The

new england journal

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medicine

editorials

Imaging Studies for Childhood Urinary Infections

F. Bruder Stapleton, M.D.
The question of whether to obtain imaging studies after a urinary tract infection in a child is a challenging one. The potential long-term morbidity associated with repeated bouts of pyelonephritis or
high-grade vesicoureteral reflux has led to the routine radiographic evaluation of children with urinary tract infections. For a number of years, renal
ultrasonography and voiding cystourethrography
have been standard diagnostic tests for young children with urinary tract infections and currently are
recommended by the American Academy of Pediatrics.1 This approach seems particularly cogent
for young children, because an acute urinary tract
infection might be the first indication of a urinary
tract obstruction or vesicoureteral reflux. Some have
advocated renal scintigraphy with technetium-99m
labeled dimercaptosuccinic acid as a first-line study
in lieu of renal ultrasonography because of its greater sensitivity in identifying acute pyelonephritis.2
Despite the intuitive rationale for obtaining renal
imaging studies in young children with urinary tract
infections, few well-designed studies have tested
the value of this approach.1,3
As reported in this issue of the Journal, Hoberman and colleagues prospectively examined the
value of current imaging techniques in 309 children
1 to 24 months old who had a first documented urinary tract infection and a fever of 38.3C or greater.4 The findings on renal ultrasonography were abnormal in only 12 percent of the children, and none
of the identified abnormalities influenced the management of the childrens urinary tract infections.
Voiding cystourethrography, performed in 302 of
the children, showed vesicoureteral reflux in 39 percent; in 96 percent of these children, the reflux was
of a low grade (grade I, II, or III). As has been shown
in many studies, the renal ultrasonogram was a
poor predictor of vesicoureteral reflux.4 Currently,

n engl j med 348;3

antimicrobial prophylaxis is given to most children

with vesicoureteral reflux, with the intent of preventing recurrent pyelonephritis and subsequent renal scarring and perhaps enhancing resolution of
the reflux.5 Limited evidence is available to support
the benefit of such antimicrobial prophylaxis.1
The goals of management of acute pyelonephritis early in life are to reduce the amount of renal parenchymal injury and to preserve renal function. In
the study by Hoberman et al., the findings on the initial dimercaptosuccinic acid scintigram were consistent with the presence of pyelonephritis in 61
percent of the children4; of those who underwent
follow-up scanning, renal scars developed in 15
percent. In the entire study group, vesicoureteral reflux was independently related to the development
of scars. Attempts to find a noninvasive test to detect vesicoureteral reflux have been unsuccessful.6
Therefore, voiding cystourethrography remains the
most important, and perhaps the only, study needed in children less than 24 months of age who have
a first urinary tract infection. The controversy concerning the routine use of dimercaptosuccinic acid
scintigraphy in either the short-term or the longterm follow-up of young children with a first febrile
urinary tract infection is not addressed in the study
by Hoberman and colleagues. Although dimercaptosuccinic acid scintigraphy is the best method for
detecting renal scars, the effect of small cortical renal scars in childhood on renal function later in life
may be less than has been traditionally feared.2,7
We do not know whether the mothers of the
young children in this study underwent ultrasonography during pregnancy. At least a minimal degree
of hydronephrosis has been identified in 2.2 percent of fetuses during routine antenatal ultrasonographic examinations.8,9 Since fetal ultrasonograms
are obtained at about 18 weeks gestation in many

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251

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obstetrical practices, it is possible that clinically significant obstructive lesions in the fetuss genitourinary tract are now being identified in utero before a
urinary tract infection develops. Although antenatal ultrasonography has a high rate of false positive
results, when performed by experienced practitioners it appears to be an excellent tool for identifying
hydronephrosis.10 Postnatal renal ultrasonography
is indicated when hydronephrosis has been seen on
the prenatal examination. When the medical history of a young child with a urinary tract infection is
being obtained, it is prudent to ask whether prenatal ultrasonography was performed and, if so, to
review the interpretive report and consider placing
the prenatal ultrasonogram in the infants record.
To date, pediatric practice guidelines have not
incorporated antenatal ultrasonography as a branch
point in decision analysis. Seamless sharing of information from the mothers prenatal care with the
subsequent health care providers for the baby may
someday be feasible as electronic records become
the standard. Evaluation of urinary tract infections
in young children may be just one example of the
opportunity to use prenatal diagnostic data for the
benefit of the child.
Several important cautionary notes are warranted if one accepts the recommendation proposed by
Hoberman et al. to limit urinary tract imaging after
a first urinary tract infection to voiding cystourethrography.4 The children in the study, who were
less than 24 months of age and had a first urinary
tract infection, were carefully evaluated, treated aggressively, and followed closely. Whether the same
recommendations are appropriate for children 24
months of age or older remains to be studied. Regardless of the approach to diagnostic imaging
after a first urinary tract infection, careful clinical
monitoring is essential, because many children have
recurrent infections. We must be careful to avoid
minimizing the importance of the diagnosis and
management of urinary tract infections, because it
is unlikely that children and families in a pediatric

of

medicine

practice will be as compliant in completing their

therapy and maintaining follow-up as those in this
study. Renal ultrasonographic examinations should
still be considered for children with urinary tract
infections that do not respond to antibiotic therapy
or that are associated with a palpable abdominal
mass, passage of a calculus, or hydronephrosis on
prenatal ultrasonography. Renal ultrasonography
continues to be a safe and relatively cost-efficient
means of assessing the anatomical features of the
upper urinary tract, when the clinical situation demands this information. A urinary tract infection
during the first two years of life may no longer be
included in this category of conditions.
From the Department of Pediatrics, University of Washington
School of Medicine, Seattle.
1. American Academy of Pediatrics, Committee on Quality Improve-

ment, Subcommittee on Urinary Tract Infection. Practice parameter:

the diagnosis, treatment, and evaluation of the initial urinary tract
infection in febrile infants and young children. Pediatrics 1999;103:
843-52. [Errata, Pediatrics 1999;103:1052, 104:118, 2000;105:
141.]
2. Biggi A, Dardanelli L, Pomero G, et al. Acute renal cortical scintigraphy in children with a first urinary tract infection. Pediatr
Nephrol 2001;16:733-8.
3. Dick PT, Feldman W. Routine diagnostic imaging for childhood
urinary tract infections: a systematic overview. J Pediatr 1996;128:
15-22.
4. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH,
Wald ER. Imaging studies after a first febrile urinary tract infection
in young children. N Engl J Med 2003;348:195-202.
5. Medical versus surgical treatment of primary vesicoureteral
reflux: report of the International Reflux Study Committee. Pediatrics 1981;67:392-400.
6. Downs SM. Urinary tract infections in febrile infants and young
children. Pediatrics 1999;103:810. abstract.
7. Nguyen HT, Bauer SB, Peters CA, et al. 99mTechnetium dimercapto-succinic acid renal scintigraphy abnormalities in infants with
sterile high grade vesicoureteral reflux. J Urol 2000;164:1674-8.
8. Morin L, Cendron M, Crombleholme TM, Garmel SH, Klauber
GT, DAlton ME. Minimal hydronephrosis in the fetus: clinical significance and implications for management. J Urol 1996;155:2047-9.
9. Reznik VM, Kaplan GW, Murphy JL, et al. Follow-up of infants
with bilateral renal disease detected in utero: growth and renal function. Am J Dis Child 1988;142:453-6.
10. Chitty LS, Hunt GH, Moore J, Lobb MO. Effectiveness of routine
ultrasonography in detecting fetal structural abnormalities in a low
risk population. BMJ 1991;303:1165-9.
Copyright 2003 Massachusetts Medical Society.

Immunosurveillance against Cancer and Immunotherapy

Synergy or Antagonism?
Thierry Boon, Ph.D., and Nicolas van Baren, M.D.
Immunologists have long been alert to the possi- of others.1 In recent years, the concept of immune
bility that the immune system eliminates many can- surveillance against cancer has received support
cers at an early stage and slows down the progress from experiments in mice. An increased incidence

252

n engl j med 348;3

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