Economic and radiation costs of initial imaging approaches after a child's first febrile urinary tract infection

Imaging of Vesicoureteral Reflux: AJR Expert Panel Narrative Review

Vesicoureteral reflux (VUR) is a common congenital anomaly of the urinary tract that can present with collecting system dilation or as a febrile infection. VUR can lead to permanent renal sequelae requiring surgery but can also spontaneously resolve without complication. Therefore, recognizing patient populations who warrant imaging for screening, confirmation, or ongoing surveillance for VUR is important, as is avoiding overdiagnosis. In the appropriate patient populations, an accurate diagnosis of VUR allows early treatment and prevention of pyelonephritis and scarring. Various imaging modalities are available to diagnose and grade VUR, including voiding cystourethrography, radionucleotide cystography, and contrast-enhanced voiding urosonography (ceVUS). The objective of this article is to summarize the current understanding of VUR diagnosis and management and to discuss these imaging modalities' strengths and pitfalls. Considerations include indications for VUR imaging, patient preparation, conduct of the examination, issues related to radiologic reporting, and cost-effectiveness. An emphasis is placed on ceVUS, which is the most recently introduced of the three imaging modalities and is receiving growing support among pediatric radiologists.

Management of Pediatric Urinary Tract Infections: A Delphi Study

Urinary tract infection (UTI) is one of the most common infectious diseases in the pediatric population and represents a major cause of antibiotic consumption and hospitalization in children. Considering the ongoing controversies on the management of pediatric UTI and the challenges due to increasing antimicrobial resistance, the aim of the present study was to evaluate the level of agreement on UTI management in pediatric age in Emilia-Romagna Region, Italy, and to assess on the basis of recent studies whether there is the need to change current recommendations used by primary care pediatricians, hospital pediatricians, and pediatric surgeons in everyday clinical practice to possibly improve outcomes. This consensus provides clear and shared indications on UTI management in pediatric age, based on the most updated literature. This work represents, in our opinion, the most complete and up-to-date collection of statements on procedures to follow for pediatric UTI, in order to guide physicians in the management of the patient, standardize approaches, and avoid abuse and misuse of antibiotics. Undoubtedly, more randomized and controlled trials are needed in the pediatric population to better define the best therapeutic management in cases with antimicrobial resistance and real usefulness of long-term antibiotic prophylaxis.

Variation in ureteric re-implantation for Australian children

BACKGROUND

Management options for vesicoureteric reflux are numerous, increasingly diversifying and debated. There is longstanding anecdotal opinion of inexplicable regional variation in vesicoureteric reflux management in Australia. This study investigates temporal trends in ureteric re-implantation for children, and variation between states and territories.

METHODS

Ureteric re-implantation data for children aged 0-14 years were retrieved from the Medicare Benefits Scheme item reports database for the 20-year period from 1998-2017. Claims data were population adjusted for each state then standardized for age using Australian Bureau of Statistics records. National and regional trends were calculated using joinpoint regression. Comparison between eastern (New South Wales, Victoria, Queensland, Tasmania, Australian Capital Territory) and western or central (Western Australia, South Australia) states was performed using the Mann-Whitney U-test.

RESULTS

There were 4919 procedure rebate claims during the study period. A national decrease in claim rates of 6.3% per 100 000 children was identified (P < 0.001). This was derived from significant decreases observed in eastern states. There was a threefold higher claim rate in Western Australia and South Australia per annum compared to the remainder of the country (4.0 versus 12.6 per 100 000; P < 0.001). For the most recent 5 years of the study period, this difference increased to a sevenfold higher rate (1.6 versus 11.1; P < 0.001).

CONCLUSION

There has been a dramatic nationwide decline in the rate of ureteric re-implantation procedure claims. Regional disparity between each side of the country is widening. Further research is required to determine if this degree of variation is warranted or unwarranted. The observed regional variation facilitates opportunity for a nationwide pragmatic clinical trial.

Urinary C-megalin for screening of renal scarring in children after febrile urinary tract infection

BackgroundFebrile urinary tract infection (fUTI) in children may cause renal scarring. This study aimed to investigate the usefulness of urinary biomarkers for diagnosing renal scarring after fUTI.MethodsThirty-seven children (median age: 1.36 years, range: 0.52-12.17 years, 25 boys) with a history of fUTI, who underwent renal scintigraphy for 4 months or longer after the last episode of fUTI, were analyzed. A spot urine sample was obtained on the day of renal scintigraphy to measure levels of total protein, N-acetyl-β-D-glucosaminidase (NAG), β₂-microglobulin (BMG), neutrophil gelatinase-associated lipocalin (NGAL), liver-type fatty acid binding protein (L-FABP), and C-megalin (full-length megalin). Results were corrected for urinary creatinine (Cr) and compared between the group with renal scarring (n=23) and that without scarring (n=14). Urinary levels of C-megalin were also measured in healthy control subjects.ResultsNo significant differences in total protein, NGAL, L-FABP, NAG, and BMG levels were found between the groups. However, C-megalin levels were significantly higher in the renal scarring group than in the non-renal scarring group and healthy controls (P<0.001). A cutoff value of 6.5 pmol/nmol of urinary C-megalin/Cr yielded 73.9% of specificity and 92.9% of sensitivity.ConclusionUrinary C-megalin is useful for diagnosing renal scarring caused by fUTI.

Urinary tract infection in children: Diagnosis, treatment, imaging - Comparison of current guidelines

BACKGROUND AND OBJECTIVE

Urinary tract infection (UTI) is a frequent disorder of childhood, yet the proper approach for a child with UTI is still a matter of controversy. The objective of this study was to critically compare current guidelines for the diagnosis and management of UTI in children, in light of new scientific data.

METHODS

An analysis was performed of the guidelines from: American Academy of Pediatrics (AAP), National Institute for Health and Care Excellence (NICE), Italian Society of Pediatric Nephrology, Canadian Paediatric Society (CPS), Polish Society of Pediatric Nephrology, and European Association of Urology (EAU)/European Society for Pediatric Urology (ESPU). Separate aspects of the approach for a child with UTI, including diagnosis, treatment and further imaging studies, were compared, with allowance for recent research in each field.

CONCLUSIONS

The analyzed guidelines tried to reconcile recent reports about diagnosis, treatment, and further diagnostics in pediatric UTI with prior practices and opinions, and economic capabilities. There was still a lack of sufficient data to formulate coherent, unequivocal guidelines on UTI management in children, with imaging tests remaining the main area of controversy. As a result, the authors formulated their own proposal for UTI management in children.

Recurrent urinary tract infections in young children: role of DMSA scintigraphy in detecting vesicoureteric reflux

BACKGROUND

Performing micturiting cystourethrography (MCUG) in young children with recurrent urinary tract infections is controversial with discrepancy among the major guidelines.

OBJECTIVE

Previous studies have shown that a normal dimercaptosuccinic acid (DMSA) scintigraphy may avoid the need of performing MCUG for detecting vesicoureteric reflux in children with first febrile urinary tract infection. However, the role of DMSA for ruling out vesicoureteric reflux in children with recurrent urinary tract infections has not been studied.

MATERIALS AND METHODS

Approval from institutional ethical review committee was sought and the requirement of informed consent was waived. A total of 50 children under the age of 10 years with recurrent urinary tract infections underwent MCUG scan within 3 months of DMSA scan from January 2011 to September 2012 at our institution. Diagnosis of recurrent urinary tract infections and grading of vesicoureteric reflux was according to previously established standards. Abnormalities on DMSA scan - scarring, hydronephrosis and reduced differential renal function - were compared with presence of vesicoureteric reflux on MCUG.

RESULTS

High-grade vesicoureteric reflux was noted on MCUG in 22 (44%) cases. The findings on DMSA included hydronephrosis and scarring in 25 (50%) and 25 (50%) cases, respectively. Abnormalities on DMSA scan for detecting the presence of high-grade vesicoureteric reflux on MCUG examination had sensitivity, specificity, positive and negative predictive values of 95.45%, 35.71%, 53.85% and 90.91%, respectively. The positive and negative likelihood ratios were 1.48 and 0.13 respectively.

CONCLUSION

DMSA scan had high overall sensitivity and negative predictive value with a low negative likelihood ratio for ruling out high-grade vesicoureteric reflux on MCUG, which may obviate the need of invasive MCUG along with its associated drawbacks.

Estimating utility values for vesicoureteral reflux in the general public using an online tool

INTRODUCTION

Cost-utility analyses are useful to study conditions without a widely accepted treatment algorithm; in pediatric urology, one such condition is vesicoureteral reflux (VUR). A necessary component of cost-utility analyses is to accurately calculate the "utility", a numerical surrogate of quality of life, for various health states. Our aims were to determine utility values for representative VUR health states and to verify the feasibility of a novel online platform for utility elicitation in order to reduce the time and expense of such analyses.

METHODS

A cross-sectional survey of American adults was conducted using the time-trade-off (TTO) method. Respondents were recruited from an online work interface, Amazon's Mechanical Turk (MTurk). Four annualized VUR health states were assessed: VUR treated with/without continuous antibiotic prophylaxis (CAP) and with/without associated febrile urinary tract infection (UTI). A 6-week post-operative scenario following open ureteroneocystostomy was also assessed.

RESULTS

We received 278 survey responses (70% response rate). The respondents were largely between the ages of 25 and 44 (59%), female (60%), and Caucasian (76%). Thirty-seven percent had a college degree, and 44% were parents. Compared with a perfect health state of 1.0, we found mean utilities of 0.87 for VUR, regardless of whether CAP was used or whether UTI was present (p=0.9). The immediate post-operative period following ureteroneocystostomy garnered an annualized utility of 0.94.

CONCLUSIONS

Our data suggest that MTurk-based utility assessment is feasible, and that subjects view the VUR health state as only slightly inferior to perfect health. This includes VUR health states incorporating CAP and febrile UTI.

Predictive risk factors in childhood urinary tract infection, vesicoureteral reflux, and renal scarring management

Approaches to the management of children with urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scars have been challenged and have become controversial over the past decade. It is difficult to determine when, how, and which patients will benefit from the diagnosis and management of this condition. Therefore, the issues of diagnostic imaging, observation, follow-up, and intervention tend to be decided more on a case-by-case basis, rather than by using an algorithm. Over the past few years, there have been advances in the identification of risk factors that predispose patients with UTI to present with VUR, to develop recurrent UTIs and renal scars, to have deteriorating renal function, to show VUR improvement and/or spontaneous resolution, and to be candidates for and benefit from early surgical intervention.

Relevance of current guidelines in the management of VUR

In recent years, there have been fundamental changes in the understanding of vesicoureteral reflux (VUR). This is reflected by current international guidelines that cover diagnosis, screening, and treatment of VUR. However, literature is still lacking and many questions are unsolved. In this article, we shortly review the important aspects of the current guidelines. Due to the lack of high-powered randomized controlled trials, guidelines often are based on an expert's opinion rather than evidence. In this review article, we address the controversies in the management of VUR; siblings and children with antenatally diagnosed hydronephrosis and the management of a patient with VUR.

CONCLUSION

With an individualized approach and patient risk stratification, the goal today must be to address the clinical problem, avoid unnecessary tests, and provide good quality of life for the patient and parents.

Identifying children with vesicoureteral reflux: a comparison of 2 approaches

PURPOSE

Various screening approaches have been proposed to identify the subgroup of children with urinary tract infection who have vesicoureteral reflux. However, few studies have compared the sensitivity of screening approaches in a representative population of young children. We compared the sensitivities of the top-down ((99m)technetium dimercaptosuccinic acid renal scan to screen) and biomarker based (C-reactive protein level at presentation) approaches in identifying children with vesicoureteral reflux.

MATERIALS AND METHODS

We calculated the sensitivity of the 2 screening approaches in detecting vesicoureteral reflux and subsequently high grade (III or greater) vesicoureteral reflux in children.

RESULTS

The top-down and C-reactive protein based approaches missed 33% and 29% of cases of high grade vesicoureteral reflux, respectively.

CONCLUSIONS

The sensitivity of the top-down approach for detecting high grade vesicoureteral reflux was lower than previously reported. Further study of novel methods to identify children at risk for renal scarring is warranted.