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What is the risk for new renal damage after recurrent febrile UTI in patients with a normal baseline DMSA? A prospective longitudinal study
Melise A. Keays, MD, Colby A. Adams, BA, Kimberly Mizener, RN, FNP-C, Janelle Traylor, FNP-C, APRN, Karen Pritzker, RN, MSN, CPNP-PC, Nicol Corbin Bush, MD MSc, Warren T. Snodgrass, MD.
UT Southwestern, Dallas, TX, USA.

Background: The risk for acquired renal damage in patients referred to urology with febrile UTIs (FUTI) and/or vesicoureteral reflux (VUR) who have a normal index DMSA renogram is unknown. We evaluated new cortical defects on DMSA after FUTI recurrence in children with prior normal DMSA in this prospective longitudinal study.
Methods: Consecutive patients from 2008-2012 referred with a history of FUTI and/or vesicoureteral reflux (VUR) underwent DMSA ≥3 months after the infection. Patients with normal DMSA (ipsilateral function ≥45% and no focal cortical uptake defects) were included. Data including gender, age, # baseline UTIs, and ultrasound and DMSA results were prospectively recorded. Patients with recurrent FUTI (positive leukocyte esterase and ≥50k CFU bacteriuria with fever ≥101°) were recommended to undergo a 2nd DMSA ≥3 months after recurrence.
Results: There were 460 patients (83% female), median age of 4.1 years (3m-18y), with normal baseline DMSA. 79 (17%) children developed ≥1 new febrile UTI(s) during mean follow up 1.2 years (1m-4.7y). Of these, 55 had a single recurrent FUTI, of whom 4/37 (11%) with follow-up imaging had an abnormal DMSA. Among the 24 patients with 2 or more FUTI recurrences, 4/16 (25%) with follow up imaging demonstrated a change in DMSA. Multiple logistic regression showed that each new FUTI conferred a 3.3-fold risk for new cortical defects (OR 3.3, 95%CI 2.0-5.3, AUC=0.88). Grade of VUR, baseline abnormal renal ultrasound, and age were not associated with increased risk for DMSA changes. All 8 patients with DMSA changes had VUR [grade 2 (n=3 patients), grade 3 (n=2), and grade 4 (n=3)]. 3/8 patients had ipsilateral renal function loss to ≤44% (6-17 percentage points).
Conclusions: During mean follow up of 1.2 years in 460 children, few developed recurrent FUTI. Of those who did, only 8 had a change from their normal baseline DMSA. The risk for new renal damage increased with increasing number of recurrent FUTIs, but still 75% of those with 2 or more infections maintained a normal DMSA scan. Although few patients had new damage, DMSA was necessary to identify them because even some patients with low grade VUR developed these changes.


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