Dimercaptosuccinic acid (dmsa) scan in unexplained pediatric hypertension with normal ultrasound and renal angiogram

CASE REPORTS

Dimercaptosuccinic acid (DMSA) scan in unexplained pediatric hypertension with normal ultrasound and renal angiogram

Pankaj Venkatrao Deshpande.

Consultant Pediatric Nephrologist, Hinduja hospital, Mahim, Mumbai, India.

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Abstract
Most guidelines, including a recent review suggest blood, urine tests, an ultrasound scan of the kidneys and a renal angiogram if required in children presenting with hypertension. A DMSA scan is recommended if the ultrasound scan shows abnormal kidney/s or there is a history of urine infections.
Two boys aged 14 years and 16 years were diagnosed with hypertension. The work-up for hypertension included blood tests, urine tests, ultrasound scan of the kidneys and a renal angiogram that were all normal. A DMSA (dimercaptosuccinic acid scan) in both boys showed reduced uptake in both kidneys. In the absence of history of urine infections, these represented dysplastic changes.
These cases highlight that in children presenting with unexplained hypertension even in the absence of an abnormal ultrasound or history of urine infections, only a DMSA scan will show abnormal uptake indicating dysplastic changes despite normal renal function and absence of significant proteinuria.

Why this article important?

There is a barrage of tests ordered for children presenting with hypertension. It starts with blood and urine tests and treating doctors are fairly quick to consider doing a renal angiogram for renal artery stenosis. While renovascular hypertension is well known and hence the awareness of doing Ct angiography, management gets stuck when that comes back showing normal arteries with no stenosis. The awareness that Renal dysplasia could have normal ultrasound images of the kidneys is lacking and it is presumed that ultrasound abnormalities will be present when there are functional abnormalities of the kidneys. As shown in these cases, only a DMSA scan can pick up such abnormalities and the cause of hypertension in these children. Hence it is important to make everyone aware that DMSA scan should be done in a child presenting with unexplained hypertension even in the absence of a history of urine infections and the presence of a normal ultrasound scan.

Summary of article

While it is well known that scarring can lead to hypertension in the long term and therefore children with urine infections and vesicoureteral reflux are followed up, the problem is with children presenting with unexplained hypertension. In the cases described, there was no history of urine infections and the ultrasound scan showed normal kidneys. The guidelines for Pediatric hypertension management would therefore not mandate doing a DMSA scan. Both the boys had abnormalities on DMSA in both kidneys suggesting that they were likely dysplastic areas in the kidneys. These children will need regular and close monitoring of renal function apart from control of hypertension. Hence it is important for pediatricians to be aware that a DMSA should be advised even in the absence of a history of urine infections and the presence of a normal ultrasound scan.

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