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Saraga M, Saraga-Babić M, Arapović A, Vukojević K, Pogorelić Z, Simičić Majce A. The Intrarenal Reflux Diagnosed by Contrast-Enhanced Voiding Urosonography (ceVUS): A Reason for the Reclassification of Vesicoureteral Reflux and New Therapeutic Approach? Biomedicines 2024; 12:1015. [PMID: 38790977 PMCID: PMC11117776 DOI: 10.3390/biomedicines12051015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Vesicoureteral reflux (VUR) is defined as the urine backflow from the urinary bladder to the pyelo-caliceal system. In contrast, intrarenal reflux (IRR) is the backflow of urine from the renal calyces into the tubulointerstitial space. VURs, particularly those associated with IRR can result in reflux nephropathy when accompanied by urinary tract infection (UTI). The prevalence of IRR in patients with diagnosed VUR is 1-11% when using voiding cystourethrography (VCUG), while 11.9-61% when applying the contrast-enhanced voiding urosonography (ceVUS). The presence of IRR diagnosed by VCUG often correlates with parenchymal scars, when diagnosed by a 99mTc dimercaptosuccinic acid scan (DMSA scan), mostly in kidneys with high-grade VURs, and when diagnosed by ceVUS, it correlates with the wide spectrum of parenchymal changes on DMSA scan. The study performed by both ceVUS and DMSA scans showed IRRs associated with non-dilated VURs in 21% of all detected VURs. A significant difference regarding the existence of parenchymal damage was disclosed between the IRR-associated and IRR-non-associated VURs. A higher portion of parenchymal changes existed in the IRR-associated VURs, regardless of the VUR grade. That means that kidneys with IRR-associated VURs represent the high-risk group of VURs, which must be considered in the future classification of VURs. When using ceVUS, 62% of places where IRR was found were still unaffected by parenchymal changes. That was the basis for our recommendation of preventive use of long-term antibiotic prophylaxis until the IRR disappearance, regardless of the VUR grade. We propose a new classification of VURs using the ceVUS method, in which each VUR grade is subdivided based on the presence of an IRR.
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Affiliation(s)
- Marijan Saraga
- School of Medicine, University of Split, 21000 Split, Croatia; (Z.P.)
| | - Mirna Saraga-Babić
- Department of Anatomy, Histology and Embryology, School of Medicine, University of Split, 21000 Split, Croatia;
| | - Adela Arapović
- Department of Pediatric, University Hospital of Split, 21000 Split, Croatia; (A.A.); (A.S.M.)
| | - Katarina Vukojević
- Department of Anatomy, Histology and Embryology, School of Medicine, University of Split, 21000 Split, Croatia;
| | - Zenon Pogorelić
- School of Medicine, University of Split, 21000 Split, Croatia; (Z.P.)
- Department of Pediatric Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Ana Simičić Majce
- Department of Pediatric, University Hospital of Split, 21000 Split, Croatia; (A.A.); (A.S.M.)
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Ansari MS, Banthia R, Jain S, Kaushik VN, Danish N, Yadav P. Long term outcomes of Cohen’s cross trigonal reimplantation for primary vesicoureteral reflux in poorly functioning kidney. World J Clin Cases 2023; 11:3750-3755. [PMID: 37383119 PMCID: PMC10294151 DOI: 10.12998/wjcc.v11.i16.3750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/19/2023] [Accepted: 05/06/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Open ureteric reimplantation by cross trigonal technique described by Cohen is considered a common surgical option for correction of vesicoureteral reflux (VUR). There is a lack of evidence in literature though for what happens to such kidneys, in the long run, particularly those which are poorly functioning.
AIM To assess the long-term outcomes of ureteric reimplantation in poorly functioning kidneys in children with unilateral primary VUR.
METHODS Children with unilateral primary VUR and a relative renal function of less than 35% who underwent open or laparoscopic ureteric reimplantation between January 2005 and January 2017 were included in the study. Patients who had a follow up of less than five years were excluded. Preoperative evaluation consisted of a voiding cystourethrogram and Dimercaptosuccinic acid (DMSA) scan. In the follow-up period, patients underwent a diuretic scan at 6 weeks and 6 months. Follow up ultrasound was done for change in grade of hydronephrosis and retrovesical ureteric diameter. Subsequent follow up was done at 6 monthly intervals with evaluation for proteinuria and hypertension and any recurrent urinary tract infection (UTI). For assessment of cortical function, DMSA was repeated annually for 5 years after surgery. A paired-samples t-test was used to test the mean difference of DMSA between pre-post observations.
RESULTS During this period, 36 children underwent ureteric reimplantation for unilateral primary VUR. After excluding those with insufficient follow-up, 31 were included in the analysis. Most of the patients were males (n = 26/31, 83.8%). Patient’s age (mean ± SD, range) was 5.21 ± 3.71, 1-18 years. The grades of VUR were grade II (1 patient), grade III (8 patients), grade IV (10 patients), and grade V (12 patients). The pre and postoperative DMSA was 24.064 ± 12.02 and 24.06 ± 10.93, which was almost the same (statistically equal, paired-samples t-test: P = 0.873). The median (range) follow-up duration was 82 (60-120) mo. One patient had persistent reflux after surgery (preoperative: grade IV, postoperative: grade III), and the very same patient developed recurrent UTI. The difference in the preoperative and postoperative DRF was less than 10% in 29 patients. In one patient, the DRF decreased by 17% (22% to 05%) while in another patient, the DRF increased by 12% (25% to 37%) after surgery. None of the patients had an increase in scarring after surgery. 15% of patients were hypertensive before surgery and all of them continued to be hypertensive after surgery while none developed hypertension after surgery. None of the patients had significant proteinuria (> 150 mg/d) during the follow-up period.
CONCLUSION Children with unilateral primary VUR and poorly functioning kidney maintain the renal function over the long term in most cases. Hypertension and proteinuria do not progress over time in these patients.
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Affiliation(s)
- Mohd Sualeh Ansari
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Ravi Banthia
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Shrey Jain
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Vinay N Kaushik
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Nayab Danish
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Priyank Yadav
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Dhua AK, Anand S, Goel P, Yadav DK, Jain V, Verma A. Publication landscape of Posterior urethral valve- A scientometric study. J Pediatr Urol 2022; 18:650-660. [PMID: 36167650 DOI: 10.1016/j.jpurol.2022.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 12/14/2022]
Abstract
UNLABELLED To assess the global research landscape in the field of Posterior urethral valve (PUV), a scientometric study was conducted to determine the quantity and quality of the research output and get insight into the key research areas and pattern of collaboration in the research community. METHODS Primary data was acquired from the Scopus® database. Various parameters like the total research productivity, citations, citations per publication, citations per year, citations per publication per year, the scientific output of countries, institutions, authors, and journals were calculated. Key research areas were inferred by examining the top-cited articles (citations >150). Collaborative maps were generated by calculating co-authorship links amongst countries and authors using VOSviewer software. RESULTS One thousand seven hundred fourteen results were found published from 1913 to 2019, receiving a total of 27,253 citations, authored by 5138 authors from 125 countries. The top three countries were the United States of America (USA), India, and the United Kingdom (UK). The leading institutes were the Children's Hospital Boston, USA (n = 48), All India Institute of Medical Sciences (AIIMS, Delhi), India (n = 38), and Great Ormond Street Hospital, UK (n- = 27). The journals which published the most articles on PUV were the Journal of Urology (n = 278), Journal of Pediatric Urology (n = 121), followed by Urology (n = 86). Leading authors were Glassberg, K. L and Bajpai M (n = 17, each), Canning DA & Kajbafzadeh, AM (n = 16, each), followed by Peters CA with 14 manuscripts. The top-cited documents (n = 10) received 2104 citations and were published between 1986 and 2010. The key areas of interest found were "long-term outcomes" (n = 4) and "fetal surgery" (n = 2). The most productive countries were also the most collaborative countries (the USA and UK). CONCLUSION In the research landscape of PUV, the USA, Children's Hospital Boston, and Glassberg, K. L, along with Bajpai, M were the top contributors in terms of the country, organization, and authors, respectively. The "Journal of Urology" and "Pediatric Nephrology" stands out in terms of bibliometric parameters considered. The hotspot topics based on the number of citations received were "long-term outcomes" and "fetal surgery" in PUV. The most productive countries were also the most collaborative countries (the USA and UK).
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Correlation of Renal Scarring to Urinary Tract Infections and Vesicoureteral Reflux in Children. Adv Urol 2022; 2022:9697931. [PMID: 35529476 PMCID: PMC9072046 DOI: 10.1155/2022/9697931] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To study the association of the grade of vesicoureteral reflux (VUR) and urinary tract infections (UTI) with renal scarring at the first clinical presentation of patients who underwent antireflux surgery. Materials and methods. Between 2015 and 2020, 150 patients (194 units) who underwent antireflux surgery had dimercaptosuccinic acid (DMSA) renal scans preoperatively. Patients were classified into the nonscar and scar groups according to DMSA scan results. Moreover, cases were classified into afebrile UTI, febrile UTI, and antenatal hydronephrosis (ANH) according to the mode of presentation. We correlated the mode of presentation and the grade of VUR to the presence/absence of renal scars in both groups. Results The mean follow-up was 45 months preoperatively. The mode of presentation was afebrile, febrile UTIs, and antenatal hydronephrosis in (50, 14), (20, 46), and (10, 10) patients in the nonscar and scar groups, respectively. Of the 20 patients who presented ANH, 10 (50%) had scars. Clinical presentation was correlated to the presence of renal scarring and its degree. The scar group had significantly higher grades of VUR than the nonscar group (grades I–II (50 units versus 10 units), grade III (28 units versus 40 units), and grade IV–V (22 units versus 44 units) for the nonscar versus scar groups, respectively (pvalue <0.001). Conclusion Renal scarring is associated with higher grades of reflux and urinary tract infections. We advocate further research investigating infants who had UTIs with or without fever for early detection of reflux.
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Werbel K, Jankowska D, Wasilewska A, Taranta-Janusz K. Clinical and Epidemiological Analysis of Children's Urinary Tract Infections in Accordance with Antibiotic Resistance Patterns of Pathogens. J Clin Med 2021; 10:jcm10225260. [PMID: 34830542 PMCID: PMC8619446 DOI: 10.3390/jcm10225260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/03/2021] [Accepted: 11/10/2021] [Indexed: 12/02/2022] Open
Abstract
The study was conducted to analyze urinary tract infections (UTI) in children by considering epidemiology and antibiotic resistance patterns of pathogens in accordance with inflammatory parameters. The research included 525 patients who demonstrated 627 episodes of UTI. The increasing resistance of bacteria was observed over the years covered by the study (p < 0.001). There was a significant increase of resistance to amoxicillin with clavulanic acid (p = 0.001), gentamicin (p = 0.017) and ceftazidime (p = 0.0005). According to the CART method, we managed to estimate C-reactive protein (CRP), procalcitonin (PCT) and white blood cell (WBC) values, in which antibiotic sensitivity was observed. In children with CRP > 97.91 mg/L, there was a high percentage of sensitive cases to amoxicillin with clavulanic acid (87.5%). Values of WBC above 14.45 K/µL were associated with E. coli more sensitivity to ampicillin. 100% of children with CRP > 0.42 mg/L and PCT ≤ 6.92 ng/mL had confirmed sensitivity to cefuroxime. Concerning sensitivity to gentamicin, the most optimal cut-off point of WBC was >7.80 K/µL, while in the case of nitrofurantoin, it was CRP value > 0.11 mg/L (which was presented in 98.50% of children). These results may guide us with antibiotic therapy and help to inhibit increasing antibiotic resistance.
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Affiliation(s)
- Katarzyna Werbel
- Department of Pediatrics and Nephrology, Medical University of Białystok, 15-274 Białystok, Poland; (K.W.); (A.W.)
| | - Dorota Jankowska
- Department of Statistics and Medical Informatics, Medical University of Białystok, 15-295 Białystok, Poland;
| | - Anna Wasilewska
- Department of Pediatrics and Nephrology, Medical University of Białystok, 15-274 Białystok, Poland; (K.W.); (A.W.)
| | - Katarzyna Taranta-Janusz
- Department of Pediatrics and Nephrology, Medical University of Białystok, 15-274 Białystok, Poland; (K.W.); (A.W.)
- Correspondence: ; Tel.: +48-85-745-06-51; Fax: +48-85-742-18-38
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Mattoo TK, Shaikh N, Nelson CP. Contemporary Management of Urinary Tract Infection in Children. Pediatrics 2021; 147:peds.2020-012138. [PMID: 33479164 DOI: 10.1542/peds.2020-012138] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 11/24/2022] Open
Abstract
Urinary tract infection (UTI) is common in children, and girls are at a significantly higher risk, as compared to boys, except in early infancy. Most cases are caused by Escherichia coli Collection of an uncontaminated urine specimen is essential for accurate diagnosis. Oral antibiotic therapy for 7 to 10 days is adequate for uncomplicated cases that respond well to the treatment. A renal ultrasound examination is advised in all young children with first febrile UTI and in older children with recurrent UTI. Most children with first febrile UTI do not need a voiding cystourethrogram; it may be considered after the first UTI in children with abnormal renal and bladder ultrasound examination or a UTI caused by atypical pathogen, complex clinical course, or known renal scarring. Long-term antibiotic prophylaxis is used selectively in high-risk patients. Few patients diagnosed with vesicoureteral reflux after a UTI need surgical correction. The most consequential long-term complication of acute pyelonephritis is renal scarring, which may increase the risk of hypertension or chronic kidney disease later in life. Treatment of acute pyelonephritis with an appropriate antibiotic within 48 hours of fever onset and prevention of recurrent UTI lowers the risk of renal scarring. Pathogens causing UTI are increasingly becoming resistant to commonly used antibiotics, and their indiscriminate use in doubtful cases of UTI must be discouraged.
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Affiliation(s)
- Tej K Mattoo
- Division of Pediatric Nephrology, Departments of Pediatrics and Urology, Wayne State University School of Medicine and Wayne Pediatrics, Detroit, Michigan;
| | - Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital and Department of Surgery, Harvard Medical School, Harvard University, Boston, Massachusetts
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Mushi MF, Alex VG, Seugendo M, Silago V, Mshana SE. C - reactive protein and urinary tract infection due to Gram-negative bacteria in a pediatric population at a tertiary hospital, Mwanza, Tanzania. Afr Health Sci 2019; 19:3217-3224. [PMID: 32127899 PMCID: PMC7040338 DOI: 10.4314/ahs.v19i4.45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction Gram-negative bacteria are the major cause of urinary tract infections (UTI) in children. There is limited data on UTI systemic response as measured using C-reactive protein (CRP). Here, we report the association of CRP and UTI among children attending the Bugando Medical Centre, Mwanza, Tanzania. Methods A cross-sectional study was conducted between May and July 2017. Urine and blood were collected and processed within an hour of collection. Data were analyzed using STATA version 13. Results Of 250 enrolled children, 76(30.4%) had significant bacteriuria with 56(22.4%, 95%CI; 11.5–33.3) having gram-negative bacteria infection. There was dual growth of gram-negative bacteria in 3 patients. Escherichia coli (32.2%, 19/59) was the most frequently pathogen detected. A total of 88/250(35.2%) children had positive CRP on qualitative assay. By multinomial logistic regression, positive CRP (RRR=4.02, 95%CI: 2.1–7.7, P<0.001) and age ≤ 2years (RRR=2.4, 95%CI: 1.23–4.73, P<0.01) significantly predicted the presence of significant bacteriuria due to gram-negative enteric bacteria. Conclusion C-reactive protein was significantly positive among children with UTI due to gram-negative bacteria and those with fever. In children with age ≤ 2 years, positive CRP indicates UTI due to gram-negative enteric bacteria.
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Affiliation(s)
- Martha F Mushi
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Science
| | - Vaileth G Alex
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Science
| | - Mwanaisha Seugendo
- Department of Pediatric and Child Health, Weill Bugando School of Medicine, Catholic University of Health and child health
| | - Vitus Silago
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Science
| | - Stephen E Mshana
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Science
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Why Does Prevention of Recurrent Urinary Tract Infection not Result in Less Renal Scarring? A Deeper Dive into the RIVUR Trial. J Urol 2019; 202:400-405. [PMID: 31026216 DOI: 10.1097/ju.0000000000000292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial reported that antibiotic prophylaxis reduced recurrent urinary tract infection but antibiotic prophylaxis was not associated with decreased new renal scarring. However, the original reports did not assess the relationship among recurrent urinary tract infection, new renal scarring and antibiotic prophylaxis in detail. Therefore, we investigated the relationship among these issues. MATERIALS AND METHODS We included subjects with dimercaptosuccinic acid scan within 6 months of enrollment and at least 1 followup dimercaptosuccinic acid scan from the RIVUR trial. The primary outcome was recurrent urinary tract infection associated new renal scarring, defined as recurrent urinary tract infection and new changes on dimercaptosuccinic acid scan. Due to a low number of events, propensity score was used to adjust for confounders. Multivariate logistic regression was fitted to investigate the associations between the covariates and the outcome. RESULTS A total of 489 patients (91% female, mean age 20.3 months) were included in the study. Any new renal scarring was more common among those with recurrent urinary tract infection (OR 4.1, 95% CI 2.0-8.5, p <0.01) after adjusting for age, sex, index urinary tract infection, duplication, bowel bladder dysfunction and antibiotic prophylaxis. Recurrent urinary tract infection associated new renal scarring occurred in 5 of 244 (2%) patients on antibiotic prophylaxis and 13 of 245 (5%) on placebo. Compared to antibiotic prophylaxis, placebo was associated with a higher risk of recurrent urinary tract infection associated new renal scarring (OR 3.1, 95% CI 1.0-8.8, p=0.04) after adjusting for age, sex, race, index urinary tract infection, bowel bladder dysfunction, duplication, hydronephrosis, vesicoureteral reflux grade and baseline renal scarring. There were no differences in scar severity at final dimercaptosuccinic acid scan (p=0.88) or change from baseline (p=0.53) between antibiotic prophylaxis and placebo. CONCLUSIONS Recurrent urinary tract infection was associated with new renal scarring in the RIVUR trial. When limited to recurrent urinary tract infection associated new renal scarring, antibiotic prophylaxis was associated with a decreased risk of this outcome. It remains unclear why new renal scarring developed in a proportion of subjects without recurrent urinary tract infection. The results should be carefully interpreted due to the inherent limitations.
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Heier E, Urban C, Abdellatif A, Thiel C, Neiger R. Assessment of individual kidney function in a dog with congenital anomalies of the urinary tract. VETERINARY RECORD CASE REPORTS 2019. [DOI: 10.1136/vetreccr-2018-000753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Evelyn Heier
- Small Animal ClinicJustus‐Liebig‐University GiessenFachbereich VeterinaermedizinGiessenGermany
| | - Christine Urban
- Small Animal ClinicJustus‐Liebig‐University GiessenFachbereich VeterinaermedizinGiessenGermany
| | - Ahmed Abdellatif
- Small Animal ClinicJustus‐Liebig‐University GiessenFachbereich VeterinaermedizinGiessenGermany
| | - Cetina Thiel
- Small Animal ClinicJustus‐Liebig‐University GiessenFachbereich VeterinaermedizinGiessenGermany
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Preventive Effect of L-Carnitine on Scar Formation During Acute Pyelonephritis: A Randomized Placebo-Controlled Trial. Am J Ther 2018; 27:e229-e234. [PMID: 30418227 DOI: 10.1097/mjt.0000000000000875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Urinary tract infection and pyelonephritis are clinical problems that frequently occur in children. Several factors are responsible for renal tissue injury, morbidity, and renal scarring after pyelonephritis. The aim of this study was to evaluate the preventive effect of L-carnitine on renal scarring in acute pyelonephritis. METHODS A randomized double-blind clinical trial was conducted on 65 children aged 6 months to 10 years. Patients were randomized into 2 groups to receive 7-day treatment with only antibiotics without L-carnitine (control group; n = 32) and 7-day treatment with L-carnitine (case group; n = 33) during the acute phase of infection. Technetium-99m-labeled dimercaptosuccinic acid (DMSA) scintigraphy was performed for all children during the acute phase (in 2-7 days of hospitalization) and late phase. P-value less than 0.05 was statistically significant. RESULTS We recruited 65 participants in the study: 32 children in control group and 33 children in case group. Three children in the control group and 2 children in the case group refused to perform the second DMSA scan. Overall, data analysis at the end of the study was done on 60 patients. Age distribution of girl patients with upper urinary infection was 6.5% in girl children aged between 6 months and 12 months, 41.1% aged between 1 and 5 years, 33.3% aged between 5 and 10 years, respectively. There was no significant difference between 2 groups in age and sex. There was no significant difference between 2 groups in systolic blood pressure, diastolic blood pressure, the lab data including urine white blood cells and serum erythrocyte sedimentation rate, and antibiogram profiles. Voiding dysfunction was detected in 10% of the participants. The baseline DMSA was not significantly difference in 2 groups, but worsening of kidney lesions was significantly higher in control group after 6 months (P = 0.012). CONCLUSION Our study showed that L-carnitine significantly decreased renal scarring because of acute pyelonephritis.
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Wang ZT, Wehbi E, Alam Y, Khoury A. A Reanalysis of the RIVUR Trial Using a Risk Classification System. J Urol 2017; 199:1608-1614. [PMID: 29198997 DOI: 10.1016/j.juro.2017.11.080] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial showed a 50% decrease in the risk of urinary tract infection recurrence in children with reflux receiving continuous antibiotic prophylaxis. We reanalyzed the RIVUR data with the purpose of using a risk classification system to identify children who are more likely to benefit from continuous antibiotic prophylaxis. MATERIALS AND METHODS Data from 607 children enrolled in the RIVUR trial were obtained from the National Institute of Diabetes and Digestive and Kidney Diseases Central Repository and analyzed. We stratified these children into low and high risk categories. The proportion of children and risk of urinary tract infection recurrence in the stratified treatment groups were compared. RESULTS Of the children 385 (63.9%) were stratified into the low risk and 217 (36.1%) into the high risk category. The proportions of children with urinary tract infection recurrence were not significantly different in the low risk category between the placebo and continuous antibiotic prophylaxis groups (p = 0.151), while urinary tract infection recurrence was significantly higher in the placebo group (31.5% vs 11.4%, p = 0.001) for high risk children. Furthermore, high risk children on placebo had a 3.7-fold increased risk of urinary tract infection recurrence during 2 years of followup compared to those on continuous antibiotic prophylaxis. CONCLUSIONS Although the RIVUR trial concluded that children with vesicoureteral reflux benefit from continuous antibiotic prophylaxis, our reanalysis of the data demonstrates that high risk children benefit more, with a number needed to treat of 5 compared to 18 in low risk children. The clinical implications of these findings suggest a need to refine current indications for continuous antibiotic prophylaxis in children with reflux, supporting a shift toward a "selective" risk based approach for management.
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Affiliation(s)
- Zhan Tao Wang
- University of California, Irvine, Irvine, California; Children's Hospital of Orange County, Orange, California; Western University, London, Ontario, Canada
| | - Elias Wehbi
- University of California, Irvine, Irvine, California; Children's Hospital of Orange County, Orange, California
| | - Yasaman Alam
- Children's Hospital of Orange County, Orange, California
| | - Antoine Khoury
- University of California, Irvine, Irvine, California; Children's Hospital of Orange County, Orange, California.
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Lee JW, Park JS, Park KB, Yoo GH, Kim SS, Lee SM. Prediction of renal cortical defect and scar using neutrophil-to-lymphocyte ratio in children with febrile urinary tract infection. Nuklearmedizin 2017; 56:109-114. [PMID: 28488726 DOI: 10.3413/nukmed-0878-17-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/10/2017] [Indexed: 11/20/2022]
Abstract
AIM This study is aimed to evaluate the predictive value of the neutrophil-to-lymphocyte ratio (NLR) for cortical defect on initial and follow-up Tc-99m dimercaptosuccinic acid (DMSA) scan in children with the first febrile urinary tract infection (UTI). METHODS We retrospectively enrolled 179 children with the first febrile UTI who underwent DMSA scan and laboratory tests. In patients with abnormal DMSA scan findings, follow-up DMSA scan was performed at least 6 months after the initial scan. All DMSA scans were classified as negative and positive cortical defects. Multiple logistic regression analyses were performed to identify the risk factors for cortical defect on initial and follow-up DMSA scan. RESULTS Cortical defects on initial DMSA scan were noted in 133 patients. Vesicoureteral reflux (VUR), white blood cell count, absolute neutrophil count, NLR, and serum C-reactive protein level were independent predictive factors for positive cortical defect on initial DMSA scan (p < 0.050). On follow-up DMSA scan, 24 of the 133 patients showed persistent cortical defects, and only VUR was significantly associated with persistent cortical defect (p = 0.002). In 84 patients who showed cortical defect on initial scan and absence of VUR, only NLR was significantly associated with persistent cortical defect on follow-up scan (p = 0.025). CONCLUSION NLR was significantly associated with persistent cortical defect on follow-up DMSA scan in patients without VUR, as well as positive cortical defect on initial scan.
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Affiliation(s)
| | | | | | | | | | - Sang Mi Lee
- Sang Mi Lee, M.D., Ph.D., Soonchunhyang University Cheonan Hospital,, 23-20 Byeongmyeong-dong,, Dongnam-gu, Cheonan,, Chungcheongnam-do, 330-721, Korea, Tel: +82-41-570-3540, Fax: +82-41-572-4655, E-mail:
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13
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Penna FJ, Caldamone A, Koyle MA. Coming full circle with vesicoureteral reflux: From Hutch to bladder and bowel dysfunction. J Pediatr Urol 2017; 13:189-191. [PMID: 28284734 DOI: 10.1016/j.jpurol.2017.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/31/2017] [Indexed: 11/30/2022]
Affiliation(s)
- F J Penna
- Division of Pediatric Urology, Children's Hospital at Dartmouth, Dartmouth Geisel School of Medicine, Lebanon, NH, USA.
| | - A Caldamone
- Division of Pediatric Urology, Hasbro Children's Hospital, Brown Alpert Medical School, Providence, RI, USA
| | - M A Koyle
- Division of Paediatric Urology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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14
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Karavanaki KA, Soldatou A, Koufadaki AM, Tsentidis C, Haliotis FA, Stefanidis CJ. Delayed treatment of the first febrile urinary tract infection in early childhood increased the risk of renal scarring. Acta Paediatr 2017; 106:149-154. [PMID: 27748543 DOI: 10.1111/apa.13636] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/07/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
Abstract
AIM This study evaluated the controversial relationship between the duration of fever before treatment initiation (FBT) for a febrile urinary tract infection (UTI), with renal scarring based on dimercaptosuccinic acid scintigraphy (DMSA) findings. METHODS The inpatient records of 148 children under two years of age with a first episode of febrile UTI were analysed. Acute and repeat DMSA findings, and clinical and laboratory parameters were evaluated. RESULTS Acute DMSA showed that 76 of the 148 children with a febrile UTI had renal lesions: 20 were mild, and 56 were moderate or severe. Repeat DMSA showed renal scarring in 34 patients. The only factors associated with the development of renal scars in the repeat DMSA were FBT of more than 72 hours, the presence and severity of vesicoureteral reflux and increased procalcitonin levels and absolute neutrophil counts. Multiple regression analysis showed that an FBT above 72 hours was the only significant factor that predicted renal scars. CONCLUSION Delay in treatment initiation of 72 hours or more was a risk factor for permanent renal scars after the first episode of febrile UTI. Other associated factors were increased procalcitonin and absolute neutrophil count on admission and the presence and severity of vesicouretal reflux.
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Affiliation(s)
- Kyriaki A. Karavanaki
- Second Department of Pediatrics; National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital; Athens Greece
| | - Alexandra Soldatou
- Second Department of Pediatrics; National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital; Athens Greece
| | - Athina Maria Koufadaki
- Second Department of Pediatrics; National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital; Athens Greece
| | - Charalampos Tsentidis
- Second Department of Pediatrics; National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital; Athens Greece
| | - Fotis A. Haliotis
- Second Department of Pediatrics; “Aghia Sophia” Children's Hospital; Athens Greece
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15
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Wongbencharat K, Tongpenyai Y, Na-Rungsri K. Renal ultrasound and DMSA screening for high-grade vesicoureteral reflux. Pediatr Int 2016; 58:214-8. [PMID: 26275163 DOI: 10.1111/ped.12803] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/02/2015] [Accepted: 08/10/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Selection of the appropriate radiologic investigation in a child after first febrile urinary tract infection (UTI) remains a contentious issue. This report investigated the effectiveness of renal bladder ultrasound (RBUS) and late 6 month dimercaptosuccinic acid (DMSA) renal scan in the detection of high-grade vesicoureteral reflux (VUR) after first febrile UTI in infants aged <1 year. METHODS A total of 387 infants aged <1 year with first febrile UTI who completed diagnostic follow up consisting of RBUS, voiding cystourethrogram (VCUG) and late 6 month DMSA scan were enrolled in the study. The effectiveness of RBUS and DMSA scan in the detection of high-grade VUR, including cost and benefit were assessed. RESULTS Abnormal RBUS was identified in 95 infants (24.5%). VUR was identified on VCUG in 79 (20.4%), of whom eight (2.1%) had high-grade VUR (grade IV-V). Abnormal renal parenchyma was identified on late 6 month DMSA scan in 22 infants (5.7%). The sensitivity of abnormal RBUS and of late 6 month DMSA scan in the prediction of high-grade VUR was 50% and 87.5%, and the proportion of infants who avoided unnecessary VCUG was 75.5% and 94.3%, respectively. CONCLUSIONS Fifty percent of high-grade VUR was not identified on RBUS screening after first febrile UTI. Although late 6 month DMSA scan had higher sensitivity in the detection of high-grade VUR, with the added benefit of detection of renal scars, the practical application of this method was limited due to its high cost, radiation exposure and the associated delay in decision making.
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16
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Keren R, Shaikh N, Pohl H, Gravens-Mueller L, Ivanova A, Zaoutis L, Patel M, deBerardinis R, Parker A, Bhatnagar S, Haralam MA, Pope M, Kearney D, Sprague B, Barrera R, Viteri B, Egigueron M, Shah N, Hoberman A. Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring. Pediatrics 2015; 136:e13-21. [PMID: 26055855 PMCID: PMC4485012 DOI: 10.1542/peds.2015-0409] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To identify risk factors for recurrent urinary tract infection (UTI) and renal scarring in children who have had 1 or 2 febrile or symptomatic UTIs and received no antimicrobial prophylaxis. METHODS This 2-year, multisite prospective cohort study included 305 children aged 2 to 71 months with vesicoureteral reflux (VUR) receiving placebo in the RIVUR (Randomized Intervention for Vesicoureteral Reflux) study and 195 children with no VUR observed in the CUTIE (Careful Urinary Tract Infection Evaluation) study. Primary exposure was presence of VUR; secondary exposures included bladder and bowel dysfunction (BBD), age, and race. Outcomes were recurrent febrile or symptomatic urinary tract infection (F/SUTI) and renal scarring. RESULTS Children with VUR had higher 2-year rates of recurrent F/SUTI (Kaplan-Meier estimate 25.4% compared with 17.3% for VUR and no VUR, respectively). Other factors associated with recurrent F/SUTI included presence of BBD at baseline (adjusted hazard ratio: 2.07 [95% confidence interval (CI): 1.09-3.93]) and presence of renal scarring on the baseline (99m)Tc-labeled dimercaptosuccinic acid scan (adjusted hazard ratio: 2.88 [95% CI: 1.22-6.80]). Children with BBD and any degree of VUR had the highest risk of recurrent F/SUTI (56%). At the end of the 2-year follow-up period, 8 (5.6%) children in the no VUR group and 24 (10.2%) in the VUR group had renal scars, but the difference was not statistically significant (adjusted odds ratio: 2.05 [95% CI: 0.86-4.87]). CONCLUSIONS VUR and BBD are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.
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Affiliation(s)
- Ron Keren
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of Pediatrics and Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Nader Shaikh
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Hans Pohl
- Division of Urology, Children’s National Health System, Washington, DC; and
| | | | - Anastasia Ivanova
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lisa Zaoutis
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa Patel
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rachel deBerardinis
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allison Parker
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sonika Bhatnagar
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Mary Ann Haralam
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Marcia Pope
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Diana Kearney
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Bruce Sprague
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Raquel Barrera
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Bernarda Viteri
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Martina Egigueron
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Neha Shah
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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17
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Chien JW, Wang LY, Cheng YS, Tsai YG, Liu CS. Urinary 8-hydroxy-2′-deoxyguanosine (8-oxodG) level can predict acute renal damage in young children with urinary tract infection. Biomarkers 2014; 19:326-31. [DOI: 10.3109/1354750x.2014.910552] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Cerwinka WH, Grattan-Smith JD, Jones RA, Haber M, Little SB, Blews DE, Williams JP, Kirsch AJ. Comparison of magnetic resonance urography to dimercaptosuccinic acid scan for the identification of renal parenchyma defects in children with vesicoureteral reflux. J Pediatr Urol 2014; 10:344-51. [PMID: 24128878 DOI: 10.1016/j.jpurol.2013.09.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 09/13/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare the accuracy of dimercaptosuccinic acid (DMSA) renal scan to magnetic resonance urography (MRU) in the identification of renal parenchyma defects (RPD). MATERIALS AND METHODS Twenty-five children with history of acute pyelonephritis and vesicoureteral reflux underwent DMSA scan and MRU to determine the presence of RPD. DMSA scans and MRUs were each evaluated by two radiologists and agreement achieved by consensus. Discordant DMSA-MRU findings were re-evaluated in a side-by-side comparison and an ultimate consensus reached. RESULTS The ultimate consensus diagnosis was 18 kidneys with RPDs in 15 patients, of which five were classified as mild RPDs, six as moderate RPDs, and seven as severe RPDs. Although DMSA scan and MRU were similar in their ability to diagnose RPDs, MRU was considered to represent the true diagnosis in 11 of the 12 discordant cases in consensus review by four pediatric radiologists. MRU showed a much higher inter-observer agreement with a weighted kappa of 0.96 for both kidneys compared to 0.71 for the right kidney and 0.86 for the left kidney by DMSA scan. CONCLUSIONS Our results suggest that MRU is superior to DMSA scan in the identification of renal parenchyma defects.
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Affiliation(s)
- W H Cerwinka
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA 30342, USA.
| | - J D Grattan-Smith
- Department of Pediatric Radiology, Children's Healthcare of Atlanta, Atlanta, GA 30342, USA
| | - R A Jones
- Department of Pediatric Radiology, Children's Healthcare of Atlanta, Atlanta, GA 30342, USA
| | - M Haber
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - S B Little
- Department of Pediatric Radiology, Children's Healthcare of Atlanta, Atlanta, GA 30342, USA
| | - D E Blews
- Department of Pediatric Radiology, Children's Healthcare of Atlanta, Atlanta, GA 30342, USA
| | - J P Williams
- Department of Pediatric Radiology, Children's Healthcare of Atlanta, Atlanta, GA 30342, USA
| | - A J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA 30342, USA
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19
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Raju GA, Marks AJ, Benoit RM, Docimo SG. Models of Care for Vesicoureteral Reflux With and Without an End Point of Reflux Resolution: A Computer Cost Analysis. J Urol 2013; 189:2287-92. [DOI: 10.1016/j.juro.2012.12.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2012] [Indexed: 11/15/2022]
Affiliation(s)
- Gaayana A. Raju
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Andrew J. Marks
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Ronald M. Benoit
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Steven G. Docimo
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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20
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Sürücü E, Demir Y, Torun Bayram M, Kavukçu S, Durak H. Is Imaging Time Between two Tc 99m DMSA Scans Sufficient for Reporting as Renal Parenchymal Scarring? Healed Parenchymal Renal Defect After 6 Years. Mol Imaging Radionucl Ther 2013; 22:14-7. [PMID: 23610726 PMCID: PMC3629786 DOI: 10.4274/mirt.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 09/06/2011] [Indexed: 02/08/2023] Open
Abstract
We aimed to report a healed renal parenchymal defect after 6 years in a 9-year-old girl who was being followed for recurrent urinary tract infection (UTI). The first UTI was at the age of two. She was being followed with ultrasonography, urine analysis and urine culture since the first UTI. Technetium-99m dimercaptosuccinic acid (DMSA) scintigraphy was repeated four times up to the present day. She had a renal parenchymal defect reported as parenchymal scarring, which healed 6 years after the first DMSA scintigraphy. Conflict of interest:None declared.
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Affiliation(s)
- Erdem Sürücü
- Dokuz Eylül university, School of Medicine, Department of Nuclear medicine, İzmir, Turkey
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21
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Coletta R, Olivieri C, Briganti V, Perrotta ML, Oriolo L, Fabbri F, Calisti A. Patients with a history of infection and voiding dysfunction are at risk for recurrence after successful endoscopic treatment of vesico ureteral reflux and deserve long-term follow up. Urol Ann 2012; 4:19-23. [PMID: 22346096 PMCID: PMC3271445 DOI: 10.4103/0974-7796.91616] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 03/27/2011] [Indexed: 11/23/2022] Open
Abstract
Aim of the Study: Subureteral endoscopic injection of a bulking agent is an attractive alternative to open surgery or antibiotic prophylaxis for vesico ureteral reflux (VUR). Little information is available about long-term risk of recurrence after an initially successful treatment. Aim of this paper was to review short- and long-term success rate of endoscopic treatment in a single Center series after risk stratification of individual patients. Materials and Methods: The records of 126 patients who underwent Deflux injection for primary VUR were examined. Indications to treatment were an unvaried high grade VUR (IV-V) at 1 year from diagnosis and/or and recurrent urinary tract infection (UTI) on antibiotic prophylaxis even in the presence of mild grade VUR (III grade). Gender, age and mode of diagnosis, infections (UTI), voiding dysfunctions, VUR grade and side, renal function, number of treatments were correlated to outcome. Long-term evaluation was planned at a minimum of 1 year from the last negative post-injection cystogram (MCUG). A new MCUG and DMSA scan were also offered to those complaining new UTI episodes. Late recurrences were correlated to history and grade of reflux. Data were analyzed with Graph Pad Instat software; the Chi-square test was used for univariate comparisons, the Fisher's exact test for categorical variables.and multiple regression tests for factors influencing outcome. Results: M/F ratio was 62 to 64; median age at diagnosis was 28 months. VUR affected 198 renal units. Preinjection VUR grade was I in 1, II in 27, III in 107, IV in 59, and V in 4 units. Reduced DMSA uptake was evidenced in 51 units and scarring in 24. Median age at treatment was 34.5 months, for persistent high grade VUR (IV–V) in 55 patients and recurrent IVU in 92. Two hundred sixty seven injections were performed on 198 ureters. Complete resolution was documented by MCUG at 3-5 months in 68%, low grading < II in 20%, persistence or unsignificant reduction in 11%. Preoperative recurrent UTI, higher grade VUR, and bilaterality were correlated to a poorer surgical outcome. Among 80 successfully treated cases, 12 complained of persistent UTI. Recurrence of VUR was demonstrated in 31% of them. Deteriorated uptake or additional scarring in 25% was independent from VUR recurrence. Preoperative recurrent UTI and voiding dysfunction correlated significantly to late outcome. Conclusions: Preoperative recurrent IVU, together with high-grade reflux, seem to correlate to lower success rate of Deflux injection for primary VUR. Even after successful endoscopic treatment, long-term surveillance may be needed among these cases, mainly if voiding dysfunction is also recorded. Late recurring VUR must be actively excluded in case of new IVU episodes.
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Affiliation(s)
- R Coletta
- Pediatric Surgery and Pediatric Urology Unit, "San Camillo - Forlanini Hospital", Rome, Italy
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22
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Tramma D, Hatzistylianou M, Gerasimou G, Lafazanis V. Interleukin-6 and interleukin-8 levels in the urine of children with renal scarring. Pediatr Nephrol 2012; 27:1525-30. [PMID: 22527530 DOI: 10.1007/s00467-012-2156-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 02/20/2012] [Accepted: 03/07/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute pyelonephritis (APN) is one of the most significant bacterial infections in infancy and early childhood, and can lead to permanent kidney damage and chronic renal failure. OBJECTIVE To evaluate interleukin-6 (IL-6) and interleukin-8 (IL-8) levels in the urine of children with renal scarring (RS), searching for clinical information about the immuno-inflammatory process that contributes to RS. METHODS Urine concentrations of IL-6 and IL-8 were evaluated in 50 children, 33 with RS detected after an episode of acute pyelonephritis (group A) and 17 children with a history of acute pyelonephritis, but without RS (group B). These children were divided into four groups: group A(1), 23 children with RS and vesicoureteral reflux (VUR); group A(2), 10 children with RS without VUR; group B(1), 13 children without RS and without VUR; group B(2), 4 children without RS, but with VUR. None of them had had urinary tract infection for a minimum of 6 months. To avoid dilution effects, urinary levels of IL-6 and IL-8 were expressed as the ratio of cytokine to urinary creatinine (pg/mg). RESULTS Urinary IL-8 levels were below the lower detection limit in all samples. IL-6 was detectable in the majority of children with RS and below the detection limits in the urine samples of children without RS. There were no statistically significant differences between urinary interleukin-6 levels in children with and those without VUR. There was a significant relationship between the grade of renal scars, the time passed since the last episode of acute pyelonephritis and the urinary levels of IL-6 (p < 0.0001 and p < 0.04 respectively). CONCLUSION Further experimental studies are required to demonstrate the correlation between histopathology and urinary cytokine levels.
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Affiliation(s)
- Despoina Tramma
- 4th Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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23
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Lorenzo AJ. Medical versus surgical management for vesicoureteric reflux: the case for medical management. Can Urol Assoc J 2011; 4:276-8. [PMID: 20694107 DOI: 10.5489/cuaj.1082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Koyle MA, Elder JS, Skoog SJ, Mattoo TK, Pohl HG, Reddy PP, Abidari JM, Snodgrass WT. Febrile urinary tract infection, vesicoureteral reflux, and renal scarring: current controversies in approach to evaluation. Pediatr Surg Int 2011; 27:337-46. [PMID: 21305381 DOI: 10.1007/s00383-011-2863-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2011] [Indexed: 10/18/2022]
Abstract
The ideal approach to the radiological evaluation of children with urinary tract infection (UTI) is in a state of confusion. The conventional bottom-up approach, with its focus on the detection of upper and lower urinary tract abnormalities, including vesicoureteral reflux, has been challenged by the top-down approach, which focuses on confirming the diagnosis of acute pyelonephritis before more invasive imaging is considered. Controversies abound regarding which approach may best assess the ultimate risk for reflux-related renal scarring. Evolving practices motivated by the emerging evidence, the desire to minimize unnecessary interventions, as well as improve compliance with recommended testing, have added to the current controversies. Recent guideline updates and ongoing clinical trials hopefully will help in addressing some of these concerns.
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Affiliation(s)
- Martin A Koyle
- Michael Mitchell Endowed Chair in Pediatric Urology, University of Washington and Seattle Children's Hospital, Seattle, WA 98105, USA.
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25
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Gurocak S, Ure I, Cumaoglu A, Gonul II, Sen I, Tan O, Aricioglu A, Bozkirli I. Renal tissue damage after experimental pyelonephritis: role of antioxidants and selective cyclooxygenase-2 inhibitors. Urology 2010; 76:508.e1-5. [PMID: 20510442 DOI: 10.1016/j.urology.2010.03.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 02/16/2010] [Accepted: 03/16/2010] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To investigate the involvement of oxidative stress in the pathogenesis of acute pyelonephritis, and to evaluate the impact of meloxicam and/or L-carnitine in addition to conventional antibiotic treatment. METHODS A total of 48 Wistar rats were divided into 4 groups according to their treatment, which was started 1 day after inoculation of all rats with Escherichia coli (ATCC 25 922, 10(10) cfu/mL). Group 1 received only antibiotic treatment with ceftriaxone (50 mg/kg, IM). Groups 2 and 3 received L-carnitine (500 mg/kg, IM) and meloxicam (3 mg/kg, IM) in addition to conventional treatment, respectively. Group 4 received combination therapy (L-carnitine and meloxicam) in addition to the first group. Rats were killed 3 and 7 days after E. coli inoculation and underwent nephrectomy. Histologic determination of tubular atrophy, acute and chronic inflammation, interstitial fibrosis and biochemical determination of superoxide dismutase and catalase activity, total thiol content, total antioxidant capacity, and malondialdehyde and protein hydroperoxide levels were measured. RESULTS Interstitial fibrosis (P = .06), chronic inflammation (P = .536), and tubular atrophy (P = 0.094) decreased in group 4 compared with the other groups, but there was a statistically significant decrease only in acute inflammation (P = .015). In addition, if the day of nephrectomy is considered, there was again a significant decrease in acute inflammation on day 7 compared with day 3 in groups 2, 3, and 4 (P = .002). Catalase significantly increased in group 2 (P = .029), group 3 (P = .02), and group 4 (P = .014), and decreased in group 1 (P = .012) in day 7. CONCLUSIONS L-carnitine and meloxicam alleviated oxidative stress, probably by decreasing lipid peroxidation and enforcing antioxidant defense system. Acute renal inflammatory injury can be prevented much more effectively by combination therapy rather than by conventional therapy alone.
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Affiliation(s)
- Serhat Gurocak
- Department of Urology, Gazi University, Faculty of Medicine, Ankara, Turkey.
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26
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Brandström P, Nevéus T, Sixt R, Stokland E, Jodal U, Hansson S. The Swedish reflux trial in children: IV. Renal damage. J Urol 2010; 184:292-7. [PMID: 20494369 DOI: 10.1016/j.juro.2010.01.060] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE We compared the development of new renal damage in small children with dilating vesicoureteral reflux randomly allocated to antibiotic prophylaxis, endoscopic treatment or surveillance as the control group. MATERIALS AND METHODS Included in the study were 128 girls and 75 boys 1 to younger than 2 years with grade III-IV reflux. Voiding cystourethrography and dimercapto-succinic acid scintigraphy were done before randomization and after 2 years. Febrile urinary tract infections were recorded during followup. Data analysis was done by the intent to treat principle. RESULTS New renal damage in a previously unscarred area was seen in 13 girls and 2 boys. Eight of the 13 girls were on surveillance, 5 received endoscopic therapy and none were on prophylaxis (p = 0.0155). New damage was more common in children with than without febrile recurrence (11 of 49 or 22% vs 4 of 152 or 3%, p <0.0001). CONCLUSIONS In boys the rate of new renal damage was low. It was significantly higher in girls and most common in the control surveillance group. There was also a strong association between recurrent febrile UTIs and new renal damage in girls.
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Affiliation(s)
- Per Brandström
- Pediatric Uro-Nephrologic Center, The Queen Silvia Children's Hospital, University of Gothenburg, Göteborg, Sweden
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27
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Oh MM, Cheon J, Kang SH, Park HS, Lee JG, Moon DG. Predictive Factors for Acute Renal Cortical Scintigraphic Lesion and Ultimate Scar Formation in Children With First Febrile Urinary Tract Infection. J Urol 2010; 183:1146-50. [DOI: 10.1016/j.juro.2009.11.051] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Indexed: 11/30/2022]
Affiliation(s)
- Mi Mi Oh
- Department of Urology, Korea University Medical Center, Seoul, Korea
| | - Jun Cheon
- Department of Urology, Korea University Medical Center, Seoul, Korea
| | - Seok Ho Kang
- Department of Urology, Korea University Medical Center, Seoul, Korea
| | - Hong Seok Park
- Korea University Institute of Regenerative Medicine, Seoul, Korea
| | - Jeong Gu Lee
- Department of Urology, Korea University Medical Center, Seoul, Korea
| | - Du Geon Moon
- Korea University Institute of Regenerative Medicine, Seoul, Korea
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Risk factors for recurrent urinary tract infections in a cohort of patients with primary vesicoureteral reflux. Pediatr Infect Dis J 2010; 29:139-44. [PMID: 20135833 DOI: 10.1097/inf.0b013e3181b8e85f] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Knowledge of risk of urinary tract infection (UTI) recurrence in vesicoureteral reflux (VUR) can help clinicians make therapeutic decisions. The aim of this retrospective cohort study was to identify risk factors associated with recurrent urinary tract infection in children with VUR. In addition, a risk score that might predict the chance of UTI recurrence was also proposed. METHODS Between 1970 and 2007, 740 patients were diagnosed with VUR and were systematically followed up at a single tertiary Renal Unit. Recurrent UTI was defined as more than 1 episode during follow-up. A binary logistic regression model was applied to identify variables independently associated with recurrent UTIs. RESULTS During follow-up, information was obtained on 58,856 person-months. Recurrent UTIs occurred in 120 (16.2%) patients. The overall incidence rate of UTI was 8.4 episodes per 1000 person-months (95% CI, 7.7, 9.2). After adjustment by multivariable analysis, 5 variables were independent predictors of recurrent UTI: UTI as clinical presentation, age < 6 months, female gender, dysfunctional elimination syndrome, and severe grade of reflux. The risk for recurrent UTI was classified as low in 24% of children, medium in 42%, and high in 34%. UTI incidence rates per 1000 person-months were 4.3 (95% CI, 3.2, 5.6), 7.9 (95% CI, 6.7, 9.1), and 11.3 (95% CI, 9.9, 12.8) for low-, medium-, and high-risk groups, respectively. CONCLUSION The prediction model of recurrent UTI allows an early recognition of patients at risk for long-term morbidity and might contribute to the formulation of therapeutic strategies.
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Tasian GE, Aaronson DS, McAninch JW. Evaluation of Renal Function After Major Renal Injury: Correlation With the American Association for the Surgery of Trauma Injury Scale. J Urol 2010; 183:196-200. [DOI: 10.1016/j.juro.2009.08.149] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Indexed: 11/25/2022]
Affiliation(s)
- Gregory E. Tasian
- Department of Urology, University of California, San Francisco and San Francisco General Hospital, San Francisco, California
| | - David S. Aaronson
- Department of Urology, University of California, San Francisco and San Francisco General Hospital, San Francisco, California
| | - Jack W. McAninch
- Department of Urology, University of California, San Francisco and San Francisco General Hospital, San Francisco, California
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Wu HY, Shortliffe LD. Top-down approach for evaluation of urinary tract infection. Urology 2009; 75:514-5. [PMID: 19879637 DOI: 10.1016/j.urology.2009.07.1264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 03/23/2009] [Accepted: 07/31/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Hsi-Yang Wu
- Department of Urology, Stanford University, Stanford, California 94305, USA.
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Pecile P, Miorin E, Romanello C, Vidal E, Contardo M, Valent F, Tenore A. Age-related renal parenchymal lesions in children with first febrile urinary tract infections. Pediatrics 2009; 124:23-9. [PMID: 19564279 DOI: 10.1542/peds.2008-1192] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of this study was to define the association between age and the occurrence of acute pyelonephritis and renal scars. METHODS Between 1999 and 2002, all children 0 to 14 years of age consecutively seen with a first febrile urinary tract infection were enrolled in the study. (99m)Tc-Dimercaptosuccinic acid renal scintigraphy was performed within 5 days after admission for the detection of renal parenchymal involvement. The presence of vesicoureteral reflux was assessed by using cystography performed 1 month after the infection. If the acute scan results were abnormal, then follow-up (99m)Tc-dimercaptosuccinic acid scanning was performed after 6 months, to assess the frequency of scars. RESULTS A total of 316 children were enrolled in the study (190 children <1 year, 99 children 1-4 years, and 27 children 5-14 years of age). (99m)Tc-Dimercaptosuccinic acid scintigraphy revealed that 59% of the children had renal involvement in the acute phase of infection. The frequency of kidney involvement in infants <1 year of age (49%) was significantly lower than that in children 1 to 4 years of age (73%) and >5 years of age (81%). Of the 187 children with positive acute (99m)Tc-dimercaptosuccinic acid scan results, 123 underwent repeat scintigraphy after 6 months. Renal scars were found for 28% of children <1 year, 37% of children 1 to 4 years, and 53% of children 5 to 14 years of age. No significant differences in the frequency of scars and the presence or absence of vesicoureteral reflux were noted. CONCLUSIONS Our findings confirm that acute pyelonephritis and subsequent renal scarring occur only in some children with first febrile urinary tract infections. Children <1 year of age with febrile urinary tract infections have a lower risk of parenchymal localization of infection and renal scarring.
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Affiliation(s)
- Paolo Pecile
- Department of Pediatrics, DPMSC, University of Udine, School of Medicine, Udine, Italy
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The "top-down" approach to the evaluation of children with febrile urinary tract infection. Adv Urol 2009:783409. [PMID: 19343189 PMCID: PMC2662435 DOI: 10.1155/2009/783409] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 11/10/2008] [Accepted: 01/24/2009] [Indexed: 11/25/2022] Open
Abstract
The evaluation of children presenting with urinary tract infection (UTI) has long entailed sonography and cystography to identify all urological abnormalities that might contribute to morbidity. The identification of vesicoureteral reflux (VUR) has been of primary concern since retrospective studies from the 1930s to 1960s established a strong association between VUR, recurrent UTI, and renal cortical scarring. It has been proposed that all VUR carries a risk for renal scarring and, therefore, all VUR should be identified and treated. We will not discuss the controversies surrounding VUR treatment in this review focusing instead on a new paradigm for the evaluation of the child with UTI that is predicated on identifying those at risk for scarring who are most deserving of further evaluation by cystography.
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Jeon JH, Lee KH, Park JS. The Effect of Renal Scarring on Spontaneous Resolution and Breakthrough Infection in Children with Vesicoureteral Reflux. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.7.699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jong Ho Jeon
- Department of Urology, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Kyung Hun Lee
- Department of Pediatrics, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Jae Shin Park
- Department of Urology, College of Medicine, Daegu Catholic University, Daegu, Korea
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Zaffanello M, Brugnara M, Franchini M, Fanos V. Is serum procalcitonin able to predict long-term kidney morbidity from urinary tract infections in children? Clin Chem Lab Med 2008; 46:1358-63. [PMID: 18844487 DOI: 10.1515/cclm.2008.282] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A new diagnostic strategy for children with febrile urinary tract infections could be the routine use of procalcitonin assessment to identify children requiring closer follow-up since being at risk for kidney damage. A total of 11 studies were published between 1998 and 2007. Children with very high procalcitonin levels during urinary tract infections are likely to be at risk of renal damage and vesico-ureteral reflux. Therefore, the prediction of long-term renal damage showed contradictory results. However, high procalcitonin values at diagnosis and positive scintigraphic scans may suggest the need to investigate for vesico-ureteral reflux. Consequently, procalcitonin levels should be included in follow-up protocols for urinary tract infections to aid in decision making concerning scintigraphic scans and voiding cystourethrograms.
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Affiliation(s)
- Marco Zaffanello
- Department of Mother-Child and Biology-Genetics, University of Verona, Verona, Italy.
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35
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Chesney RW, Carpenter MA, Moxey-Mims M, Nyberg L, Greenfield SP, Hoberman A, Keren R, Matthews R, Matoo TK. Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR): background commentary of RIVUR investigators. Pediatrics 2008; 122 Suppl 5:S233-9. [PMID: 19018047 PMCID: PMC4336951 DOI: 10.1542/peds.2008-1285c] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Because of the frequency of urinary tract infections in children, off-label use of antimicrobial prophylaxis is often the usual treatment of children with vesicoureteral reflux, and such use is increasingly being called into question; hence, a definitive study to determine the value of antimicrobial prophylaxis with regard to the recurrence of urinary tract infection and the incidence of renal scarring is essential. The currently recommended follow-up procedures (repeated urine cultures, renal and genitourinary imaging, antimicrobial therapy and prophylaxis, as well as other factors including cleanliness, adequate bladder and bowel emptying, and compliance with protocols) are expensive (in terms of time, attention to detail, and cost) and cumbersome. Such recommendations should be evidence-based.
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Affiliation(s)
- Russell W. Chesney
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Myra A. Carpenter
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Leroy Nyberg
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | | | - Alejandro Hoberman
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ron Keren
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ron Matthews
- Department of Urology, Johns Hopkins University, Baltimore, Maryland
| | - Tej K. Matoo
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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Affiliation(s)
- Ron Keren
- Department of Pediatrics and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Keren R, Carpenter MA, Hoberman A, Shaikh N, Matoo TK, Chesney RW, Matthews R, Gerson AC, Greenfield SP, Fivush B, McLurie GA, Rushton HG, Canning D, Nelson CP, Greenbaum L, Bukowski T, Primack W, Sutherland R, Hosking J, Stewart D, Elder J, Moxey-Mims M, Nyberg L. Rationale and design issues of the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. Pediatrics 2008; 122 Suppl 5:S240-50. [PMID: 19018048 PMCID: PMC2842127 DOI: 10.1542/peds.2008-1285d] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our goal is to determine if antimicrobial prophylaxis with trimethoprim/sulfamethoxazole prevents recurrent urinary tract infections and renal scarring in children who are found to have vesicoureteral reflux after a first or second urinary tract infection. DESIGN, PARTICIPANTS, AND METHODS The Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study is a double-blind, randomized, placebo-controlled trial. Six hundred children aged 2 to 72 months will be recruited from both primary and subspecialty care settings at clinical trial centers throughout North America. Children who are found to have grades I to IV vesicoureteral reflux after the index febrile or symptomatic urinary tract infection will be randomly assigned to receive daily doses of either trimethoprim/sulfamethoxazole or placebo for 2 years. Scheduled follow-up contacts include in-person study visits every 6 months and telephone interviews every 2 months. Biospecimens (urine and blood) and genetic specimens (blood) will be collected for future studies of the genetic and biochemical determinants of vesicoureteral reflux, recurrent urinary tract infection, renal insufficiency, and renal scarring. RESULTS The primary outcome is recurrence of urinary tract infection. Secondary outcomes include time to recurrent urinary tract infection, renal scarring (assessed by dimercaptosuccinic acid scan), treatment failure, renal function, resource utilization, and development of antimicrobial resistance in stool flora. CONCLUSIONS The RIVUR study will provide useful information to clinicians about the risks and benefits of prophylactic antibiotics for children who are diagnosed with vesicoureteral reflux after a first or second urinary tract infection. The data and specimens collected over the course of the study will allow researchers to better understand the pathophysiology of recurrent urinary tract infection and its sequelae.
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Affiliation(s)
- Ron Keren
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Myra A. Carpenter
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Alejandro Hoberman
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nader Shaikh
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tej K. Matoo
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Russell W. Chesney
- Department of Pediatrics, Le Bonheur Children's Medical Center, Memphis, Tennessee
| | - Ranjiv Matthews
- Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Arlene C. Gerson
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Saul P. Greenfield
- Department of Urology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Barbara Fivush
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gordon A. McLurie
- Department of Urology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - H. Gil Rushton
- Department of Urology, Children's National Medical Center, Washington, DC
| | - Douglas Canning
- Department of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Caleb P. Nelson
- Department of Urology, Children's Hospital Boston, Boston, Massachusetts
| | - Lawrence Greenbaum
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Timothy Bukowski
- Department of Urology, University of North Carolina, Chapel Hill, North Carolina
| | - William Primack
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Richard Sutherland
- Department of Urology, University of North Carolina, Chapel Hill, North Carolina
| | - James Hosking
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Dawn Stewart
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Jack Elder
- Department of Urology, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive Kidney Disease, National Institutes of Health, Bethesda, Maryland
| | - Leroy Nyberg
- National Institute of Diabetes and Digestive Kidney Disease, National Institutes of Health, Bethesda, Maryland
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Renal Scars, Dimercapto-Succinic Acid Defects—What's in a Name? J Urol 2008; 180:2303-4. [DOI: 10.1016/j.juro.2008.09.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Parvex P, Willi J, Kossovsky M, Girardin E. Longitudinal Analyses of Renal Lesions Due to Acute Pyelonephritis in Children and Their Impact on Renal Growth. J Urol 2008; 180:2602-6; discussion 2606. [DOI: 10.1016/j.juro.2008.08.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Indexed: 10/21/2022]
Affiliation(s)
- P. Parvex
- Department of Pediatric Nephrology, University Hospital, Geneva, Switzerland
| | - J.P. Willi
- Department of Nuclear Medicine, University Hospital, Geneva, Switzerland
| | - M.P. Kossovsky
- Division of Primary Care, University Hospital, Geneva, Switzerland
| | - E. Girardin
- Department of Pediatric Nephrology, University Hospital, Geneva, Switzerland
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40
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Oh MM, Jin MH, Bae JH, Park HS, Lee JG, Moon DG. The Role of Vesicoureteral Reflux in Acute Renal Cortical Scintigraphic Lesion and Ultimate Scar Formation. J Urol 2008; 180:2167-70. [DOI: 10.1016/j.juro.2008.07.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Indexed: 10/21/2022]
Affiliation(s)
- Mi Mi Oh
- Department of Urology, Korea University Hospital 80, Seoul, Republic of Korea
| | - Myeong Heon Jin
- Department of Urology, Korea University Hospital 80, Seoul, Republic of Korea
| | - Jae Hyun Bae
- Department of Urology, Korea University Hospital 80, Seoul, Republic of Korea
| | - Hong Seok Park
- Department of Urology, Korea University Hospital 80, Seoul, Republic of Korea
| | - Jeong Gu Lee
- Department of Urology, Korea University Hospital 80, Seoul, Republic of Korea
| | - Du Geon Moon
- Department of Urology, Korea University Hospital 80, Seoul, Republic of Korea
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Chevalier I, Benoît G, Gauthier M, Phan V, Bonnin ACB, Lebel MH. Antibiotic prophylaxis for childhood urinary tract infection: a national survey. J Paediatr Child Health 2008; 44:572-8. [PMID: 19012629 DOI: 10.1111/j.1440-1754.2008.01385.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To describe attitudes of paediatricians and paediatric nephrologists regarding antibiotic prophylaxis for urinary tract infection (UTI) and determine the factors associated with its use. METHOD A self-administered questionnaire was mailed to Canadian paediatricians (1136) and paediatric nephrologists (42). RESULTS The response rate was 58.1% (684 physicians); 436 who had made a decision about antibiotic prophylaxis for childhood UTI in the previous year were included in the analysis. Of these, 407 (93.3%) were certified in paediatrics and 29 (6.7%) were paediatric nephrologists. Most respondents prescribed prophylaxis for children with grade III-V vesicoureteral reflux (VUR) (96.5%-98%); 69.8 and 92.8% prescribed it for children with grades I and II VUR, respectively. Factors significantly associated with use of prophylaxis for children with grade I VUR were frequency of decision-making about prophylaxis, city size and province. Fifteen percent of physicians felt that their practice regarding antibiotic prophylaxis for children with VUR was evidence based. A hundred one respondents (24.3%) prescribed prophylaxis for infants with a first febrile UTI in the absence of VUR. Nineteen percent felt that their practice regarding antibiotic prophylaxis for these infants was evidence based. Prescription of prophylaxis for children >12 months with recurrent UTI in the absence of VUR was influenced by frequency of pyelonephritis (88.5% of respondents) and presence of voiding dysfunction (53.8%). Nine percent of physicians felt that their practice for these children was evidence based. CONCLUSION Opinions of Canadian paediatricians and paediatric nephrologists regarding antibiotic prophylaxis for UTI in children vary widely, probably because of the paucity of solid evidence about prophylaxis.
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The outcome of surgery versus medical management in the treatment of vesicoureteral reflux. Adv Urol 2008:437560. [PMID: 18670634 PMCID: PMC2479883 DOI: 10.1155/2008/437560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Accepted: 06/12/2008] [Indexed: 11/18/2022] Open
Abstract
Evaluation of the relative merits of medical versus surgical management of vesicoureteral reflux (VUR) has been limited by the few prospective studies comparing these strategies. Among those trials that have been reported, the only consistent positive finding has been that incidence of febrile UTI is lower among children undergoing surgical treatment in comparison with medical treatment. Studies have not found significant differences in overall incidence of UTI, or in rates of new renal scarring or progression of existing scarring. It is likely that there is a subset of children with VUR who do benefit from aggressive treatment of their VUR, but we are not yet able to fully determine which children these are. It is hoped that future research will further clarify which treatments are useful in which children.
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The relationship between urinary tract infections and vesicoureteral reflux in Turkish children. Int Urol Nephrol 2008; 41:947-51. [DOI: 10.1007/s11255-008-9420-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2007] [Accepted: 06/23/2008] [Indexed: 12/29/2022]
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Current status of Gil-Vernet trigonoplasty technique. Adv Urol 2008:536428. [PMID: 18682815 PMCID: PMC2494586 DOI: 10.1155/2008/536428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2008] [Accepted: 06/02/2008] [Indexed: 11/18/2022] Open
Abstract
Significant controversy exists regarding vesicoureteral reflux (VUR) management, due to lack of sufficient prospective studies. The rationale for surgical management is that VUR can cause recurrent episodes of pyelonephritis and long-term renal damage. Several surgical techniques have been introduced during the past decades. Open anti-reflux operations have high success rate, exceeding 95%, and long durability. The goal of this article is to review the Gil-Vernet trigonoplasty technique, which is a simple and highly successful technique but has not gained the attention it deserves. The mainstay of this technique is approximation of medial aspects of ureteral orifices to midline by one mattress suture. A unique advantage of Gil-Vernet trigonoplasty is its bilateral nature, which results in prevention from contralateral new reflux. Regarding not altering the normal course of the ureter in Gil-Vernet procedure, later catheterization of and retrograde access to the ureter can be performed normally. There is no report of ureterovesical junction obstruction following Gil-Vernet procedure. Gil-Vernet trigonoplasty can be performed without inserting a bladder catheter and drain on an outpatient setting. Several exclusive advantages of Gil-Vernet trigonoplasty make it necessary to reconsider the technique role in VUR management.
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Value of comprehensive renal ultrasound in children with acute urinary tract infection for assessment of renal involvement: comparison with DMSA scintigraphy and final diagnosis. Eur Radiol 2008; 18:2981-9. [PMID: 18641996 DOI: 10.1007/s00330-008-1081-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 05/09/2008] [Accepted: 05/17/2008] [Indexed: 10/21/2022]
Abstract
The aim of this study was to evaluate the value of comprehensive renal ultrasound (US), i.e., combining greyscale US and amplitude-coded color Doppler sonography (aCDS), for assessment of urinary tract infection (UTI) in infants and children, compared to (1) (99m)Tc DMSA scintigraphy and (2) final diagnosis. Two hundred eighty-seven children with UTI underwent renal comprehensive US and DMSA scintigraphy. The results were compared with regard to their reliability to diagnose renal involvement, using (1) DMSA scintigraphy and (2) final diagnosis as the gold standard. Sixty-seven children clinically had renal involvement. Sensitivity increased from 84.1% using only aCDS to 92.1% for the combined US approach, using DMSA scintigraphy as the reference standard. When correlated with the final diagnosis, sensitivity for DMSA scintigraphy was 92.5%; sensitivity for comprehensive US was 94.0%. Our data demonstrate an increasing sensitivity using the combination of renal greyscale US supplemented by aCDS for differentiation of upper from lower UTI. Sensitivity for DMSA and comprehensive US was similar for both methods compared to the final diagnosis. Comprehensive US should gain a more important role in the imaging algorithm of children with acute UTI, thereby reducing the radiation burden.
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Dimercaptosuccinic acid (DMSA) renal scan in the evaluation of hypertension in children. Pediatr Nephrol 2008; 23:435-8. [PMID: 18026997 DOI: 10.1007/s00467-007-0656-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 09/11/2007] [Accepted: 09/12/2007] [Indexed: 10/22/2022]
Abstract
Renal scarring is known to be associated with hypertension. The primary objective of this study was to investigate the prevalence of renal scarring in children referred to our clinic with hypertension. The secondary objective was to compare renal ultrasound (US) examination with dimercaptosuccinic acid (DMSA) renal scan in diagnosing renal scars in these patients. The study included 159 patients who underwent DMSA renal scan as well as renal US for the evaluation of hypertension of unknown etiology. Thirty-three (21%) patients were found to have renal scars; their demographic details, including mean age and gender distribution, were not significantly different from those without renal scars. In comparison with the DMSA renal scan, sensitivity and specificity of renal US in diagnosing renal scars were 36% and 94%, respectively. In our study, in which the prevalence of scarring was 21%, this gave positive predictive and negative predictive values of 63% and 85%, respectively. In conclusion, our study indicates that renal scarring is present in 21% of otherwise healthy children who are evaluated for newly diagnosed hypertension, and renal US is not a sensitive imaging modality to rule out renal scarring.
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Abstract
PURPOSE OF REVIEW To highlight recent controversies regarding the rationale and effectiveness of imaging and treatment strategies for children who experience a first urinary tract infection. RECENT FINDINGS The yield of renal ultrasound for children who have had a first urinary tract infection is relatively low, and the most commonly identified abnormalities are of unclear clinical significance. If concerned about renal ultrasound abnormalities, clinicians should not be reassured by a normal late trimester prenatal ultrasound because its negative predictive value is not sufficiently high. Vesicoureteral reflux is neither necessary nor sufficient for developing renal scars. Some pyelonephritis and renal scarring may be related to vesicoureteral reflux that is missed by standard voiding cystourethrogram but detectable during positional instillation of contrast cystography. Dimercaptosuccinic acid scans provide important information about presence of pyelonephritis and renal scars, and have high negative predictive value for ruling out high-grade (III-V) vesicoureteral reflux. Antimicrobial prophylaxis may not be effective for preventing recurrent infections and may result in antimicrobial resistance. Endoscopic therapy (Deflux) has demonstrated moderate success in correcting vesicoureteral reflux, but little is known about its impact on recurrent infection and renal scarring. SUMMARY Debate continues about optimal imaging strategies after first urinary tract infection. More research is needed on the effectiveness of interventions designed to prevent recurrent infections and renal scarring.
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Ochoa Sangrador C, Formigo Rodríguez E. Pruebas diagnósticas de imagen recomendadas en la infección urinaria. An Pediatr (Barc) 2007; 67:498-516. [DOI: 10.1016/s1695-4033(07)70717-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Doganis D, Siafas K, Mavrikou M, Issaris G, Martirosova A, Perperidis G, Konstantopoulos A, Sinaniotis K. Does early treatment of urinary tract infection prevent renal damage? Pediatrics 2007; 120:e922-8. [PMID: 17875650 DOI: 10.1542/peds.2006-2417] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Therapeutic delay has been suggested as the most important factor that is likely to have an effect on the development of scarring after acute pyelonephritis. However, this opinion has not been supported by prospective studies, so we tested it. METHODS In a prospective clinical study, we evaluated whether the time interval between the onset of the renal infection and the start of therapy correlates with the development of acute inflammatory changes and the subsequent development of renal scars, documented by dimercaptosuccinic acid scintigraphy. A total of 278 infants (153 male and 125 female) aged 0.5 to 12.0 months with their first urinary tract infection were enrolled in the study. RESULTS The median time between the onset of infection and the institution of therapy was 2 days (range: 1-8 days). Renal inflammatory changes were documented in 57% of the infants. Renal defects were recorded in 41% of the patients treated within the first 24 hours since the onset of fever versus 75% of those treated on day 4 and onward. Renal scarring was developed in 51% of the infants with an abnormal scan in the acute phase of infection. The frequency of scarring in infants treated early and in those whose treatment was delayed did not differ, suggesting that once acute pyelonephritis has occurred, ultimate renal scarring is independent of the timing of therapy. Acute inflammatory changes and subsequent scarring were more frequent in the presence of vesicoureteral reflux, especially that which is high grade. However, the difference was not significant, which suggests that renal damage may be independent of the presence of reflux. CONCLUSIONS Early and appropriate treatment of urinary tract infection, especially during the first 24 hours after the onset of symptoms, diminishes the likelihood of renal involvement during the acute phase of the infection but does not prevent scar formation.
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Affiliation(s)
- Dimitrios Doganis
- First Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece.
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Montini G, Toffolo A, Zucchetta P, Dall'Amico R, Gobber D, Calderan A, Maschio F, Pavanello L, Molinari PP, Scorrano D, Zanchetta S, Cassar W, Brisotto P, Corsini A, Sartori S, Da Dalt L, Murer L, Zacchello G. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. BMJ 2007; 335:386. [PMID: 17611232 PMCID: PMC1955287 DOI: 10.1136/bmj.39244.692442.55] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the efficacy of oral antibiotic treatment alone with treatment started parenterally and completed orally in children with a first episode of acute pyelonephritis. DESIGN Multicentre, randomised controlled, open labelled, parallel group, non-inferiority trial. SETTING 28 paediatric units in north east Italy. PARTICIPANTS 502 children aged 1 month to <7 years with clinical pyelonephritis. INTERVENTION Oral co-amoxiclav (50 mg/kg/day in three doses for 10 days) or parenteral ceftriaxone (50 mg/kg/day in a single parenteral dose) for three days, followed by oral co-amoxiclav (50 mg/kg/day in three divided doses for seven days). Main outcomes measures Primary outcome was the rate of renal scarring. Secondary measures of efficacy were time to defervescence (<37 degrees C), reduction in inflammatory indices, and percentage with sterile urine after 72 hours. An exploratory subgroup analysis was conducted in the children in whom pyelonephritis was confirmed by dimercaptosuccinic acid (DMSA) scintigraphy within 10 days after study entry. RESULTS Intention to treat analysis showed no significant differences between oral (n=244) and parenteral (n=258) treatment, both in the primary outcome (scarring scintigraphy at 12 months 27/197 (13.7%) v 36/203 (17.7%), difference in risk -4%, 95% confidence interval -11.1% to 3.1%) and secondary outcomes (time to defervescence 36.9 hours (SD 19.7) v 34.3 hours (SD 20), mean difference 2.6 (-0.9 to 6.0); white cell count 9.8x10(9)/l (SD 3.5) v 9.5x10(9)/l (SD 3.1), mean difference 0.3 (-0.3 to 0.9); percentage with sterile urine 185/186 v 203/204, risk difference -0.05% (-1.5% to 1.4%)). Similar results were found in the subgroup of 278 children with confirmed acute pyelonephritis on scintigraphy at study entry. CONCLUSIONS Treatment with oral antibiotics is as effective as parenteral then oral treatment in the management of the first episode of clinical pyelonephritis in children. TRIAL REGISTRATION Clinical Trials NCT00161330 [ClinicalTrials.gov].
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Affiliation(s)
- Giovanni Montini
- Nephrology, Dialysis, and Transplant Unit, Paediatric Department, Azienda Ospedaliera-University of Padua, 35128 Padua, Italy.
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