M. Wang1, J. Michaud1, N. Gupta1, T. Bosemani1, M. Wang1 1Johns Hopkins,Urology,Baltimore, MD, USA
Introduction: Recent initiative set forth by the American Board of Internal Medicine, Choosing Wisely, asks physicians to carefully consider the risk and benefits of medical interventions. We examine our current protocol regarding pediatric patients who present with febrile urinary tract infection, who underwent DMSA scans. Specifically, calculating the added cost when compared to a dedicated pediatric renal ultrasound and the radiation dose associated with each scan.
Methods: DMSA renal scans are often utilized in the evaluation of pediatric patient present with febrile UTI. Given the prevalence of these exams in pediatric urology practice; we sought to quantify the cost, radiation exposure, and relative clinical utility when compared to dedicated pediatric renal ultrasound (RUS) in our patient population.
We conducted an IRB approved retrospective study of children referred to our institution for history of febrile UTIs between the years 2004-2013. Inclusion criteria: 1) children diagnosed with vesico-ureteral reflux (VUR) via voiding cystourethrogram (VCUG), 2) fever > 380 C, 2) urine culture with single organism of >50,000 cfu, and 3) patients who underwent both DMSA and RUS. Cost of each scan including professional and facility fee at our institution, radiation dosage, and radiographic results were analyzed.
Outcome measurements and statistical analysis: Chart review, and radiation dose equivalents were estimate from the Radiation Internal Dose Information Center (Oak Ridge Institute for Science and Education, Oak Ridge, TN).
Results:126 children (102 girls and 24 boys) met the inclusion criteria. The median age at presentation with febrile UTI was 8.1 months. The median age at first DMSA was 10.1 months. A total of 145 RUS and 171 DMSA were performed during the study period. Cost analysis revealed $865/RUS. DMSA $1,062/scan, and $2,115/scan for those children who need anesthetic sedation. The mean cumulative effective dose per patient/ DMSA was 3.75 mSv. This increased to 6.95 mSv for patients who underwent 3 scans. Limitations include retrospective design, tertiary referral center.
Conclusion:Both cost and radiation exposure from DMSA were significant when compared to RUS. Radiation exposure approached that of a pediatric chest CT (2-5 mSv) for a single DMSA.
Radiation exposure in early childhood can have significant impact on future cancer risk. Given the improved sensitivity of newer ultrasounds and comparable cost, efforts should be made to determine which children with urinary tract infection would benefit most from nuclear tests.