Institute of Nuclear Medicine, General University Hospital in Prague and Charles University 1st Faculty of Medicine, U Nemocnice 5, 128 08 Praha 2, Czech Republic.
Department of Radiation Protection, General University Hospital in Prague and Charles University 1st Faculty of Medicine, U Nemocnice 2, 128 08 Praha 2, Czech Republic.
J Pediatr Urol. 2023 Aug;19(4):456-462. doi: 10.1016/j.jpurol.2023.01.017. Epub 2023 Feb 13.
Renal changes may have long-term sequalae and prevention is a main goal of management of primary vesicoureteral reflux (VUR).
This study aims to reveal how much Tc-DMSA scintigraphy findings are reflected in the adopted surgical or non-surgical treatment in children with diagnosed primary VUR and to give the clinicians information regarding their final therapeutic decision.
A total 207 children with primary VUR who underwent non-acute Tc-DMSA scan were retrospectively evaluated. The presence of renal changes, their grading, differential function asymmetry (<45%) and grade of VUR were compared with subsequent choice of therapy.
Altogether 92 (44%) children had asymmetric differential function, 122 (59%) showed presence of renal changes, 79 (38%) had high-grade VUR (IV-V). Patients with renal changes had lower differential function (41%vs.48%) and higher grade of VUR. The incidence of high-grade changes (G3+G4B) afflicting more than one third of the kidney was significantly different between grade I-II, III and IV-V VUR (9%, 27%, 48%, respectively). Renal changes were detected in 76% of surgically and 48% of non-surgically treated patients, high-grade Tc-DMSA changes in 69% and 31%, respectively. In children with no scars/dysplasia (G0+G4A), non-surgical treatment prevailed in 77%. The independent predictors for surgical intervention were presence of renal changes and higher grade of VUR, but not functional asymmetry.
Over the last 20 years, there has been a shift toward more non-surgical management of VUR. The long-term outcome of this approach should be thoroughly studied. This is the first study analysing renal status in VUR patients using Tc-DMSA scan and its grading regarding the adopted treatment. Renal changes in almost half of non-surgically treated children with VUR should be an indicator for earlier diagnosis and effective treatment of acute pyelonephritis and VUR. We recommend distinguishing grade III VUR, as a moderate-grade VUR, because it is linked to higher incidence of high-grade Tc-DMSA changes (G3+G4B); our findings of 65% of grade III VURs treated non-surgically should be cautionary. Grade III VUR does not mean a low-risk condition and should alert the clinician to evaluate the extent of renal changes and unmask high-risk cases.
Our data strengthens the need to investigate the extent of renal changes in VUR patients regarding treatment decision. Performing Tc-DMSA scan individualizes the treatment of VUR patients; its grading can distinguish grade III-VUR as a separate risk entity because it differs significantly in terms of incidence of high-grade renal changes and chosen therapy.
肾脏变化可能会带来长期的后遗症，因此预防是原发性输尿管反流（VUR）管理的主要目标。
本研究旨在揭示 Tc-DMSA 闪烁显像检查结果在诊断为原发性 VUR 的儿童中采用的手术或非手术治疗中的反映程度，并为临床医生提供有关其最终治疗决策的信息。
回顾性评估了 207 例接受非急性 Tc-DMSA 扫描的原发性 VUR 儿童。比较了肾脏变化的存在、分级、差异功能不对称（<45%）和 VUR 分级与后续治疗选择之间的关系。
共有 92 例（44%）患儿存在差异功能不对称，122 例（59%）存在肾脏变化，79 例（38%）存在高等级 VUR（IV-V）。有肾脏变化的患者差异功能较低（41%对 48%），VUR 等级较高。高等级变化（G3+G4B）影响超过三分之一肾脏的发生率在 I-II 级、III 级和 IV-V 级 VUR 之间有显著差异（分别为 9%、27%、48%）。在接受手术和非手术治疗的患者中，分别有 76%和 48%检测到肾脏变化，有 69%和 31%检测到高等级 Tc-DMSA 变化。在无瘢痕/发育不良（G0+G4A）的儿童中，非手术治疗占 77%。手术干预的独立预测因素是存在肾脏变化和较高的 VUR 等级，但不是功能不对称。
在过去的 20 年中，VUR 的非手术治疗方法已经发生了转变。这种方法的长期效果应该进行彻底研究。这是第一项使用 Tc-DMSA 扫描分析 VUR 患者的肾脏状况并对其进行分级以确定治疗方法的研究。在接受非手术治疗的 VUR 患儿中，近一半的患儿存在肾脏变化，这应该是早期诊断和有效治疗急性肾盂肾炎和 VUR 的一个指标。我们建议区分 III 级 VUR，因为它是一种中度 VUR，因为它与更高比例的高等级 Tc-DMSA 变化（G3+G4B）相关；我们发现 65%的 III 级 VUR 患者接受非手术治疗，这应该是值得警惕的。III 级 VUR 并不意味着低风险，它应该提醒临床医生评估肾脏变化的程度，并发现高危病例。
我们的数据加强了需要根据治疗决策调查 VUR 患者肾脏变化程度的必要性。进行 Tc-DMSA 扫描可以使 VUR 患者的治疗个体化；其分级可以将 III-VUR 区分出来，因为它在高等级肾脏变化的发生率和选择的治疗方法方面存在显著差异，因此可以作为一个单独的风险实体。
