Risk Of Renal Scarring Research Articles

Clinical, uropathogenic, and radiological profile of culture-positive urinary tract infections in children below 18 months of age

Background: Urinary tract infections (UTIs) are common in children and have the risk of renal scarring. To better identify this at risk group, the following study was carried out to analyze the clinical profile of children below 18 months of age with culture-positive UTI and the outcome of radiological investigations. The primary objective was to assess the clinical profile of culture-positive UTI children and diagnostic yield and correlation between radiological tests. The secondary objectives were to assess the prevalent uropathogens and their antibiogram. Materials and Methods: For this retrospective study, clinical details regarding radiological investigations, prevalent uropathogens and antibiograms, common antibiotics used in treatment, and uroprophylaxis were obtained through electronic medical records in children <18 months of age admitted with culture-positive UTI. Results: In 225 children seen over a period of 36 months, a slight male predominance (56%) was observed. Ultrasonography (USG) was done in nearly all children, micturating cystourethrography (MCU) was performed in only 40% of patients, dimercaptosuccinic acid (DMSA), performed after 6 months of the index UTI, in one-fifths of the patients. All three investigations were performed in one out of six children. USG and MCU used in combination detected the highest number of significant abnormalities (39%) compared to USG and DMSA (32%). Escherichia coli was the predominant uropathogen identified. Significant meropenem resistance (52%) was observed in the community-acquired UTI. Conclusion: The evaluation and follow-up of infants and young children with UTI show inadequate radiological evaluation, which could increase the risk of undetected and untreated renal sequelae.

The impact of reflux pressure on renal scarring in children with sterile vesicoureteral reflux

Vesicoureteral reflux (VUR) is a complex disease as patient spectrum is variable. Some cases struggle with recurrent febrile urinary tract infections (UTI) and end-up with renal scars despite intervention. While others suffer no clinical problems and need no treatment. The detrimental effect of VUR on kidneys depends on many factors like grade of reflux, detrusor pressure, and presence of voiding dysfunction. The adverse effects of sterile VUR on kidneys is still under discussion. Thus, we assessed the impact of detrusor pressure at VUR onset on renal scarring in children with sterile reflux. We retrospectively reviewed the five years follow-up data of 38 children who had unilateral VUR without UTI under treatment. No febrile or afebrile UTIs were detected during the follow-up in any children. All children were assessed with annual video-urodynamics and renal scintigraphy for five consecutive years. The detrusor pressure at VUR onset, grade of VUR, presence of involuntary detrusor contractions, bladder capacity and the presence of renal scaring were recorded. All VURs were recorded during the voiding phase and children with VUR during the filling phase were excluded from the study. In the first line of video-urodynamic studies, the mean detrusor pressure at VUR onset was 24.3±14.8cm/H2O (median 34.5cm/H2O, min: 6 - max: 47). There was no relation between boys and girls regarding median detrusor pressure at VUR onset (p=0.356). Eventually, 22 (57.9%) children developed renal scars and ended up with surgery. There was no relation between scar development and age at first presentation (p=0.888) The cut-off value for detrusor pressure at VUR onset was noted as 26cm/H2O (AUC: 0.849 [p<0.01], Figure). In children who developed renal scars eventually, the median detrusor pressure at VUR onset was significantly higher (p<0.01). The detrimental effect of VUR on kidneys is associated with recurrent infections, bladder dysfunction, and detrusor pressure. Dispute over risk of renal scarring in patients with sterile VUR still continues. Children in whom VUR start at higher voiding pressures suffer more renal scars. The threshold of voiding detrusor pressure for risky patients is identified as 26cm/H2O. It is true that patients suffering recurrent febrile UTIs have higher risk of developing renal scarring. However, the impact of sterile reflux should not be underestimated, since renal scars due to sterile reflux may develop in patients under antibiotic prophylaxis.

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

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

New strategy of color and power doppler sonography combined with DMSA in the assessment of acute pyelonephritis in infants

BackgroundThe purpose of this study was to evaluate the clinical value of color and power doppler sonography (CPDS) when combined it with 99mTc-dimercaptosuccinic acid scintigraphy (DMSA) in assessment of acute pyelonephritis (APN) in infants.MethodsA total of 79 children with APN admitted to our hospital from June 2016 to Jan 2019 were enrolled, including 52 boys and 27 girls, age range 1 month to 3 years old. All cases followed the diagnostic criteria for acute pyelonephritis and excluded anatomical abnormalities of urinary system. All 79 patients were examined by urinary ultrasonography (US), CPDS, and DMSA within 48 h of fever and analyzed the clinical value of combining the two methods in the assessment of APN in infants.ResultsAmong 79 children, urinary ultrasonography revealed 2 cases of renal cortical echo changes, both located in the upper pole of the kidney, 24 cases of kidney enlargement, and 1 case of left kidney shrinkage. Ninety-five kidneys were shown to be diseased with DMSA, while 105 kidneys abnormal by CPDS. The sensitivity of CPDS was 69.4%, and the specificity was 38.1%. In children younger than 6 months, the sensitivity of CPDS was 56.9%, which was 84.2% in childeren between 6 months to 1 year, and 94.4% from 1 to 3 years old, respectively. The corresponding specificity of CPDS was 44.1, 26.7, and 35.7%. There was no significant correlation between CPDS levels and DMSA positive results. The abnormal rate of intermediate part in the kidneys was significantly lower than that in the upper and lower poles. Children with abnormal CPDS have a greater risk of renal scarring(p < 0.05).ConclusionAbnormalities detected by CPDS in a cohort of infants with APN poorly correlated with DMSA findings. But the sensitivity of CPDS is highly age-related, it can be used as a non-invasive helpful tool for early diagnosis of acute pyelonephritis in infants older than 6 months old.

Long-term outcomes of urinary tract infection (UTI) in childhood: The LUCI study

Background Guidelines recommend the prompt diagnosis and treatment of UTI in young children to reduce the risk of renal scarring and possible long-term complications. However, the evidence for this association is weak and has been questioned. There is an urgent need to clarify this as the correct approach to urine sampling and diagnosis of UTI in children hinges on this association.&#x0D; Main Aim Determine outcomes following UTI in childhood (&lt;5years)&#x0D; Approach We used the Secure Anonymised Information Linkage (SAIL) Databank to access demographic, hospital, GP and microbiology data from children in Wales. Children with &gt;1 microbiologically confirmed UTI (mcUTI) aged &lt;5, were compared to those with no mcUTI. The primary outcome was renal scarring and secondary outcomes included hypertension, chronic kidney disease and renal failure. The primary analysis used multinomial regression and time to event models.&#x0D; Results A cohort of 159,201 children was defined. 11,099 (7.0%) had &gt;1 mcUTI.&#x0D; The overall prevalence of renal scarring in the cohort by age 7 was 0.16%; 1.26% in those with &gt;1 mcUTI; 0.08% in those with no mcUTI. The unadjusted odds ratio (OR) was 16.62 (12.91-21.39) and adjusted 3.64 (2.57-5.14). Among the group with &gt;1 mcUTI, predictors of renal scarring were VUR, younger age of first UTI, and greater number of UTIs &lt;5&#x0D; Conclusion UTI was associated with renal scarring even after adjusting for covariates.&#x0D; The prevalence of renal scarring in children with &gt;1 mcUTI was lower than expected. Possible explanations include poor coding in routine data, different patient populations or missed renal scarring diagnoses. We are currently validating our results using radiology data. If renal scarring diagnoses are being missed, a more proactive urine sampling and imaging strategy may be indicated. However, if renal scarring rates are low following UTI, this may not be necessary.

CME Questions

CME Questions| November 01 2019 CME Questions AAP Grand Rounds (2019) 42 (5): 60. https://doi.org/10.1542/gr.42-5-60 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation CME Questions. AAP Grand Rounds November 2019; 42 (5): 60. https://doi.org/10.1542/gr.42-5-60 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All AAP SitesAll PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP News Search Advanced Search Topics: education, medical, continuing, objective (goal) The following continuing medical education questions cover the content of the November 2019 issue of AAP Grand Rounds. Please keep this issue. Each year’s material is worth up to 18 AMA PRA Category 1 Credit(s)TM. Complete and claim credit online at www.aapgrandrounds.org. Need username and password? Contact customer service at 866-843-2271. Understand the association of gluten intake during the first 5 years of life with the risk of celiac disease.Detail the risk of renal scarring with number of febrile UTIs.Describe the association of stricter firearm laws with pediatric firearm-related mortality. 2019 You do not currently have access to this content.

Serum soluble ST2 as a marker of renal scar in pediatric upper urinary tract infection

Background and objectivesUpper urinary tract infection is the most common serious bacterial infection in childhood. Patients with upper urinary tract infection have a risk for renal scarring with subsequent complications including hypertension, proteinuria, and progressive renal failure. However, the predictive biomarkers of renal scarring in children with upper urinary tract infection are still unknown. In this study, we evaluated whether soluble ST2 levels can be biomarkers of subsequent renal scarring in patients with upper urinary tract infection. Design, setting, participants, and measurementsWe retrospectively studied pediatric patients with upper urinary tract infection at a tertiary center. Twenty-eight children had an upper urinary tract infection with (n = 14) and without (n = 14) renal scarring and underwent 99mtechnetium dimercaptosuccinic acid imaging. In addition, 13 control subjects were enrolled. The clinical data and serum cytokine levels, including soluble ST2 levels, were compared between those with and without renal scars. ResultsSerum soluble ST2 levels were significantly higher in the scar group than in the non-scar group, whereas there was no difference in the levels of serum interferon-γ, interleukin-6, interleukin-10, soluble tumor necrosis factor receptor 1, and transforming growth factor-β between the scar and non-scar groups. The area under the curve for differentiating between the non-scar and scar groups on the basis of measurements of serum soluble ST2 was 0.79, with a sensitivity and specificity of 92.9% and 64.3%, respectively. ConclusionThese results suggest that serum soluble ST2 levels on admission could be a useful biomarker of subsequent renal scarring in pediatric patients with upper urinary tract infection.

What Factors Might Cause Delay in Providing Antibiotics to Children with UTI

Prompt initiation of antibiotic therapy for urinary tract infection (UTI) may reduce risk for renal scarring. To identify risk factors for delayed

Vesicoureteral Reflux and Renal Scarring in Infants After the First Febrile Urinary Tract Infection.

Introduction:The objective of this research was to determine whether vesicoureteral reflux(VUR) was associated with evolution to renal scarring (RS) following a febrile urinary tract infection (UTI) in infants.Materials and methods:Our research included 100 infants, ages up to 1 year with a first febrile UTI. The diagnostic was based on results of: laboratory findings, ultrasonography (USG), voiding cystourethrography (VCUG) and initial and control renal scintigraphy (DMSA renal scan) withtechnetium99mTcsuccimer (dimercaptosuccinic acid), to assess the acute pyelonephritis (APN), VUR and RS.Results:APN was proven with DMSA renal scan in 66 (66%) infants. Twenty-two infants (33.3%) had VUR in-group of patients with APN. On the control DMSA scan, performed 6 months after the first DMSA, the presence of RS was found in 18 (27.27%) infants. In infants with renal scars VUR were discovered in 9 of them (50%).Conclusions:The pathogenesis of RS after febrile UTI in young children is multifactorial. Children with VUR have an increased risk for APN and RS. However, VUR is not the only precondition for RS. Creating a renal scarring cannot be imagined without the inflammatory process of the upper urinary system. Therefore, early detection and treatment of febrile UTIs in children and identify children at risk for RS are of primary importance.

Antibiotics Prophylaxis in Patients with CAKUT, Does It Actually Prevent UTI? A Single Center Experience at South Africa

Background: Congenital anomalies of the kidney and urinary tract (CAKUT) are a well-documented risk factor for the development of urinary tract infection (UTI) in children. Prevention of UTI in this group of patients is advocated due to their increased risk of renal scarring, hypertension and end stage kidney failure. Methods: A 10-year retrospective review of CAKUT patients at the Johannesburg Academic Hospital, who were placed on prophylactic antibiotics over a certain period was done. The rate of UTI, the types of causative organisms isolated and the efficacy of prophylactic antibiotics in preventing UTI were documented. Results: Thirty-six (36) out of 134 patients had been started on prophylactic antibiotics after the diagnosis of CAKUT was made. There was a statistically significant association between the use of prophylactic antibiotics and the rate of UTI (p Conclusion: Antibiotic prophylaxis was very effective in decreasing the rate of UTI in our cohort of patients with CAKUT.

The Role of Renal Ultrasound in Children With Febrile Urinary Tract Infection

Background: This study was designed to examine the capability of renal ultrasonography (US) for predicting vesicoureteral reflux (VUR) and renal scarring (RS), and to assess, using initial US, the significant urologic abnormalities that impact on management of children hospitalized with the first febrile urinary tract infection (UTI). Methods: Hospitalized children aged <= 2 years with the first febrile UTI were prospectively evaluated using imaging studies, including 99mTc dimercaptosuccinic acid (DMSA) scan, US, and voiding cystourethrography. Results: Of the 310 children analyzed (195 boys and 115 girls), 105 (33.9%) had abnormal US. Acute DMSA scans were abnormal in 194 children (62.6%), including 89 (45.9%) with concomitant abnormal US. There was VUR in 107 children (34.5%), including 79 (25.5%) with grades III-V VUR. The sensitivity and negative predictive values of US were 52.3% and 75.1%, respectively, for grades I-V VUR; and 68.4% and 87.8%, respectively, for grades III-V VUR. Eighty-five children (27.4%) had RS, including 55 (64.7%) with abnormal US. Of the 105 children with abnormal US, 33 (31.4%) needed subsequent management (surgical intervention, parental counseling, or follow-up of renal function). Nephromegaly on initial US and grades III-V VUR were risk factors of RS. Conclusions: Abnormal US may carry a higher probability of grades III-V VUR and RS, and can affect subsequent management in a significant number of children. Nephromegaly on initial US and grades III-V VUR are strongly associated with an increased risk for RS. Thus, US should be performed on children after the first febrile UTI and children with normal US may not require voiding cystourethrography. Int J Clin Pediatr. 2018;7(1-2):6-12 doi: https://doi.org/10.14740/ijcp295e

Molecular and Imaging Diagnostic Techniques for Urinary Tract Infections: Modern Approaches

In developing countries, the frequent failure of the available phenotypic approaches for laboratory diagnosis of urinary tract infections in providing results at the point where medical care is mostly required, becomes a major barrier to efficient antibiotic treatment and management of urinary tract infections in the public health sector. This review therefore focuses on molecular and imaging diagnostic techniques for urinary tract infection as rapid and effective modern approaches requires in health care delivery. Currently, available laboratory diagnoses of urinary tract infection in developing countries are mostly phenotypic approaches, and takes not less than two-four days before completion and result made available for appropriate treatment. From literature, it is apparent that these old-century approaches produce portion of patients’ result that does not fit the true picture; and the techniques had been found with more disadvantages than advantages. Molecular approaches are now emerging as modern laboratory test techniques which enable rapid and effective diagnosis of urinary tract infection with Biosensor, Microfluidics, Polymerase Chain Reaction (PCR) and other integrated platforms technologies. These emerging technologies could improve urinary tract infection diagnosis via direct pathogen detection from urine samples, rapid antimicrobial susceptibility testing, high precision and point of care testing in public health sector. Imaging techniques have also been so useful in identifying risk factors and abnormalities that can be modified; to decrease likelihood of recurrent (upper) UTI; and to reduce risk of renal scarring. These approaches however, had proved so successful that seems they will replace old-century testing methods, and hence, provides efficient antibiotic treatment and management; therefore, saving health care costs and valuable diagnosis time.

Urinary Tract Infections in Infants and Children.

Urinary tract infections (UTI) are one of the most common infections in children and symptoms may be nonspecific. The risk of renal scarring is highest in children under 1 year of age with febrile UTI and high-grade vesicoureteral reflux (VUR). Although treatment of UTI is usually straightforward, given increased rates of antimicrobial resistance worldwide, the choice of treatment for pediatric UTI should be guided by community resistance patterns whenever feasible. The benefit of antimicrobial prophylaxis after first UTI and/or in the presence of VUR remains controversial, but a recent meta-analysis supports continuous antimicrobial prophylaxis in children with VUR, indicating a need for more research in this area.

Vesico-ureteral reflux: Diagnosis and treatment recommendations

Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux. Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage. The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies. Decisions on treatment should be made individually with parents taking into account all the findings available.

Role of Renal Ultrasonography in Predicting Vesicoureteral Reflux and Renal Scarring in Children Hospitalized with a First Febrile Urinary Tract Infection

This study was designed to examine the capability of renal ultrasonography (US) for predicting vesicoureteral reflux (VUR) and renal scarring (RS), and to assess, using initial US, the significant urologic abnormalities that impact on management of children hospitalized with a first febrile urinary tract infection (UTI). Hospitalized children aged ≤ 2 years with a first febrile UTI were prospectively evaluated using imaging studies, including (99m)Tc dimercaptosuccinic acid (DMSA) scan, US, and voiding cystourethrography. Of the 310 children analyzed (195 boys and 115 girls), 105 (33.9%) had abnormal US. Acute DMSA scans were abnormal in 194 children (62.6%), including 89 (45.9%) with concomitant abnormal US. There was VUR in 107 children (34.5%), including 79 (25.5%) with Grades III-V VUR. The sensitivity and negative predictive values of US were 52.3% and 75.1%, respectively, for Grades I-V VUR and 68.4% and 87.8%, respectively, for Grades III-V VUR. Eighty-five children (27.4%) had RS, including 55 (64.7%) with abnormal US. Of the 105 children with abnormal US, 33 (31.4%) needed subsequent management (surgical intervention, parental counseling, or follow up of renal function). Nephromegaly on initial US and Grades III-V VUR were risk factors of RS. Abnormal US may carry a higher probability of Grades III-V VUR and RS, and can affect subsequent management in a significant number of children. Nephromegaly on initial US and Grades III-V VUR are strongly associated with an increased risk for RS. Thus, US should be performed on children after a first febrile UTI and children with normal US may not require voiding cystourethrography.

Renal Outcome of Children With Horseshoe Kidney: A Single-center Experience

To assess the clinical features, additional abnormalities, and renal consequences of children with horseshoe kidney (HSK). The medical records of 41 children with HSK followed in our pediatric nephrology clinic between the years of 2004 and 2014 were retrospectively reviewed. There were 22 girls (53.6%) and 19 boys (46.4%) aged 60 (2-192) months. The median follow-up time was 48 (12-120) months. HSK was incidentally found in 12 patients (29.3%), and 5 patients (12.2%) were prenatally diagnosed. Urinary tract abnormalities including vesicoureteral reflux (n= 8), ureteropelvic junction obstruction (n= 7), and duplex system (n= 3) were identified in 18 patients (43.9%). Eight children (19.5%) had bladder dysfunction, and 9 patients (21.9%) had additional systemic abnormalities. Urinary tract infection had been detected in 17 patients (41.4%). Seven patients (17%) required surgical intervention including pyeloplasty (n= 3), ureteroneocystostomy (n= 3), and upper pole heminephrectomy (n= 1). Renal scarring (RS) occurred in 10 patients (24.4%). Six patients (14.6%) developed proteinuria and 4 (9.8%) complicated with hypertension. Three patients (7.3%) progressed to chronic kidney disease (CKD). Multivariate logistic regression analysis showed that proteinuria, hypertension, and RS are independently associated with CKD. Children with HSK might be examined for additional urologic and nonurologic abnormalities. Patients might be closely followed up for the increased risk of urinary tract infection and RS. Proteinuria, hypertension, and presence of RS seem to be the major determinants for progression to CKD in children with HSK.

Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data.

No studies have systematically examined the accuracy of clinical, laboratory, and imaging variables in detecting renal scarring in children and adolescents with a first urinary tract infection. To identify independent prognostic factors for the development of renal scarring and to combine these factors in prediction models that could be useful in clinical practice. MEDLINE and EMBASE. We included patients aged 0 to 18 years with a first urinary tract infection who underwent follow-up renal scanning with technetium Tc 99m succimer at least 5 months later. We pooled individual patient data from 9 cohort studies. We examined the association between predictor variables assessed at the time of the first urinary tract infection and the development of renal scarring. Renal scarring was defined by the presence of photopenia on the renal scan. We assessed the following 3 models: clinical (demographic information, fever, and etiologic organism) and ultrasonographic findings (model 1); model 1 plus serum levels of inflammatory markers (model 2); and model 2 plus voiding cystourethrogram findings (model 3). Of the 1280 included participants, 199 (15.5%) had renal scarring. A temperature of at least 39°C, an etiologic organism other than Escherichia coli, an abnormal ultrasonographic finding, polymorphonuclear cell count of greater than 60%, C-reactive protein level of greater than 40 mg/L, and presence of vesicoureteral reflux were all associated with the development of renal scars (P ≤ .01 for all). Although the presence of grade IV or V vesicoureteral reflux was the strongest predictor of renal scarring, this degree of reflux was present in only 4.1% of patients. The overall predictive ability of model 1 with 3 variables (temperature, ultrasonographic findings, and etiologic organism) was only 3% to 5% less than the predictive ability of models requiring a blood draw and/or a voiding cystourethrogram. Patients with a model 1 score of 2 or more (21.7% of the sample) represent a particularly high-risk group in whom the risk for renal scarring was 30.7%. At this cutoff, model 1 identified 44.9% of patients with eventual renal scarring. Children and adolescents with an abnormal renal ultrasonographic finding or with a combination of high fever (≥39°C) and an etiologic organism other than E coli are at high risk for the development of renal scarring.

Clinical aspects and evolution of urinary tract infection in preterm infants

Objective. The aim of the study is a comparative analysis of cases of UTI in children 0-3 years (preterm and term infants) admitted to the IVth Pediatric Clinic , “Sf. Maria” Emergency Hospital for Children, Iasi, between January 2007 – December 2011. Material and methods. We performed a retrospective study on a group of 298 children, age 0-3 years, hospitalized with urinary tract infection (UTI). We identified the features of preterm infants with UTI according to the degree of prematurity, UTI etiology, comorbidities, developmental issues, responsiveness to treatment, and impact of UTI on kidney. Results. The study group was divided into term and preterm children (defined as gestational age less than 37 weeks, weighing less than 2500g). Preterm UTI risk was influenced by age, being 3 times higher compared with children aged 1-3 years. The average age of UTI was 8.8 months for preterms and 14.09 months for term babies. Most preterm children were classified in LBW category. The etiology of urinary infection was dominated in both subgroups by E. coli, Proteus mirabilis and Klebsiella pneumoniae. In preterm children, opportunistic bacteria (bacillus Pseudomonas, enterococci, Acinetobacter) determined 16% of UTIs, compared to only 2% in term children. Fever was the dominant clinical sign in all patients. Other signs on preterms were loss of appetite, prolonged jaundice, diarrhea, respiratory distress. The onset of acute renal failure occurred in 12.5% of preterm and only 1% of term children. First line antibiotherapy was effective in most cases. In microbial resistance, the most frequently involved were aminopenicillins, Sulfamethoxazole-Trimethoprim and cephalosporins. Conclusions. The early diagnosis and treatment have an important role in reducing infectious morbidity, the risk of renal scarring and rapid nutritional rehabilitation in preterm infants.

Incidence of Abnormal Imaging and Recurrent Pyelonephritis after First Febrile Urinary Tract Infection in Children 2 to 24 Months Old

The AAP (American Academy of Pediatrics) no longer recommends voiding cystourethrogram in children 2 to 24 months old who present with a first urinary tract infection if renal-bladder ultrasound is normal. We identified factors associated with abnormal imaging and recurrent pyelonephritis in this population. We retrospectively evaluated children diagnosed with a first episode of pyelonephritis at age 2 to 24 months using de-identified electronic medical record data from an institutional database. Data included age at first urinary tract infection, gender, race/ethnicity, need for hospitalization, intravenous antibiotic use, history of abnormal prenatal ultrasound, renal-bladder ultrasound and voiding cystourethrogram results, urinary tract infection recurrence and surgical intervention. Risk factors for abnormal imaging and urinary tract infection recurrence were analyzed by univariate logistic regression, the chi-square test and survival analysis. We identified 174 patients. Of the 154 renal-bladder ultrasounds performed 59 (38%) were abnormal. Abnormal prenatal ultrasound (p = 0.01) and the need for hospitalization (p = 0.02) predicted abnormal renal-bladder ultrasound. Of the 95 patients with normal renal-bladder ultrasound 84 underwent voiding cystourethrogram. Vesicoureteral reflux was more likely in patients who were white (p = 0.003), female (p = 0.02) and older (p = 0.04). Despite normal renal-bladder ultrasound, 23 of 84 patients (24%) had dilating vesicoureteral reflux. Of the 95 patients with normal renal-bladder ultrasound 14 (15%) had recurrent pyelonephritis and 7 (7%) went on to surgical intervention. Despite normal renal-bladder ultrasound after a first pyelonephritis episode, a child may still have vesicoureteral reflux, recurrent pyelonephritis and the need for surgical intervention. If voiding cystourethrogram is deferred, parents should be counseled on these risks.

Voiding Cystourethrography Is Mandatory in Infants with Febrile Urinary Tract Infection

Vesicoureteral reflux (VUR) is common condition in infants with febrile urinary tract infections (UTIs). Both VUR and febrile UTIs are risk factors for renal scars, characterized by glomerular hypertrophy with global or segmental sclerosis as cardinal features in pathology. Because renal scars may cause hypertension or chronic kidney diseases in later life, voiding cystourethrography (VCUG) has been mandatory for infants following their first febrile UTIs to identify VUR. However, increasing evidence suggests that the presence of VUR may not represent a direct risk factor for renal scars, which has led to an increase in the use of a stratified approach, in which VCUG is not performed for all patients. This study was conducted to verify whether the stratified approach is justified to identify infants at risk for renal scarring. The medical records of 306 infants with first febrile UTIs (median age, 4 months; 0-72 months) were reviewed. VUR was detected in 40.4% (67/166) of patients by the non-stratified approach, in which VCUG was performed in all patients. In contrast, VUR was identified in only 27.1% (38/140) of patients by the stratified approach, in which VCUG was performed only in the patients with high risk of developing renal scars. This difference in the discovery rate was significant (p = 0.02). Renal bladder ultrasonography had the sensitivities of as low as 45.7% and 52.9% in detecting VUR and in predicting renal scarring assessed by renal scintigraphy, respectively. In conclusion, VCUG should be performed in all infants after their first febrile UTIs.