Rushton H G, Majd M
Department of Urology, Children's National Medical Center, Washington, D.C.
J Urol. 1992 Nov;148(5 Pt 2):1726-32. doi: 10.1016/s0022-5347(17)37014-3.
Renal cortical scintigraphy has been reported to be useful in children for confirmation of the diagnosis of acute pyelonephritis. Subsequent experimental studies have demonstrated that dimercaptosuccinic acid (DMSA) scintigraphy, when compared directly with histopathology, is highly reliable for the detection and localization of parenchymal inflammatory changes associated with acute pyelonephritis. Recent clinical studies of acute pyelonephritis using DMSA scintigraphy reveal that the majority (50 to 91%) of children with febrile urinary tract infections have abnormal DMSA renal scan findings and that the majority of these children do not have demonstrable vesicoureteral reflux. However, when vesicoureteral reflux is present, renal cortical abnormalities are demonstrated by DMSA scintigraphy in 79 to 86% of the kidneys. In children with febrile urinary tract infections routine clinical and laboratory parameters are not reliable in the differentiation of acute pyelonephritis, documented by DMSA renal scan findings, from urinary tract infections without parenchymal involvement. Furthermore, the presence of P-fimbriated Escherichia coli associated with febrile urinary tract infections does not reliably predict those kidneys that have acute parenchymal inflammation demonstrated by DMSA renal scans. DMSA is also the isotope agent of choice for the detection of renal scarring. Clinical studies report greater sensitivity of DMSA renal scintigraphy for the detection of renal scarring when compared with the excretory urogram, particularly in infants and young children. In a recent prospective study of post-pyelonephritic renal scarring in children we found that acquired renal scarring only occurs in sites corresponding exactly to previous areas of acute pyelonephritis demonstrated by DMSA scintigraphy at the time of infection. Furthermore, once acute pyelonephritis occurs, ultimate renal scarring is independent of the presence or absence of vesicoureteral reflux. These findings provide convincing evidence that renal parenchymal infection, rather than vesicoureteral reflux, is the prerequisite for acquired (postnatal) renal scarring. Vesicoureteral reflux as a risk factor for acquired renal scarring is directly related to its role as a risk factor for acute pyelonephritis. We conclude that DMSA scintigraphy is a valid tool for confirming the diagnosis of acute pyelonephritis in children and for identifying kidneys at risk for subsequent renal scarring.
据报道，肾皮质闪烁扫描术对儿童急性肾盂肾炎的诊断确认很有用。随后的实验研究表明，与组织病理学直接比较时，二巯基丁二酸（DMSA）闪烁扫描术对于检测和定位与急性肾盂肾炎相关的实质炎症变化高度可靠。近期使用DMSA闪烁扫描术对急性肾盂肾炎的临床研究显示，大多数（50%至91%）发热性尿路感染儿童的DMSA肾扫描结果异常，且这些儿童中的大多数并无明显的膀胱输尿管反流。然而，当存在膀胱输尿管反流时，79%至86%的肾脏通过DMSA闪烁扫描术显示有肾皮质异常。在发热性尿路感染儿童中，常规临床和实验室参数在区分由DMSA肾扫描结果证实的急性肾盂肾炎与无实质受累的尿路感染方面并不可靠。此外，与发热性尿路感染相关的P菌毛大肠杆菌的存在并不能可靠地预测那些通过DMSA肾扫描显示有急性实质炎症的肾脏。DMSA也是检测肾瘢痕的首选同位素剂。临床研究报告称，与排泄性尿路造影相比，DMSA肾闪烁扫描术检测肾瘢痕的敏感性更高，尤其是在婴幼儿中。在最近一项关于儿童肾盂肾炎后肾瘢痕形成的前瞻性研究中，我们发现获得性肾瘢痕仅发生在与感染时DMSA闪烁扫描术显示的先前急性肾盂肾炎区域完全对应的部位。此外，一旦发生急性肾盂肾炎，最终的肾瘢痕形成与膀胱输尿管反流的有无无关。这些发现提供了令人信服的证据，即肾实质感染而非膀胱输尿管反流是获得性（产后）肾瘢痕形成的先决条件。膀胱输尿管反流作为获得性肾瘢痕形成的危险因素与其作为急性肾盂肾炎危险因素的作用直接相关。我们得出结论，DMSA闪烁扫描术是确认儿童急性肾盂肾炎诊断以及识别有后续肾瘢痕形成风险的肾脏的有效工具。
