Evaluation in children after febrile urinary tract infection involves voiding cystourethrogram, which emphasizes urinary reflux rather than renal risk. We believe that early dimercapto-succinic acid renal scan after febrile urinary tract infection predicts clinically significant reflux and which children should undergo voiding cystourethrogram. The criticism of this approach is that some reflux and preventable renal damage would be missed. This study validates the use of initial dimercapto-succinic scan and presents 5-year renal outcomes.

Materials and Methods:

We prospectively studied children with febrile urinary tract infection using initial dimercapto-succinic acid renal scan, voiding cystourethrogram and renal/bladder ultrasound. Children with anatomical or neurological genitourinary abnormality and protocol failures were excluded from analysis. Dimercapto-succinic acid scan was repeated at 6 months if initially abnormal. Followup was done every 6 months in all children for at least 5 years.


A total of 121 children fit study inclusion criteria and completed the 5-year study. Overall 88 initial dimercapto-succinic acid scans (73%) were abnormal and 78 children (64%) had urinary reflux. The OR of having clinically significant reflux predicted by abnormal initial scan was 35.4. Abnormal followup scan did not predict clinically significant reflux. Overall subsequent urinary tract infection developed in 32 patients (26.5%) and 27 (85%) had an abnormal initial scan. No child with a normal initial scan had clinically significant reflux.


Dimercapto-succinic acid scan can predict clinically significant reflux and children at greatest renal risk. Initial dimercapto-succinic acid scan should be done in all children after febrile urinary tract infection while voiding cystourethrogram should be reserved for those with an abnormal initial dimercapto-succinic acid scan.


  • 1 : Technical report: urinary tract infections in febrile infants and young children: The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics1999; 103: e54. Google Scholar
  • 2 Guidelines on the management of acute urinary tract infection in childhood: Working Group of the Research Unit of the Royal College of Physicians. J R Coll Phys1996; 25: 36. Google Scholar
  • 3 : Children with urinary infection: a comparison of those with and those without vesicoureteric reflux. Kidney Int1981; 20: 717. Google Scholar
  • 4 : The evaluation of acute pyelonephritis and renal scarring with technetium—dimercaptosuccinic acid renal scintigraphy: evolving concepts and future directions. Pediatr Nephrol1997; 11: 108. Google Scholar
  • 5 : Medical versus surgical treatment in children with severe bilateral vesicoureteric reflux and bilateral nephropathy: a randomized trial. Lancet2001; 357: 1329. Google Scholar
  • 6 : End-stage reflux nephropathy. Renal Failure1994; 16: 27. Google Scholar
  • 7 : Development of hypertension and uremia after pyelonephritis in childhood: 27 year follow-up. BMJ1989; 299: 703. Google Scholar
  • 8 : Ten-year results of randomized treatment of children with severe vesicoureteral reflux: Final report of the International Reflux Study in Children. Pediatr Nephrol2006; 21: 785. Google Scholar
  • 9 : Renal cortical involvement in children with first UTI: does it differ in the presence of primary VUR?. Ann Nucl Med2008; 22: 877. Google Scholar
  • 10 : Primary vesicoureteric reflux as a predictor of renal damage in children hospitalized with urinary tract infection: a systematic review and meta-analysis. J Am Soc Nephrol2003; 14: 739. Google Scholar
  • 11 : The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection. Arch Dis Child2005; 90: 733. Google Scholar
  • 12 : Post-pyelonephritic renal scars are not associated with vesicoureteral reflux in children. J Urol2005; 173: 1345. LinkGoogle Scholar
  • 13 : Long-term evolution of renal damage associated with unilateral vesicoureteral reflux. J Urol2007; 178: 1043. LinkGoogle Scholar
  • 14 : Vesicoureteral reflux and urinary tract infection: evolving practices and current controversies in pediatric imaging. AJR Am J Roentgenol2009; 192: 1197. Google Scholar
  • 15 : Impact of micturating cystourethrography and DMSA renal scintigraphy on the investigation scheme in children with urinary tract infection. Ann Nucl Med2008; 22: 661. Google Scholar
  • 16 : Normal dimercapto succinic acid scintigraphy makes voiding cystourethrography unnecessary after urinary tract infection. J Pediatr2007; 151: 581. Google Scholar
  • 17 : Imaging in childhood urinary tract infections: time to reduce investigations. Pediatr Nephrol2008; 23: 9. Google Scholar
  • 18 : Does a normal DMSA obviate the performance of voiding cystourethrography in evaluation of young children after their first urinary tract infection?. J Pediatr2007; 150: 96. Google Scholar
  • 19 : Dimercaptosuccinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. J Urol2004; 172: 1071. LinkGoogle Scholar
  • 20 : Value of imaging studies after a first febrile urinay tract infection in young children: data from Italian Renal Infection Study I. Pediatrics2009; 123: e239. Google Scholar
  • 21 : Imaging studies for first urinary tract infection in infants less than 6 months old: can they be more selective. Pediatr Nephrol2009; 24: 1699. Google Scholar
  • 22 : Diagnosis, Treatment, and Long-Term Management: National Institute for Health and Clinical Excellence Guidelines. In: . London, United Kingdom: National Collaborating Center for Women's and Children's Health2007: 6. Google Scholar
  • 23 : The dysfunctional voiding symptom score system: quantitative standardization of dysfunctional voiding symptoms in children. J Urol2000; 164: 1011. LinkGoogle Scholar
  • 24 : importance of methodology on 99technetium dimercapto-succinic acid scintigraphic imaging quality: imaging pilot study for RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) multicenter investigation. J Urol2009; 182: 272. LinkGoogle Scholar
  • 25 : Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study. J Pediatr Urol2009; 5: 336. Google Scholar
  • 26 : Antibiotic prophylaxis for children with primary vesicoureteral reflux: where do we stand today?. Adv UrolJuly 29, 2008; : 1. Google Scholar
  • 27 : Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med2009; 361: 1748. Google Scholar
  • 28 : Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med2003; 348: 195. Google Scholar
  • 29 : Pediatric radiation exposure and effective dose reduction during voiding cystourethrography. Radiology2008; 249: 1002. Google Scholar
  • 30 : Evaluation of reflux nephropathy, pyelonephritis and renal dysplasia. Pediatr Radiol, suppl.2008; 38: S83. Google Scholar

Children's Hospital at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire