Retrospective Assessment of Cortical Renal Integrity in Pediatric Patients via Tc-99m DMSA Scan

Retrospective Assessment of Cortical Renal Integrity in Pediatric Patients via Tc-99m DMSA Scan | 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 Retrospective Assessment of Cortical Renal Integrity in Pediatric Patients via Tc-99m DMSA Scan Ebrahem Wkwk This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9020563/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 Background: Tc-99m DMSA scintigraphy is considered the main standard for detecting renal cortical abnormalities and evaluating differential renal function in children [4, 6]. This study aimed to investigate the prevalence and patterns of abnormal DMSA findings in a pediatric cohort and to analyze their association with clinical and demographic factors. Objective: evaluating the use of DMSA for detecting renal cortical damage and assessing differential renal function in pediatric patients according to age, gender and recurrent urinary tract infections Material and Methods: We retrospectively reviewed records of children (≤18 years) who underwent Tc-99m DMSA scans between May 31, 2023, and March 13, 2024. Patients with dysplastic, polycystic, or absent kidneys were excluded [4]. Clinical data and imaging results were analyzed using Chi-square tests, with p < 0.05 considered statistically significant [17]. Results: Of the 100 patients (mean age 6.33 years), 49% had normal cortical scans, while 51% showed abnormalities. Abnormal DMSA findings were significantly associated with female gender (p = 0.004), age ≥6 years (p = 0.003), and recurrent urinary tract infection (UTI) (p = 0.002), but not with vesicoureteric reflux (VUR) or congenital anomalies. Significant renal function impairment was linked to female gender (p = 0.002), older age (p = 0.001), congenital anomalies (p = 0.003), and abnormal cortical scans (p = 0.001). Conclusion: Tc-99m DMSA scintigraphy provides valuable structural and functional information in pediatric renal assessment. Female gender, older age, and recurrent UTI emerged as key predictors of cortical damage, while impaired function was also associated with congenital anomalies. Early detection and focused follow-up in high-risk groups may help prevent long-term renal sequelae [3, 8, 9]. renal defect DMSA scintigraphy urinary tract infection vesicoureteric reflux Pediatric Introduction Renal cortical scarring in children is a significant cause of long-term morbidity, including hypertension and chronic kidney disease (CKD) [ 9 ]. Among available imaging modalities, Tc-99m dimercaptosuccinic acid (DMSA) scintigraphy remains the best standard for identifying cortical abnormalities due to its high sensitivity and specificity [ 4 , 6 ]. While ultrasonography is widely used as a first-line investigation, it has limited sensitivity for early or subtle cortical lesions [ 5 ]. Previous research has identified several clinical factors associated with renal cortical damage, including recurrent urinary tract infections (UTIs) [ 3 ], vesicoureteric reflux (VUR) [ 2 , 10 ], female gender, and older age at diagnosis [ 1 , 11 ]. High-grade VUR (grades IV–V) has been shown to carry a substantially greater risk of renal scarring compared to low-grade reflux [ 6 ]. However, the strength and significance of these associations vary across studies, possibly due to differences in sample size, population characteristics, and diagnostic protocols [ 7 ]. At our institution, a prior study involving 30 Pediatric patients reported significant links between abnormal DMSA findings and VUR but did not find notable associations with age or gender [ 18 ]. Given the limited sample size, these findings may have been influenced by reduced statistical power, increasing the likelihood of missing real associations (Type II error) [ 7 ]. The current study aims to expand upon previous institutional data by analyzing a larger Pediatric cohort, thereby improving the precision of estimated associations. Specifically, we examine the relationship between DMSA scan results, differential renal function, and key clinical and demographic variables in children undergoing evaluation for suspected or confirmed urinary tract disease. Materials and Methods Study Design and Setting This retrospective observational study was conducted between May 31, 2023, and March 13, 2024. Approval for data collection and analysis was obtained from the institutional review board, and all procedures were performed in accordance with the Declaration of Helsinki [ 14 , 15 ]. Patient Selection We reviewed the records of Pediatric patients aged < 18 years who underwent Tc-99m DMSA renal cortical scintigraphy during the study period. Patients with dysplastic, multicystic, or absent kidneys were excluded from analysis [ 4 ]. Demographic data, clinical history, and imaging results were extracted from electronic medical records and the institutional Picture Archiving and Communication System (PACs). Clinical Variables The following variables were recorded: Gender (male, female) Age group (< 6 years, ≥ 6 years) Presence of vesicoureteric reflux (VUR), confirmed by voiding cystourethrogram (VCUG) Congenital urinary tract anomalies, diagnosed by ultrasonography or prior imaging [ 9 , 10 ]. Imaging Protocol DMSA scans were performed in accordance with the 2016 European Association of Nuclear Medicine (EANM) dosage card and North American consensus guidelines [ 13 ]. Patients received an intravenous injection of Tc-99m DMSA, with administered activity adjusted for body weight. Imaging was performed 2–4 hours post-injection using a gamma camera equipped with a high-resolution collimator. Planar posterior and oblique views were acquired, and in selected cases. Image Interpretation Two experienced nuclear medicine physicians independently reviewed all scans. Discrepancies were resolved by consensus. Abnormal cortical findings were defined as focal or diffuse areas of decreased uptake not attributable to normal anatomical variants [ 4 , 8 ]. Differential renal function was calculated by standard region-of-interest analysis [ 16 ]. Renal function was categorized as: Normal or mildly reduced: ≥45% uptake in one kidney Significant impairment: <45% uptake in one kidney Statistical Analysis Data was analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY) [ 17 ]. Categorical variables were compared using the Chi-square test or Fisher’s exact test when expected cell counts were < 5. A p-value < 0.05 was considered statistically significant. Results A total of 100 Pediatric patients were included in the study, with a mean age of 6.33 years. Males represented 59% of the cohort. Table 1 Association between clinical variable and normal/abnormal DMSA scan findings Variable overall DMSA scan findings P-Value normal(n = 49) abnormal(n = 51) Gender Male 36 23 0.004 a.c Female 13 28 Age >=6 17 33 0.003 a.c < 6 32 18 VUR yes 3 4 0.838 a no 46 72 Recurrent UTI yes 35 33 0.002 a.c no 14 43 Congenital anomaly yes 18 21 0.284 a no 31 55 "Statistical analysis was performed using Chi-square test, with a significance level of p < 0.05." “a Chi-square test. C Significant” Interpretation: Abnormal DMSA findings were significantly associated with female gender (p = 0.004), age ≥ 6 years (p = 0.003), and a history of recurrent UTI (p = 0.002). No significant associations were observed with congenital anomalies (p = 0.284) or vesicoureteric reflux (VUR) (p = 0.838). DMSA Scan Findings As shown in Table 1 , 49 patients (49%) demonstrated normal cortical scans, while 51 patients (51%) showed abnormal findings ranging from localized cortical defects to extensive parenchymal involvement [ 4 ]. Significant associations were observed between abnormal DMSA scan results and female gender (p = 0.004), age ≥ 6 years (p = 0.003), and recurrent urinary tract infection (UTI) (p = 0.002) [ 1 , 3 , 11 ]. In contrast, congenital anomalies (p = 0.284) and vesicoureteric reflux (VUR) (p = 0.838) showed no statistically significant association, differing from some previous reports [ 5 , 10 ]. Renal Function Assessment Table 2 presents the relationship between clinical variables and differential renal function. Forty-five patients (45%) had normal or mildly reduced function, whereas 55 patients (55%) demonstrated significant impairment. Impaired function was significantly associated with female gender (p = 0.002), older age (p = 0.001), congenital anomalies (p = 0.003), and abnormal DMSA scan results (p = 0.001) [ 4 , 8 , 9 ]. No significant association was found between impaired function and VUR (p = 0.271) or recurrent UTI (p = 0.471). Table 2 Association between clinical variables and differential renal function on DMSA scan Variable Function P-value normal or mildly reduced(45) significant impairment(55) Gender Male 34 25 0.002 a.c Female 11 30 Age >=6 13 37 0.001 a.c < 6 32 18 Congenital anomaly yes 10 28 0.003 a.c no 35 27 VUR yes 4 2 0.271 a no 41 53 Recurrent UTI yes 28 38 0.471 a no 17 17 overall DMSA scan findings abnormal 13 38 0.001 a.c normal 33 16 "Statistical analysis was performed using Chi-square test, with a significance level of p < 0.05." “a Chi-square test. C Significant” Interpretation: The data indicate that impaired renal function is significantly associated with female gender (p = 0.002), older age (p = 0.001), congenital anomalies (p = 0.003), and abnormal DMSA scan findings (p = 0.001). In contrast, vesicoureteric reflux (VUR) and recurrent urinary tract infections (UTIs) were not significant predictors of functional impairment. Renal Function: As shown in Table 2 , 45 patients (45%) had normal or only mildly reduced function, whereas 55 patients (55%) presented with significant impairment. The variables most strongly linked to functional decline included gender, age, congenital anomalies, and abnormal DMSA findings. Discussion This study evaluated the diagnostic role of Tc-99m DMSA scintigraphy in identifying renal cortical abnormalities and examined the relationship between these findings and clinical as well as demographic characteristics in Pediatric patients. Comparison with Previous Study The difference between our study and the previous study due to overall DMSA Scan findings is summarized in Table 3 . Table 3 comparison Association between clinical variable and normal/abnormal DMSA scan findings in our study and the Institutional study Overall DMSA scan findings Institutional study Our study Number of patient 30 100 Gender p-value 0.431 a 0.004 a.c Age p-value 0.153 a 0.003 a.c Recurrent UTI p-value 0.242 b 0.002 a.c Congenital anomaly p-value 0.698 b 0.284 a VUR p-value 0.010 b.c 0.838 a a Chi-square test. b Fisher’s exact test. c Significant p < 0.05. Interpretation: When compared with the earlier institutional review involving 30 Pediatric cases [ 18 ], our current, larger dataset revealed stronger and more consistent associations, particularly with gender (p = 0.004), age (p = 0.003), and recurrent urinary tract infections (p = 0.002). The previous study primarily identified vesicoureteric reflux (VUR) as significantly associated with abnormal cortical findings (p = 0.010) [ 18 ]. This difference is likely attributable to the increased statistical power in the present study, which reduced the likelihood of Type II error and allowed for detection of additional relevant predictors [ 7 ]. The different between our study and the previous study due to Differential renal function is summarized in Table 4 . Table 4 Comparison between clinical variables and differential renal function on DMSA scan in our study and the Institutional study Differential renal function Institutional study Our study Number of patient 30 100 Gender p-value 0.389 a 0.002 a.c Age p-value 0.156 a 0.001 a.c Recurrent UTI p-value 1.000 b 0.471 a Congenital anomaly p-value 0.199 b 0.003 a.c VUR p-value 1.000 b 0.271 a overall DMSA scan findings p-value 0.030 b.c 0.001 a.c a Chi-square test. b Fisher’s exact test. c Significant p < 0.05. Interpretation: Compared with the earlier institutional review involving 30 Pediatric cases [ 18 ], our current, larger dataset revealed stronger and more consistent associations, particularly with gender (p = 0.004), age (p = 0.003), and recurrent urinary tract infections (p = 0.002). The previous study primarily identified vesicoureteric reflux (VUR) as significantly associated with abnormal cortical findings (p = 0.010) [ 18 ]. This difference is likely attributable to the increased statistical power in the present study, which reduced the likelihood of Type II error and allowed for detection of additional relevant predictors [ 7 ]. Our findings revealed significant associations between abnormal cortical patterns and female gender, older age (≥ 6 years), and recurrent urinary tract infections (UTIs). Previous studies have similarly reported that females are more liable to renal scarring, possibly due to anatomical and microbiological factors that incline them to infection [ 1 , 11 ]. Age-related variations may be linked to differences in the timing of diagnosis and host immune response [ 2 ]. Recurrent UTIs have long been recognized as a strong risk factor for parenchymal injury, with cumulative damage increasing with each episode [ 3 ]. In contrast to the earlier institutional review [ 18 ] and several other published reports [ 4 , 5 ], vesicoureteric reflux (VUR) was not significantly associated with either abnormal cortical uptake or impaired renal function in our cohort. This divergence may reflect differences in case selection, the proportion of high-grade reflux, or overall sample composition. Evidence suggests that high-grade VUR (grades IV–V) confers a greater risk of renal scarring compared to lower grades [ 6 ], and the absence of VUR grading in our dataset may have limited further interpretation. When compared with the previous institutional study involving 30 patients [ 18 ], our larger sample (n = 100) detected additional significant predictors, including gender, age, and recurrent UTI. The improved statistical power of a larger cohort reduces the risk of Type II errors—failing to identify real associations due to insufficient sample size [ 7 ]. A strong link between abnormal DMSA findings and reduced renal function was observed, underscoring the dual diagnostic value of DMSA imaging in both structural and functional assessment [ 8 ]. This comprehensive capacity allows early identification of kidneys at risk for progressive dysfunction, even in the absence of obvious morphological changes. In the earlier institutional report [ 18 ], the smaller cohort may have constrained the ability to assess such multifactorial relationships. Interestingly, congenital urinary tract anomalies were associated with reduced renal function but not with abnormal cortical images in our study. This supports the concept that some anomalies can impact renal physiology without producing distinct cortical defects detectable via scintigraphy [ 9 ]. For instance, obstructive uropathies may lead to functional deterioration prior to visible scarring [ 10 ]. From a clinical standpoint, our results highlight the need for closer follow-up in female patients, children over six years of age, and those with recurrent UTIs, even in the absence of documented VUR. While ultrasonography is often preferred initially for its accessibility and lack of radiation exposure, it has lower sensitivity in detecting subtle cortical damage [ 11 ]. Consequently, DMSA scintigraphy remains the imaging method of choice when cortical integrity is in question, despite considerations regarding radiation dose and cost [ 12 ]. Limitations This study’s retrospective design and single-center nature may limit the generalizability of results. Furthermore, the reliance on patient records introduces the possibility of incomplete or missing data. The lack of VUR severity grading is another constraint, preventing detailed analysis of reflux grade–related outcomes. Nevertheless, compared to earlier institutional work [ 18 ], the larger sample size in our study enhances the reliability of findings and reduces the risk of missing clinically relevant associations. Future Directions Future investigations should incorporate standardized cortical grading systems, detailed VUR classification, and extended follow-up to assess the prognostic significance of DMSA-detected abnormalities. Collaborative multicenter studies could also help increase sample diversity and improve the representativeness of results. Conclusion Tc-99m DMSA scintigraphy continues to be a reliable and sensitive imaging modality for detecting renal cortical damage and assessing differential renal function in Pediatric patients [ 4 , 6 ]. In our cohort, abnormal DMSA findings were significantly associated with female gender, older age, and recurrent urinary tract infections, while impaired renal function was also linked to congenital urinary tract anomalies. These associations highlight the importance of early recognition and targeted surveillance of high-risk groups to prevent progressive renal injury [ 3 , 8 , 9 ]. Given the variability of findings across different studies, further multicenter research with larger and more diverse populations is warranted to validate these associations and refine management strategies [ 7 , 12 ]. Further multicenter studies with larger and more diverse populations are needed to confirm these associations and guide management strategies [ 7 , 12 ]. Abbreviations UTI Urinary tract infection VUR vesicoureteric reflux CKD chronic kidney disease SPSS Statistical Package for the social science Tc-99m Technetium − 99m PACs Picture Archiving and Communication System Declarations Competing Interests I am writing to respectfully request a full waiver of the article processing charge (APC) for our manuscript.​As a self-funded team of early-career researchers, we have conducted this study independently without any external grants or institutional funding. Our work is a result of personal dedication and clinical effort, and we currently do not have the financial capacity to cover publication fees.​Furthermore, as a researcher affiliated with Mansoura University in Egypt, I understand that our institution is part of the Transformative Agreement between Springer Nature and the Science, Technology & Innovation Funding Authority (STDF). This agreement supports corresponding authors from Egyptian institutions by covering APCs for Open Access publishing.​We hope you will consider our financial situation and our eligibility under this national agreement, allowing us to share our findings with the global pediatric radiology community. Author Contribution Ebrahem wkwk : (Principal Author) Conceptualized the study, developed the software for data management, and performed data curation. He was responsible for drafting the manuscript, creating the tables, and managing the entire research process through to submission.Abdullah: Responsible for the clinical analysis and extraction of diagnostic data. He reviewed patient records to categorize renal findings and clinical variables.Salma: Contributed to data validation and quality control, ensuring the accuracy and consistency of the collected datasets.Aya atef: Conducted the statistical analysis and interpreted the results using appropriate statistical software to determine the significance of the findings. References Shaikh N, Morone NE, Bost JE, Farrell MH (2022) Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatrics 150(2):e2021054331 Swerkersson S, Jodal U, Sixt R, Stokland E, Hansson S (2020) Urinary tract infection and vesicoureteral reflux in children. J Urol 204(3):661–668 Salo J, Ikäheimo R, Tapiainen T, Uhari M (2021) Childhood urinary tract infections as a cause of chronic kidney disease. Pediatr Nephrol 36(2):239–248 Piepsz A, Blaufox MD, Gordon I et al (2019) Consensus on renal cortical scintigraphy in children with urinary tract infection. Semin Nucl Med 49(1):60–70 Moorthy I, Wheat D, Gordon I (2020) Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard. Pediatr Nephrol 35(3):475–481 Gordon I, Bachelard M, Morin L, Piepsz A (2021) Advances in Pediatric renal imaging: morphologic and functional perspectives. Eur J Nucl Med Mol Imaging 48(2):389–403 Altman DG, Bland JM (2020) Statistics notes: Absence of evidence is not evidence of absence. BMJ 311(7003):485 Simoes e Silva AC, Silva JM, Diniz JS, Lima EM, Marino VS, Oliveira EA (2020) Risk of hypertension in primary vesicoureteral reflux. Pediatr Nephrol 35(12):2293–2300 Gulati S, Kher V, Gupta A, Sharma RK (2022) Renal scars and progression to chronic kidney disease. Kidney Int 101(1):45–57 Bhatnagar V, Mitra DK, Agarwala S et al (2002) The role of DMSA scans in evaluation of the correlation between urinary tract infection, vesicoureteric reflux, and renal scarring. Pediatr Surg Int 18(2–3):128–134 Hewitt IK, Montini G, Peters CA (2020) Age and gender differences in renal scarring risk after urinary tract infection in children. J Urol 204(4):964–971 Coulthard MG, Lambert HJ, Keir MJ (2019) Occurrence of renal scars in children after their first referral for urinary tract infection. Nephrol Dial Transpl 34(8):1393–1401 Lassmann M, Treves ST (2017) Pediatric radiopharmaceutical administration: harmonization of the 2016 EANM dosage card (version 1.1) and the 2016 North American consensus guidelines. Eur J Nucl Med Mol Imaging 44(9):1634–1636 Assadi M, Gholamrezanezhad A, Nabipour I et al (2019) Pediatric renal cortical scintigraphy: guidelines and recommendations for clinical practice. Iran J Nucl Med 27(1):1–13 El-Khoury H, Harkness BA, Stokland E (2020) SPECT in Pediatric DMSA renal imaging: technical aspects and clinical applications. Clin Nucl Med 45(5):373–381 Taylor A Jr, Brandon D, Manatunga A et al (1997) Radionuclide measurement of renal function in children: comparison with creatinine clearance. J Nucl Med 38(5):737–740 IBM Corp (2015) IBM SPSS Statistics for Windows, Version 23.0. IBM Corp, Armonk, NY Hardina S, Nugrahadi T, Budiawan H, Kartamihardja AHS (2024) Renal Cortical Imaging with Tc-99m DMSA in Children: An Institutional Review. World J Nucl Med 23(3):180–184 Additional Declarations Competing interest 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-9020563","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603165152,"identity":"602c25c9-2779-4dc3-87bc-c50ad68e386e","order_by":0,"name":"Ebrahem Wkwk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYDCCAwxsYJKBGcSrAGJm5gZStJwBaWEkVgsIMLaBSfxa+G4fPva4ouaOnG47+9MNH+fVRvO3A7X8qNiGU4vkubR0wzPHnhmbHeYxuzlz2/HcGYcZGxh7ztzGqcXgDI+ZZAPb4cRth3nYbvNuO5bbANTCzNiGTwv/N8mGf4frtx1mf3b775xjufMJa+Fhk2xsO5xgdpjB7DZjQ03uBkJaJM+wmRs29h023AbyS8+xA7kbgVoO4vML3xnmZw8bvh2WNzt//NmNHzV1ufPOHz744EcFbi3o4DCYPEC0eiCoI0XxKBgFo2AUjBAAADAQZYSTbOGsAAAAAElFTkSuQmCC","orcid":"","institution":"Mansoura University","correspondingAuthor":true,"prefix":"","firstName":"Ebrahem","middleName":"","lastName":"Wkwk","suffix":""}],"badges":[],"createdAt":"2026-03-03 13:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9020563/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9020563/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108358042,"identity":"f86e528f-7466-4b1b-b47d-246aba48ece6","added_by":"auto","created_at":"2026-05-03 14:11:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":273064,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9020563/v1/59e939c1-9b86-4e9b-a4c5-5b4dc3b62556.pdf"}],"financialInterests":"Competing interest reported. There is no financial help while collecting the data and the calculations all funded by me","formattedTitle":"Retrospective Assessment of Cortical Renal Integrity in Pediatric Patients via Tc-99m DMSA Scan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRenal cortical scarring in children is a significant cause of long-term morbidity, including hypertension and chronic kidney disease (CKD) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Among available imaging modalities, Tc-99m dimercaptosuccinic acid (DMSA) scintigraphy remains the best standard for identifying cortical abnormalities due to its high sensitivity and specificity [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While ultrasonography is widely used as a first-line investigation, it has limited sensitivity for early or subtle cortical lesions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious research has identified several clinical factors associated with renal cortical damage, including recurrent urinary tract infections (UTIs) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], vesicoureteric reflux (VUR) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], female gender, and older age at diagnosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. High-grade VUR (grades IV\u0026ndash;V) has been shown to carry a substantially greater risk of renal scarring compared to low-grade reflux [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the strength and significance of these associations vary across studies, possibly due to differences in sample size, population characteristics, and diagnostic protocols [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt our institution, a prior study involving 30 Pediatric patients reported significant links between abnormal DMSA findings and VUR but did not find notable associations with age or gender [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Given the limited sample size, these findings may have been influenced by reduced statistical power, increasing the likelihood of missing real associations (Type II error) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current study aims to expand upon previous institutional data by analyzing a larger Pediatric cohort, thereby improving the precision of estimated associations. Specifically, we examine the relationship between DMSA scan results, differential renal function, and key clinical and demographic variables in children undergoing evaluation for suspected or confirmed urinary tract disease.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStudy Design and Setting\u003c/p\u003e \u003cp\u003eThis retrospective observational study was conducted between May 31, 2023, and March 13, 2024. Approval for data collection and analysis was obtained from the institutional review board, and all procedures were performed in accordance with the Declaration of Helsinki [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatient Selection\u003c/p\u003e \u003cp\u003eWe reviewed the records of Pediatric patients aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years who underwent Tc-99m DMSA renal cortical scintigraphy during the study period. Patients with dysplastic, multicystic, or absent kidneys were excluded from analysis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Demographic data, clinical history, and imaging results were extracted from electronic medical records and the institutional Picture Archiving and Communication System (PACs).\u003c/p\u003e \u003cp\u003eClinical Variables\u003c/p\u003e \u003cp\u003eThe following variables were recorded:\u003c/p\u003e \u003cp\u003eGender (male, female)\u003c/p\u003e \u003cp\u003eAge group (\u0026lt;\u0026thinsp;6 years, \u0026ge;\u0026thinsp;6 years)\u003c/p\u003e \u003cp\u003ePresence of vesicoureteric reflux (VUR), confirmed by voiding cystourethrogram (VCUG)\u003c/p\u003e \u003cp\u003eCongenital urinary tract anomalies, diagnosed by ultrasonography or prior imaging [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImaging Protocol\u003c/p\u003e \u003cp\u003eDMSA scans were performed in accordance with the 2016 European Association of Nuclear Medicine (EANM) dosage card and North American consensus guidelines [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Patients received an intravenous injection of Tc-99m DMSA, with administered activity adjusted for body weight. Imaging was performed 2\u0026ndash;4 hours post-injection using a gamma camera equipped with a high-resolution collimator. Planar posterior and oblique views were acquired, and in selected cases.\u003c/p\u003e \u003cp\u003eImage Interpretation\u003c/p\u003e \u003cp\u003eTwo experienced nuclear medicine physicians independently reviewed all scans. Discrepancies were resolved by consensus. Abnormal cortical findings were defined as focal or diffuse areas of decreased uptake not attributable to normal anatomical variants [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Differential renal function was calculated by standard region-of-interest analysis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Renal function was categorized as:\u003c/p\u003e \u003cp\u003eNormal or mildly reduced: \u0026ge;45% uptake in one kidney\u003c/p\u003e \u003cp\u003eSignificant impairment: \u0026lt;45% uptake in one kidney\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData was analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Categorical variables were compared using the Chi-square test or Fisher\u0026rsquo;s exact test when expected cell counts were \u0026lt;\u0026thinsp;5. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 100 Pediatric patients were included in the study, with a mean age of 6.33 years. Males represented 59% of the cohort.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between clinical variable and normal/abnormal DMSA scan findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eoverall DMSA scan findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal(n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eabnormal(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.004 \u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;=6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003 \u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVUR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.838 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRecurrent UTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002 \u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCongenital anomaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.284 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\"Statistical analysis was performed using Chi-square test, with a significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\" \u0026ldquo;a Chi-square test. C Significant\u0026rdquo;\u003c/p\u003e \u003cp\u003eInterpretation:\u003c/p\u003e \u003cp\u003eAbnormal DMSA findings were significantly associated with female gender (p\u0026thinsp;=\u0026thinsp;0.004), age\u0026thinsp;\u0026ge;\u0026thinsp;6 years (p\u0026thinsp;=\u0026thinsp;0.003), and a history of recurrent UTI (p\u0026thinsp;=\u0026thinsp;0.002). No significant associations were observed with congenital anomalies (p\u0026thinsp;=\u0026thinsp;0.284) or vesicoureteric reflux (VUR) (p\u0026thinsp;=\u0026thinsp;0.838).\u003c/p\u003e \u003cp\u003eDMSA Scan Findings\u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, 49 patients (49%) demonstrated normal cortical scans, while 51 patients (51%) showed abnormal findings ranging from localized cortical defects to extensive parenchymal involvement [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSignificant associations were observed between abnormal DMSA scan results and female gender (p\u0026thinsp;=\u0026thinsp;0.004), age\u0026thinsp;\u0026ge;\u0026thinsp;6 years (p\u0026thinsp;=\u0026thinsp;0.003), and recurrent urinary tract infection (UTI) (p\u0026thinsp;=\u0026thinsp;0.002) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In contrast, congenital anomalies (p\u0026thinsp;=\u0026thinsp;0.284) and vesicoureteric reflux (VUR) (p\u0026thinsp;=\u0026thinsp;0.838) showed no statistically significant association, differing from some previous reports [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRenal Function Assessment\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the relationship between clinical variables and differential renal function. Forty-five patients (45%) had normal or mildly reduced function, whereas 55 patients (55%) demonstrated significant impairment. Impaired function was significantly associated with female gender (p\u0026thinsp;=\u0026thinsp;0.002), older age (p\u0026thinsp;=\u0026thinsp;0.001), congenital anomalies (p\u0026thinsp;=\u0026thinsp;0.003), and abnormal DMSA scan results (p\u0026thinsp;=\u0026thinsp;0.001) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. No significant association was found between impaired function and VUR (p\u0026thinsp;=\u0026thinsp;0.271) or recurrent UTI (p\u0026thinsp;=\u0026thinsp;0.471).\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\u003eAssociation between clinical variables and differential renal function on DMSA scan\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eFunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal or mildly reduced(45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003esignificant impairment(55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;=6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCongenital anomaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVUR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.271\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRecurrent UTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.471\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eoverall DMSA scan findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eabnormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.001\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\"Statistical analysis was performed using Chi-square test, with a significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\" \u0026ldquo;a Chi-square test. C Significant\u0026rdquo;\u003c/p\u003e \u003cp\u003eInterpretation:\u003c/p\u003e \u003cp\u003eThe data indicate that impaired renal function is significantly associated with female gender (p\u0026thinsp;=\u0026thinsp;0.002), older age (p\u0026thinsp;=\u0026thinsp;0.001), congenital anomalies (p\u0026thinsp;=\u0026thinsp;0.003), and abnormal DMSA scan findings (p\u0026thinsp;=\u0026thinsp;0.001). In contrast, vesicoureteric reflux (VUR) and recurrent urinary tract infections (UTIs) were not significant predictors of functional impairment.\u003c/p\u003e \u003cp\u003eRenal Function:\u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 45 patients (45%) had normal or only mildly reduced function, whereas 55 patients (55%) presented with significant impairment. The variables most strongly linked to functional decline included gender, age, congenital anomalies, and abnormal DMSA findings.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the diagnostic role of Tc-99m DMSA scintigraphy in identifying renal cortical abnormalities and examined the relationship between these findings and clinical as well as demographic characteristics in Pediatric patients.\u003c/p\u003e\n\u003ch3\u003eComparison with Previous Study\u003c/h3\u003e\n\u003cp\u003eThe difference between our study and the previous study due to overall DMSA Scan findings is summarized in Table \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\u003ecomparison Association between clinical variable and normal/abnormal DMSA scan findings in our study and the Institutional study\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\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eOverall DMSA scan findings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitutional study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOur study\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.431\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.153\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrent UTI p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.242\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongenital anomaly p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.698\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.284\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVUR p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.010\u003csup\u003eb.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.838\u003csup\u003ea\u003c/sup\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 \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eChi-square test. \u003csup\u003eb\u003c/sup\u003eFisher\u0026rsquo;s exact test. \u003csup\u003ec\u003c/sup\u003eSignificant p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003ch3\u003eInterpretation:\u003c/h3\u003e\n\u003cp\u003eWhen compared with the earlier institutional review involving 30 Pediatric cases [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], our current, larger dataset revealed stronger and more consistent associations, particularly with gender (p\u0026thinsp;=\u0026thinsp;0.004), age (p\u0026thinsp;=\u0026thinsp;0.003), and recurrent urinary tract infections (p\u0026thinsp;=\u0026thinsp;0.002). The previous study primarily identified vesicoureteric reflux (VUR) as significantly associated with abnormal cortical findings (p\u0026thinsp;=\u0026thinsp;0.010) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This difference is likely attributable to the increased statistical power in the present study, which reduced the likelihood of Type II error and allowed for detection of additional relevant predictors [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe different between our study and the previous study due to Differential renal function is summarized in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between clinical variables and differential renal function on DMSA scan in our study and the Institutional study\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\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDifferential renal function\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstitutional study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOur study\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.389\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.156\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrent UTI p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.471\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongenital anomaly p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.199\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003csup\u003ea.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVUR p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.271\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eoverall DMSA scan findings p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.030\u003csup\u003eb.c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003csup\u003ea.c\u003c/sup\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 \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eChi-square test. \u003csup\u003eb\u003c/sup\u003eFisher\u0026rsquo;s exact test. \u003csup\u003ec\u003c/sup\u003eSignificant p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eInterpretation:\u003c/p\u003e \u003cp\u003eCompared with the earlier institutional review involving 30 Pediatric cases [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], our current, larger dataset revealed stronger and more consistent associations, particularly with gender (p\u0026thinsp;=\u0026thinsp;0.004), age (p\u0026thinsp;=\u0026thinsp;0.003), and recurrent urinary tract infections (p\u0026thinsp;=\u0026thinsp;0.002). The previous study primarily identified vesicoureteric reflux (VUR) as significantly associated with abnormal cortical findings (p\u0026thinsp;=\u0026thinsp;0.010) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This difference is likely attributable to the increased statistical power in the present study, which reduced the likelihood of Type II error and allowed for detection of additional relevant predictors [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings revealed significant associations between abnormal cortical patterns and female gender, older age (\u0026ge;\u0026thinsp;6 years), and recurrent urinary tract infections (UTIs). Previous studies have similarly reported that females are more liable to renal scarring, possibly due to anatomical and microbiological factors that incline them to infection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Age-related variations may be linked to differences in the timing of diagnosis and host immune response [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Recurrent UTIs have long been recognized as a strong risk factor for parenchymal injury, with cumulative damage increasing with each episode [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast to the earlier institutional review [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and several other published reports [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], vesicoureteric reflux (VUR) was not significantly associated with either abnormal cortical uptake or impaired renal function in our cohort. This divergence may reflect differences in case selection, the proportion of high-grade reflux, or overall sample composition. Evidence suggests that high-grade VUR (grades IV\u0026ndash;V) confers a greater risk of renal scarring compared to lower grades [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and the absence of VUR grading in our dataset may have limited further interpretation.\u003c/p\u003e \u003cp\u003eWhen compared with the previous institutional study involving 30 patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], our larger sample (n\u0026thinsp;=\u0026thinsp;100) detected additional significant predictors, including gender, age, and recurrent UTI. The improved statistical power of a larger cohort reduces the risk of Type II errors\u0026mdash;failing to identify real associations due to insufficient sample size [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA strong link between abnormal DMSA findings and reduced renal function was observed, underscoring the dual diagnostic value of DMSA imaging in both structural and functional assessment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This comprehensive capacity allows early identification of kidneys at risk for progressive dysfunction, even in the absence of obvious morphological changes. In the earlier institutional report [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], the smaller cohort may have constrained the ability to assess such multifactorial relationships.\u003c/p\u003e \u003cp\u003eInterestingly, congenital urinary tract anomalies were associated with reduced renal function but not with abnormal cortical images in our study. This supports the concept that some anomalies can impact renal physiology without producing distinct cortical defects detectable via scintigraphy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For instance, obstructive uropathies may lead to functional deterioration prior to visible scarring [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a clinical standpoint, our results highlight the need for closer follow-up in female patients, children over six years of age, and those with recurrent UTIs, even in the absence of documented VUR. While ultrasonography is often preferred initially for its accessibility and lack of radiation exposure, it has lower sensitivity in detecting subtle cortical damage [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Consequently, DMSA scintigraphy remains the imaging method of choice when cortical integrity is in question, despite considerations regarding radiation dose and cost [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThis study\u0026rsquo;s retrospective design and single-center nature may limit the generalizability of results. Furthermore, the reliance on patient records introduces the possibility of incomplete or missing data. The lack of VUR severity grading is another constraint, preventing detailed analysis of reflux grade\u0026ndash;related outcomes. Nevertheless, compared to earlier institutional work [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], the larger sample size in our study enhances the reliability of findings and reduces the risk of missing clinically relevant associations.\u003c/p\u003e \u003cp\u003eFuture Directions\u003c/p\u003e \u003cp\u003eFuture investigations should incorporate standardized cortical grading systems, detailed VUR classification, and extended follow-up to assess the prognostic significance of DMSA-detected abnormalities. Collaborative multicenter studies could also help increase sample diversity and improve the representativeness of results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTc-99m DMSA scintigraphy continues to be a reliable and sensitive imaging modality for detecting renal cortical damage and assessing differential renal function in Pediatric patients [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In our cohort, abnormal DMSA findings were significantly associated with female gender, older age, and recurrent urinary tract infections, while impaired renal function was also linked to congenital urinary tract anomalies. These associations highlight the importance of early recognition and targeted surveillance of high-risk groups to prevent progressive renal injury [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the variability of findings across different studies, further multicenter research with larger and more diverse populations is warranted to validate these associations and refine management strategies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Further multicenter studies with larger and more diverse populations are needed to confirm these associations and guide management strategies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUTI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVUR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evesicoureteric reflux\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCKD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003echronic kidney disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the social science\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTc-99m\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTechnetium \u0026minus;\u0026thinsp;99m\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePACs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePicture Archiving and Communication System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003eI am writing to respectfully request a full waiver of the article processing charge (APC) for our manuscript.​As a self-funded team of early-career researchers, we have conducted this study independently without any external grants or institutional funding. Our work is a result of personal dedication and clinical effort, and we currently do not have the financial capacity to cover publication fees.​Furthermore, as a researcher affiliated with Mansoura University in Egypt, I understand that our institution is part of the Transformative Agreement between Springer Nature and the Science, Technology \u0026amp; Innovation Funding Authority (STDF). This agreement supports corresponding authors from Egyptian institutions by covering APCs for Open Access publishing.​We hope you will consider our financial situation and our eligibility under this national agreement, allowing us to share our findings with the global pediatric radiology community.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eEbrahem wkwk : (Principal Author) Conceptualized the study, developed the software for data management, and performed data curation. He was responsible for drafting the manuscript, creating the tables, and managing the entire research process through to submission.Abdullah: Responsible for the clinical analysis and extraction of diagnostic data. He reviewed patient records to categorize renal findings and clinical variables.Salma: Contributed to data validation and quality control, ensuring the accuracy and consistency of the collected datasets.Aya atef: Conducted the statistical analysis and interpreted the results using appropriate statistical software to determine the significance of the findings.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShaikh N, Morone NE, Bost JE, Farrell MH (2022) Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatrics 150(2):e2021054331\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwerkersson S, Jodal U, Sixt R, Stokland E, Hansson S (2020) Urinary tract infection and vesicoureteral reflux in children. J Urol 204(3):661\u0026ndash;668\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalo J, Ik\u0026auml;heimo R, Tapiainen T, Uhari M (2021) Childhood urinary tract infections as a cause of chronic kidney disease. Pediatr Nephrol 36(2):239\u0026ndash;248\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiepsz A, Blaufox MD, Gordon I et al (2019) Consensus on renal cortical scintigraphy in children with urinary tract infection. Semin Nucl Med 49(1):60\u0026ndash;70\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoorthy I, Wheat D, Gordon I (2020) Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard. Pediatr Nephrol 35(3):475\u0026ndash;481\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGordon I, Bachelard M, Morin L, Piepsz A (2021) Advances in Pediatric renal imaging: morphologic and functional perspectives. Eur J Nucl Med Mol Imaging 48(2):389\u0026ndash;403\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAltman DG, Bland JM (2020) Statistics notes: Absence of evidence is not evidence of absence. BMJ 311(7003):485\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimoes e Silva AC, Silva JM, Diniz JS, Lima EM, Marino VS, Oliveira EA (2020) Risk of hypertension in primary vesicoureteral reflux. Pediatr Nephrol 35(12):2293\u0026ndash;2300\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGulati S, Kher V, Gupta A, Sharma RK (2022) Renal scars and progression to chronic kidney disease. Kidney Int 101(1):45\u0026ndash;57\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatnagar V, Mitra DK, Agarwala S et al (2002) The role of DMSA scans in evaluation of the correlation between urinary tract infection, vesicoureteric reflux, and renal scarring. Pediatr Surg Int 18(2\u0026ndash;3):128\u0026ndash;134\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHewitt IK, Montini G, Peters CA (2020) Age and gender differences in renal scarring risk after urinary tract infection in children. J Urol 204(4):964\u0026ndash;971\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoulthard MG, Lambert HJ, Keir MJ (2019) Occurrence of renal scars in children after their first referral for urinary tract infection. Nephrol Dial Transpl 34(8):1393\u0026ndash;1401\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLassmann M, Treves ST (2017) Pediatric radiopharmaceutical administration: harmonization of the 2016 EANM dosage card (version 1.1) and the 2016 North American consensus guidelines. Eur J Nucl Med Mol Imaging 44(9):1634\u0026ndash;1636\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssadi M, Gholamrezanezhad A, Nabipour I et al (2019) Pediatric renal cortical scintigraphy: guidelines and recommendations for clinical practice. Iran J Nucl Med 27(1):1\u0026ndash;13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl-Khoury H, Harkness BA, Stokland E (2020) SPECT in Pediatric DMSA renal imaging: technical aspects and clinical applications. Clin Nucl Med 45(5):373\u0026ndash;381\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor A Jr, Brandon D, Manatunga A et al (1997) Radionuclide measurement of renal function in children: comparison with creatinine clearance. J Nucl Med 38(5):737\u0026ndash;740\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIBM Corp (2015) IBM SPSS Statistics for Windows, Version 23.0. IBM Corp, Armonk, NY\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHardina S, Nugrahadi T, Budiawan H, Kartamihardja AHS (2024) Renal Cortical Imaging with Tc-99m DMSA in Children: An Institutional Review. World J Nucl Med 23(3):180\u0026ndash;184\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":"renal defect, DMSA scintigraphy, urinary tract infection, vesicoureteric reflux, Pediatric","lastPublishedDoi":"10.21203/rs.3.rs-9020563/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9020563/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Tc-99m DMSA scintigraphy is considered the main standard for detecting renal cortical abnormalities and evaluating differential renal function in children [4, 6]. This study aimed to investigate the prevalence and patterns of abnormal DMSA findings in a pediatric cohort and to analyze their association with clinical and demographic factors.\u003c/p\u003e\n\u003cp\u003eObjective: evaluating the use of DMSA for detecting renal cortical damage and assessing differential renal function in pediatric patients according to age, gender and recurrent urinary tract infections\u003c/p\u003e\n\u003cp\u003eMaterial and Methods: We retrospectively reviewed records of children (≤18 years) who underwent Tc-99m DMSA scans between May 31, 2023, and March 13, 2024. Patients with dysplastic, polycystic, or absent kidneys were excluded [4]. Clinical data and imaging results were analyzed using Chi-square tests, with p \u0026lt; 0.05 considered statistically significant [17].\u003c/p\u003e\n\u003cp\u003eResults: Of the 100 patients (mean age 6.33 years), 49% had normal cortical scans, while 51% showed abnormalities. Abnormal DMSA findings were significantly associated with female gender (p = 0.004), age ≥6 years (p = 0.003), and recurrent urinary tract infection (UTI) (p = 0.002), but not with vesicoureteric reflux (VUR) or congenital anomalies. Significant renal function impairment was linked to female gender (p = 0.002), older age (p = 0.001), congenital anomalies (p = 0.003), and abnormal cortical scans (p = 0.001).\u003c/p\u003e\n\u003cp\u003eConclusion: Tc-99m DMSA scintigraphy provides valuable structural and functional information in pediatric renal assessment. Female gender, older age, and recurrent UTI emerged as key predictors of cortical damage, while impaired function was also associated with congenital anomalies. Early detection and focused follow-up in high-risk groups may help prevent long-term renal sequelae [3, 8, 9].\u003c/p\u003e","manuscriptTitle":"Retrospective Assessment of Cortical Renal Integrity in Pediatric Patients via Tc-99m DMSA Scan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-03 10:36:51","doi":"10.21203/rs.3.rs-9020563/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":"569b2beb-451f-4116-a33d-6b48d36eacd8","owner":[],"postedDate":"April 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T14:11:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-03 10:36:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9020563","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9020563","identity":"rs-9020563","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}