급성 신우신염의 표지자로서 혈청 procalcitonin의 임상적 유용성 = Clinical Usefulness of Serum Procalcitonin as a Biomarker of Acute Pyelonephritis

다국어 초록 (Multilingual Abstract)

Purpose: The clinical usefulness of serum procalcitonin (PCT) was evaluated for the diagnosis of acute pyelonephritis (APN) in infants with urinary tract infections (UTIs).
Methods: A total of 46 infants (between 1 and 12 months of age) were enrolled in this study. Laboratory studies including the WBC count, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and PCT were measured before initiation of intravenous antibiotic treatment and a 99mTc-DMSA renal scan was performed during treatment.
Results: There were no significant differences in the mean age, gender and microorganisms detected between the patients with a lower UTI and those with APN. The duration of fever before and after treatment was significantly longer in the APN group. Except for the WBC count, there was a significantly higher ESR, serum CRP and PCT levels detected in the APN group. Although the serum CRP and PCT showed similar sensitivity and specificity for the diagnosis of APN, simultaneous measurement of the ESR, serum CRP and PCT increased the specificity and accuracy for the diagnosis of APN. Furthermore, only the serum PCT showed a statistically significant difference between the groups with no or only a very mild renal lesion (group 1) and the groups with significant renal lesions (group 2).
Conclusion: The serum PCT combined with the ESR and serum CRP was a helpful marker for the diagnosis of APN. In addition, the serum PCT could be a useful predictor of the severity of renal parenchymal involvement associated with APN.

국문 초록 (Abstract)

목 적: 요로감염은 소아에서 흔한 세균성 감염 중의 하나로, 특히 영아에서 가장 높은 유병율을 보인다. 최근 보고에 의하면 급성 신우신염의 진단에 혈청 procalcitonin (PCT)이 높은 민감도와 특이도를 보여 유용한 비 침습적인 진단적 표지자로 제시되고 있다. 이에 본 연구는 요로감염에서 급성 신우신염을 구분함에 있어 혈청 PCT의 진단적 유용성을 알아보고자 시행되었다.
방 법: 2009년 1월부터 2010년 5월까지 경북대학교병원 소아청소년과에 요로감염을 진단 받고 입원한 생후 1개월에서 12개월 사이의 영아 46명을 대상으로 하였다. 입원 후 정맥용 항생제 투여 전에 말초 혈액 백혈구 수, ESR, 혈청 CRP, 혈청 PCT 수치를 측정하였고 치료 기간 중에 99mTc-DMSA 신스캔을 시행하여 신우신염의 여부를 확인하였다.
결 과: 급성 신우신염군과 하부 요로감염군 사이에 나이, 성별, 소변 배양검사에서 배양되는 균에 따른 유의한 차이는 보이지 않았으나, 입원 전 발열기간과 입원 후 발열기간은 유의한 차이를 보였다. ESR, 혈청 CRP, 혈청 PCT는 급성 신우신염군에서 유의하게 높게 나타났으며, 말초 혈액 백혈구 수는 유의한 차이를 보이지 않았다. 급성 신우신염을 감별하는데 혈청 PCT과 CRP는 거의 동일한 민감도와 특이도를 보였으며 ESR, 혈청 CRP, 혈청 PCT의 동시 측정시 더 높은 특이도와 정확도를 보였다. 심한 급성 신우신염군인 그룹 2에서는 혈청 PCT (cutoff: 1 ng/mL)의 민감도와 특이도가 85.7%와 76.9%로 가장 유의하게 높았다.
결 론: 혈청 PCT은 급성 신우신염을 진단하는데 CRP보다 더 좋은 염증 표지자는 되지 못하나, ESR, 혈청 CRP와 함께 검사시 기존 염증 표지자들의 진단적 정확도와 특이도를 높여 급성 신우신염 진단에 도움이 되며, 급성 신우신염에 의한 신실질 손상 정도를 가장 잘 반영하는 염증 표지자로 생각된다.

참고문헌 (Reference)

1 허미나, "혈액 배양 양성 패혈증 환자에서 프로칼시토닌과 C-반응성 단백의 진단 유용성 비교 분석" 대한진단검사의학회 29 (29): 529-535, 2009

2 이승주, "소아 요로감염의 임상 지침" 대한소아과학회 52 (52): 976-983, 2009

3 김동욱, "소아 상부 요로감염의 진단을 위한혈청 procalcitonin 검사의 유용성" 대한소아과학회 49 (49): 87-92, 2006

4 Craig JC, "Variability in the interpretation of dimercaptosuccinic acid scintigraphy after urinary tract infection in children" 39 : 1428-1432, 1998

5 Bigot S, "Usefulness of procalcitonin for the diagnosis of acute pyelonephritis in children" 12 : 1075-1080, 2005

6 Ginsburg CM, "Urinary tract infections in young infants" 69 : 409-412, 1982

7 Müller B, "Ubiquitous expression of the calcitonin-i gene in multiple tissues in response to sepsis" 86 : 396-404, 2001

8 Rushton HG, "The evaluation of acute pyelonephritis and renal scarring with technetium 99m-dimercaptosuccinic acid renal scintigraphy: evolving concepts and future directions" 11 : 108-120, 1997

9 Cornu C, "Survey of the attitudes to management of acute pyelonephritis in children. GEP" 8 : 275-277, 1994

10 Smellie JM, "Retrospective study of children with renal scarring associated with reflux and urinary infection" 308 : 1193-1196, 1994

11 Gürgöze MK, "Proinflammatory cytokines and procalcitonin in children with acute pyelonephritis" 20 : 1445-1448, 2005

12 Pecile P, "Procalcitonin: a marker of severity of acute pyelonephritis among children" 114 : e249-e254, 2004

13 Gendrel D, "Procalcitonin, a marker of bacterial infection" 25 : 133-134, 1997

14 Benador N, "Procalcitonin is a marker of severity of renal lesions in pyelonephritis" 102 : 1422-1425, 1998

15 Becker KL, "Procalcitonin assay in systemic inflammation, infection, and sepsis: Clinical utility and limitations" 36 : 941-952, 2008

16 van Rossum AM, "Procalcitonin as an early marker of infection in neonates and children" 4 : 620-630, 2004

17 Leroy S, "Procalcitonin as a predictor of vesicoureteral reflux in children with a first febrile urinary tract infection" 115 : e706-e709, 2005

18 Bressan S, "Procalcitonin as a predictor of renal scarring in infants and young children" 24 : 1199-1204, 2009

19 Chan YL, "Procalcitonin as a marker of bacterial infection in the emergency department: an observational study" 8 : R12-R20, 2004

20 Smolkin V, "Procalcitonin as a marker of acute pyelonephritis in infants and children" 17 : 409-412, 2002

21 Pecile P, "Procalcitonin and pyelonephritis in children" 20 : 83-87, 2007

22 Glauser MP, "Prevention of chronic experimental pyelonephritis by suppression of acute suppuration" 61 : 403-407, 1978

23 "Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection" 103 : 843-852, 1999

24 Handmaker H, "Nuclear renal imaging in acute pyelonephritis" 12 : 246-253, 1982

25 Russwurm S, "Molecular aspects and natural source of procalcitonin" 37 : 789-797, 1999

26 Brunkhorst FM, "Kinetics of procalcitonin in iatrogenic sepsis" 24 : 888-889, 1998

27 Tuerlinckx D, "Is procalcitonin a good marker of renal lesion in febrile urinary tract infection?" 164 : 651-652, 2005

28 Patel K, "Intra-and interobserver variability in interpretation of DMSA scans using a set of standardized criteria" 23 : 506-509, 1993

29 Assicot M, "High serum procalcitonin concentrations in patients with sepsis and infection" 341 : 515-518, 1993

30 Winberg J, "Epidemiology of symptomatic urinary tract infection in childhood"

31 Prat C, "Elevated serum procalcitonin values correlate with renal scarring in children with urinary tract infection" 22 : 438-442, 2003

32 Björgvinsson E, "Diagnosis of acute pyelonephritis in children: comparison of sonography and 99mTc-DMSA scintigraphy" 157 : 539-543, 1991

33 Zorc JJ, "Diagnosis and Management of Pediatric Urinary Tract Infections" 18 : 417-422, 2005

34 Jacobson SH, "Development of hypertension and uraemia after pyelonephritis in childhood : 27 year follow up" 299 : 703-706, 1989

35 Camacho V, "DMSA study performed during febrile urinary tract infection: a predictor of patient outcome?" 31 : 862-866, 2004

36 Biggi A, "Acute renal cortical scintigraphy in children with a first urinary tract infection" 16 : 733-738, 2001

37 Roberts KB, "A synopsis of the American Academy of Pediatrics' practice parameter on the diagnosis, treatment, and evaluation of the initail urinary tract infection in febrile infants and young children" 20 : 344-347, 1999