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Semiquantitative Analysis of Power Doppler Ultrasonography Versus Tc-99M DMSA Scintigraphy in Diagnostic and Severity Assessment of Acute Childhood Pyelonephritis

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Semiquantitative Analysis of Power Doppler Ultrasonography Versus Tc-99M DMSA Scintigraphy in Diagnostic and Severity Assessment of Acute Childhood Pyelonephritis 495 Original Article Semiquantitative analysis of power doppler ultrasonography versus Tc-99m DMSA scintigraphy in diagnostic and severity assessment of acute childhood pyelonephritis Hui Zhu1, Minguang Chen2, Hongxia Luo1, Yin Pan1, Wenjie Zheng2, Yan Yang1 1Department of Ultrasound, 2Department of Pediatrics, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China Contributions: (I) Conception and design: H Zhu, Y Yang; (II) Administrative support: Y Yang; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Wenjie Zheng. Department of Pediatrics, the Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Western Road, Wenzhou, China. Email: [email protected]. Yan Yang, Department of Ultrasound, the Second Affiliated Hospital of Wenzhou Medical University 109 Xueyuan Western Road, Wenzhou, China. Email: [email protected]. Background: This study aimed to compare the diagnostic and predictive value of power Doppler ultrasonography (PDU) with Tc-99m dimercaptosuccinic acid (DMSA) renal scintigraphy in pediatric acute pyelonephritis (APN) using a semiquantitative analysis system. Methods: A total of 92 children and infants (184 kidneys) were hospitalized with possible APN. All children were examined by PDU and DMSA scintigraphy within 72 hours of admission. An empiric 9-point semiquantitative analysis system was used to sort kidneys into four grades (grade 0–III). Patients with several episodes of APN and congenital structural anomalies were excluded. Results: Of 184 kidneys, we found 68 abnormal (grade I–III) and 116 normal (Grade 0) with DMSA scintigraphy, and 84 abnormal and 100 normal with PDU. In all, 23 kidneys were shown to be diseased by PDU but normal on DMSA scintigraphy while 7 kidneys showed the opposite trend. The sensitivity and specificity of PDU for diagnosing APN was 89.7% and 80.2%, respectively (P<0.05). In children older than 6 months, the sensitivity was higher (92%, P<0.05) than that in children younger than 6 months (87%, P<0.05). A moderate agreement (41%, P<0.05) on grade was found between the two methods. Conclusions: With the help of a semiquantitative analysis system, PDU can obviate the use of DMSA scintigraphy in children older than 6 months for APN diagnosis. Keywords: Power Doppler ultrasonography (PDU); Tc-99m dimercaptosuccinic acid renal scintigraphy (Tc-99m DMSA renal scintigraphy); acute pyelonephritis (APN); semiquantitative analysis system Submitted Feb 14, 2020. Accepted for publication Jul 22, 2020. doi: 10.21037/tp-20-59 View this article at: http://dx.doi.org/10.21037/tp-20-59 Introduction and treatment, 40–60% of children with this condition will develop permanent renal scarring with sequelae of Febrile urinary tract infection (UTI) is the second most common infectious disease in infants and children and hypertension and renal failure (2). The diagnosis of APN is the most common disease in children under the age initially made through urinalysis and the presence of clinical of two (1). About 50–90% children with febrile UTI symptoms, which makes it hard to differentiate it from have renal parenchyma involvement which indicates lower UTI (3). Therefore, a fast and accurate diagnosis is acute pyelonephritis (APN). Without prompt diagnosis required. © Translational Pediatrics. All rights reserved. Transl Pediatr 2020;9(4):487-495 | http://dx.doi.org/10.21037/tp-20-59 488 Zhu et al. PDU in acute pyelonephritis According to the literature, Tc-99m dimercaptosuccinic clinical examination including abdominal and lumbar fossa acid (DMSA) renal scintigraphy is the most reliable palpation, temperature and blood pressure measurement, diagnostic tool for suspected APN, and it is able to evaluate standardized blood studies including C-reactive protein the degree of renal parenchymal involvement (4-6). (CRP), differential blood count, iconography, renal However, DMSA scintigraphy has the disadvantages of function, and liver function analysis. A midstream urine ionizing radiation exposure, invasiveness, and relatively high sample was taken for N-acetylglucosaminidase (NAG), β2- cost, rendering it unappealing to children and parents (7). microglobulin (β2-MG), dipstick analysis, and culturing. The recent development of power Doppler ultrasonography Clinical examination results, urine samples and blood (PDU) shows encouraging results in diagnosing APN, samples were collected on admission before commencing with a reported accuracy of 89% (7-10). With additional usual intravenous antibiotic treatment, and PDU and advantages of being radiation-free, convenient, and low Tc-99m DMSA renal scintigraphy were performed within cost, PDU may be a new tool in APN diagnosis (7-10). 72 hours of admission. Young, uncooperative patients were However, experiments in clinic and on piglet models duly sedated before examination. revealed the lower accuracy of PDU compared with DMSA scintigraphy (11-13). Thus, the purpose of this study was to assess the DMSA diagnostic and predictive value of PDU for APN in Tc-99m DMSA renal scintigraphy was performed using children, with the help of a new semiquantitative system, the standard protocol (16). In brief, a dose of 3.7 MBq/kg and to determine whether PDU may supersede Tc-99m (0.1 mCi/kg) Tc-99m DMSA was intravenously injected, DMSA in renal scintigraphy. and 2–4 h later, images were obtained in the planar anterior, We present the following article in accordance with posterior, and right and left posterior oblique using an the STARD reporting checklist (available at http://dx.doi. Orbiter Siemens gamma camera with a low-energy high- org/10.21037/tp-20-59). resolution parallel-hole collimator. Images were obtained for 300,000–500,000 counts on a 256×256 matrix format. Methods International Radionuclide Nephrourology Group (IRN) consensus criteria were used for interpretation of DMSA Clinical and biologic findings scintigraphy results. To standardize the interpretation, an From December 2016 to April 2017, we evaluated 92 empiric 9-point semiquantitative analysis that evaluated the infants and children (36 girls and 56 boys; aged 36 days to lesion size and radioactivity of each kidney was performed. 10 years; mean age 18.0±2.8 months) who were admitted The kidneys were divided into three zones (the upper to the Pediatric Nephrology Department with potential pole, midzone, and lower pole), and the radioactive uptake APN. The retrospective trial was conducted in accordance of each zone was scored from 0 (no uptake) to 3 (normal with the Declaration of Helsinki (as revised in 2013). The uptake). The sum of the zone scores was considered the study was approved by institutional board of The Second total score of each kidney. An 8–9 score was considered Affiliated Hospital of Wenzhou Medical University (No. grade 0 (normal), a 6–7 score was considered grade I (mildly L-2019-08), and informed consent was given by all the abnormal), a 4–5 score was considered grade II (moderately patients and/or their guardians. The inclusion criteria were abnormal), and a 0–3 score was considered grade III as follows: (I) age between 1 week and 16 years (inclusive); (severely abnormal) (17,18). (II) clinical diagnosis of APN including (i) fever >38.5 Two expert senior physicians who were blinded to the or localized symptoms of APN, (ii) pyuria or a positive other examination results and clinical information analyzed ℃ urine culture (>10 white blood cells per cubic millimeter all the images. If disagreements occurred, a final diagnosis and bacteriuria to the extent of 104 colony-forming was made after discussion. units per milliliter) (14,15); (III) children and parents’ consent to accept both PDU and Tc-99m DMSA renal PDU scintigraphy. Exclusion criteria included several previous episodes of APN and congenital structural anomalies of Grey-scale ultrasonography and PDU were performed the urinary system. All children underwent a standardized using the Esaote MyLab Class C with variable-frequency © Translational Pediatrics. All rights reserved. Transl Pediatr 2020;9(4):487-495 | http://dx.doi.org/10.21037/tp-20-59 Translational Pediatrics, Vol 9, No 4 August 2020 489 Table 1 Comparative results of Tc-99m DMSA scintigraphy and power Doppler sonography in 184 kidneys Tc-99m DMSA Scintigraphy (kidneys) Grade 0 Grade I Grade II Grade III Total Grade 0 93 13 8 2 116 Grade I 3 11 5 8 27 Grade II 4 12 7 2 25 Grade III 0 6 2 8 16 Total 100 42 22 20 184 DMSA, dimercaptosuccinic acid; Grade 0, normal; Grade I–III, abnormal. (2.5–4.0 MHz) curved transducers in prone and supine Results positions for both axial and longitudinal scans. Grey- Comparison of characteristics and biologic findings in scale ultrasonography of the kidneys was performed to children exclude structural urinary tract anomalies and to evaluate size, echogenicity, and stasis. The parameters of PDU All 92 children met the diagnostic criteria of febrile APN. were individualized for each kidney in every patient for Among them, 52 (56.5%) were abnormal (grade I–III) on the optimized visualization of the parenchymal perfusion DMSA scintigraphy, and 58 (63.0%) were abnormal on map. To standardize the interpretation, the same 9-point PDU. Based on urine analysis, 83 patients (90.2%) had semiquantitative analysis was performed. Briefly, each increased neutrophil esterase in urine, 30 patients (32.6%) kidney was divided into three zones, and the perfusion of had positive urinary nitrite, 24 patients (26.1%) had each zone was scored from 0 (no perfusion) to 3 (normal elevated urine NAG, and 19 patients (20.7%) had increased perfusion). A grade 0, I, II, or III was determined by a total urine β2-MG. Blood analysis revealed high CRP (≥20 mg/L) score of 8–9, 6–7, 4–5, and 0–3 in each kidney, respectively. and elevated white blood cell count in 76 (82.6%) and Grade 0 indicated a normal kidney, and grades I–III 79 patients (85.9%) respectively.
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