of 12 children with grade III of VUR. Patients with VUR grade IV-V (n = 11) were members of the third group. The control group consisted of 17 healthy children. Microalbuminuria was examined in samples of morning urine specimens using a microalbumin/creatinine reagent kit. Serum urea, creatinine levels and creatinine clearance (CCR) were measured as markers of renal function. The mean value of microalbumin excretion in the third group showed a statistically significant increase (p < 0.001) compared to all other groups. CCR in the third group was statistically significantly decreased (p < 0.05) in comparison to the group of healthy children. There were no statistically significant changes of microalbumin excretion and CCR in the first and second group compared to control values. We discussed the presence of microalbuminuria and decrease of CCR in children with high grade of VUR as a possible consequence of retrograde urine flow (intrarenal reflux), glomerulosclerosis, and consecutive hyperfiltration.     

Post-pyelonephritic renal scars are not associated with vesicoureteral reflux in children

PURPOSE: Children with pyelonephritis are at risk for renal damage. We assess the value of clinical signs and urological abnormalities in predicting renal scars in children following pyelonephritis. MATERIALS AND METHODS: A total of 64 hospitalized children (29 females and 35 males, median age 2.9 years) underwent ultrasonography and technetium labeled dimercapto-succinic acid (DMSA) scintigraphy imaging within 1 week following the diagnosis of the first pyelonephritis. Voiding cystourethrography was performed 8 weeks after the diagnosis. Followup DMSA scintigraphy was performed in 58 patients after 2 years of followup. RESULTS: Urological abnormalities observed were vesicoureteral reflux (VUR, grade 2 or higher) in 11 patients (19%), nonrefluxing and nonobstructed megaureter in 2 (4%) and pyeloureteral obstruction in 1 (2%). The first DMSA scintigraphy showed parenchymal defects in 48% of patients. VUR did not increase the risk of renal defects. At 2 years after the infection 12 of the 58 patients (21%) had renal scars. Nine of these patients did not have VUR. However, 2 patients with high grade VUR and repeat infections demonstrated deterioration of kidney function during followup. The patients with renal scars were older than those without scars (3.1 vs 0.8 years, p = 0.0291) at the time of infection. CONCLUSIONS: Renal scars after first pyelonephritis are in most cases not associated with abnormalities of the urinary tract, but are caused by the infection itself. However, structural abnormalities may predispose to recurrent infections. Following pyelonephritis new renal scars may develop in all age groups in both sexes.     

Predictors of renal scar in children with urinary infection and vesicoureteral reflux

We evaluated the predictors of renal scar in children with urinary tract infections (UTIs) having primary vesicoureteral reflux (VUR). Data of patients who were examined by dimercaptosuccinic acid (DMSA) scintigraphy between 1995 and 2005 were evaluated retrospectively. Gender, age, reflux grade, presence/development of scarring, breakthrough UTIs, and resolution of reflux, were recorded. The relation of gender, age and VUR grade to preformed scarring and the relation of gender, age, VUR grade, presence of preformed scarring, number of breakthrough UTIs and reflux resolution to new scarring were assessed. There were 138 patients [male/female (M/F) 53/85]. Multivariate analysis showed that male gender [odds ratio (OR) 2.5], age ≥ 27 months in girls (OR 4.2) and grades IV–V reflux (OR 12.4) were independent indicators of renal scarring. On the other hand, only the presence of previous renal scarring was found to be an independent indicator for the development of new renal scar (OR 13.4). In conclusion, while the most predictive variables for the presence of renal scarring among children presenting with a UTI were male gender, age ≥ 27 months in girls, and grades IV–V reflux, the best predictor of new scar formation was presence of previous renal scarring.     

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

International Urology and Nephrology - Vesicoureteral reflux (VUR) is the most common congenital urinary tract abnormality in children. The objective of this study was to evaluate the diagnostic...     

Clinical course of 735 children and adolescents with primary vesicoureteral reflux

The purpose of this retrospective cohort study was to report the clinical course of children with primary vesicoureteral reflux (VUR). Between 1970 and 2004, 735 patients were diagnosed with VUR and were systematically followed in a single tertiary renal unit. Patients were followed up for a mean time of 76 months (6 months to 411 months). The events of interest were reflux resolution, renal damage, urinary tract infection (UTI), chronic kidney disease (CKD), and hypertension. Survival analysis was performed in order to evaluate reflux resolution and CKD. Renal damage was detected at admission in 319 patients (43.4%). Continuous low-dose antibiotic prophylaxis was administered to 624 patients (91.2%); 499 (73%) patients subsequently had no UTI or fewer than three episodes. The median time of persistence of reflux according to Kaplan–Meier analysis was 38 months for grade I/II [95% confidence interval (95% CI), 33–43], 98 months for grade III (95% CI, 78.5–105), and 156 months for grade IV/V (95% CI, 122–189). Twenty patients (3%) developed hypertension. It was estimated that the probability of CKD was 5% at 10 years after diagnosis of VUR; for children diagnosed after 1990 the probability of CKD was only 2%. Renal function impairment occurred in patients with severe bilateral reflux or in patients with contralateral renal hypoplasia. There has been an improvement of prognosis for patients diagnosed in the past 15 years.