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Meta-Analysis
. 2016 Jul 5;7(7):CD010657.
doi: 10.1002/14651858.CD010657.pub2.

Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections

Nader Shaikh  1 , Russell B Spingarn, Stephanie W Hum
Affiliations
Meta-Analysis

Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections

Nader Shaikh et al. Cochrane Database Syst Rev. .

Abstract

Background: There is considerable interest in detecting vesicoureteral reflux (VUR) because its presence, especially when severe, has been linked to an increased risk of urinary tract infections and renal scarring. Voiding cystourethrography (VCUG), also known as micturating cystourethrography, is the gold standard for the diagnosis of VUR, and the grading of its severity. Because VCUG requires bladder catheterisation and exposes children to radiation, there has been a growing interest in other screening strategies that could identify at-risk children without the risks and discomfort associated with VCUG.

Objectives: The objective of this review is to evaluate the accuracy of two alternative imaging tests - the dimercaptosuccinic acid renal scan (DMSA) and renal-bladder ultrasound (RBUS) - in diagnosing VUR and high-grade VUR (Grade III-V VUR).

Search methods: We searched MEDLINE, EMBASE, BIOSIS, and the Cochrane Register of Diagnostic Test Accuracy Studies from 1985 to 31 March 2016. The reference lists of relevant review articles were searched to identify additional studies not found through the electronic search.

Selection criteria: We considered published cross-sectional or cohort studies that compared the results of the index tests (DMSA scan or RBUS) with the results of radiographic VCUG in children less than 19 years of age with a culture-confirmed urinary tract infection.

Data collection and analysis: Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate summary sensitivity and specificity values.

Main results: A total of 42 studies met our inclusion criteria. Twenty studies reported data on the test performance of RBUS in detecting VUR; the summary sensitivity and specificity estimates were 0.44 (95% CI 0.34 to 0.54) and 0.78 (95% CI 0.68 to 0.86), respectively. A total of 11 studies reported data on the test performance of RBUS in detecting high-grade VUR; the summary sensitivity and specificity estimates were 0.59 (95% CI 0.45 to 0.72) and 0.79 (95% CI 0.65 to 0.87), respectively. A total of 19 studies reported data on the test performance of DMSA in detecting VUR; the summary sensitivity and specificity estimates were 0.75 (95% CI 0.67 to 0.81) and 0.48 (95% CI 0.38 to 0.57), respectively. A total of 10 studies reported data on the accuracy of DMSA in detecting high-grade VUR. The summary sensitivity and specificity estimates were 0.93 (95% CI 0.77 to 0.98) and 0.44 (95% CI 0.33 to 0.56), respectively.

Authors' conclusions: Neither the renal ultrasound nor the DMSA scan is accurate enough to detect VUR (of all grades). Although a child with a negative DMSA test has an < 1% probability of having high-grade VUR, performing a screening DMSA will result in a large number of children falsely labelled as being at risk for high-grade VUR. Accordingly, the usefulness of the DMSA as a screening test for high-grade VUR should be questioned.

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Conflict of interest statement

  1. Nader Shaikh: none known

  2. Russell B Spingarn: none known

  3. Stephanie W Hum: none known

Figures

1
1
Study flow diagram.
2
2
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies
3
3
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study
4
4
Ultrasound to detect VUR (all grades)
5
5
Ultrasound to detect high‐grade VUR
6
6
DMSA to detect VUR (all grades)
7
7
DMSA to detect high‐grade VUR
8
8
DMSA to detect renal units with VUR (all grades)
9
9
DMSA to detect renal units with high‐grade VUR
10
10
Ultrasound versus DMSA for the detection of VUR (indirect comparison)
11
11
Ultrasound versus DMSA for the detection of High‐Grade VUR (indirect comparison)
12
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Direct comparison of ultrasound and DMSA tests in detecting VUR
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Direct comparison of ultrasound and DMSA in detecting high‐grade VUR
1
1. Test
Ultrasound.
2
2. Test
Ultrasound for high‐grade VUR.
3
3. Test
Ultrasound Renal Units.
4
4. Test
Ultrasound for high‐grade VUR (Renal Units).
5
5. Test
DMSA.
6
6. Test
DMSA for high‐grade VUR.
7
7. Test
DMSA Renal‐Units.
8
8. Test
DMSA for high‐grade VUR (Renal Units).
See this image and copyright information in PMC

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  • doi: 10.1002/14651858.CD010657

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References

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Caillaud 2013 {published data only}
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Calleja Gero 2008 {published data only}
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Castello Girona 1995 {published data only}
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Cemerlic‐Zecevic 2002 {published data only}
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    1. Geronikola‐Trapali X, Armeniakos I, Karampina P, Stafanoyiannis A, Lyra V, Bakalis S, et al. The art of timing for DMSA study for the evaluation of patient outcome after urinary tract infection (UTI) [abstract]. Acta Paediatrica, International Journal of Paediatrics 2010;99:81‐2. [EMBASE: 70313069]
Ghiro 2002 {published data only}
    1. Ghiro L, Cracco AT, Sartor M, Comacchio S, Zacchello G, Dall'Amico R, et al. Retrospective study of children with acute pyelonephritis. Evaluation of bacterial etiology, antimicrobial susceptibility, drug management and imaging studies. Nephron 2002;90(1):8‐15. [MEDLINE: ] - PubMed
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    1. Gomez Tellado M, Vela Nieto D, Pais Pineiro E, Candal Alonso J. Comparative sensitivity of intravenous urography, ultrasonography and DMSA scan in the diagnosis of vesicoureteral reflux nephropathy [Sensibilidad comparada de la urografia intravenosa, la ecografia y el DMSA scan en la deteccion de la nefropatia del reflujo vesicoureteral]. Archivos Espanoles de Urologia 1994;47(10):1007‐10. [MEDLINE: ] - PubMed
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    1. Gupta N, Abulaban O, Goodfellow T, Helm E. Predictors of vesicoureteric reflux in infants with urinary tract infection using National Institute for Clinical Excellence (NICE) criteria [abstract]. Pediatric Radiology 2011;41:S279‐80. [EMBASE: 70646880]
Halevy 2013 {published data only}
    1. Halevy R, Smolkin V, Sakran W, Haimovitz L, Koren A. Urinary tract infection in infants: pyelonephritis or not [abstract]. Pediatric Nephrology 2013;28(8):1383‐4. [EMBASE: 71127038]
Hamoui 2008 {published data only}
    1. Hamoui N, Hagerty JA, Maizels M, Yerkes EB, Chaviano A, Shore R, et al. Ultrasound fails to delineate significant renal pathology in children with urinary tract infections: a case for dimercapto‐succinic acid scintigraphy. Journal of Urology 2008;180(4 Suppl):1639‐42. [MEDLINE: ] - PubMed
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Hannula 2010 {published data only}
    1. Hannula A, Venhola M, Renko M, Pokka T, Huttunen NP, Uhari M. Vesicoureteral reflux in children with suspected and proven urinary tract infection. Pediatric Nephrology 2010;25(8):1463‐9. [MEDLINE: ] - PubMed
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Hansson 2004 {published data only}
    1. Hansson S, Dhamey M, Sigstrom O, Sixt R, Stokland E, Wennerstrom M, et al. Dimercapto‐succinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. Journal of Urology 2004;172(3):1071‐3. [MEDLINE: ] - PubMed
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    1. Haznedaroglu A, Buyan N, Hasanoglu E, Atasever T, Gokcora N. The importance of DMSA scintigraphy in the diagnosis and follow‐up of first symptomatic urinary tract infection in childhood [abstract]. Pediatric Nephrology 1996;10:C137.
Herz 2005 {published data only}
    1. Herz DB. Can Dimercaptosiccinic acid scan predict clinically significant vesicoureteral reflux in infants with febrile urinary tract infection? [abstract]. Journal of Urology 2005;173:217‐8.
Herz 2010 {published data only}
    1. Herz D, Merguerian P, McQuiston L, Danielson C, Gheen M, Brenfleck L. 5‐year prospective results of dimercapto‐succinic acid imaging in children with febrile urinary tract infection: Proof that the top‐down approach works. Journal of Urology 2010;184(4 Suppl):1703‐8. [MEDLINE: ] - PubMed
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    1. Hiraoka M, Hashimoto G, Hayashi S, Hori C, Tsuchida S, Tsukahara H, et al. Ultrasonography for the detection of ureteric reflux in infants with urinary infection. Acta Paediatrica Japonica 1996;38(3):248‐51. [MEDLINE: ] - PubMed
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    1. Honkinen O, Ruuskanen O, Rikalainen H, Makinen EO, Valimaki I. Ultrasonography as a screening procedure in children with urinary tract infection. Pediatric Infectious Disease 1986;5(6):633‐5. [MEDLINE: ] - PubMed
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    1. Inoue Y, Fujinaga S, Hirano D, Endo A, Nishizaki N, Ohtomo Y, et al. Is it possible to avoid unnecessary voiding cystourethrography by performing acute Technetium‐99m dimercaptosuccinic acid scintigraphy and renal ultrasound scanning after first febrile urinary tract infection in children? [abstract]. Pediatric Nephrology 2011;26(5):828. [EMBASE: 70391931]
Jakobsson 1996 {published data only}
    1. Jakobsson B, Svensson L. Identifying children at risk after acute pyelonephritis [abstract]. Pediatric Nephrology 1996;10:C138.
Jakobsson 1997 {published data only}
    1. Jakobsson B, Svensson L. Transient pyelonephritic changes on 99mTechnetium‐dimercaptosuccinic acid scan for at least five months after infection. Acta Paediatrica 1997;86(8):803‐7. [MEDLINE: ] - PubMed
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    1. Jarmolinski T, Marciniak SH, Pacanowska B, Dudarenko G. Is it necessary to perform voiding cystourethrography (VCUG) in every child with acute pyelonephritis (APN)? [abstract]. Pediatric Nephrology 2011;26(9):1717‐8. [EMBASE: 70530915]
Jaukovic 2009 {published data only}
    1. Jaukovic L, Ajdinovic B, Dopudja M, Krstic Z. Renal scintigraphy in children with vesicoureteral reflux. Indian Journal of Pediatrics 2009;76(10):1023‐6. [MEDLINE: ] - PubMed
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Johnson 1985 {published data only}
    1. Johnson CE, Shurin PA, Marchant CD, Strieter CM, Murdell‐Panek D, Debaz BP, et al. Identification of children requiring radiologic evaluation for urinary infection. Pediatric Infectious Disease 1985;4(6):656‐63. [MEDLINE: ] - PubMed
Johnson 1986 {published data only}
    1. Johnson CE, DeBaz BP, Shurin PA, DeBartolomeo R. Renal ultrasound evaluation of urinary tract infections in children.[Erratum appears in Pediatrics 1987 Jul;80(1):121]. Pediatrics 1986;78(5):871‐8. [MEDLINE: ] - PubMed
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    1. Juliano TM, Stephany HA, Clayton DB, Thomas JC, Pope JC, Adams MC, et al. Incidence of abnormal imaging and recurrent pyelonephritis after first febrile urinary tract infection in children 2 to 24 months old. Journal of Urology 2013;190(4 Suppl):1505‐10. [MEDLINE: ] - PMC - PubMed
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    1. Kanellopoulos TA, Vassilakos PJ, Kantzis M, Ellina A, Kolonitsiou F, Papanastasiou DA. Low bacterial count urinary tract infections in infants and young children. European Journal of Pediatrics 2005;164(6):355‐61. [MEDLINE: ] - PubMed
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Kass 1992 {published data only}
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Kljucevsek 2009 {published data only}
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    1. Lee MD, Lin CC, Huang FY, Tsai TC, Huang CT, Tsai JD. Screening young children with a first febrile urinary tract infection for high‐grade vesicoureteral reflux with renal ultrasound scanning and technetium‐99m‐labeled dimercaptosuccinic acid scanning. Journal of Pediatrics 2009;154(6):797‐802. [MEDLINE: ] - PubMed
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    1. Martinez M, Bolong D. TC99‐DMSA scan as first investigation to detect vesicoureteral reflux as documented in VCUG: a 10‐year retrospective review of DMSA and VCUG imaging in patients with first febrile urinary tract infection: a top‐down approach [abstract]. Journal of Urology 2012;187(4 Suppl 1):e249‐50. [EMBASE: 70720310]
Masalskiene 2011 {published data only}
    1. Masalskiene J, Pundziene B, Verbliugeviciute G. Comparison of renal ultrasound with fluoroscopic voiding cystourethrography for the detection of vesicoureteral reflux in infants [abstract]. Pediatric Nephrology 2011;26(9):1687. [EMBASE: 70530817]
Massanyi 2013 {published data only}
    1. Massanyi EZ, Preece J, Gupta A, Lin SM, Wang MH. Utility of screening ultrasound after first febrile UTI among patients with clinically significant vesicoureteral reflux. Urology 2013; Vol. 82, issue 4:905‐9. [MEDLINE: ] - PubMed
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Mersdorf 1997 {published data only}
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    1. Mingin GC, Nguyen HT, Baskin LS, Harlan S. Abnormal dimercapto‐succinic acid scans predict an increased risk of breakthrough infection in children with vesicoureteral reflux.[Erratum appears in J Urol. 2005 May;173(5):1832 Note: Harlan, Susan [added]]. Journal of Urology 2004;172(3):1075‐7. [MEDLINE: ] - PubMed
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    1. Mohkam M, Maham S, Rahmani A, Naghi I, Otokesh B, Raiati H, et al. Technetium Tc 99m dimercaptosuccinic acid renal scintigraphy in children with acute pyelonephritis correlation with other imaging tests. Iranian Journal of Kidney Diseases 2010;4(4):297‐301. [MEDLINE: ] - PubMed
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Monakil 2013 {published data only}
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Rosenberg 1992 {published data only}
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Schiavina 1988 {published data only}
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Schneider 1986 {published data only}
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Schneider 1997 {published data only}
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Sciagra 1996 {published data only}
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Sreenarasimhaiah 1995 {published data only}
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Tan 1988 {published data only}
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References to studies awaiting assessment

Alvarez 2007 {published data only}
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