Published online January 12, 2009
PEDIATRICS (doi:10.1542/peds.2008-1003)

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ARTICLE

Value of Imaging Studies After a First Febrile Urinary Tract Infection in Young Children: Data From Italian Renal Infection Study 1

Giovanni Montini, MD^a, Pietro Zucchetta, MD^b, Lisanna Tomasi, MD^a, Enrico Talenti, MD^c, Waifro Rigamonti, MD^d, Giorgio Picco, MD^e, Alberto Ballan, MD^f, Andrea Zucchini, MD^g, Laura Serra, MD^h, Vanna Canella, MDⁱ, Marta Gheno, MD^j, Andrea Venturoli, MD^k, Marco Ranieri, MD^l, Valeria Caddia, MD^m, Carla Carasi, MD^a, Roberto Dall'Amico, MDⁿ and Ian Hewitt, MBBS, FRACP^a

^a Departments of Pediatric Nephrology
^b Nuclear Medicine
^c Radiology
^d Urology, Azienda Ospedaliera, University of Padua, Padua, Italy
^e Pediatric Unit, Hospital of Bassano, Bassano del Grappa, Italy
^f Pediatric Unit, Hospital of Dolo, Dolo, Italy
^g Pediatric Unit, Hospital of Faenza/Lugo, Lugo, Italy
^h Pediatric Unit, Hospital of Imola, Imola, Italy
ⁱ Pediatric Unit, Hospital of Monselice, Monselice, Italy
^j Pediatric Unit, Hospital of Venice, Venice, Italy
^k Pediatric Unit, Hospital of Forli, Forli, Italy
^l Pediatric Unit, Hospital of San Donà di Piave, San Donà di Piave, Italy
^m Pediatric Unit, Hospital of Feltre, Feltre, Italy
ⁿ Pediatric Unit, Hospital of Pordenone, Pordenone, Italy

OBJECTIVE. We examined the diagnostic accuracy of routine imaging studies (ultrasonography and micturating cystography) for predicting long-term parenchymal renal damage after a first febrile urinary tract infection.

METHODS. This study addressed the secondary objective of a prospective trial evaluating different antibiotic regimens for the treatment of acute pyelonephritis. Data for 300 children 2 years of age, with normal prenatal ultrasound results, who completed the diagnostic follow-up evaluation (ultrasonography and technetium-99m-dimercaptosuccinic acid scanning within 10 days, cystography within 2 months, and repeat technetium-99m-dimercaptosuccinic acid scanning at 12 months to detect scarring) were analyzed. Outcome measures were sensitivity, specificity, and negative and positive predictive values for ultrasonography and cystography in predicting parenchymal renal damage on the 12-month technetium-99m-dimercaptosuccinic acid scans.

RESULTS. The kidneys and urinary tracts were mostly normal. The acute technetium-99m-dimercaptosuccinic acid scans showed pyelonephritis in 54% of cases. Renal scarring developed in 15% of cases. The ultrasonographic and cystographic findings were poor predictors of long-term damage, showing minor sonographic abnormalities for 12 and reflux for 23 of the 45 children who subsequently developed scarring.

CONCLUSIONS. The benefit of performing ultrasonography and scintigraphy in the acute phase or cystourethrography is minimal. Our findings support (1) technetium-99m-dimercaptosuccinic acid scintigraphy 6 months after infection to detect scarring that may be related to long-term hypertension, proteinuria, and renal function impairment (although the degree of scarring was generally minor and did not impair renal function) and (2) continued surveillance to identify recurrent urinary tract infections that may warrant further investigation.

Key Words: pyelonephritis • scintigraphy • ultrasonography • urinary tract infection • vesicoureteric reflux • renal scarring

Abbreviations: DMSA—technetium-99m-dimercaptosuccinic acid • UTI—urinary tract infection • APN—acute pyelonephritis • PPV—positive predictive value • NPV—negative predictive value • RRF—relative renal function • NICE—National Institute for Health and Clinical Excellence • CI—confidence interval

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Accepted Oct 17, 2008.

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