Renal cortical scintigraphy in the diagnosis of acute pyelonephritis

doi:10.1016/S0001-2998(05)80085-6

Seminars in Nuclear Medicine

Volume 22, Issue 2, April 1992, Pages 98-111

https://doi.org/10.1016/S0001-2998(05)80085-6 Get rights and content

Comparative clinical studies have shown renal cortical scintigraphy, using technetium-99m (^99mTc)-labeled glucoheptonate or dimercaptosuccinic acid (DMSA), to be significantly more sensitive than either intravenous pyelography or renal sonography in the diagnosis of acute pyelonephritis. However, due to uncertainties about the diagnostic accuracy of the clinical and laboratory parameters used in these studies, true sensitivity of renal cortical scintigraphy was unknown. Therefore, we evaluated the accuracy of [^99mTc]DMSA scintigraphy in the diagnosis of experimentally induced acute pyelonephritis in piglets using strict histopathologic criteria as the standard of reference. The sensitivity and specificity of the DMSA scan for the diagnosis of acute pyelonephritis were 91% and 99%, respectively, with an overall 97% agreement between the scintigraphic and histopathologic findings. Based on the results of this experimental study, we used the [^99mTc]DMSA scan as the standard of reference for the diagnosis of acute pyelonephritis, and conducted a prospective clinical study of 94 children hospitalized with the diagnosis of acute febrile urinary tract infection (UTI). The aims of this study were (1) to determine the relationship among vesicoureteral reflux, P-fimbriated Escherichia coli, acute pyelonephritis, and renal scarring, and (2) to evaluate the diagnostic reliability of the clinical and laboratory parameters commonly used in the diagnosis of acute pyelonephritis. We documented acute pyelonephritis in 62 (66%) of 94 patients. Vesicoureteral reflux was demonstrated in 29 (31%) of the total group and in only 23 (37%) of 62 patients with acute pyelonephritis. The prevalence of P-fimbriae in the E coli isolates was 64% in the patients with acute pyelonephritis and 78% in those with a normal DMSA scan. Even in patients without reflux, P-fimbriae were found in 71% of isolates from the patients with acute pyelonephritis and in 75% of those with a normal renal scan. Follow-up DMSA scans were obtained in 33 patients with acute pyelonephritis in 38 kidneys. We found complete resolution of the acute inflammatory changes in 58% of the involved kidneys and renal scarring in the remaining 42%, including 40% of the kidneys associated with reflux and 43% of those without reflux. The results of these experimental and clinical studies show the following: (1)[^99mTc]DMSA renal cortical scintigraphy is a highly sensitive and reliable technique for the diagnosis of acute pyelonephritis; (2) the diagnosis of acute pyelonephritis in children based on clinical and laboratory observations is unreliable; (3) acute pyelonephritis in the absence of reflux is common; (4) the presence of P-fimbriae alone does not fully explain the pathogenesis of acute pyelonephritis in the absence of reflux; (5) although high grades of reflux may be a risk factor for acute pyelonephritis, the risk of pyelonephritis in patients with lower grades of reflux is the same as in those with no reflux; and (6) once acute pyelonephritis occurs, subsequent renal scarring is independent of the presence or absence of reflux. We conclude that DMSA renal cortical scintigraphy is a valuable diagnostic tool for investigating UTI, particularly in children. More precise diagnosis of acute pyelonephritis allows for newer insights into the pathophysiology of the disease and prevention of its sequelae, and in the future it may change the approach to the imaging evaluation and management of children with UTI.

References (53)

BhathenaDB et al.
Focal and segmental glomerular sclerosis in reflux nephropathy
Am J Med
(1980)
SteinhardtGF
Reflux nephropathy
J Urol
(1985)
WinbergJ et al.
Clinical pyelonephritis and focal renal scarring: A selected review of pathogenesis, prevention, and prognosis
Pediatr Clin North Am
(1982)
RansleyPG et al.
Reflux nephropathy: Effects of antimicrobial therapy on the evolution of the early pyelonephritic scar
Kidney Int
(1981)
RobertsJA
Pathogenesis of pyelonephritis
J Urol
(1983)
RobertsJA et al.
Immunology of pyelonephritis in the primate model: Live versus heat killed bacteria
Kidney Int
(1981)
RobertsJA et al.
Immunology of pyelonephritis in the primate model. V. Effect of superoxide dismutase
J Urol
(1982)
SkoogSJ et al.
A nonsurgical approach to the management of primary vesicoureteral reflux
J Urol
(1987)
BuschR et al.
Correlation of symptoms and results of direct bacterial localization in patients with urinary tract infections
J Urol
(1984)
RushtonHG et al.
Evaluation of ^99mTc-dimercaptosuccicic acid renal scans in experimental acute pyelonephritis in piglets
J Urol
(1988)

ConwayJJ

The role of scintigraphy in urinary tract infection

WinterAL et al.

Acquired renal scars in children

J Urol

(1983)

MajdM et al.

Relationship among vesicoureteral reflux, P-fimbriated Escherichia coli, and acute pyelonephritis in children with febrile urinary tract infection

J Pediatr

(1991)

AskariA et al.

Vesicoureteral reflux in black girls

J Urol

(1982)

Svanborg EdénC et al.

Variable adherence to normal human urinary tract epithelial cells of Escherichia coli strains associated with various forms of urinary infection

Lancet

(1976)

LefflerH et al.

Chemical identification of glycosphingolipid receptor for Escherichia coli attaching to human urinary tract epithelial cells and agglutinating human erythrocytes

FEMS Microbiol Lett

(1980)

KälleniusG et al.

The P^k antigen as receptor for the hemagglutination pyelonephritis E. coli

FEMS Microbiol Lett

(1980)

KälleniusG et al.

Occurence of P-fimbriated Escherichia coli in urinary tract infections

Lancet

(1981)

RobertsJA et al.

Experimental pyelonephritis in the monkey. VII. Ascending pyelonephritis in the absence of vesicoureteral reflux

J Urol

(1985)

HollandNH et al.

Hypertension in children with chronic pyelinephritis

Kidney Int

(1975)

WallaceDMA et al.

The long term follow-up of surgically treated vesicoureteral reflux

Br J Urol

(1978)

Kincaid-SmithP

Glomerular lesions in atrophic pyelonephritis and reflux nephropathy

Kidney Int

(1975)

TorresVE et al.

The progression of vesicoureteral reflux nephropathy

Ann Int Med

(1980)

BergerRE et al.

Vesicoureteral reflux in children with uremia: Prognostic indicators for treatment and survival

JAMA

(1981)

BaileyRR

End-stage reflux nephropathy

Nephron

(1981)

SenekjianHO et al.

Vesicoureteral reflux and reflux nephropathy

Am J Nephrol

(1982)

Cited by (174)

Role of Functional SPECT and PET in Renal Emergencies
2023, Seminars in Nuclear Medicine
Renal scintigraphy is a centerpiece of nuclear medicine and is also commonly applied for (peri-)acute care. In this regard, referrals by the treating physician include: I.) acute obstructions caused by gradual and infiltrative tumor growth or renal off-target effects under anti-tumor treatment, II.) functional issues in infants, for example, structural abnormalities such as duplex kidneys or uroliths in adults, which can also trigger III.) Infections of renal parenchyma. Renal radionuclide imaging is also requested due to IV.) acute trauma to the abdomen, for example, to assess renal scarring or upon further follow-up after reconstructive surgery. We will discuss clinical applications of (peri-)acute renal scintigraphy, along with future prospects on the use of more advanced nuclear imaging techniques such as renal positron emission tomography.
Diffusion-weighted magnetic resonance imaging is more sensitive than dimercaptosuccinic acid scintigraphy in detecting parenchymal lesions in children with acute pyelonephritis: A prospective study
2018, Journal of Pediatric Urology
Citation Excerpt :
The DMSA-SRS probably becomes positive in the early phase of the inflammatory response because of ischemia. The acute parenchymal inflammatory changes are reversible and do not lead to renal scarring in most cases [5]. DW-MRI is based on molecular vibrations caused by diffusion.
Static renal scintigraphy is the gold standard for detection of inflammatory changes in the renal parenchyma in acute pyelonephritis. Our aim was to determine whether diffusion-weighted magnetic resonance imaging (DW-MRI) was comparable with static renal scintigraphy (DMSA-SRS) to demonstrate acute renal parenchymal lesions.
To compare ^99mTc-dimercaptosuccinic acid static renal scintigraphy (DMSA-SRS) with diffusion-weighted magnetic resonance imaging (DW-MRI) for detecting acute inflammatory changes in the renal parenchyma in children with febrile urinary tract infection.
Thirty-one children (30 girls) aged 3–18 years with a first episode of febrile UTI without a previously detected congenital malformation of the urinary tract, were prospectively included. DMSA-SRS and DW-MRI were performed within 5 days of diagnosis to detect renal inflammatory lesions. The DW-MRI examination was performed without contrast agent and without general anesthesia. Late examinations were performed after 6 months using both methods to detect late lesions.
DW-MRI confirmed acute inflammatory changes of the renal parenchyma in all 31 patients (100%), mostly unilateral. DMSA-SRS detected inflammatory lesions in 22 children (71%; p = 0.002). The lesions were multiple in 26/31 children (84%) on DW-MRI and in 9/22 (40%) on DMSA-SRS. At the control examination, scarring of the renal parenchyma was found equally by DW-MRI and DMSA-SRS in five patients (16%), three of whom were the same patients. The overall concordance of positive and negative late findings occurred in 87% of patients. There was correspondence in the anatomical location of acute and late lesions.
The clinical significance of acute and late parenchymal findings on DWI-MR is yet to be determined. A limitation of our study is the age of the patients (older than 3 years) who are less sensitive to scar development; therefore, a smaller number of patients with scars could be analyzed during control examination. Further studies using the DW-MRI should confirm its reliability to detect acute and late lesions in younger children and infants and determine the clinical consequences.
DW-MRI has higher sensitivity for detecting acute renal inflammatory lesions and multifocal lesions than DMSA-SRS. The incidence of scars was low and corresponded with the anatomical location of acute and late lesions.
Comparison of relative renal functions calculated with <sup>99m</sup>Tc-DTPA and <sup>99m</sup>Tc-DMSA for kidney patients of wide age ranges
2018, Physica Medica
Citation Excerpt :
DMSA renal scan images provide a good definition of the cortical outline, as well as they show the relative distribution of functional tissue. It is primarily used in humans for cortical imaging and estimation of functional renal mass [5–7], the applications of which include detection of pyelonephritis [8] and renal scars [9,10]. On the other hand, 99mTc-DTPA dynamic agent is freely filterable at the glomerular function, but it is neither secreted nor resorbed by the kidney tubules.
Renal scintigraphy is an imaging method that uses small amount of radioactive materials called radiotracers, a Gamma camera and a computer to evaluate kidney functions and its anatomy. The present work reports the comparison of the relative renal functions (RRF) calculated with technetium-99m dimercaptosuccinic acid (^99mTc‑DMSA) and technetium-99m diethylenetriaminepentaacetic acid (^99mTc‑DTPA) for kidney patients of ages between 5 months and 71 years. A total of 50 patients including 29 male and 21 female has been selected and studied for renography. The mean RRFs have been found to be 52.68 ± 23.63% and 47.32 ± 23.63% respectively for the left and right kidneys with ^99mTc-DMSA measurement. With ^99mTc-DTPA the values are 52.74 ± 23.54% and 47.26 ± 23.54% for the same. In bivariate correlation analysis, a significant positive correlation (r = 0.996, P < .001) has been found between the RRFs calculated with the two methods. Following the patients’ diagnosis, in ANOVA test, no difference has been found between the RRFs calculated for the left and right kidneys. In Bland-Altman plots, the mean difference between the two methods has been found to be 0.1 and the correlation limit lies between −4.3 and 4.2. According to the result obtained in the present work, both the ^99mTc-DMSA and ^99mTc-DTPA scanning methods provide almost the same RRF values. It is, therefore, always not necessary to calculate the RRFs with both the methods. This study suggests that ^99mTc-DMSA may be the primary choice for the evaluation of RRF, but if the glomerular filtration rate (GFR) and renogram curve are required, ^99mTc-DTPA can be the obvious selection.
Impact of cytokine genetic polymorphisms on the risk of renal parenchymal infection in children
2017, Journal of Pediatric Urology
Acute pyelonephritis is associated with renal scarring in up to 30% of patients. Renal scarring may cause significant long-term morbidity. The pathogenesis of acute pyelonephritis remains unclear, although it involves interaction among uroepithelium, the immune system cells, and the locally produced cytokines. That some UTI-prone children develop acute pyelonephritis, and eventually renal parenchymal scarring, suggests a genetic role. Interleukin-6, interleukin-8, chemokine receptor-1 (CXCR1), and tumor necrosis factor-alpha (TNFα), the key regulators of the host immune responses, are proteins whose secretion is controlled by genes. We postulated that functional polymorphic variants of their genes might have a role in APN susceptibility.
We sought to investigate a possible association of the common functional polymorphisms in genes encoding IL-6, IL-8, CXCR1, and TNFα with the risk of APN in children.
Urine culture was used to diagnose 300 children with UTI, of mean age of 51.31 ± 37.4 months (2–180 months). 99Tc-DMSA scans diagnosed 86 children with APN. Follow-up scans identified new renal scars in 18 children. Six functional single-nucleotide polymorphisms (SNPs) in genes encoding IL-6, IL-8, CXCR1, and TNFα were genotyped in all subjects (IL-6 rs1800795 (−174G/C), IL-6 rs1800796 (−572G/C), IL-8 rs2227306 (781C/T), IL8 rs4073 (−251A/T), CXCR1 rs2234671 (2607G/C), and TNFα rs1800629 (−308G/A)).
TT genotype of IL-8 −251A/T polymorphism was significantly higher in APN patients (26.7%) than those with lower UTI (11.7%, p = 0.01) and control individuals (12.2%, p = 0.002). T allele was significantly more common in APN than in lower UTI (p = 0.025) and was significantly more common in APN (46%) than in the controls (p = 0.001). Similarly, TT genotype of IL-8 781C/T polymorphism was significantly more common in APN patients (31.4%) than those with lower UTI (17.3%, p = 0.003) and the controls (14.3%, p = 0.001). T allele was significantly more common in APN (55%) than lower UTI (40%, p = 0.005) and controls (37%, p = 0.001). However, IL-8 −251A/T and +781C/T SNPs did not qualify as an independent risk for parenchymal infection (OR 1.9, 95% CI 0.68–2.6, p = 0.13 and OR 2.3, 95% CI 0.89–3.7, p = 0.091, respectively). Lower UTI did not differ from the controls. The frequency of the genotypes and alleles of IL-6, CXCR1, and TNFα SNPs did not differ significantly among the different groups of the study.
IL-8 −251A/T and +781C/T SNPs are associated with susceptibility to renal parenchymal infection in children and could be implicated in APN risk. However, none of these variants could clearly and independently predict this risk.
Nuclear Medicine in Pediatric Nephro-Urology: An Overview
2017, Seminars in Nuclear Medicine
In the context of ante-natally diagnosed hydronephrosis, the vast majority of children with a dilated renal pelvis do not need any surgical treatment, as the dilatation resolves spontaneously with time. Slow drainage demonstrated at Tc-99m-mercaptoacetyltriglycine (MAG3) renography does not necessarily mean obstruction. Obstruction is defined as resistance to urinary outflow with urinary stasis at the level of the pelvic-ureteric junction (PUJ) which, if left untreated, will damage the kidney. Unfortunately this definition is retrospective and not clinically helpful. Therefore, the identification of the kidney at risk of losing function in an asymptomatic patient is a major research goal. In the context of renovascular hypertension a DMSA scan can be useful before and after revascularisation procedures (angioplasty or surgery) to assess for gain in kidney function. Renal calculi are increasingly frequent in children. Whilst the vast majority of patients with renal stones do not need functional imaging, DMSA scans with SPECT and a low dose limited CT can be very helpful in the case of complex renal calculi. Congenital renal anomalies such as duplex kidneys, horseshoe kidneys, crossed-fused kidneys and multi-cystic dysplastic kidneys greatly benefit from functional imaging to identify regional parenchymal function, thus directing further management. Positron emission tomography (PET) is being actively tested in genito-urinary malignancies. Encouraging initial reports suggest that F-18-fluorodeoxyglucose (FDG) PET is more sensitive than CT in the assessment of lymph nodal metastases in patients with genito-urinary sarcomas; an increased sensitivity in comparison to isotope bone scans for skeletal metastatic disease has also been reported. Further evaluation is necessary, especially with the promising advent of PET/MRI scanners. Nuclear Medicine in paediatric nephro-urology has stood the test of time and is opening up to new exciting developments.
Hypertension in pediatric patients with renal scarring in association with vesicoureteral reflux
2013, Urology
Citation Excerpt :
They found home BP measurements were superior to clinical BP measurements in predicting hypertension. Although severe hypertension secondary to reflux nephropathy develops at any age, previous studies showed that it is more frequent during adolescence and adulthood.22,23 In line with these findings, the frequency of hypertension gradually increased by age in the present study, with a frequency of 9.7% during adolescence.
To examine the reflux nephropathy rate and severity as well as the hypertension rate in pediatric patients with vesicoureteral reflux (VUR).
The study included 240 patients with VUR. Renal scarring (RS) was demonstrated by renal parenchymal examination using technetium-99m–labeled dimercaptosuccinic acid (^99mTc-DMSA) scintigraphy. Office measurements of arterial blood pressure and ambulatory blood pressure monitoring (ABPM) of VUR patients were done during the follow-up period.
Follow-up was a mean duration of 24 months. Rates of RS and hypertension increased parallel to increases in the degree of VUR. A gradual elevation in hypertension rates was evident during the follow-up period. All patients with hypertension had RS. Severe RS in 56 patients was associated with increasing blood pressure readings by 24-hour ABPM or office measurements in 19 patients (33.9%). ABPM measurements enabled us to detect additional patients compared with office measurements alone.
Hypertension is a serious complication in children with reflux nephropathy and is associated with the severity of RS and VUR grade. ABPM seems to be superior over office measurements of blood pressure in identifying patients with hypertension.

View all citing articles on Scopus

View full text

Renal cortical scintigraphy in the diagnosis of acute pyelonephritis

Am J Med

J Urol

Pediatr Clin North Am

Kidney Int

J Urol

Kidney Int

J Urol

J Urol

J Urol

J Urol

J Urol

J Pediatr

J Urol

Lancet

FEMS Microbiol Lett

FEMS Microbiol Lett

Lancet

J Urol

Hypertension in children with chronic pyelinephritis

Kidney Int

The long term follow-up of surgically treated vesicoureteral reflux

Br J Urol

Glomerular lesions in atrophic pyelonephritis and reflux nephropathy

Kidney Int

The progression of vesicoureteral reflux nephropathy

Ann Int Med

Vesicoureteral reflux in children with uremia: Prognostic indicators for treatment and survival

JAMA

End-stage reflux nephropathy

Nephron

Vesicoureteral reflux and reflux nephropathy

Am J Nephrol