THE EVALUATION OF RENAL CORTICAL SCINTIGRAPHY IN VESICOURETERAL REFLUX SUSPECTED PEDIATRIC PATIENTS WITH RADIONUCLIDE CYSTOGRAPHY

Öz

OBJECTIVE: Vesicoureteral reflux VUR can be diagnosed in 21-57 % of children with urinary tract infection and may have important consequences leading to chronic renal failure. Radionuclide cystography RNC is an effective and reliable method in the diagnosis and follow up of children with VUR. In this study, we evaluated renal parenchymal damage with Tc99m-DMSA scintigraphy in the VUR positive and negative children diagnosed with RNC.MATERIAL AND METHODS: A total of 392 renal units in 121 girls and 75 boys; age range, 3 months -13 years, were evaluated with direct or indirect RNC and renal cortical scintigraphy who were referred to Nuclear Medicine Department for recurrent urinary tract infection. All the patients were subjected to clinical assessment, laboratory investigation urine analysis, creatinine and urine culture and renal ultrasonography analysis US . Patients kidneys were evaluated in 4 groups; in the 1st group kidneys with both RNC and DMSA results were normal, 2nd group neither RNC nor DMSA results were normal, 3rd group RNC results were abnormal but DMSA results were normal and the 4th group RNC results were normal but DMSA results were normal.RESULTS: Positive VUR was scintigraphically evident in 69 patients with 77 renal units. Thirty-five kidneys had grade 1 , 13 kidneys had grade 2, 13 kidneys had grade 3 VUR and 8 patients had bilateral VUR . In the first group, there were 212 renal unites 54.1% , in 2nd group there were 58 renal unites 14.8 % , in the 3rd group there were 98 renal unites 25.0 % and in the 4th group there were 24 renal unites 6.1 % . US findings were abnormal in 131 33.4 % kidney units. CONCLUSION: In the comparision of RNC abnormal kidneys with Tc-99m DMSA scintigraphy normal and abnormal kidneys: abnormal kidneys were more commonly positive. There was no statistical difference of US for parenchyma pathology between RNC positive and RNC negative cases. Renal scanning with Tc99m DMSA, RNC and renal US should be complementary both in VUR positive and VUR negative cases

Anahtar Kelimeler

• Vesicoureteral reflux VUR,Radionuclide cystography RNC,Tc-99m DMSA

RADYONÜKLİD SİSTOGRAFİ İLE VEZİKOÜRETERAL REFLÜ DÜŞÜNÜLEN PEDİATRİK OLGULARDA KORTİKAL RENAL SİNTİGRAFİ DEGERLENDİRİLMESİ

Öz

AMAÇ: Vezikoüreteral reflü VUR üriner enfeksiyon geçiren çocukların %21-57’unda saptanmakta olup, kronik böbrek yetmezliğine kadar uzanabilen önemli sonuçları vardır. Vezikoüreteral reflü olan çocukların tanı ve takibinde radyonüklid sistografi RNS etkin ve güvenilir bir tanı yöntemidir. Bu çalışmada RNS ile tanı konulan VUR pozitif ve negatif çocuklarda renal parankim hasar gelişmesini Tc99m-DMSA sintigrafisi ile değerlendirdik.GEREÇ VE YÖNTEMLER: Tekrarlayan üriner sistem enfeksiyonu ile başvuran 196 çocuğa ait 121 kız, 75 erkek; 3 ay-13 yaş aralığında toplam 392 adet renal unite direkt veya indirekt RNS sonrasında renal kortikal sintigrafi ile değerlendirildi. Tüm hastalar klinik olarak değerlendirildi ve kreatinin, idrar analizleri ve idrar kültürleri bakıldı. Ayrıca tüm hastaların renal Ultrasonları US yapıldı. İncelenen böbrekler 4 gruba ayrıldı. Birinci grupta hem RNS hem DMSA sonuçları normal, 2.ci grupta hem RNS hem DMSA sonuçları anormal, 3.cü grupta RNS sonucu anormal ancak DMSA sonucu normal ve 4.cü grupta RNS sonucu normal ancak DMSA sonucu anormal böbrekler alındı. BULGULAR: 69 hastada 77 renal ünitte sintigrafik olarak VUR tesbit edildi. Otuzbeş renal ünitte grade 1, 13 renal ünitte grade 2, 13 renal ünitte grade 3 VUR olup, 8 hastada VUR bilateraldi. Birinci grupta 212 %54.1 , 2.ci grupta 58 % 14.8 , 3.ncü grupta 98 % 25.0 ve 4.cü grupta 24 renal ünite % 6.1 bulundu. Renal US 131 böbrekte %33.4 anormal olarak değerlendirildi.SONUÇ: RNS sonuçları anormal hastalarla Tc-99m DMSA sintigrafisi normal ve anormal olan hastalar karşılaştırıldığında, anormal olan hastalar daha sıklıkla pozitif olarak bulundu. US sonuçları ile RNS sonuçları normal hastalarla veya anormal hastalar arasında anlamlı ilişki bulunamadı. Gerek VUR pozitif gerekse VUR negatif hastalarin tanılarında Tc99m DMSA sintigrafisi, RNS ve renal US birbirlerini tamamlayıcı olarak kullanılmalıdırlar

Anahtar Kelimeler

• Vezikoüreteral reflü,Radyonüklid Sistografi,Tc99m-DMSA

Kaynakça

1. 1)Rosenberg AR, Rossleigh MA, Brydon MP, Bass SJ, Leighton DM, Farnsworth RH. Evaluation of acut urinary tract infection in children by dimercaptosuccinic acid scintigraphy: A prospective study. J Urol. 1992; 148: 1746-1749.
2. 2)Majd M, Rushton HG, Jantausch B, Wiedermann BL. Relationship among vesicoüreteral reflux, p-fimbriated Escherichia coli, and acut pyelonephritis in children with febrile urinary tract infection. J Pediatr. 1991; 119: 578-585.
3. 3)Ditchfield MR, de Campo JF, Cook DJ et al: Vesicoureteral reflux: an accurate predictor of acute pyelonephritis in childhood urinary tract infections? Radiol. 1994; 190: 413-415.
4. 4)Lama G, Tedesco MA, Graziano L, Calabrese E, Grassia C, Natale F, Pacileo G, Rambaldi PF, Esposito-Salsano M. Reflux nephropathy and hypertension: correlation with the progression of renal damage. Pediatr Nephrol. 2003; 18: 241-245.
5. 5)Ziessman H. A, O’Malley J, Thrall J. Nuclear Medicine Requisites 3’rd edition. Philadelphia: Elsiever-Mosby. 2006; 215-262.
6. 6)Hansson S: Urinary tract infection in children The point of view of the pediatric nephrologist, in Prigent A, Piepz A (eds): Functional imaging in Nephro-Urology. London Taylor and Francis. 2006; 233-239.
7. 7)Ziessman H. A. The Requisites Nuclear Medicine. Third Edition.
8. 8)Rossleigh MA. Renal infection and vesico-ureteric reflux. Semin Nucl Med. 2007; 37: 261-268.

9. 9)Jakobsson B, Esbjorner E, Hanssoon S. Minimum incidence and diagnostic rate of first urinary tract infection. Pediatrics. 1999; 104: 222-226.
10. 10)Cleper R, Krause I, Eisenstein B, Davidovits M. Prevalence of vesicoureteral reflux in neonatal urinary tract infection. Clin Pediatr (phila). 2004; 43: 619-625.
11. 11)Rushton HG, Majd M. Dimercaptosuccinic acid renal scintigraphy for the evaluation of pyelonephritis and scaring: a review of experimental and clinical studies. J Urol. 1992; 148: 1726-1732.
12. 12)Marks SD, Gordon I, Tullus K. Imaging in childhood urinary tract infections: time to reduce investigations. Pediatr Nephrol. 2008; 23: 9-17.
13. 13)Stefanidis CJ, Siomou E. Imaging strategies for vesicoureteral reflux diagnosis. Pediatr Nephrol. 2007; 22: 937-947.
14. 14)Sastrre JB, Aparicio AR, Cotallo GD, Colomer BF, Hernandrez MC. Urinary tract infection in the newborn: clinical and radio imaging studies. Pediatr Nephrol. 2007; 22: 1735-1741.
15. 15)Ozdogan O, Turkmen M, Atasever S, Arslan G, Soylu A, Kasap B. New quantitative parameters for evaluating radionuclide cystography and their value in understanding the physiology of reflux. Journal of Nuclear Medicine Technology. 2009; 37: 101-106.
16. 16)Wennerström M, Hansson S, Jodal U, Stokland E. Disappearance of vesicoureteral reflux in children. Arch pediatr Adolesc Med. 1998; 152: 879-883.
17. 17)Jaukovic L, Ajdinovic B, Dobudja M, Krstic Z. Renal scintigraphy in children with vesicoureteral reflux. Indian Journal of Pediatrics. 2009; 76: 1023-1026.
18. 18)Ajdinovic B, Jaukovic Lj.Krstic Z, Dopudja M. Technetium 99m dimercaptosuccinic acid renal scintigraphy in children with urinary tract infection. Hell J Nucl Med. 2006; 9: 27-30.
19. 19)Olbing H, Smellie JM, Jodal U, Lax H. New renal scars in children with severe VUR: a 10-year study of randomized treatment. Pediatr Nephrol. 2003; 18: 1128-1131.
20. 20)Lee JH, Son CH, Lee MS, Park YS. Vesicoureteral reflux increases the risk of renal scars: a study of unilateral reflux. Pediatr Nephrol. 2006; 9: 1281-1284.
21. 21)Garin EH, Olavarria F, Nieto VG, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: A mul ticanter, randomised controlled study. Pediatrics. 2006; 626-632.
22. 22)Lebowitz RL et al. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol. 1985; 15: 105-109.
23. 23)Smellie JM, Prescod NP, Shaw PJ, Risdon RA, Bryant TN. Childhood reflux and urinary tract infection: a fallow-up of 10- 41 years in 226 adults. Pediatr Nephrol. 1998; 12: 727-736.
24. 24)Farnsworth RH, Rossleigh MA, Leighton DM, Bass SJ, Rosenberg AR. The detection of reflux nephropathy in infants by Technetium 99m Dimercapto-succinic acid studies. J Urol. 1991; 145: 542-546.
25. 25)Stokland E, Hellstrom M, Jacobsson B, Jodal U, Sixt R. Renal damage one year after first urinary tract infection: role of dimercaptosuccinic acid scintigraphy. Journal of pediatrics. 1996; 129: 815-820.
26. 26)Beriaghdar F, Panahi Y, Einollahi B, Moharamzad Y, Nemati E, Amirsalari S. Predisposing factors for renal scarring in children with urinary tract infection. Saudi j Kidney Dis Transpl. 2012; 23: 532-537.
27. 27)Lin KY, Chiu NT, Chen MJ, et al. Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection. Pediatr Nephrol. 2003; 18: 362-365.
28. 28)Zaki M, Badawi M, Al Mutari G, Ramadan D, Adul Rahman M. Acute pyelonephritis and renal scarring in Kuwaiti children: a follow-up study using Tc99m DMSA renal scintigraphy. Pediatr Nephrol. 2005; 20: 1116-1119.
29. 29)Oh MM, Jin MH, Bae JH, Park HS, Lee JG. Moon du G. The role of vesicoureteral reflux in acute renal cortical scintigraphic lesion and ultimate scar formation. J Urol. 2008; 180: 2167-2170.
30. 30)Vernon SJ, Coulthard MG, Lambert HJ, Keir MJ, Matthews JN. New renal scarring in children who at age 3 and 4 years had had normal scans with dimercaptosuccinic acid: follow up study. Bmj. 1997; 315: 905-908.
31. 31)Bensman A, Ulinski T. International vesicoureteral reflux study: Unsolved questions remaining. Paediatr Nephrol. 2006; 21: 757-758.
32. 32)Wheeler D, Vimalachandra D, Hodson EM, Roy LP, Smith G, Craig JC. Antibiotics and surgery for vesicoureteral reflux: A meta-analysis of randomised controlled trials. Arch Dis child. 2003; 88: 688-694.
33. 33)Garin EH, Olavarria F, Garcia Nieto V, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis:A multi centre randomised, controlled study. Pediatrics. 2006; 117: 626-632.
34. 34)Wald ER. Vesicoureteral reflux:The role antibiotic prophylaxis. Pediatrics. 2006; 117: 919-922.
35. 35)Biassoni L, Chippington S. Imaging in urinary tract infections: Current strategies and new trends. Semin Nucl Med. 2008; 38: 56-66.
36. 36)Downs SM. Technical report: urinary tract infections in febrile infants and young children. The urinary tract subcommittee of the american academy of pediatrics committee on quality improvement. Pediatrics. 1999; 103: 54.
37. 37)Zaffanello M, Franchini M, Brugnara M, Fanos V. Evoluating kidney damage from vesico-ureteral reflux in children. 2009; 20: 57-68.
38. 38)Piepsz A, Ham HR. Pediatric Applications of renal nuclear medicine. Semin Nucl Med. 2006; 36: 16-35.
39. 39)Saraga M, Stanicic A, Markovic V. The role of direct radionuclide cystography in evaluation of vesicoureteral reflux. Scand J Urol Nephrol. 1996; 30: 367-371.
40. 40)Bower G., Lovegrove FT, Geijsel H., Van der Schaff A, Guelfi G. Comparison of direct and indirect radionuclide cystography. Journal of Nuclear Medicine. 1985; 26: 465–468.
41. 41)Gordon I, Peters AM, Morony S. Indirect radionuclide cystography: a sensitive technique fort the detection of vesicoureteral reflux. Pediatric Nephrology. 1990; 4: 604-606.
42. 42)De Sadeleer C, De Boe V, Keuppens F, Desprechins B, Verboven M, Piepsz A. How good is technetium-99m mercaptoacetyltriglycine indirect cystography? Eur J Nucl Med. 1994; 21: 223-227.
43. 43)Sükan A, Bayazit AK, Kibar M, et al. Comparison of direct radionuclide cystography and voiding direct cystography in the detection of vesicoureteral reflux. Annals of Nuclear Medicine. 2003; 17: 549-553.
44. 44)Michaella M. Prasad and Earl Y. Cheng. Radiographic Evaluation of Children with Febrile Urinary Tract Infection: Bottom-Up, Top-Down, or None of the Above? Advances in Urology. doi:10.1155/2012/716739.
45. 45)Unver T, Alpay H, Biyikli NK, Ones T. Comparison of direct radionuclide cystography and voiding cystourethrography in detecting vesicoureteral reflux. Pediatrics International. 2006; 48: 287-291.
46. 46)Piscitelli A, Galiano R, Serrao F, et al. Which cystography in the diagnosis and grading of vesicoureteral reflux? Pediatric Nephrology. 2008; 23: 107-110.