Pediatric Urology

Comparative Efficacies of Procalcitonin

and Conventional Inflammatory Markers
for Prediction of Renal Parenchymal
Inflammation in Pediatric First Urinary
Tract Infection
Aggeliki Kotoula, Stefanos Gardikis, Aggelos Tsalkidis, Elpis Mantadakis,
Athanassios Zissimopoulos, Savvas Deftereos, Gregorios Tripsianis,
Konstantinos Manolas, Athanassios Chatzimichael, and George Vaos
OBJECTIVES To compare the reliability of procalcitonin (PCT) with conventional laboratory parameters in
predicting for renal parenchymal inflammation (RPI).
METHODS The study cohort consisted of 57 children who were admitted for a first-episode urinary tract
infection. All patients underwent measurement of the leukocyte count, erythrocyte sedimenta-
tion rate (ESR), C-reactive protein (CRP), and serum PCT. RPI was evaluated by technetium-
99m dimercaptosuccinic acid (DMSA) scintigraphy within 7 days of admission. If the first
DMSA findings were abnormal, another analysis was performed 6 months later. The cutoff points
for ESR, CRP, and PCT were established by comparing the areas under their receiver operating
characteristic curves. Statistical analysis was performed using 1-way analysis of variance.
RESULTS Of the 57 children, 27 were diagnosed with RPI on the basis of positive DMSA results. The ESR,
CRP, and PCT levels were significantly greater (P ⬍ .001) in the patients with RPI than in those
without RPI. In contrast, the leukocyte count was the same in both groups (P ⬎ .05). PCT was
a more sensitive and specific marker for differentiating upper and lower urinary tract infection
than ESR and CRP. Persistent lesions at the site of previous RPI were found in 12 patients in
the follow-up DMSA analysis, with total regression evident in the remaining 15. The PCT levels
were significantly greater in those with persistent renal lesions than in those with total regression
(P ⫽ .005).
CONCLUSIONS Serum PCT is a more reliable biologic marker than the ESR, CRP, or leukocyte count for the
early prediction of RPI in children with a first episode of urinary tract infection. In addition, the
greater the elevation of PCT at admission, the more positive the correlation for subsequent
permanent renal damage. UROLOGY 73: 782–786, 2009. © 2009 Elsevier Inc.

U
rinary tract infection (UTI) is frequently en-
countered in children, with a prevalence of
5.3% among febrile infants.1 UTI is especially
common in white girls ⬍2 years old, without a definite
source of fever.2 The nonspecific nature of symptoms
among febrile infants and small children makes it difficult
to clinically differentiate between UTI with renal paren-
chymal inflammation (RPI) and UTI without RPI.1-3
From the Departments of Pediatrics, Pediatric Surgery, Nuclear Medicine, Radiology,
Medical Statistics, and Surgery, Alexandroupolis University Hospital, Democritus
University of Thrace School of Medicine, Alexandroupolis, Greece
Reprint requests: George Vaos, M.D., Ph.D., Department of Pediatric Surgery,
Alexandroupolis University Hospital, Democritus University of Thrace School of Med-
icine, Alexandroupolis 68100 Greece. E-mail: gvaos@med.duth.gr
Submitted: July 2, 2008, accepted (with revisions): October 7, 2008
782 © 2009 Elsevier Inc.
All Rights Reserved
The accurate diagnosis and early treatment of UTI with
RPI is important because of its association with renal
scarring.4,5 Therefore, a rapid and readily available diag-
nostic test would be valuable for the early diagnosis of
RPI, which requires more aggressive therapy than UTI
without RPI and meticulous patient follow-up.
At present, renal scintigraphy with technetium-99m
dimercaptosuccinic acid (DMSA) is considered the ref-
erence standard for the diagnosis of RPI and for assessing
the extent and progression of renal parenchymal dam-
age.6-9 However, factors limiting the widespread use of
DMSA scintigraphy include its cost, limited availability
in several countries, inability in some cases to differen-
tiate between pre-existent scars and acute inflammation,
and the exposure of patients to radiation.
0090-4295/09/$34.00
doi:10.1016/j.urology.2008.10.042
 Procalcitonin (PCT), a 116-amino acid propeptide of
calcitonin that is devoid of hormonal activity, was ini-
tially described as a potential marker of bacterial infec-
tions. PCT is almost undetectable under physiologic con-
ditions (⬍0.5 ng/mL), but it increases to very high levels
in response to bacterial endotoxins, which appears to be
related to the severity of infection. Longitudinal mea-
surements of PCT in patients with bacteremia have
shown that it decreases within 48 hours of the adminis-
tration of antibiotics. In the first 2 days after birth, PCT
can be physiologically elevated without evidence of an
underlying neonatal infection. From the third day on-
ward, the same reference values can applied to both
children and adults.10,11 PCT has been used as a biologic
marker for assessing RPI in patients with UTI, but only a
few published studies have addressed the correlation be-
tween PCT and RPI.12
The aim of this study was to determine the reliabilities
of PCT and conventional laboratory parameters such
as the leukocyte count, erythrocyte sedimentation rate
(ESR), and serum C-reactive protein (CRP) in predict-
ing for RPI in children with a first episode of febrile UTI,
as assessed by DMSA scintigraphy.
MATERIAL AND METHODS
We prospectively studied children who were hospitalized in the
Department of Paediatrics, Alexandroupolis University Hospi-
tal, from September 1, 2006 to December 31, 2007 with a first
episode of proven UTI. In our study, we included only patients
with no history of UTI or previous febrile episodes and without
an obvious site of infection. Urine specimens were obtained mainly
by suprapubic aspiration, urethral catheterization, or midstream
clean-void catching. In 5 patients, the urine specimen was
collected by sterile urine bags (2 successive samples). All urine
samples were cultured using standard microbiologic techniques.
UTI was defined as any growth of a single bacterial pathogen
from suprapubic aspiration or ⬎104 colony-forming units
(CFUs)/mL from a catheterized specimen or ⬎105 CFUs/mL in
samples collected by midstream clean-void urine or urine bags.
In patients with positive urine bag samples, UTI was confirmed
only when the first and the second confirmatory bag samples
were positive.
On admission and before initiating antibiotic treatment, all
patients underwent clinical evaluation and laboratory investi-
gations, including leukocyte count, ESR, serum CRP, and PCT
measurements. The following data were recorded in the clinical
evaluation performed on admission: core temperature and the
presence of vomiting, diarrhea, or decreased oral intake before
admission. To determine the PCT level, 2 mL of blood was
centrifuged, and the serum was separated and assessed using a
rapid, quantitative immunochromatographic test (Brahms Di-
agnostica, Hennigsdorf, Berlin, Germany). The result of the
PCT measurement was obtained within approximately 2 hours
after taking the blood sample.
DMSA scintigraphy was performed within 7 days of the
confirmed UTI diagnosis. DMSA studies with a gamma camera
(Millenium MPR; General Electric, Milwaukee, Wisconsin)
were performed 4 hours after the intravenous injection of an
age-adjusted dose of technetium-DMSA (range 40-100 MBq).
Renal pathologic findings were defined by scintigraphy as focal
UROLOGY 73 (4), 2009
or multifocal perfusion defects or a diffuse decrease in, or
absence of, DMSA uptake. For DMSA grading, we slightly
modified the score system initially described by Benador et al.13
by using the following 4 scores based on describing DMSA renal
lesions as positive when they covered ⬎4% of the surface area,
which corresponds to the minimal affected area that DMSA
can be detected with certainty according to our criteria: 0,
absence of lesion; 1, defect covering 4%-10%; 2, defect cover-
ing 10%-30%; and 3, defect covering ⬎30%. If the first DMSA
outcome was abnormal, another analysis was performed 6
months later, and the diagnosis of UTI with RPI was confirmed
only in children with lesions that had at least partially re-
gressed. Therefore, all renal lesions on the first scans repre-
sented RPI rather than pre-existing lesions. Moreover, accord-
ing to the recommended guidelines, a renal ultrasound scan was
obtained within 48 hours of diagnosis, and voiding cystoure-
thrography (VCUG) was performed after 4-5 weeks of UTI
treatment when the urine specimen was sterile. The hospital
ethics committee approved the study, and the parents of all
participating children provided written or oral consent.
The quantitative variables are expressed as the median and
range. Qualitative variables are expressed as frequencies and
percentages. Statistical significance was determined using the
Mann-Whitney U test, ␹2 test, and Fisher’s exact test, as
appropriate. The area under the receiver operating characteris-
tics (ROC) curve was calculated to evaluate the diagnostic
significance of the tested parameters. All tests were 2 tailed, and
statistical significance was set at P ⬍ .05. All statistical analyses
were performed using the Statistical Package for Social Sci-
ences, version 13.0 (SPSS, Chicago, IL).
RESULTS
A total of 57 children, 14 boys and 43 girls, with a
median age of 12 months (range 2-108) were consecu-
tively enrolled in the study. Of the 57 children, 27 (21
girls and 6 boys, median age 11 months, range 3-108)
were diagnosed with UTI and RPI on the basis of positive
renal scintigraphy results, with a score of 1-3 (group 1).
The remaining 30 children (22 girls and 8 boys, median
age 17.5 months, range 2-105) had normal scintigraphy
results (score 0) and thus were considered to have UTI
without RPI (group 2). Most of the patients in both
groups were girls. Some clinical symptoms identified dur-
ing history taking on admission, such as a history of
diarrhea and poor oral intake, were more common in
group 1. The body temperature was ⱖ38°C in all patients
in group 1 and in 21 of the 30 patients in group 2. Of the
57 children, 35, 7, 7, and 8 were aged ⱕ15, 16-30, 31-48,
and ⬎48 months, respectively. Of the children ⱕ15
months old, 20 were in group 1.
Of the 27 children in group 1, 8, 9, and 10 had a score
of 1, 2, and 3, respectively. The median PCT levels
increased significantly with the extent of RPI (P ⫽ .004).
Patients with lesions scored as 1, 2, and 3 on DMSA
analysis had a median PCT level of 1.6 ng/mL (range
0.7-5.2), 2.0 ng/mL (range 1.5-7.2), and 11.2 ng/mL
(range 4.2-13.2), respectively.
Compared with group 2, the median leukocyte count
on admission was marginally elevated in group 1 (12 750
vs 19 000/␮L, P ⫽ .056), and the median ESR, serum
783
 1,0
0,8
Sensitivity
0,6
0,4
PCT
0,2 CRP
ESR
Reference Line
0,0
0,0 0,2 0,4 0,6 0,8
1 - Specificity
Figure 1. Receiver operating characteristic curve for
specificity and sensitivity of PCT (procalcitonin), CRP (C-
reactive protein), and ESR (erythrocyte sedimentation
rate) measurements.
CRP, and serum PCT levels were significantly greater in
group 1 (17.5 vs 40.0 mm/h, P ⬍ .001; 0.5 vs 9.0 mg/dL,
P ⬍ .001; and 0.3 vs 4.8 ng/mL, P ⬍ .001, respectively).
The ROC curves for the sensitivity and specificity of
the ESR, CRP, and PCT measurements are shown in Fig.
1. The median area under the ROC curve was 0.883 for
ESR (95% confidence interval [CI] 0.797-0.969, P ⬍
.001), 0.957 for CRP (95% CI 0.914-1.000, P ⬍ .001),
and 0.988 for PCT (95% CI 0.969-1.000, P ⬍ .001). The
characteristics of the ESR, CRP, and PCT measurements
for predicting UTI with RPI are summarized in Table 1.
A combined analysis of PCT and CRP revealed that the
simultaneous presence of a PCT level of ⱖ0.85 ng/mL
and CRP level of ⱖ3.50 mg/dL had a sensitivity of 78%
(95% CI 57%-91%), specificity of 100% (95% CI 88%-
100%), positive predictive value of 100%, negative pre-
dictive value of 83%, and an accuracy of 89.5% (51 of 57
patients) in predicting for RPI.
Of the 27 children in group 1, 15 had abnormal renal
ultrasound findings suggestive RPI. Only 51 of the chil-
dren underwent VCUG at 4-5 weeks after the first man-
ifestation of UTI; 6 patients in group 2 did not undergo
VCUG because their parents refused permission. Of
these 51 children, 14 had vesicoureteral reflux (VUR).
Of the 14 children, 8 were in group 1, and of these 8
children, 2, 3, and 3 had a VUR grade of 3, 4, and 5,
respectively, with 1 of the patients with VUR grade 4
also having ureteral duplication. The remaining 6 pa-
tients with VUR were in group 2, and 1, 3, and 2 had
grade VUR 1, 2, and 3, respectively.
The median PCT levels did not differ in the patients in
group 1 with or without VUR (2.0 ng/mL, range 1.2-11.4,
vs 2.0 ng/mL, range 0.7-13.0 ng/mL; P ⫽ 1.000) or
784
between the 2 groups when stratified by the presence of
VUR (29.6% vs 25.0%, P ⫽ .7120.5).
All children in group 1 underwent follow-up renal
DMSA scanning 6 months later. Persistent lesions and
total regression at the site of previous RPI was evident in
12 (44.5%) and 15 patients, respectively. Of the 12
patients with a persistent lesion, 1, 3, and 8 had had a
score of 1, 2, and 3, respectively, on the first DMSA scan,
with an overall median PCT level at admission of 10.4
ng/mL (range 1.6-13.0). Additionally, persistent lesions
were found in 1 of 8 (12.5%), 3 of 9 (33.3%), and 8 of 10
(80.0%) patients with a score of 1, 2, and 3 on the first
DMSA scan, respectively. The incidence of persistent
lesions tended to increase as the initial DMSA score
increased (P for linear trend ⫽ .004). Of the 15 children
with normal follow-up DMSA results, 7, 6, and 2 had a
score of 1, 2, and 3 on the initial DMSA scan, respec-
1,0
tively, with a median PCT level of 1.9 ng/mL (range
0.7-10.0). Moreover, 5 of the 12 patients with persistent
lesions and 3 of the 15 patients with total regression had
VUR. No statistically significant difference was found in
the incidence of persistent lesions in patients who had
VUR (5/12; 41.7%) vs patients with no VUR (7/12;
58.3%; P ⫽ .414). The PCT level was significantly
greater in the patients with persistent renal lesions than
in those with total regression (P ⫽ .005). The PCT level
tended to be greater in patients with VUR and persistent
lesions (median 7.2 ng/mL, range 1.6 –11.4) than in those
with VUR and total regression (median 4.8 ng/mL, range
1.2-5.0), but the difference was not statistically signifi-
cant (P ⫽ .297). Moreover, the PCT level was signifi-
cantly greater in children with persistent lesions and
VUR than those with persistent lesions, without VUR
(median 12.0 ng/mL, range 11.3-13.2, vs median 4.2
ng/mL, range 1.6-11.7; P ⫽ .012).
COMMENT
The early diagnosis of RPI is challenging in the absence
of specific symptoms, particularly during infancy.1-3 It is
necessary to be able to distinguish between UTI with and
without RPI, because RPI can induce permanent renal
scarring, which can lead to arterial hypertension and
chronic renal failure.4,5 Therefore, the accurate diagnosis
of RPI and its early treatment is important. Although
RPI is frequently referred to as acute pyelonephritis, we
refrain from using this term because it is a clinical de-
scription that cannot be accurately applied to infants or
young children.
DMSA scintigraphy performed during the acute phase
of infection is very sensitive in assessing RPI.10 In an
experimental refluxing piglet model, DMSA was com-
pared with the histologic proof of RPI. DMSA scanning
was found to be highly sensitive and reliable for the
detection and localization of experimental acute pyelo-
nephritis, with a sensitivity of 87%-89% and specificity of
100%.7-9 However, scintigraphy might not differentiate
old scarring from acute RPI unless follow-up DMSA
UROLOGY 73 (4), 2009
Table 1. Characteristics of ESR, CRP, and PCT measurements for prediction of renal parenchymal involvement
Variable Sensitivity (%) Specificity (%) PPV (%) NPV (%) Overall Agreement Kappa P Value
ESR (mm/h)
ⱖ25 100 (87-100) 70 (51-85) 75 100 84.2 0.689 ⬍ .001
ⱖ30 85 (66-95) 73 (54-87) 74 85 79 0.581 ⬍ .001
ⱖ35 67 (46-83) 87 (69-96) 82 74 77.2 0.538 ⬍ .001
ⱖ75 33 (17-54) 100 (88-100) 100 63 68.4 0.345 .001
CRP (mg/dL)
ⱖ1.85 100 (87-100) 70 (51-85) 75 100 84.2 0.689 ⬍ .001
ⱖ3.50 81 (61-93) 90 (72-97) 88 84 85.9 0.717 ⬍ .001
ⱖ6.60 74 (54-88) 100 (88-100) 100 81 87.7 0.750 ⬍ .001
PCT (ng/mL)
ⱖ0.50 100 (87-100) 83 (65-94) 84 100 91.2 0.826 ⬍ .001
ⱖ0.85 89 (70-97) 97 (81-100) 96 91 92.9 0.859 ⬍ .001
ⱖ1.20 85 (65-95) 100 (88-100) 100 88 93 0.858 ⬍ .001
PPV, positive predictive value; NPV, negative predictive value; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; PCT,
procalcitonin.
Data in parentheses are ranges.

scanning is performed. In the present study, renal lesions
of varying degrees were observed using DMSA scintigra-
phy in 47.5% of children with a first episode of UTI in
the acute phase. Most of these children with presumed
RPI were girls. The overall prevalence of RPI in our study
and its greater incidence in girls are in agreement with
the available published data.4
In our study, leukocytosis was more prominent in chil-
dren with RPI, although this did not reach statistical signif-
icance. In contrast, the ESR was significantly greater in
group 1 than in group 2. However, using the ESR as a
possible marker of RPI was inadequate, because all the
calculated statistical parameters were ⬍80% for the 4
cutoff values tested. The biochemical markers CRP and
PCT correlated well with abnormal DMSA results. More
specifically, 3 of the CRP cutoff values produced reason-
able sensitivity, specificity, and positive and negative
predictive values, with a cutoff of 3.5 mg/dL being the
best (values ⬎80% for all statistical parameters). Using
cutoff values of 0.5, 0.85, and 1.2 ng/mL for PCT showed
excellent sensitivity, specificity, positive predictive val-
ues, and negative predictive values, with a cutoff value of
0.85 ng/mL producing the best performance (values
⬎90% for all statistical parameters). PCT was superior
to CRP as an indicator of RPI, because the ROC curve
for specificity and sensitivity was greater for PCT than for
CRP. Moreover, combining the greatest cutoff values for
PCT and CRP was not superior to PCT alone in predict-
ing for RPI.
Our data are in agreement with those of previous
studies showing that RPI is indicated better by PCT than
by CRP,12 although in our study, CRP performed better
than in the published studies. Furthermore, our results
suggest that PCT is a reliable marker for detecting RPI
during UTI in children. However, 2 studies found that
PCT was not a sensitive and specific measure for the early
diagnosis of RPI.14,15 We believe that our method is more
clearly defined than the method used in those 2 studies.
That our results were different was likely a result of age
and sex differences in the populations studied and also
likely a result of the different definitions used for UTI and
PRI.16 Finally, our results are in agreement with the vast
majority of published reports,13,17-22 which are also in-
congruent with the results of those 2 studies.14,15
Renal ultrasonography was performed by a senior pe-
diatric radiologist at the first 48 hours of admission to
exclude any renal dysplastic formation.23 Abnormal renal
ultrasound results were detected in 55.6% of our patients
with RPI. These results are comparable to the published
data showing that renal ultrasonography is relatively in-
sensitive for documenting RPI.24 We found VUR in
27.4% of our patients, and its prevalence did not differ
significantly between the 2 groups. These results are in
accordance with VUR not being a prerequisite for PRI in
children with UTI.25,26 Nevertheless, the VUR grades
were more severe in group 1 than in group 2. The PCT
levels did not differ significantly between the patients in
group 1 with or without VUR, consistent with 2 previous
reports,12,19 but a tendency was seen toward greater PCT
levels in patients with VUR and persistent lesions com-
pared with patients with VUR and the total regression of
lesions. The absence of statistical significance in this
tendency might have been because of the small numbers
of patients. In addition, the median PCT level was sig-
nificantly greater in patients with VUR and persistent
lesions than in those without VUR and persistent lesions.
In the present study, we also found a significant relation-
ship between elevated PCT levels and the severity of RPI,
with a positive correlation for consequent permanent renal
lesions, in agreement with previous studies.12,17,20 Thus,
PCT can be a helpful tool in identifying the patients who
are more prone to renal scarring and deciding the appropri-
ate management.12,27 Therefore, our results suggest that
elevated PCT levels in a patient with febrile UTI could be
used as an indicator for selecting which patients with a first
episode of febrile UTI actually require additional evaluation
with VCUG and/or DMSA scanning. Additional and well-
designed prospective studies, including those involving
larger cohorts, should be performed to test this hypothesis.

UROLOGY 73 (4), 2009 785

CONCLUSIONS
The results of this study, although limited because of the
small number of patients, suggest that PCT is a reliable
biologic marker for predicting for RPI in a first episode of
UTI in infants and children and exhibits greater sensitivity
and specificity than CRP and ESR. In addition, the greater
the elevation of PCT at admission, the more positive the
correlation for subsequent permanent renal damage. Addi-
tional studies are necessary to clarify the optimal PCT cutoff
in children with UTI and to delineate the relationship
between the PCT level and the severity of renal damage and
the probability of subsequent renal scarring.
References
1. Hoberman A, Chao HP, Keller DM, et al. Prevalence of urinary
tract infection in febrile infants. J Pediatr. 1993;123:17-23.
2. Shaw KN, Gorelick M, McGowan KL, et al. Prevalence of urinary
tract infection in febrile young children in the emergency depart-
ment. Pediatrics. 1998;102:16-20.
3. Hoberman A, Wald ER. Urinary tract infections in young febrile
children. Pediatr Infect Dis J. 1997;16:11-17.
4. Lin KY, Chiu NT, Chen MJ, et al. Acute pyelonephritis and
sequelae of renal scar in pediatric first febrile urinary tract infection.
Pediatr Nephrol. 2003;18:362-365.
5. Jakobsson B, Berg U, Svensson L. Renal scarring after acute pye-
lonephritis. Arch Dis Child. 1994;70:111-115.
6. Rushton HG. The evaluation of acute pyelonephritis and renal
scarring with technetium 99m-dimercaptosuccinic acid renal scin-
tigraphy: evolving concepts and future directions. Pediatr Nephrol.
1997;11:108-120.
7. Rushton HG, Majd M, Chandra R, et al. Evaluation of 99m
technetium-dimercaptosuccinic acid renal scans in experimental
acute pyelonephritis in piglets. J Urol. 1988;140:1169-1174.
8. Parkhouse HF, Godley ML, Cooper J, et al. Renal imaging with
99m
Tc-labelled DMSA in the detection of acute pyelonephritis: an
experimental study in the pig. Nucl Med Commun. 1989;10:63-70.
9. Majd M, Nussbaum-Blask AR, Markle BM, et al. Acute pyelone-
phritis: comparison of diagnosis with 99mTc-DMSA SPECT, spiral
CT, MR imaging, and power Doppler US in an experimental pig
model. Radiology. 2001;218:101-108.
10. van Rossum AM, Wulkan RW, Oudesluys-Murphy AM. Procalci-
tonin as an early marker of infection in neonates and children.
Lancet Infect Dis. 2004;4:620-630.
11. Hatherill M, Tibby SM, Sykes K, et al. Diagnostic markers of
infection: comparison of procalcitonin with C reactive protein and
leukocyte count. Arch Dis Child. 1999;81:417-421.
786
12. Pecile P, Romanello C. Procalcitonin and pyelonephritis in chil-
dren. Curr Opin Infect Dis. 2007;20:83-872.
13. Benador N, Siegrist CA, Gendrel D, et al. Procalcitonin is a marker
of severity of renal lesions in pyelonephritis. Pediatrics. 1998;102:
1422-1425.
14. Tuerlinckx D, Vander Borght T, Glupczynski Y, et al. Is procalci-
tonin a good marker of renal lesion in febrile urinary tract infec-
tion? Eur J Pediatr. 2005;164:651-652.
15. Guven AG, Kazdal HZ, Koyun M, et al. Accurate diagnosis of
acute pyelonephritis: how helpful is procalcitonin? Nucl Med Com-
mun. 2006;27:715-721.
16. Repetto HA, Alarcon PA, Pellegrini M. Procalcitonin as a marker
of acute pyelonephritis. Pediatr Nephrol. 2003;18:726.
17. Gervaix A, Galetto-Lacour A, Gueron T, et al. Usefulness of
procalcitonin and C-reactive protein rapid tests for the manage-
ment of children with urinary tract infection. Pediatr Infect Dis J.
2001;20:507-511.
18. Smolkin V, Koren A, Raz R, et al. Procalcitonin as a marker of
acute pyelonephritis in infants and children. Pediatr Nephrol. 2002;
17:409-412.
19. Prat C, Dominguez J, Rodrigo C, et al. Elevated serum procalcito-
nin values correlate with renal scarring in children with urinary
tract infection. Pediatr Infect Dis J. 2003;22:438-442.
20. Pecile P, Miorin E, Romanello C, et al. Procalcitonin: a marker of
severity of acute pyelonephritis among children. Pediatrics. 2004;
114:249-254.
21. Bigot S, Leblond P, Foucher C, et al. Usefulness of procalcitonin
for the diagnosis of acute pyelonephritis in children. Arch Pediatr.
2005;12:1075-1080.
22. Gurgoze MK, Akarsu S, Yilmaz E, et al. Proinflammatory cytokines
and procalcitonin in children with acute pyelonephritis. Pediatr
Nephrol. 2004;20:1445-1448.
23. Joseph VT. The management of renal condition in the perinatal
period. Early Hum Dev. 2006;82:313-324.
24. Wang YT, Chiu NT, Chen MJ, et al. Correlation of renal ultra-
sonographic findings with inflammatory volume from dimercapto-
succinic acid renal scans in children with acute pyelonephritis.
J Urol. 2005;173:190-194.
25. Elison BS, Taylor D, Van der Wall H, et al. Comparison of DMSA
scintigraphy with intravenous urography for the detection of renal
scarring and its correlation with vesicoureteric reflux. Br J Urol.
1992;69:294-302.
26. Scherz HC, Downs TM, Caesar R. The selective use of dimercap-
tosuccinic acid renal scans in children with vesicoureteral reflux.
J Urol. 1994;152:628-631.
27. Leroy S, Adamsbaum C, Marc E, et al. Procalcitonin as a predictor
of vesicoureteral reflux in children with a first febrile urinary tract
infection. Pediatrics. 2005;115:706-709.
UROLOGY 73 (4), 2009