DMSA study performed during febrile urinary tract infection: a predictor of patient outcome?

  • V. Camacho
  • M. Estorch
  • G. Fraga
  • E. Mena
  • J. Fuertes
  • M. A. Hernández
  • A. Flotats
  • I. Carrió
Original Article


Technetium-99m dimercaptosuccinic acid (DMSA) study has been advocated as a method for the assessment of renal sequelae after acute febrile urinary tract infection (UTI). However, it is not known whether DMSA scintigraphy performed during acute UTI has any prognostic value for outcome assessment. The objective of this study was to evaluate the usefulness of DMSA scintigraphy performed during UTI as a predictor of patient outcome, to identify children at risk of events [vesico-ureteral reflux (VUR) or recurrent UTI] that may lead to the development of progressive renal damage. One hundred and fifty-two children (including 78 girls) with a mean age of 20 months (range 1 month to 12 years) with first febrile UTI were evaluated by DMSA scintigraphy during acute UTI. After acute UTI, children were explored by voiding cysto-urethrography. Children who presented an abnormal DMSA study, or a normal DMSA study but VUR or recurrent UTI, underwent a DMSA control study 6 months after UTI. Children with VUR were followed up by direct radionuclide cystography. DMSA scintigraphy performed during acute UTI was normal in 112 children (74%). In 95 of these children, follow-up DMSA scintigraphy was not performed owing to a good clinical outcome. In the remaining 17 children, follow-up scintigraphy was normal. Forty children (26%) presented abnormal DMSA study during acute UTI. Twenty-five of them presented a normal follow-up DMSA, and 15 presented cortical lesions. Children with abnormal DMSA had a higher frequency of VUR than children with normal DMSA (48% vs 12%). It is concluded that children with normal DMSA during acute UTI have a low risk of renal damage. Children with normal follow-up DMSA and low-grade VUR have more frequent spontaneous resolution of VUR.


DMSA scintigraphy Acute febrile urinary tract infection Vesico-ureteral reflux Recurrent urinary tract infection 


  1. 1.
    Rushton HG. Urinary tract infections in children: epidemiology, evaluation and management. Pediatr Clin North Am 1997; 44:1133–1169.PubMedGoogle Scholar
  2. 2.
    Stork JE. Urinary tract infection in children. Adv Pediatr Infect Dis 1987; 2:115–134.PubMedGoogle Scholar
  3. 3.
    Eggli DF, Tulchinsky M. Scintigraphic evaluation of pediatric urinary tract infection. Semin Nucl Med 1993; 3:199–218.Google Scholar
  4. 4.
    Jacobson SH, Eklof O, Eriksson CG, Lins LE, Tidgren B, Winberg J. Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up. BMJ 1989; 299:703–706.PubMedGoogle Scholar
  5. 5.
    Merrick MV, Notghi A, Chalmers N, Wilkinson AG, Uttley WS. Long term follow up to determine the prognostic value of imaging after urinary tract infections. Part 1. Reflux. Arch Dis Child 1995; 72:388–392.Google Scholar
  6. 6.
    Merrick MV, Notghi A, Chalmers N, Wilkinson AG, Uttley WS. Long term follow up to determine the prognostic value of imaging after urinary tract infections. Part 2. Scarring. Arch Dis Child 1995; 72:393–396.PubMedGoogle Scholar
  7. 7.
    Risdon RA, Godley ML, Gordon I, Ransley PG. Renal pathology and the99mTc-DMSA image before and after treatment of the evolving pyelonephritic scar: and experimental study. J Urol 1994; 152:1260–1266.PubMedGoogle Scholar
  8. 8.
    Stokland E, Hellström M, Jacobsson B, Sixt R. Imaging of renal scarring. Acta Paediatr Suppl 1999; 431:13–21.CrossRefGoogle Scholar
  9. 9.
    Piepsz A, Colarinha P, Gordon I, Hahn K, Olivier P, Roca I, Sixt R, van Persen J. Guidelines for99mTc-DMSA scintigraphy in children. Eur J Nucl Med 2001; 28:BP37–BP41.Google Scholar
  10. 10.
    Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Mobius TE. International system of radiographic grading of vesicoureteric reflux: International Reflux Study in Children. Pediatr Radiol 1985; 15:105–109.PubMedGoogle Scholar
  11. 11.
    Piepsz A, Hahn K, Roca I, Ciofetta G, Toth G, Gordon I, Kolinska J, Gwidlet J. A radiopharmaceutical schedule for imaging in paediatrics. Eur J Nucl Med 1990; 17:127–129.PubMedGoogle Scholar
  12. 12.
    Bush R, Huland H. Correlation of symptoms and results of bacterial localization in patients with urinary tract infections. J Urol 1984; 132:282–285.PubMedGoogle Scholar
  13. 13.
    Risdon RA, Godley ML, Parkhouse HF, Gordon I, Ransley PG. Renal pathology and the99mTc-DMSA image during the evolution of the early pyelonephritic scar: an experimental study. J Urol 1994; 151:767–773.PubMedGoogle Scholar
  14. 14.
    Jakobsson B, Berg U, Svensonn L. Renal scarring after acute pyelonephritis. Arch Dis Child 1994; 70:111–115.PubMedGoogle Scholar
  15. 15.
    Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med 2003; 348:195–202.CrossRefPubMedGoogle Scholar
  16. 16.
    Stokland E, Hellström M, Jacobsson B, Jodal U, Sixt R. Renal damage one year after first urinary tract infection: role of dimercaptosuccinic acid scintigraphy. J Pediatr 1996; 129:815–820.PubMedGoogle Scholar
  17. 17.
    Jakobsson B, Soderlundh S, Berg U.99Tc-dimercaptosuccinic acid (DMSA) in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings. Pediatr Nephrol 1992; 6:328–334.PubMedGoogle Scholar
  18. 18.
    Stokland E, Hellström M, Jacobsson B, Jodal U, Lundgreen P, Sixt R. Early99mTc dimercaptosuccinic acid (DMSA) scintigraphy in symptomatic first-time urinary tract infection. Acta Paedriat 1996; 85:430–436.Google Scholar
  19. 19.
    Miller T, Phillips S. Pyelonephritis: the relationship between infection, renal scarring, and antimicrobial therapy. Kidney Int 1981; 19:654–662.PubMedGoogle Scholar
  20. 20.
    Biggi A, Dardanelli L, Cussino P, Pomero G, Noello C, Sernia O, Spada A, Camuzzini G. Prognostic value of the acute DMSA scan in children with first urinary tract infection. Pediatr Nephrol 2001; 16:800–804.CrossRefPubMedGoogle Scholar
  21. 21.
    Ditchfield MR, Campo JF, Nolan TM, Cook DJ, Grimwood K, Powell HR, Sloane R, Cahill S. Risk factors in the development of early renal cortical defects in children with urinary tract infection. AJR 1994; 162:1393–1397.Google Scholar
  22. 22.
    Lomberg H, Hanson LA, Jacobsson B, Jodal U, Leffler H, Eden C. Correlation of P blood group, vesicoureteral reflux, and bacterial attachment in patients with recurrent pyelonephritis. N Engl J Med 1983; 308:1189–1192.PubMedGoogle Scholar
  23. 23.
    Goldraich NP, Manfroi A. Febrile urinary tract infection: Escherichia coli susceptibility to oral antimicrobials. Pediatr Nephrol 2002; 17:173–176.PubMedGoogle Scholar
  24. 24.
    Shaw KN, Gorelich MH. Urinary tract infection in pediatric patient. Pediatr Clin North Am 1999; 46:1111–1124.PubMedGoogle Scholar
  25. 25.
    Leffler H, Svanborg Eden C. Chemical identification of a glycosphingolipid receptor for Escherichia coli attaching to human urinary tract epithelial cells and agglutinating human erythrocytes. FEMS Microbiol Lett 1980; 8:297–302.CrossRefGoogle Scholar
  26. 26.
    Majd M, Rushton HG, Jantausch B, Wiedermann BL. Relationship among vesicoureteral reflux, P-fimbriated Escherichia coli, and acute pyelonephritis in children with febrile urinary tract infection. J Paediatr 1991; 119:578–585.Google Scholar
  27. 27.
    Cascio S, Chertin B, Colhoun E, Puri P. Renal parenchymal damage in male infants with high grade vesicoureteral reflux diagnosed after the first urinary tract infection. J Urol 2002; 168:1708–1710.CrossRefPubMedGoogle Scholar
  28. 28.
    Poli-Merol ML, Francois S, Pfliger F, Lefebvre F, Roussel B, Liehn JC, Daoud S. Interest of direct radionuclide cystography in repeated urinary tract infection exploration in childhood. Eur J Pediatr Surg 1998; 8:339–342.PubMedGoogle Scholar
  29. 29.
    Piepsz A, Biggi A, Sixt R, Gordon I, Frokiaer J, Eskild-Jensen A, Fettich J. Symposium on radionuclides in paediatric nephro-urology. Nucl Med Commun 2003; 24:11–22.CrossRefPubMedGoogle Scholar
  30. 30.
    Camacho Marti V, Estorch Cabrera M, Caffaratti Sfulcini J, Fraga Rodriguez GM, Orsola De Los Santos A, Rodriguez Villamil L, Garat Barredo JM, Cubells Riero J, Carrio Gasset I. Role of direct radionuclide cystography and renal study by dimercaptosuccinic acid (DMSA) in the diagnosis and follow-up of vesicoureteral reflux. Rev Esp Med Nucl 2002; 21:269–274.PubMedGoogle Scholar
  31. 31.
    Sillen U. Vesicoureteral reflux in infants. Pediatr Nephrol 1999; 13:335–361.Google Scholar
  32. 32.
    Wennerstrom M, Hansson S, Jodal U, Stokland E. Disappearance of vesicoureteral reflux in children. Arch Pediatr Adolesc Med 1998; 152:879–893.PubMedGoogle Scholar
  33. 33.
    Schwab CW, Wu HY, Selman H, Smith GH, Snyder HM, Canning DA. Spontaneous resolution of vesicoureteral reflux: a 15-year perspective. J Urol 2002; 168:2594–2599PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • V. Camacho
    • 1
  • M. Estorch
    • 1
  • G. Fraga
    • 1
  • E. Mena
    • 1
  • J. Fuertes
    • 1
  • M. A. Hernández
    • 1
  • A. Flotats
    • 1
  • I. Carrió
    • 1
  1. 1.Department of Nuclear MedicineHospital de la Santa Creu i Sant PauBarcelonaSpain

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