Jacobs Journal of Clinical Case Reports

DMSA Scan for Revealing VUR in Pyelonephritis in Children in Northern Israel

*Wael Nasser
Department Of Pediatric Cardiology And Nephrology, Baruch Padeh Poriya Medical Center, Lower Galilee, Israel

*Corresponding Author:
Wael Nasser
Department Of Pediatric Cardiology And Nephrology, Baruch Padeh Poriya Medical Center, Lower Galilee, Israel
Email:wael-nasser@hotmail.com

Published on: 2019-08-22

Abstract

Introduction and Objective: It is estimated that 31.1% of pediatric patients with UTI also suffer from Vesicoureteral reflux (VUR). Having both UTI and VUR simultaneously poses as a risk factor for developing pyelonephritis and renal scarring. Pyelonephritis may be detected using Dimercaptosuccinic acid (DMSA) - a radionuclide scan to discover renal scarring, with minimal radiation. On the other hand, the gold standard for VUR diagnosis is voiding cystourethrogram (VCUG), a traumatic test with high radiation, which is unsuitable for discovering renal scarring. Therefore, the objective of this research is to examine DMSA as a possible means to replace VCUG in VUR diagnosis. Methods: a retrospective study of 88 children from birth to age 9 with symptoms fitting of UTI. These children were tested for VUR presence using VCUG and DMSA. Results: 19 of the 88 patients did not undergo DMSA. Out of the 69 pediatric patients who were tested, 39 did not have reflux while 30 had VUR. Among the 39 children without reflux, 69.2% had typical DMSA results, while 30.8% had abnormal DMSA results, meaning almost 70% of DMSA findings were compatible with the diagnosis among the children without reflux. Among the 30 remaining patients- 12 were diagnosed with VUR grade I-II and 18 were diagnosed with VUR grade III-V, according to VCUG results. 66.7% of the patients with VUR grade I-II had abnormal DSMA results, while a remarkable figure of 88.9% of children with VUR grade III-V had abnormal DSMA results. Conclusion: DMSA may be used as a useful tool for VUR diagnosis, replacing VCUG.

Keywords

Dimercaptosuccinic acid (DMSA); Vesicoureteral reflux (VUR); Pyelonephritis

Introduction

Urinary tract infection (UTI) is a common cause for hospitalization among pediatric patients. Patients between the ages of 2 months and two years presenting with fever should be examined for the presence of UTI. [1] It is estimated that 31.1% of pediatric patients with UTI also suffer from Vesicoureteral reflux (VUR) - a retrograde flow of urine. [2] Having both UTI and VUR simultaneously poses as a risk factor for developing pyelonephritis and renal scarring as the bacterial infection is moving upwards through the urinary system. Reflux allows the infected urine in the bladder to reach the upper urinary tract and the kidneys, causing pyelonephritis, inflammation of the kidneys. Pyelonephritis may be detected using Dimercaptosuccinic acid (DMSA) - a radionuclide scan that uses Dimercaptosuccinic acid to discover renal scarring, with minimal radiation. On the other hand, according to the EAU (European association of urology) and the ESPU (European society of pediatric urology) guidelines, the gold standard for VUR diagnosis is voiding cystourethrogram (VCUG) [3]. This test takes pride in having a high detection rate, but unfortunately, VCUG uses ionizing radiation and is considered traumatic for the patients as it includes the insertion of a urethral catheter.[3] Besides, VCUG is unsuitable for discovering renal scarring- a common clinical manifestation of pyelonephritis which may arise due to reflux, especially in high-grade VUR. Therefore, the objective of this research is to examine DMSA as a possible means to replace VCUG in VUR diagnosis.