Ultrasound vs Direct Radionuclide Cystography in Infants: Diagnosis of High-Grade Vesicoureteral Reflux during First Febrile Urinary Tract Infection

Ultrasound vs Direct Radionuclide Cystography in Infants: Diagnosis of High-Grade Vesicoureteral Reflux during First Febrile Urinary Tract Infection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ultrasound vs Direct Radionuclide Cystography in Infants: Diagnosis of High-Grade Vesicoureteral Reflux during First Febrile Urinary Tract Infection Fatemeh Hajizadeh Saffar, Nahid Rahimzadeh, Rozita Hosseini Shamsabadi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5925466/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Renal damage caused by infantile Urinary Tract Infection has led to various imaging techniques being proposed for the early diagnosis of Vesicoureteral Reflux. The goal of this study is to determine the possibility of Ultrasound replacing more invasive and costly methods for diagnosing high-grade vesicoureteral reflux in infants with their first febrile urinary tract infection. Material & Methods Infants with their first febrile Urinary Tract Infection underwent Sonography and Radionuclide Cystography. The evidence of high-grade Vesicoureteral Reflux obtained from these two imaging methods was compared and contrasted. Results A total of 175 patients, 70.3% of which were female, were included in this study, with an average age of 7.2 months. USG was normal in 98 (56%) patients, with 59 patients (33.7%) having signs of severe hydronephrosis. DRNC showed that most patients (64.6%) were devoid of VUR, however among those diagnosed most were of high-grade. Abnormal USG findings were statistically significant compared to VUR and high-grade VUR (P-value = 0.0001), especially in the presence of hydronephrosis. Conclusion This study shows that pathological findings in USG are significantly correlated to VUR diagnosis, and can be used as an alternative in resource-poor settings. Urinary Tract Infections Vesicoureteral Reflux Ultrasonography Direct Radionuclide Cystography Infants Figures Figure 1 1. Introduction Urinary Tract Infections (UTIs) are considered one of the most important and common serious infections during infancy. Due to the potential for renal damage following febrile UTIs, diagnostic methods for identifying children at risk are of great interest. The simultaneous presence of high-grade Vesicoureteral Reflux (VUR) increases the likelihood of renal damage and the risk of recurring infections [ 1 ]. When febrile UTI is accompanied by vesicoureteral reflux grades three to five, there is imaging evidence of pyelonephritis in 90% of cases [ 2 ]. High-grade VUR increases the likelihood of renal scarring, which leads to long term irreversible sequelae such as kidney dysfunction, hypertension, and growth disturbances in children. Therefore, several diagnostic modalities such as Voiding Cystourethrography (VCUG), Direct Radionuclide Cystography (DRNC), and Ultrasonography (USG), have been incorporated into different guidelines. Although VCUG with fluoroscopy continues to be the diagnostic gold standard of VUR in children due to its ability to precisely document anatomical abnormalities, its use of ionization radiation remains a concern [ 3 ]. As such, other diagnostic methods such as DRNC have seen increased use, which deploy less radiation, and although have a lower reported accuracy have been seen to diagnose VUR in the absence of an abnormal VCUG [ 1 , 4 ]. Most cases of VUR are classified as mild to moderate, which typically tend to spontaneously improve without any adverse or irreversible effects [ 4 ]. In spite of their unique diagnostic capabilities, techniques such as VCUG and DRNC are invasive and costly, and produce results which are often not clinically relevant. As such imaging guidelines for UTIs in children are evolving towards becoming simpler, less invasive, and more cost-effective. This study aims to examine the diagnostic accuracy of Ultrasounds in infantile VUR during initial febrile UTIs and to develop evidence-based imaging protocols. 2. Material and Methods In this study infants presenting with their first episode of febrile UTI, confirmed by positive urine culture, initially underwent USG by a radiologist. Following negative urine cultures, all patients underwent DRNC by a different operator who was blinded to the result of the USG. Evidence of various ultrasound indicators previously association with reflux, and signs of high-grade VUR in DRNC were obtained were statistically compared. VUR was categorized into groups according to severity, with grades 4 and 5 documented has high-grade [ 5 , 6 ]. Hydronephrosis was also categorized according to the US criteria [ 7 ]. Infants with a previous history of UTI or suspected UTI with initial negative urine cultures were excluded from the study. Data was gathered by reviewing the files of infants treated in Ali-Asghar Children’s Hospital from 2014–2017. The obtained results for quantitative variables are expressed as mean ± standard deviation (SD), and for categorical variables, they are presented as percentages. Comparison between quantitative variables was performed using the T-test or, if the distribution was non-normal, the Mann-Whitney test. Comparison between categorical variables was conducted using the Chi-square test or Fisher's exact test. The correlation between quantitative variables was examined using Pearson Correlation Coefficient and Spearman rank correlation. For determining diagnostic accuracy indices, cross-tabulation method, sensitivity, and specificity formulas were utilized and analyzed using SPSS version 20. 3. Results 3-1. Demographic Profile and USG Results This study was conducted on 175 patients, with an average age of 10.5 months, and a standard deviation of 7.2 months. 123 patients (70.3%) were female while 52 patients (29.7%) were male. Ultrasound was performed for all cases, 98 patients (56%) had a completely normal ultrasound devoid of any abnormalities. Hydronephrosis was seen in 59 patients (33.7%), of which 15 cases ( 8.5 %) were severe, and 20 cases (1 1.4 %) had varying degrees of ureteral dilatation (Table 1). Table 1. Relationship between hydronephrosis and dilation of Ureter found in USG and evidence of VUR in DRNC. Findings Any VUR No VUR Total No Hydronephrosis 28 88 116 Dilated 1 1 2 No Dilation 27 87 114 Mild Hydronephrosis 18 14 32 Dilated 5 2 7 No Dilation 13 12 25 Moderate Hydronephrosis 7 5 12 Dilated 3 1 4 No Dilation 4 4 8 Severe Hydronephrosis 9 6 15 Dilated 4 3 7 No Dilation 5 3 8 Total 62 113 175 3 − 2. DRNC Results Normal Cystography using DRNC was documented in 113 patients (64.6%) without any signs of VUR. Out of the 350 kidneys examined, 29 kidneys (8.2%) had low-grade VUR, 24 (6.8%) had moderate VUR, and 45 (12.8%) had high-grade VUR (Fig. 1 & Table 2 ). The prevalence of reflux between male and female patients was compared using the Mann-Whitney test, which did not display a significant difference (P-value of 0.84). Additionally, the prevalence of high-grade reflux was also compared, using the same means, also showing no significant statistical difference (P-value of 0.13). Table 2 Relationship between Left and Right Kidney DRNC findings. Left Kidney VUR No VUR Low Grade Moderate Grade High Grade Total Right Kidney VUR No VUR 113 5 3 3 124 Low Grade 1 9 0 2 12 Moderate Grade 8 1 3 2 14 High Grade 6 2 4 13 25 Total 128 17 10 20 175 3–3. Correlation between Results In this study, according to the results of the Chi-square test, abnormal USG findings, in particular hydronephrosis were strongly associated with both the presence of VUR and high grade VUR (P-value of 0.0001). Additionally, the difference in kidney length was strongly associated with reflux and high-grade reflux (P-value of 0.0001), while the difference in renal parenchyma was only associated with high-grade reflux (P-value of 0.03). Individual variations in kidney length were not statistically significant in determining the presence of VUR or high grade VUR in the associated kidney, as was also seen with left kidney parenchyma thickness. However, of note was variations of right kidney parenchyma thickness, which was statistically significant in detecting the presence of right-sided VUR, and was strongly associated with high grade VUR of the affected kidney (P-value of 0.003) (Table 3 ). Table 3 Results of Chi-square test and statistical relation between various observations and the presence of VUR and High-Grade VUR. P-value Observations Presence of VUR High-Grade VUR Ureteral Dilatation 0.01 0.002 Hydronephrosis 0.0001 0.0001 Abnormal USG 0.0001 0.0001 Kidney Length Difference 0.0001 0.0001 Kidney Parenchyma Difference 0.28 0.03 Right Kidney Length 0.97 0.69 Left Kidney Length 0.38 0.80 Left Kidney Parenchyma Thickness 0.38 0.25 Right Kidney Parenchyma Thickness 0.04 0.003 3–4. Sensitivity and Specificity The results of this study showed that USG had a sensitivity and specificity of 66.13% and 68.14% when diagnosing VUR of any grade. This correlates to a Positive and Negative Predictive Value (PPV & NPV) of 43.25% and 78.57%. Patients with pathological findings in their sonography had a 4.18-fold greater risk of having reflux (Odds Ratio = 4.18, Confidence Interval [CI]: 2.16–8.06). In addition, the sensitivity and specificity of severe hydronephrosis in diagnosing high-grade VUR was 25% and 95.1% respectively. This shows a 1.5-fold higher risk in having high-grade VUR compared to VUR of any grade (Odds Ratio = 6.48, Confidence Interval [CI]: 2.15–19.52). 4. Discussion Urinary tract infections are one of the most important and common infections during childhood. With the widespread use of vaccines against pneumococcus and Haemophilus influenzae, as well as the reduction of meningitis and bacteremia caused by them, more attention has been paid to the urinary system as a common site for serious infections accompanied by bacteremia [ 8 ]. Due to non-specific symptoms and challenges in obtaining reliable samples, diagnosing UTIs in children can be problematic. The link between UTIs in childhood and improper kidney function in adulthood has been established [ 8 ]. Diagnostic methods to determine children at risk of kidney damage following UTIs are of great importance. The presence of concomitant high-grade vesicoureteral reflux increases the likelihood of kidney damage. In cases of grades 3–5 reflux accompanied by febrile UTI, pyelonephritis will be detected in up to 90% of kidney imaging cases [ 4 , 8 ]. High-grade reflux increases the likelihood of kidney scarring, leading to consequences such as reduced kidney function, high blood pressure, and growth disturbances. Therefore, invasive diagnostic methods for reflux, such as cystography, have been incorporated into various guidelines for evaluating children with febrile UTIs [ 1 , 9 , 10 ]. However, the role of vesicoureteral reflux in renal damage is not completely clear, as pyelonephritis and even progressive kidney scarring have been reported in the absence of reflux, and thus the use of cystography for all children has been questioned in recent studies [ 11 ]. The effectiveness of prophylactic antibiotics has also come into question, leading to the decreased importance of performing cystography for all patients [ 8 ]. Long-term prophylactic antibiotic therapy was recommended for children with vesicoureteral reflux in older studies, but this approach has been challenged [ 8 ]. Furthermore, most cases of low-grade reflux improve spontaneously and without complications, and low to moderate-grade reflux does not increase the incidence of UTIs, pyelonephritis, or kidney scarring [ 2 , 5 , 10 , 12 ]. Although standard imaging studies have been part of the management of patients with first-time urinary tract infections, the impact of the information obtained from these studies on subsequent actions and patient outcomes is unclear. The goal of these imaging studies is early detection of congenital urinary anomalies that may predispose to future infections or renal parenchymal damage [ 3 , 5 , 10 , 13 ]. Given the cost and invasiveness of some of these tests, efforts are being made to simplify these protocols logically. Sonography is a non-invasive and complication-free method for evaluating the urinary system recommended in all guidelines for all children with febrile urinary tract infections. If sufficient information about the urinary system of infants with febrile UTIs can be obtained using this method, subsequent interventions costs, complications, and radiation exposure can be prevented [ 3 – 5 , 9 , 10 , 13 ]. As detailed in the results section, our study found that ultrasound performed at this center had a stronger correlation with cystography results than expected. Considering the importance of limiting radiation exposure to the ovaries and the potential for trauma during catheterization, the prioritization of unnecessary cystography cases was evident. In this study only 62 (35.4%) patients had signs of VUR in DRNC, of which only 45 of the 350 kidneys examined has signs of high-grade VUR. This indicates that cystography was only effective in about a quarter of cases and most patients did not benefit from this intervention. Given the comparable prevalence of reflux and high-grade reflux in both genders, there seems to be no need for sex-specific post-urinary tract infection investigations. Abnormal ultrasound, hydronephrosis, and hydroureter were strongly associated with reflux and high-grade reflux. Contrary to expectations, kidney length did not have a significant relationship with reflux. However, when kidney length was abnormal for the patient's age and size, it was classified as abnormal on ultrasound. Therefore, the lack of correlation with absolute kidney length can be justified by placing the normal kidneys (which make up the majority) in the study group. Furthermore, abnormal kidney length can exceed normal limits (resulting from hydronephrosis or duplication) or be less than normal (due to deformity, scarring, or atrophy). While the presence of reflux did not correlate with kidney length, there may be a relationship when comparing very small or large sizes. This investigation was not conducted in this study; instead, the absolute difference in kidney length and its correlation with reflux were evaluated, showing a strong relationship as expected. Consequently, the difference in renal parenchyma of both kidneys also had a significant relationship, as anticipated. Despite the interpretative challenges in the relationship of kidney length with renal parenchymal thickness, this study surprisingly showed a strong correlation between the size of the right renal parenchyma and reflux. Further investigation is needed to confirm or refute the definitive presence of such a correlation. 5. Conclusion In this study we explored the diagnostic accuracy of sonography in infants presenting with their first episode of febrile UTI. Although hydronephrosis, hydroureter, and total renal abnormalities were seen so be statistically significant in the diagnosis of VUR of any grade, the sensitivity and specificity was poor. However, in regards to high-grade VUR, the diagnosis of severe hydronephrosis in USG had a strong correlation and specificity. Ultimately, this does not change current guidelines in the diagnosis of VUR, however this study shows that USG can be used in poor-resource settings and in patients with absolute contraindications to more invasive methods to diagnose and manage high-grade VUR. Declarations Funding Funding was provided by Iran University of medical Sciences Conflicts of interest The authors declare no conflict of interest Ethics approval Ethical approval for the study was granted by the Ethics Committee of Iran University of Medical Sciences (Code 9311165005). The study adheres to strict confidentiality guidelines and commits to addressing any adverse events in accordance with ethical standards. Consent to participate This was a retrospective study conducted using anonymized data from patient files of children admitted to Ali Asghar Children’s Hospital for routine treatment. Consent for publication This was a retrospective study conducted using anonymized data from patient files of children admitted to Ali Asghar Children’s Hospital for routine treatment. Availability of data and material Data will be available upon reasonable request from the corresponding author. Code availability (software application or custom code) Not applicable Authors' contributions Dr. Fatemeh Hajizadeh Saffar: Conceptualization, Methodology, Investigation, Writing - Original Draft Preparation, Writing - Review & Editing Dr. Nahid Rahimzadeh: Supervision, Validation, Writing - Review & Editing. Dr. Rozita Hosseini Shamsabadi: Project Administration, Writing - Review & Editing. Dr. Reza Nejad Shahrokh Abadi: Writing - Original Draft Preparation. Data Curation, Formal Analysis References Dalirani R, Mahyar A, Sharifian M, Mohkam M, Esfandiar N, Ghehsareh Ardestani A. The value of direct radionuclide cystography in the detection of vesicoureteral reflux in children with normal voiding cystourethrography. Pediatr Nephrol. 2014;29(12):2341–2345. doi: 10.1007/s00467-014-2871-y Choi EJ, Lee MJ, Park S-A, Lee O-K. Predictors of high-grade vesicoureteral reflux in children with febrile urinary tract infections. Child Kidney Dis. 2017;21(2):136–141. Chua ME, Kim JK, Mendoza JS, et al. The evaluation of vesicoureteral reflux among children using contrast-enhanced ultrasound: a literature review. J Pediatr Urol. 2019;15(1):12–17. doi: https://doi.org/10.1016/j.jpurol.2018.11.006 Ataei F, Neshandar Asli I, Mohkam M, et al. Diagnostic Value of Technetium-99m-Dimercaptosuccinic Acid Scintigraphy in Prediction of Vesicoureteral Reflux in Children with First-time Febrile Urinary Tract Infection. Int J Pediatr. 2017;5(11):6031–6040. doi: 10.22038/ijp.2017.26012.2219 Leroy S, Vantalon S, Larakeb A, Ducou-Le-Pointe H, Bensman A. Vesicoureteral reflux in children with urinary tract infection: comparison of diagnostic accuracy of renal US criteria. Radiology. 2010;255(3):890–898. Al Qahtani W, Sarhan O, Al Otay A, El Helaly A, Al Kawai F. Primary Bilateral High-Grade Vesicoureteral Reflux in Children: Management Perspective. Cureus. 2020;12(12):e12266. doi: 10.7759/cureus.12266 Onen A. Grading of Hydronephrosis: An Ongoing Challenge. Front Pediatr. 2020;8:458. doi: 10.3389/fped.2020.00458 Roberts KB, Subcommittee on Urinary Tract Infection SC on QI and M. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595–610. Quirino IG, Silva JMP, Diniz JS, et al. Combined use of late phase dimercapto-succinic acid renal scintigraphy and ultrasound as first line screening after urinary tract infection in children. J Urol. 2011;185(1):258–263. Lee H, Hyun Soh B, Hee Hong C, Joon Kim M, Won Han S. The efficacy of ultrasound and dimercaptosuccinic acid scan in predicting vesicoureteral reflux in children below the age of 2 years with their first febrile urinary tract infection. Pediatr Nephrol. 2009;24:2009–2013. Moorthy I, Easty M, McHugh K, Ridout D, Biassoni L, Gordon I. The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection. Arch Dis Child. 2005;90(7):733–736. Garin EH, Olavarria F, Nieto VG, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006;117(3):626–632. 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(3):195–202. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5925466","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453696405,"identity":"06137288-fa79-4ef0-be5b-ab68ebf2850f","order_by":0,"name":"Fatemeh Hajizadeh Saffar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYBAC9hlAosKGgYEfxEsoIEILzw0gcSaNgUGyAaTFgBQtBgdAXKK0SLc//HAgwS7f+PzqxA8PDBjk+cUOENAic8ZY4kBCsuW2G283SwAdZjhzdgJ+LfYSOQzSH38wG5jdOLsBpCXB4DYBLTwS6Y9/HEioNzCecXbzDyK1JJgBHXbYwIC/dxuxtuSYWRxIOG4gcYN3m0WCgQRhv4AcduNAQrUBf//ZzTd/VNjI80sT0IIAEmCVEsQqBwH+A6SoHgWjYBSMgpEEAHrwRWrmX2nEAAAAAElFTkSuQmCC","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Fatemeh","middleName":"Hajizadeh","lastName":"Saffar","suffix":""},{"id":453696407,"identity":"6326478c-e64b-445c-9403-8a2e0f87fa2f","order_by":1,"name":"Nahid Rahimzadeh","email":"","orcid":"","institution":"Iran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nahid","middleName":"","lastName":"Rahimzadeh","suffix":""},{"id":453696409,"identity":"936de979-a94a-4fa2-9c7c-a9a9f00728d0","order_by":2,"name":"Rozita Hosseini Shamsabadi","email":"","orcid":"","institution":"Iran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rozita","middleName":"Hosseini","lastName":"Shamsabadi","suffix":""},{"id":453696410,"identity":"52c17933-a348-4c03-8505-304fb274dfbd","order_by":3,"name":"Reza Nejad Shahrokh Abadi","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Reza","middleName":"Nejad Shahrokh","lastName":"Abadi","suffix":""}],"badges":[],"createdAt":"2025-01-29 16:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5925466/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5925466/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82581918,"identity":"eb6dc70d-9fb1-4428-b1c2-d6325c98d628","added_by":"auto","created_at":"2025-05-13 06:39:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20163,"visible":true,"origin":"","legend":"\u003cp\u003eDisplaying the DRNC results of examined kidneys.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5925466/v1/eba92a676a0a0d53a22778d0.png"},{"id":83276792,"identity":"6395fd06-6680-4c78-9a6d-de8e1ea1f2ce","added_by":"auto","created_at":"2025-05-22 09:17:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":688001,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5925466/v1/401800ec-4a3c-4a58-b663-550b0f7b614f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ultrasound vs Direct Radionuclide Cystography in Infants: Diagnosis of High-Grade Vesicoureteral Reflux during First Febrile Urinary Tract Infection","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eUrinary Tract Infections (UTIs) are considered one of the most important and common serious infections during infancy. Due to the potential for renal damage following febrile UTIs, diagnostic methods for identifying children at risk are of great interest. The simultaneous presence of high-grade Vesicoureteral Reflux (VUR) increases the likelihood of renal damage and the risk of recurring infections [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. When febrile UTI is accompanied by vesicoureteral reflux grades three to five, there is imaging evidence of pyelonephritis in 90% of cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. High-grade VUR increases the likelihood of renal scarring, which leads to long term irreversible sequelae such as kidney dysfunction, hypertension, and growth disturbances in children. Therefore, several diagnostic modalities such as Voiding Cystourethrography (VCUG), Direct Radionuclide Cystography (DRNC), and Ultrasonography (USG), have been incorporated into different guidelines. Although VCUG with fluoroscopy continues to be the diagnostic gold standard of VUR in children due to its ability to precisely document anatomical abnormalities, its use of ionization radiation remains a concern [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As such, other diagnostic methods such as DRNC have seen increased use, which deploy less radiation, and although have a lower reported accuracy have been seen to diagnose VUR in the absence of an abnormal VCUG [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Most cases of VUR are classified as mild to moderate, which typically tend to spontaneously improve without any adverse or irreversible effects [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In spite of their unique diagnostic capabilities, techniques such as VCUG and DRNC are invasive and costly, and produce results which are often not clinically relevant. As such imaging guidelines for UTIs in children are evolving towards becoming simpler, less invasive, and more cost-effective. This study aims to examine the diagnostic accuracy of Ultrasounds in infantile VUR during initial febrile UTIs and to develop evidence-based imaging protocols.\u003c/p\u003e"},{"header":"2. Material and Methods","content":"\u003cp\u003eIn this study infants presenting with their first episode of febrile UTI, confirmed by positive urine culture, initially underwent USG by a radiologist. Following negative urine cultures, all patients underwent DRNC by a different operator who was blinded to the result of the USG. Evidence of various ultrasound indicators previously association with reflux, and signs of high-grade VUR in DRNC were obtained were statistically compared. VUR was categorized into groups according to severity, with grades 4 and 5 documented has high-grade [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Hydronephrosis was also categorized according to the US criteria [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Infants with a previous history of UTI or suspected UTI with initial negative urine cultures were excluded from the study. Data was gathered by reviewing the files of infants treated in Ali-Asghar Children\u0026rsquo;s Hospital from 2014\u0026ndash;2017. The obtained results for quantitative variables are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and for categorical variables, they are presented as percentages. Comparison between quantitative variables was performed using the T-test or, if the distribution was non-normal, the Mann-Whitney test. Comparison between categorical variables was conducted using the Chi-square test or Fisher's exact test. The correlation between quantitative variables was examined using Pearson Correlation Coefficient and Spearman rank correlation. For determining diagnostic accuracy indices, cross-tabulation method, sensitivity, and specificity formulas were utilized and analyzed using SPSS version 20.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3-1. Demographic Profile and USG Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted on 175 patients, with an average age of 10.5 months, and a standard deviation of 7.2 months. 123 patients (70.3%) were female while 52 patients (29.7%) were male. Ultrasound was performed for all cases, 98 patients (56%) had a completely normal ultrasound devoid of any abnormalities. Hydronephrosis was seen in 59 patients (33.7%), of which 15 cases (\u003cspan dir=\"RTL\"\u003e8.5\u003c/span\u003e%) were severe, and \u003cspan dir=\"RTL\"\u003e20\u003c/span\u003e cases (1\u003cspan dir=\"RTL\"\u003e1.4\u003c/span\u003e%) had varying degrees of ureteral dilatation (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Relationship between hydronephrosis and dilation of Ureter found in USG and evidence of VUR in DRNC.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"523\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFindings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAny VUR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNo VUR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNo Hydronephrosis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e28\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e88\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e116\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cem\u003eDilated\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo Dilation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMild Hydronephrosis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cem\u003eDilated\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo Dilation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eModerate Hydronephrosis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cem\u003eDilated\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo Dilation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSevere Hydronephrosis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cem\u003eDilated\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo Dilation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e62\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e113\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e175\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cbr\u003e\n\u003ch3\u003e3 − 2. DRNC Results\u003c/h3\u003e\n\u003cp\u003eNormal Cystography using DRNC was documented in 113 patients (64.6%) without any signs of VUR. Out of the 350 kidneys examined, 29 kidneys (8.2%) had low-grade VUR, 24 (6.8%) had moderate VUR, and 45 (12.8%) had high-grade VUR (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u0026amp; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The prevalence of reflux between male and female patients was compared using the Mann-Whitney test, which did not display a significant difference (P-value of 0.84). Additionally, the prevalence of high-grade reflux was also compared, using the same means, also showing no significant statistical difference (P-value of 0.13).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationship between Left and Right Kidney DRNC findings.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eLeft Kidney VUR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNo VUR\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLow Grade\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eModerate Grade\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eHigh Grade\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eRight Kidney VUR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo VUR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e124\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLow Grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eModerate Grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh Grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e128\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e175\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e3–3. Correlation between Results\u003c/h3\u003e\n\u003cp\u003eIn this study, according to the results of the Chi-square test, abnormal USG findings, in particular hydronephrosis were strongly associated with both the presence of VUR and high grade VUR (P-value of 0.0001). Additionally, the difference in kidney length was strongly associated with reflux and high-grade reflux (P-value of 0.0001), while the difference in renal parenchyma was only associated with high-grade reflux (P-value of 0.03). Individual variations in kidney length were not statistically significant in determining the presence of VUR or high grade VUR in the associated kidney, as was also seen with left kidney parenchyma thickness. However, of note was variations of right kidney parenchyma thickness, which was statistically significant in detecting the presence of right-sided VUR, and was strongly associated with high grade VUR of the affected kidney (P-value of 0.003) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of Chi-square test and statistical relation between various observations and the presence of VUR and High-Grade VUR.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePresence of VUR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eHigh-Grade VUR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreteral Dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydronephrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal USG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney Length Difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney Parenchyma Difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight Kidney Length\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft Kidney Length\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft Kidney Parenchyma Thickness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight Kidney Parenchyma Thickness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e3–4. Sensitivity and Specificity\u003c/h3\u003e\n\u003cp\u003eThe results of this study showed that USG had a sensitivity and specificity of 66.13% and 68.14% when diagnosing VUR of any grade. This correlates to a Positive and Negative Predictive Value (PPV \u0026amp; NPV) of 43.25% and 78.57%. Patients with pathological findings in their sonography had a 4.18-fold greater risk of having reflux (Odds Ratio\u0026thinsp;=\u0026thinsp;4.18, Confidence Interval [CI]: 2.16\u0026ndash;8.06). In addition, the sensitivity and specificity of severe hydronephrosis in diagnosing high-grade VUR was 25% and 95.1% respectively. This shows a 1.5-fold higher risk in having high-grade VUR compared to VUR of any grade (Odds Ratio\u0026thinsp;=\u0026thinsp;6.48, Confidence Interval [CI]: 2.15\u0026ndash;19.52).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eUrinary tract infections are one of the most important and common infections during childhood. With the widespread use of vaccines against pneumococcus and Haemophilus influenzae, as well as the reduction of meningitis and bacteremia caused by them, more attention has been paid to the urinary system as a common site for serious infections accompanied by bacteremia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Due to non-specific symptoms and challenges in obtaining reliable samples, diagnosing UTIs in children can be problematic. The link between UTIs in childhood and improper kidney function in adulthood has been established [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Diagnostic methods to determine children at risk of kidney damage following UTIs are of great importance. The presence of concomitant high-grade vesicoureteral reflux increases the likelihood of kidney damage. In cases of grades 3\u0026ndash;5 reflux accompanied by febrile UTI, pyelonephritis will be detected in up to 90% of kidney imaging cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. High-grade reflux increases the likelihood of kidney scarring, leading to consequences such as reduced kidney function, high blood pressure, and growth disturbances. Therefore, invasive diagnostic methods for reflux, such as cystography, have been incorporated into various guidelines for evaluating children with febrile UTIs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the role of vesicoureteral reflux in renal damage is not completely clear, as pyelonephritis and even progressive kidney scarring have been reported in the absence of reflux, and thus the use of cystography for all children has been questioned in recent studies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The effectiveness of prophylactic antibiotics has also come into question, leading to the decreased importance of performing cystography for all patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Long-term prophylactic antibiotic therapy was recommended for children with vesicoureteral reflux in older studies, but this approach has been challenged [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, most cases of low-grade reflux improve spontaneously and without complications, and low to moderate-grade reflux does not increase the incidence of UTIs, pyelonephritis, or kidney scarring [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although standard imaging studies have been part of the management of patients with first-time urinary tract infections, the impact of the information obtained from these studies on subsequent actions and patient outcomes is unclear. The goal of these imaging studies is early detection of congenital urinary anomalies that may predispose to future infections or renal parenchymal damage [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Given the cost and invasiveness of some of these tests, efforts are being made to simplify these protocols logically. Sonography is a non-invasive and complication-free method for evaluating the urinary system recommended in all guidelines for all children with febrile urinary tract infections. If sufficient information about the urinary system of infants with febrile UTIs can be obtained using this method, subsequent interventions costs, complications, and radiation exposure can be prevented [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As detailed in the results section, our study found that ultrasound performed at this center had a stronger correlation with cystography results than expected. Considering the importance of limiting radiation exposure to the ovaries and the potential for trauma during catheterization, the prioritization of unnecessary cystography cases was evident.\u003c/p\u003e \u003cp\u003eIn this study only 62 (35.4%) patients had signs of VUR in DRNC, of which only 45 of the 350 kidneys examined has signs of high-grade VUR. This indicates that cystography was only effective in about a quarter of cases and most patients did not benefit from this intervention. Given the comparable prevalence of reflux and high-grade reflux in both genders, there seems to be no need for sex-specific post-urinary tract infection investigations. Abnormal ultrasound, hydronephrosis, and hydroureter were strongly associated with reflux and high-grade reflux. Contrary to expectations, kidney length did not have a significant relationship with reflux. However, when kidney length was abnormal for the patient's age and size, it was classified as abnormal on ultrasound. Therefore, the lack of correlation with absolute kidney length can be justified by placing the normal kidneys (which make up the majority) in the study group. Furthermore, abnormal kidney length can exceed normal limits (resulting from hydronephrosis or duplication) or be less than normal (due to deformity, scarring, or atrophy). While the presence of reflux did not correlate with kidney length, there may be a relationship when comparing very small or large sizes. This investigation was not conducted in this study; instead, the absolute difference in kidney length and its correlation with reflux were evaluated, showing a strong relationship as expected. Consequently, the difference in renal parenchyma of both kidneys also had a significant relationship, as anticipated. Despite the interpretative challenges in the relationship of kidney length with renal parenchymal thickness, this study surprisingly showed a strong correlation between the size of the right renal parenchyma and reflux. Further investigation is needed to confirm or refute the definitive presence of such a correlation.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn this study we explored the diagnostic accuracy of sonography in infants presenting with their first episode of febrile UTI. Although hydronephrosis, hydroureter, and total renal abnormalities were seen so be statistically significant in the diagnosis of VUR of any grade, the sensitivity and specificity was poor. However, in regards to high-grade VUR, the diagnosis of severe hydronephrosis in USG had a strong correlation and specificity. Ultimately, this does not change current guidelines in the diagnosis of VUR, however this study shows that USG can be used in poor-resource settings and in patients with absolute contraindications to more invasive methods to diagnose and manage high-grade VUR.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding was provided by Iran University of medical Sciences\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was granted by the Ethics Committee of Iran University of Medical Sciences (Code\u0026nbsp;9311165005). The study adheres to strict confidentiality guidelines and commits to addressing any adverse events in accordance with ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective study conducted using anonymized data from patient files of children admitted to Ali Asghar Children\u0026rsquo;s Hospital for routine treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective study conducted using anonymized data from patient files of children admitted to Ali Asghar Children\u0026rsquo;s Hospital for routine treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability (software application or custom code)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Fatemeh Hajizadeh Saffar: Conceptualization, Methodology, Investigation, Writing - Original Draft Preparation, Writing - Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eDr. Nahid Rahimzadeh: Supervision, Validation, Writing - Review \u0026amp; Editing.\u003c/p\u003e\n\u003cp\u003eDr. Rozita Hosseini Shamsabadi: Project Administration, Writing - Review \u0026amp; Editing.\u003c/p\u003e\n\u003cp\u003eDr. Reza Nejad Shahrokh Abadi: Writing - Original Draft Preparation. Data Curation, Formal Analysis\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDalirani R, Mahyar A, Sharifian M, Mohkam M, Esfandiar N, Ghehsareh Ardestani A. The value of direct radionuclide cystography in the detection of vesicoureteral reflux in children with normal voiding cystourethrography. Pediatr Nephrol. 2014;29(12):2341\u0026ndash;2345. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00467-014-2871-y\u003c/span\u003e\u003cspan address=\"10.1007/s00467-014-2871-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi EJ, Lee MJ, Park S-A, Lee O-K. Predictors of high-grade vesicoureteral reflux in children with febrile urinary tract infections. Child Kidney Dis. 2017;21(2):136\u0026ndash;141.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChua ME, Kim JK, Mendoza JS, et al. The evaluation of vesicoureteral reflux among children using contrast-enhanced ultrasound: a literature review. J Pediatr Urol. 2019;15(1):12\u0026ndash;17. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpurol.2018.11.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jpurol.2018.11.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtaei F, Neshandar Asli I, Mohkam M, et al. Diagnostic Value of Technetium-99m-Dimercaptosuccinic Acid Scintigraphy in Prediction of Vesicoureteral Reflux in Children with First-time Febrile Urinary Tract Infection. Int J Pediatr. 2017;5(11):6031\u0026ndash;6040. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.22038/ijp.2017.26012.2219\u003c/span\u003e\u003cspan address=\"10.22038/ijp.2017.26012.2219\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeroy S, Vantalon S, Larakeb A, Ducou-Le-Pointe H, Bensman A. Vesicoureteral reflux in children with urinary tract infection: comparison of diagnostic accuracy of renal US criteria. Radiology. 2010;255(3):890\u0026ndash;898.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Qahtani W, Sarhan O, Al Otay A, El Helaly A, Al Kawai F. Primary Bilateral High-Grade Vesicoureteral Reflux in Children: Management Perspective. Cureus. 2020;12(12):e12266. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.12266\u003c/span\u003e\u003cspan address=\"10.7759/cureus.12266\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnen A. Grading of Hydronephrosis: An Ongoing Challenge. Front Pediatr. 2020;8:458. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fped.2020.00458\u003c/span\u003e\u003cspan address=\"10.3389/fped.2020.00458\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoberts KB, Subcommittee on Urinary Tract Infection SC on QI and M. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595\u0026ndash;610.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuirino IG, Silva JMP, Diniz JS, et al. Combined use of late phase dimercapto-succinic acid renal scintigraphy and ultrasound as first line screening after urinary tract infection in children. J Urol. 2011;185(1):258\u0026ndash;263.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee H, Hyun Soh B, Hee Hong C, Joon Kim M, Won Han S. The efficacy of ultrasound and dimercaptosuccinic acid scan in predicting vesicoureteral reflux in children below the age of 2 years with their first febrile urinary tract infection. Pediatr Nephrol. 2009;24:2009\u0026ndash;2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoorthy I, Easty M, McHugh K, Ridout D, Biassoni L, Gordon I. The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection. Arch Dis Child. 2005;90(7):733\u0026ndash;736.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarin EH, Olavarria F, Nieto VG, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006;117(3):626\u0026ndash;632.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoberman 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(3):195\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Urinary Tract Infections, Vesicoureteral Reflux, Ultrasonography, Direct Radionuclide Cystography, Infants","lastPublishedDoi":"10.21203/rs.3.rs-5925466/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5925466/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eRenal damage caused by infantile Urinary Tract Infection has led to various imaging techniques being proposed for the early diagnosis of Vesicoureteral Reflux. The goal of this study is to determine the possibility of Ultrasound replacing more invasive and costly methods for diagnosing high-grade vesicoureteral reflux in infants with their first febrile urinary tract infection.\u003c/p\u003e\u003ch2\u003eMaterial \u0026amp; Methods\u003c/h2\u003e \u003cp\u003eInfants with their first febrile Urinary Tract Infection underwent Sonography and Radionuclide Cystography. The evidence of high-grade Vesicoureteral Reflux obtained from these two imaging methods was compared and contrasted.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 175 patients, 70.3% of which were female, were included in this study, with an average age of 7.2 months. USG was normal in 98 (56%) patients, with 59 patients (33.7%) having signs of severe hydronephrosis. DRNC showed that most patients (64.6%) were devoid of VUR, however among those diagnosed most were of high-grade. Abnormal USG findings were statistically significant compared to VUR and high-grade VUR (P-value\u0026thinsp;=\u0026thinsp;0.0001), especially in the presence of hydronephrosis.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study shows that pathological findings in USG are significantly correlated to VUR diagnosis, and can be used as an alternative in resource-poor settings.\u003c/p\u003e","manuscriptTitle":"Ultrasound vs Direct Radionuclide Cystography in Infants: Diagnosis of High-Grade Vesicoureteral Reflux during First Febrile Urinary Tract Infection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 06:39:43","doi":"10.21203/rs.3.rs-5925466/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c820b217-8cc0-4a80-8968-d9fcf6efa117","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-22T09:09:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 06:39:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5925466","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5925466","identity":"rs-5925466","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}