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Abdelhalim A, Khoury AE. Critical appraisal of the top-down approach for vesicoureteral reflux. Investig Clin Urol 2017; 58:S14-S22. [PMID: 28612056 PMCID: PMC5468260 DOI: 10.4111/icu.2017.58.s1.s14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/14/2017] [Indexed: 11/18/2022] Open
Abstract
Vesicoureteral reflux (VUR) has been linked to recurrent urinary tract infections (UTIs), renal scarring, hypertension, renal insufficiency and end-stage kidney disease. Different imaging strategies have been proposed to approach children presenting with UTI to sort out patients with significant VUR while minimizing patient morbidity, radiation exposure and financial burden. None of these imaging strategies is universally accepted. The“top-down approach” (TDA) aims at restricting the number of voiding cystourethrograms (VCUGs) and its associated morbidity while identifying patients with clinically-significant reflux. In this approach, children presenting with febrile UTIs are acutely investigated with dimercapto-succinic acid (DMSA) renal scans to identify patients with renal parenchymal inflammation. Those with evidence of renal affection are offered VCUG and late DMSA scan to identify VUR and permanent renal scarring, respectively. Although TDA could identify clinically-significant VUR with high sensitivity, it is not without limitations. The approach segregates patients based on the presence of DMSA cortical lesions omitting the morbidity and the economic burden of UTI. Additionally, some of DMSA lesions are attributed to congenital dysplasia and unrelated to UTI. Ionizing radiation exposure, financial costs, limited availability of DMSA scans in the acute setting, variability in interpreting the results and low yield of actionable findings on DMSA scans are some other limitations. In this review, we tried to address the drawbacks of the TDA and reinforce the value of patient-centered approach for VUR.
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Affiliation(s)
- Ahmed Abdelhalim
- Department of Urology, University of California, Irvine, Children's Hospital of Orange County, Orange, CA, USA.,Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Antoine E Khoury
- Department of Urology, University of California, Irvine, Children's Hospital of Orange County, Orange, CA, USA
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Prasad MM, Cheng EY. Imaging studies and biomarkers to detect clinically meaningful vesicoureteral reflux. Investig Clin Urol 2017; 58:S23-S31. [PMID: 28612057 PMCID: PMC5468261 DOI: 10.4111/icu.2017.58.s1.s23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/19/2017] [Indexed: 11/26/2022] Open
Abstract
The work-up of a febrile urinary tract infection is generally performed to detect vesicoureteral reflux (VUR) and its possible complications. The imaging modalities most commonly used for this purpose are renal-bladder ultrasound, voiding cystourethrogram and dimercapto-succinic acid scan. These studies each contribute valuable information, but carry individual benefits and limitations that may impact their efficacy. Biochemical markers are not commonly used in pediatric urology to diagnose or differentiate high-risk disease, but this is the emerging frontier, which will hopefully change our approach to VUR in the future. As it becomes more apparent that there is tremendous clinical variation within grades of VUR, the need to distinguish clinically significant from insignificant disease grows. The unfortunate truth about VUR is that recommendations for treatment may be inconsistent. Nuances in clinical decision-making will always exist, but opinions for medical versus surgical intervention should be more standardized, based on risk of injury to the kidney.
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Affiliation(s)
| | - Earl Y Cheng
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Urinary tract infection in small children: the evolution of renal damage over time. Pediatr Nephrol 2017; 32:1907-1913. [PMID: 28681079 PMCID: PMC5579136 DOI: 10.1007/s00467-017-3705-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/01/2017] [Accepted: 05/11/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Our objective was to analyze the evolution of kidney damage over time in small children with urinary tract infection (UTI) and factors associated with progression of renal damage. METHODS From a cohort of 1003 children <2 years of age with first-time UTI, a retrospective analysis of 103 children was done. Children were selected because of renal damage at index 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy at least 3 months after UTI, and a late DMSA scan was performed after at least 2 years. Damage was classified as progression when there was a decline in differential renal function (DRF) by ≥4%, as regression when there was complete or partial resolution of uptake defects. RESULTS Of 103 children, 20 showed progression, 20 regression, and 63 remained unchanged. There were no differences between groups regarding gender or age. In the progression group, 16/20 (80%) children had vesicoureteral reflux (VUR) grade III-V and 13 (65%) had recurrent UTI. In multivariable regression analysis, both VUR grade III-V and recurrent UTI were associated with progression. In the regression group, 16/20 (80%) had no VUR or grade I-II, and two (10%) had recurrent UTI. CONCLUSIONS Most small children with febrile UTI do not develop renal damage and if they do the majority remain unchanged or regress over time. However, up to one-fifth of children with renal damage diagnosed after UTI are at risk of renal deterioration. These children are characterized by the presence of VUR grades III-V and recurrent febrile UTI and may benefit from follow-up.
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Abstract
Vesicoureteral reflux (VUR) is defined as a retrograde flow of urine from the urinary bladder to the kidneys. VUR can lead to renal damage in presence of urinary tract infection. In this case report, we performed prenatal ultrasound diagnosis to identify VUR of a fetus. Furthermore, this VUR case was confirmed by postnatal micturating cystourethrogram (MCUG). Hence, prenatal ultrasound detection of VUR is considered to be useful because it may provide us evidence to design therapeutic strategy to prevent potential renal damage as early as possible.
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Affiliation(s)
- Tao Zhang
- Ultrasound Department, Hubei Provincial Maternal and Child Health Hospital, Wuhan 430070, China
| | - Shali Wu
- Ultrasound Department, Hubei Provincial Maternal and Child Health Hospital, Wuhan 430070, China
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Bush NC, Keays M, Adams C, Mizener K, Pritzker K, Smith W, Traylor J, Villanueva C, Snodgrass WT. Renal damage detected by DMSA, despite normal renal ultrasound, in children with febrile UTI. J Pediatr Urol 2015; 11:126.e1-7. [PMID: 25842992 DOI: 10.1016/j.jpurol.2015.01.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES 2011 American Academy of Pediatrics guidelines recommended renal-bladder ultrasound (RBUS) as the only evaluation after febrile urinary tract infection (FUTI) in infants aged 2-24 months. We determined the sensitivity, specificity, and false negative rate of RBUS to identify DMSA-detected renal damage in this age group as well as in older children. METHODS Consecutive patients referred to pediatric urology with a history of FUTI underwent DMSA ≥ 3 months after FUTI. Abnormal RBUS was defined as: Society of Fetal Urology hydronephrosis grades I-IV; hydroureter ≥ 7 mm; renal scar defined as focal parenchymal thinning; and/or size discrepancy ≥ 1 cm between kidneys. Abnormal DMSA was presence of any focal uptake defects and/or split renal function < 44%. We calculated sensitivity, specificity, positive and negative predictive values, and false negative rates of RBUS compared to DMSA. RESULTS 618 patients (79% female), median age 3.4 years, were referred for FUTIs. Of the 512 (83%) with normal RBUS, 99 (19%) had abnormal DMSA. Children with normal RBUS after their first FUTI had abnormal DMSA in 15/151 (10%) aged ≤ 24 months and 23/119 (19%) aged > 24 months. RBUS had poor sensitivity (34%) and low positive predictive value (47%) to identify patients with renal damage. 99/149 (66%) children with renal damage on DMSA had normal RBUS. CONCLUSION After FUTI, 66% of children with reduced renal function and/or renal cortical defects found by DMSA scintigraphy had a normal RBUS. Since abnormal DMSA may correlate with increased risk for VUR, recurrent FUTI and renal damage, our data suggest RBUS alone will fail to detect a significant proportion of patients at risk. The data suggest that imaging after FUTI should include acute RBUS and delayed DMSA, reserving VCUG for patients with abnormal DMSA and/or recurrent FUTI.
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Affiliation(s)
- N C Bush
- Pediatric & Adult Reconstructive Center for Urology, Dallas, TX, USA.
| | - M Keays
- Children's Hospital of Eastern Ontario, Ottawa, Canada.
| | - C Adams
- University of Texas Southwestern, Dallas, TX, USA
| | - K Mizener
- Pediatric & Adult Reconstructive Center for Urology, Dallas, TX, USA.
| | - K Pritzker
- University of Texas Southwestern, Dallas, TX, USA
| | - W Smith
- University of Texas Southwestern, Dallas, TX, USA
| | - J Traylor
- University of Texas Southwestern, Dallas, TX, USA
| | - C Villanueva
- Children's Hospital and Medical Center, University of Nebraska, Omaha, NE, USA
| | - W T Snodgrass
- Pediatric & Adult Reconstructive Center for Urology, Dallas, TX, USA.
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Prevalence and risk factors for renal scars in children with febrile UTI and/or VUR: a cross-sectional observational study of 565 consecutive patients. J Pediatr Urol 2013; 9:856-63. [PMID: 23465483 PMCID: PMC3770743 DOI: 10.1016/j.jpurol.2012.11.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 11/19/2012] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine prevalence and risk factors for renal scar in children referred for urologic assessment of febrile UTI and/or VUR. METHODS Pre-determined risk factors for renal scar were prospectively recorded in consecutive patients referred for UTI/VUR. Age, gender, VUR grade, and reported number of febrile and non-febrile UTIs were analyzed with logistic regression to determine risk for focal cortical defects on non-acute DMSA. RESULTS Of 565 consecutive children, 24 (4%) had congenital renal dysplasia and 84 (15.5%) had focal defect(s). VUR, especially grades IV-V, recurrent febrile UTI, and older age increased risk. For any age child with the same number of UTIs, VUR increased odds of renal defect 5.4-fold (OR = 5.4, 95% CI = 2.7-10.6, AUC = 0.759). CONCLUSIONS Focal DMSA defects were present in 15.5% of 565 consecutive children referred for febrile UTI and/or VUR; 4% had presumed congenital reflux nephropathy without cortical defect. All VUR grades increased risk for these defects, as did recurrent febrile UTIs and older age. However, 43% with grades IV-V VUR and 76% with recurrent UTI had normal DMSA.
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Radiographic evaluation of children with febrile urinary tract infection: bottom-up, top-down, or none of the above? Adv Urol 2011; 2012:716739. [PMID: 21860620 PMCID: PMC3155794 DOI: 10.1155/2012/716739] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/14/2011] [Indexed: 11/18/2022] Open
Abstract
The proper algorithm for the radiographic evaluation of children with febrile urinary tract infection (FUTI) is hotly debated. Three studies are commonly administered: renal-bladder ultrasound (RUS), voiding cystourethrogram (VCUG), and dimercapto-succinic acid (DMSA) scan. However, the order in which these tests are obtained depends on the methodology followed: bottom-up or top-down. Each strategy carries advantages and disadvantages, and some groups now advocate even less of a workup (none of the above) due to the current controversies about treatment when abnormalities are diagnosed. New technology is available and still under investigation, but it may help to clarify the interplay between vesicoureteral reflux, renal scarring, and dysfunctional elimination in the future.
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Grazioli S, Parvex P, Merlini L, Combescure C, Girardin E. Antenatal and postnatal ultrasound in the evaluation of the risk of vesicoureteral reflux. Pediatr Nephrol 2010; 25:1687-92. [PMID: 20524012 DOI: 10.1007/s00467-010-1543-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 04/15/2010] [Accepted: 04/16/2010] [Indexed: 11/28/2022]
Abstract
Antenatal hydronephrosis (ANH) is a frequent anomaly detected on fetal ultrasound scans. There is no consensus recommendation for the postnatal follow-up and/or the necessity to perform a voiding cystourethrography (VCUG) to diagnose vesicoureteral reflux (VUR). We conducted a cohort/non-randomized trial of 121 patients with ANH, defined as an anterior posterior diameter (APD) >or=5 mm after the 20th week of gestation, to evaluate the ability of the antenatal and postnatal ultrasonography results to predict VUR. All infants had two successive ultrasounds at 5 days and 1 month, respectively, after birth. A VCUG was performed at 6 weeks in children with a persistent APD >or=5 mm and/or an ureteral dilatation observed on at least one of two postnatal ultrasounds. In total, 88 patients had VCUG and nine had VUR, with five having high-grade reflux (>grade II). The risk of VUR increased significantly with the degree of APD detected on the postnatal ultrasound scan (p = 0.03). The odds ratios were 5.0 [95% confidence interval (CI) 0.5-51.2] for APD = 7-9 mm and 9.1 (95% CI 1.0-80.9) for APD >or=10 mm. The results of this study show that among our patient cohort antenatal ultrasound was not predictive of reflux. There was, however, a relation between the importance of the postnatal renal pelvis diameter and the risk of VUR. A cut-off of 7 mm showed a fair ability of ultrasonography to predict VUR and a cut-off of 10 mm enabled all severe refluxes in the 88 patients who had a VCUG to be diagnosed.
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Affiliation(s)
- Serge Grazioli
- Department of Pediatric, Pediatric Nephrology Unit, University Hospital of Geneva, University of Geneva, 6 Willy-Donzé Street, 1211 Geneva, Switzerland
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Steinhardt GF. Editorial comment. J Urol 2010; 184:296-7. [PMID: 20494371 DOI: 10.1016/j.juro.2010.01.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Geelhoed JJM, Taal HR, Steegers EAP, Arends LR, Lequin M, Moll HA, Hofman A, van der Heijden AJ, Jaddoe VWV. Kidney growth curves in healthy children from the third trimester of pregnancy until the age of two years. The Generation R Study. Pediatr Nephrol 2010; 25:289-98. [PMID: 19898876 PMCID: PMC7811527 DOI: 10.1007/s00467-009-1335-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 09/02/2009] [Accepted: 09/16/2009] [Indexed: 11/29/2022]
Abstract
Information about growth of kidney structures in early life is limited. In a population-based prospective cohort study, from foetal life onwards, we constructed reference curves for kidney growth from the third trimester of pregnancy until early childhood, using data from 1,158 healthy children. Kidney size, defined as length, width, depth and volume, was measured in the third trimester of pregnancy and at the postnatal ages of 6 months and 24 months. Analyses were based on more than 2,500 kidney measurements. In the third trimester of pregnancy and at 6 months of age all kidney measurements were larger in boys than in girls. At 24 months of age, these gender differences were only significant for left kidney structures and right kidney length. Both groups showed trends towards smaller left kidney measurements than right kidney measurements at all ages. Gender-specific reference curves based on post-conceptional and postnatal ages were constructed for left and right kidney length, width, depth and volume. We concluded that kidney size is influenced by age and gender. Left kidney size tended to be smaller than right kidney size, except for kidney length. The reference curves can be used for assessing kidney structures by ultrasound in foetal life and early childhood.
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Affiliation(s)
- J. J. Miranda Geelhoed
- The Generation R Study Group (AE-006), Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - H. Rob Taal
- The Generation R Study Group (AE-006), Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Eric A. P. Steegers
- Department of Obstetrics & Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia R. Arends
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Psychology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten Lequin
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Henriëtte A. Moll
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Vincent W. V. Jaddoe
- The Generation R Study Group (AE-006), Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
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Zaffanello M, Cataldi L, Brugnara M, Franchini M, Bruno C, Fanos V. Hidden high-grade vesicoureteral reflux is the main risk factor for chronic renal damage in children under the age of two years with first urinary tract infection. ACTA ACUST UNITED AC 2009; 43:494-500. [DOI: 10.3109/00365590903286663] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Marco Zaffanello
- Department of Mother–Child and Biology–Genetics, University of Verona, Verona, Italy
| | - Luigi Cataldi
- Division of Neonatology, Catholic University of Sacred Heart, Rome, Italy
| | - Milena Brugnara
- Department of Mother–Child and Biology–Genetics, University of Verona, Verona, Italy
| | - Massimo Franchini
- Immunohematology and Transfusion Center, Department of Pathology and Laboratory Medicine, University Hospital of Parma, Parma, Italy
| | - Costanza Bruno
- Department of Morphological–Biomedical Science, University of Verona, Verona, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, University of Cagliari, Cagliari, Italy
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