title: Top-down approach is possible strategy for predicting breakthrough fUTIs and renal scars in infants.
abstract: BACKGROUND
  Acute-phase technetium-99 m dimercaptosuccinic acid (DMSA) scintigraphy is recommended for initial imaging in children with febrile urinary tract infection (fUTI). Recently, the importance of identifying patients at risk of recurrent fUTI (r-fUTI) has been emphasized. To clarify the effectiveness of DMSA scintigraphy for predicting r-fUTI in infants, we investigated the relationship between defects on DMSA scintigraphy and r-fUTI.
  
  
  METHODS
  Seventy-nine consecutive infants (male: female, 60:19) with fUTI were enrolled in this study. DMSA scintigraphy was performed in the acute phase, and patients with defect underwent voiding cystourethrography and chronic-phase (6 months later) DMSA scintigraphy. Patients were followed on continuous antibiotic prophylaxis (CAP).
  
  
  RESULTS
  Defects on acute-phase DMSA scintigraphy were observed in 32 children (40.5%) of 79. The mean follow-up observation period was 17.0 ± 10.1 months. Four patients had r-fUTI (5%). Two of them had defects on DMSA scintigraphy in both the acute phase and chronic phase, and had bilateral vesicoureteral reflux (VUR) grade IV. Two others had r-fUTI without defects on DMSA and did not have VUR. Twelve patients had defect on chronic-phase DMSA scintigraphy and four of them had no VUR.
  
  
  CONCLUSIONS
  The top-down approach is a possible method for predicting r-fUTI in infants and does not miss clinically significant VUR. Also, given that the prevalence of r-fUTI was 5% regardless of the presence of defects on acute-phase DMSA, then, in conjunction with genital hygiene and CAP, acute-phase DMSA might be unnecessary if chronic-phase DMSA is performed for all patients to detect renal scar.
authors.affiliation: Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Shina
authors.identifier: http://orcid.org/0000-0002-5938-5377
authors.initials: S
authors.lastname: Kawai
authors.affiliation: Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Kanai
authors.affiliation: Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Taiju
authors.initials: T
authors.lastname: Hyuga
authors.affiliation: Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Shigeru
authors.initials: S
authors.lastname: Nakamura
authors.affiliation: Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Jun
authors.initials: J
authors.lastname: Aoyagi
authors.affiliation: Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Takane
authors.initials: T
authors.lastname: Ito
authors.affiliation: Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Saito
authors.affiliation: Department of Pediatrics, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Jun
authors.initials: J
authors.lastname: Odaka
authors.affiliation: Department of Pediatric Radiology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Rieko
authors.initials: R
authors.lastname: Furukawa
authors.affiliation: Department of Pediatric Radiology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Toshinori
authors.initials: T
authors.lastname: Aihara
authors.affiliation: Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan.
authors.forename: Hideo
authors.initials: H
authors.lastname: Nakai
mesh_terms: D002921:Cicatrix / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000209:etiology*; D005260:Female; D005334:Fever / Q000209:etiology; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007223:Infant; D007668:Kidney / Q000000981:diagnostic imaging* / Q000473:pathology; D008297:Male; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D012008:Recurrence; D018570:Risk Assessment; D019783:Technetium Tc 99m Dimercaptosuccinic Acid; D014552:Urinary Tract Infections / Q000150:complications / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000473:pathology
chemical_list: D019275:Radiopharmaceuticals; D019783:Technetium Tc 99m Dimercaptosuccinic Acid
keywords: diagnostic imaging; dimercaptosuccinic acid scintigraphy; infant; urinary tract infection; vesicoureteral reflux