Complexities of correctly studying and reporting potential racial associations of medical conditions

Abstract

Febrile urinary tract infections (UTIs) and febrile recurrent UTIs, compared with UTIs without fever, have been associated with substantial increase in the risk for renal scarring. In this volume of The Journal of Pediatrics, Hum et al report the re-analysis of data from two 2-year prospective studies (completed 10 years ago) of children 2-72 months of age who were followed after first or second symptomatic UTIs. The final sample size of 500 children was accrued from the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study, in which all children had vesicoureteral reflux, and the Careful Urinary Tract Infection Evaluation (CUTIE) study in which no child had vesicoureteral reflux. Patients in both studies were followed for recurrent UTI and febrile illnesses, closely and prospectively, to minimize possible differences related to ascertainment. In multivariate analysis, non-Black race was most significant association with recurrent febrile UTI, with an 8-fold increased odds ratio. The authors of the current report concluded with the intention that their findings should stimulate other studies to explore further the relationship between race and UTIs, and cautioned that race should not be used to make decisions regarding management of children with UTI. The Journal’s decision to publish the article was difficult and was based on the importance of the study question, the methodology, the exceptional quality of the two 2 studies from which data were derived, and thorough peer review. Although race is now considered a social construct with limited value as a biological proxy, non-Black race has been identified multiple times previously as a risk factor for recurrent UTIs. There was considerable discussion among The Journal’s editors concerning the categorization of race simply as Black and non-Black, and how the study findings might be interpreted. We agreed that if a de novo study with the same approach were submitted today, it would likely not be accepted. That being said, it is possible that the differential finding in regard to race relates to social determinants of health or subtle biological effects, such as circumcision that tracks with race. Unfortunately, the available data did not permit this factor to be examined. The Journal editors agree that race should not be used as a factor in decisions regarding UTI management. Further research is needed, and future work should use specific racial and ethnic categories, rather than collective terms, with clear a priori hypotheses about potential risk factors and the driving forces. Article page 152 ▸ Risk Factors for the Development of Febrile Recurrences in Children with a History of Urinary Tract InfectionThe Journal of PediatricsVol. 243PreviewTo identify risk factors for febrile recurrence of urinary tract infections (UTIs) in children with a history of UTI. Full-Text PDF