Chronic renal failure — is modern management of urinary tract infection and antenatal hydronephrosis affecting the outcome?

Abstract

End stage renal failure (ESRF) due to urinary tract infection (UTI) is the commonest potentially preventable cause of ESRF in children and adults. Despite this the simple answer to the question posed in the title is that there is no good evidence to support the proposition that modem management of UTI has affected the incidence of ESRF either in children or in adults. There is, however, overwhelming evidence that modem approaches to UTI should reduce the incidence of ESRF. This paradox is worth exploring because in many respects UTI could be considered a paradigm of present day paediatrics. It is difficult to demonstrate a direct link between UTI and the remote outcome of ESRF which may be delayed for decades after the initial insult and even more difficult, if not impossible, to demonstrate that any intervention has affected this outcome. There is a danger if health provision is increasingly dependent on demonstration of measurable, often short-term, improvements in outcome that problems such as UTI that cannot be encapsulated in such a simple way will not receive the attention they deserve. There are many other problems in paediatrics which are similarly threatened. A further difficulty is that almost all reports of management of UTI have identified deficiencies in clinical practice which reduce the impact of rational management based on research findings and this further hinders the demonstration of an improving outcome. For a variety of reasons the evidence with regards to the impact of the management of antenatal hydronephrosis is even more debatable.