Vesicoureteral Reflux Group Research Articles

Role of vesicoureteral reflux on pediatric kidney allograft function.

Vesicoureteral reflux (VUR) is a common urologic complication of pediatric kidney transplant, though there is little data on the effect of VUR on histologic graft changes or graft survival. All pediatric patients who received a kidney transplant from 2007 to 2020 were selected for retrospective chart review. All participants underwent a voiding cystourethrogram (VCUG) at a 6-month post-transplant. Patients were then categorized into two groups based on vesicoureteral reflux grade: no/low-grade VUR (grades 0-2) and high-grade VUR (grades 3-5). Outcomes collected included graft failure rates, graft function, urinary tract infections(UTIs), proteinuria, and Banff scores at 3- and 12-month post-transplant surveillance kidney biopsies. There were 74 pediatric patients who received a kidney transplant in the designated time-period, and of those 39 had no/low-grade VUR and 35 had high-grade VUR. There was no difference in graft failure among the two groups over time when stratified for age (p = 0.389, CI 0.53-5.08). Patients with high grade VUR had a higher risk of UTI development overall (RR 1.89, 95%CI 1-3.6, p = 0.041), mostly accounted for from increased development of febrile UTI (RR 1.66, 95%CI 1.1-2.6, p = 0.038). Unselected pediatric kidney transplant recipients with high-grade vesicoureteral reflux on VCUG at a 6-month post-kidney transplant are more likely to have febrile UTI compared to those in the low-grade VUR group. There is no difference in graft survival among the two groups.

Assessment of Urinary and Serum Neutrophil Gelatinase-Associated Lipocalin (NGAL) Levels as Novel Predictors for Vesicoureteral Reflux Diagnosis in Children with Febrile Urinary Tract Infection.

The invasive, expensive, and time-consuming nature of radiological examinations for vesicoureteral reflux (VUR) has compelled researchers to search for new markers to predict VUR. This study was designed to evaluate the usefulness of serum and urine concentrations of neutrophil gelatinase-associated lipocalin (NGAL) in predicting the existence of VUR. This cross-sectional study involved all patients with a first febrile urinary tract infection (UTI) referred to Ali Asghar Children's Hospital. Each patient included in the study had clinical symptoms of pyelonephritis and a positive urine culture. The patients were divided into 2 groups: VUR and non-VUR. The serum and urinary NGAL levels were calculated in both groups. The receiver operating characteristic (ROC) curve was used to look for serum and urinary NGAL cut-points that differentiated the VUR group from the non-VUR group. Among the 40 children in the study, 23 belonged to the VUR group. The median age was 2.5 years (range, 0.3-8 years), and 35 patients were girls. ROC curve analysis showed that only the urinary NGAL level was significantly related to VUR. There was no association between serum NGAL levels and VUR. According to the ROC curve, a urinary NGAL level cut-off value of 15 ng/mL was likely to be diagnostic of VUR with 82.6% sensitivity and 58.8% specificity. The urinary NGAL level, specifically with a cut-off value of 15 ng/mL, can indicate the existence of VUR in patients with UTI with near-acceptable levels of sensitivity and specificity.

Laparoscopic and Robot-assisted Laparoscopic Reimplantation for Lower Ureter Pathology. A Multi-institutional Comparative Study in 1343 Patients

ObjectiveTo evaluate the outcomes of children with vesicoureteral reflux (VUR) and obstructive megaureter (OM) utilizing various laparoscopic and robot assisted approaches. Materials and methodsRetrospective review of all pediatric laparoscopic and robot assisted cases for lower ureter pathology was performed between 2016-2022 in 13 academic centers worldwide. Five surgical approaches were assessed: LEUR,LVCUR,LDECUR,RALUR and RADECUR. Results1343 patients (490 boys and 853 girls) with a median age of 30 month (IQR 12-63) were treated at 13 centers. 908 patients (68%) underwent reimplantation due to VUR (unilateral in 818 and bilateral in 90 patients). 435 (32%) had a surgery due to UVJ obstruction. Mean length of follow up was 14 month (IQR 8-33). Median operative time was 202 minutes (IQR 142-220) in the robotic arm compared to 240 minutes (IQR 160-267) in the laparoscopic (p=0.45). Intracorporeal excisional tapering was performed in 118 (8%) of the patients. 6 patients in the OM group required additional surgery due to progressive obstruction. In the VUR group, 84% underwent VCUG postoperatively. 5.6% showed residual reflux. Grade 1-2 Clavien-Dindo complications occurred in 10 patients (0.7%) and 6 (0.4%) in the laparoscopic and robotic arm respectively. Grade 3 complication occurred in 17 (1.2% and 8 (0.5%) in both arms respectively. Surgical success was achieved in 96% of patients. ConclusionLaparoscopic and robot assisted laparoscopic approaches are simple, safe, and effective for treating all grades of VUR and OM. Robot assisted approach is beneficial in terms of operative time, intracorporeal suturing and lower complications rate.

Voiding Cystourethrogram Before Pyeloplasty: To Do or Not To Do?

To assess the incidence of concomitant vesicoureteral reflux (VUR) in unilateral cases of ureteropelvic junction obstruction(UPJO) and to identify factors that predict VUR. Files of 381 pediatric patients who underwent unilateral pyeloplasty between 2000 and 2017 were retrospectively reviewed.A total of 270 patients with available data and ≥5 years of follow-up were eligible for this study.Demographic parameters,preoperative hydronephrosis grade,renal pelvis anteroposterior diameter(APD),renal parenchymal thickness(PT),split renal functions on MAG-3 scan and VUR status were noted.The patients were divided into two groups:Those with concomitant VUR(Group I, n:24, 8.9%) and those without VUR(Group II,n:246, 91.1%). Among 270 patients(205 boys,75.9%) with a median age of 4 months(2-98),197 (72.9%)had antenatal hydronephrosis.Median follow-up was 11 years(5-22).Among 24 patients with concurrent VUR,6(25%) had Grade II VUR,whereas Grade III-V VUR was detected in 18(75%).Of these,12(50%) had ipsilateral VUR,3(12.5%) had contralateral,and 9(37.5%) had bilateral VUR.In a median 137-month follow-up,spontaneous VUR resolution was observed in 6(25%) patients,whereas 15 (62.5%) patients underwent endoscopic subureteral injection and 3(12.5%) patients ureteroneocystostomy,respectively.Preoperative APD[35.5, IQR(27.6-36.0) vs. 26.5 IQR(25.0-35.0), p=0.004] were significantly higher in Group I,whereas Group I had significantly lower PT[3.7, IQR(3.4-6.4) vs. 5.8 IQR(4.4-6.1), p=0.026].Predictive factors for concomitant VUR were presentation with febrile UTI(OR:2.769,p=0.048), PT<3.95 mm(OR:1.367,p=0.043),and APD>28.8 mm (OR:1.035,p=0.001). Our results indicated that concomitant VUR and UPJO might be detected in 1 out of every 11 patients undergoing pyeloplasty,while some type of surgical intervention for VUR was required in 75% of these patients.Thus,VCUG prior to pyeloplasty may be limited in those presenting with febrile UTI,having higher APD and lower PT on preoperative urinary ultrasonography.

Does preoperative screening VCUG affect the outcomes and complications of pyeloplasty in patients with ureteropelvic junction obstruction?

The role of voiding cystourethrogram (VCUG) in evaluating vesicoureteral reflux (VUR) in patients with known ureteropelvic junction obstruction (UPJO) remains unclear. While VCUG is frequently performed, the incidence of concomitant VUR and UPJO is low, and VUR is often low-grade with high rates of spontaneous regression. To analyze the clinical relevance of VCUG in patients with UPJO by determining its incidence and studying the difference in clinical outcomes between patients with known, unknown, and negative VUR. Retrospective review of patients with UPJO who underwent pyeloplasty from 2012 to 2020 with <18 years-old, unilateral UPJO, postoperative follow-up of ≥2 months and had at least 1 renal ultrasound (US) after pyeloplasty. Results were compared among 3 groups: patients who underwent VCUG before pyeloplasty and were found to have VUR (group 1), patients who underwent VCUG before pyeloplasty without VUR (group 2), and patients who did not have a VCUG before pyeloplasty (group 3). A total of 275 patients met the inclusion criteria, of which 21 patients were classified in group 1, 166 patients in group 2, and 88 patients in group 3 (Table). The age at preoperative VCUG was 14.7±32.9 months in group 1 and 15.17±35.8 months in group 2 (p=0.960). Overall, the incidence of concomitant UPJO and VUR was 11.2%. In group 1 the initial VUR grade was 5 in 2 patients, 4 in 3, 3 in 5, 2 in 7, and 1 in 4 patients. Of these, only 1 patient required ureteral reimplantation after pyeloplasty. Post-pyeloplasty, no significant differences were observed in complications (p=0.7436), length of follow up (p=0.3212), SFU grade 4 hydronephrosis (p=0.2247), postoperative UTIs (p=0.1047) and pyeloplasty success rate (p=0.4206) among the 3 groups. Despite the use of antibiotic prophylaxis being significantly different amongst the three groups (p<0.001), it was not associated with a lower incidence of postoperative UTIs (group 1 p=0.068, group 2 p=0.486, group 3 p=1). In patients with reflux, an increase in age was associated with a decrease in the rates of complications (p=0.019). We found no significant difference in the outcomes in patients who had a preoperative VCUG as compared to those who did not. The preoperative diagnosis of VUR by VCUG changed the management in less than 1% of the study population and thus its role in patients with UPJO should be reevaluated.

Vesicoureteral Reflux Causes Interstitial Inflammation in Pediatric Kidney Allograft: A Clinicopathological Analysis of 1-Year Protocol Biopsies

Introduction: At present, there is limited evidence of the histological impact of vesicoureteral reflux (VUR) on pediatric kidney allografts. In this study, we aimed to investigate the relationship between VUR diagnosed by voiding cystourethrography (VCUG) and 1-year protocol biopsy results. Methods: One hundred thirty-eight pediatric kidney transplantations were performed in Toho University Omori Medical Center between 2009 and 2019. We included 87 pediatric transplant recipients who were evaluated for VUR by VCUG prior to or at the time of the 1-year protocol biopsy and underwent a 1-year protocol biopsy after transplantation. We evaluated the clinicopathological findings of the VUR and non-VUR groups, and histological scores were evaluated using the Banff score. Tamm-Horsfall protein (THP) within the interstitium was identified by light microscopy. Results: Of the 87 transplant recipients, 18 cases (20.7%) were diagnosed with VUR by VCUG. The clinical background and findings were not significantly different between the VUR and non-VUR groups. The pathological findings revealed a significantly higher Banff total interstitial inflammation (ti) score in the VUR group than in the non-VUR group. Multivariate analysis indicated a significant relationship between the Banff ti score and THP within the interstitium, and VUR. The 3-year protocol biopsy results (n = 68) revealed a significantly higher Banff interstitial fibrosis (ci) score in the VUR group than in the non-VUR group. Conclusion: VUR caused interstitial fibrosis in the 1-year pediatric protocol biopsies, and interstitial inflammation at the 1-year protocol biopsy may affect interstitial fibrosis at the 3-year protocol biopsy.

Ultrasound screening of kidney size in children with and without vesicoureteral reflux

"Evaluation of the size of the kidney's parameters of patients with vesicoureteral reflux (VUR) can provide relevant knowledge about the prognosis factors of VUR's complications. The study aimed to assess the size of the renal parameters of children with VUR and compare the results with healthy matched cases by the ultrasound method. Methods: In this case-control study, children under 14 years of age with VUR in our pediatric urology practice from May 2019 to May 2020 were included. Eighty children were included in the two groups (case (40 cases) and control group (40 cases)) in the study. The case group included children with VUR, while the control group included healthy children. The data regarding Urinary Tract Infection (UTI), the length and width of the kidney, the size of the pelvis, parenchyma thickness, and volume of the kidney were recorded. Results: The mean age of children was 3.07 ± 3.05 years, and 35.0% of them were male. The mean number of UTIs in the VUR group was 1.90 ± 1.15 and in the control group was 1.10±0.30 (P=0.031). The incidence of UTIs was significantly higher in the VUR group than in the control group (P&lt;0.001). Length, width, the posterior-anterior diameter of kidney, renal parenchyma thickness, and renal volume in the VUR group were significantly lower than the control group (P&lt; 0.001). There was no difference between case and control groups in terms of anterior-posterior diameter of the pelvis (P= 0.653). Conclusions: The results showed that the size of kidneys parameters in children with VUR was less than in the control group. Also, the incidence of UTIs in the VUR group was significantly higher than in the control group. Ultrasound is a safe and non-invasive tool that can use for checking the size of the children's kidneys with VUR for predict of possible complications "

Is there a relationship between renal scarring and neutrophil-to-lymphocyte ratio in patients with vesicoureteral reflux?

Vesicoureteral reflux (VUR) exacerbates the risk of renal scarring by establishing a ground for pyelonephritis. It is known that the inflammatory process is more influential than the direct damage caused by bacterial infection in the development of renal scars after pyelonephritis. Therefore, the present study aims to investigate the relationship between renal scarring and systemic inflammatory markers in patients with VUR. Hundred and ninety-two patients (116 females, 76 males) diagnosed with VUR were divided into two groups based on the presence or absence of renal scarring and into three groups according to the grade of VUR (low, moderate and high). Neutrophil count, lymphocyte count, mean platelet volume (MPV) and neutrophil-to-lymphocyte ratio (NLR) were compared among the groups. Of the 192 patients, 102 had renal scarring. The age and gender distribution did not differ significantly between the groups with and without renal scarring (p > 0.05). However, the grade of reflux and lymphocyte count were significantly higher in the group with renal scarring (p < 0.05), and the NLR was significantly lower in the group with renal scarring (p < 0.05). The lymphocyte count was significantly higher (p < 0.05) and NLR was significantly lower in the high-grade VUR group (p < 0.05). However, MPV values did not differ significantly (p > 0.05) between the groups. NLR can be used to predict renal scarring in patients with VUR, especially in the period of 3-6 months after the first attack of infection, and may even serve as a candidate marker for treatment selection. However, larger series and prospective studies are needed.

Pyelonephritis in Pediatric Uropathic Patients: Differences from Community-Acquired Ones and Therapeutic Protocol Considerations. A 10-Year Single-Center Retrospective Study.

Pyelonephritis (PN) represents an important cause of morbidity in the pediatric population, especially in uropathic patients. The aim of the study is to demonstrate differences between PNs of uropathic patients and PNs acquired in community in terms of uropathogens involved and antibiotic sensitivity; moreover, to identify a proper empiric therapeutic strategy. A retrospective study was conducted on antibiograms on urine cultures from PNs in vesicoureteral reflux (VUR) patients admitted to pediatric surgery department and from PNs in not VUR patients admitted to Pediatric Emergency Unit between 2010 and 2020. We recorded 58 PNs in 33 patients affected by VUR and 112 PNs in the not VUR group. The mean age of not VUR patients at the PN episode was 1.3 ± 2.6 years (range: 20 days of life–3 years), and almost all the urine cultures, 111 (99.1%), isolated Gram-negative bacteria and rarely, 1 (0.9%), Gram-positive bacteria. The Gram-negative uropathogens isolated were Escherichia coli (97%), Proteus mirabilis (2%), and Klebsiella spp. (1%). The only Gram-positive bacteria isolated was an Enterococcus faecalis. As regards the antibiograms, 96% of not VUR PNs responded to beta-lactams, 99% to aminoglycosides, and 80% to sulfonamides. For the VUR group, mean age was 3.0 years ± 3.0 years (range: 9 days of life–11 years) and mean number of episodes per patient was 2.0 ± 1.0 (range: 1–5); 83% of PNs were by Gram-negatives bacteria vs. 17% by Gram-positive: the most important Gram-negative bacteria were Pseudomonas aeruginosa (44%), Escherichia coli (27%), and Klebsiella spp. (12%), while Enterococcus spp. determined 90% of Gram-positive UTIs. Regimen ampicillin/ceftazidime (success rate: 72.0%) was compared to ampicillin/amikacin (success rate of 83.0%): no statistically significant difference was found (p = 0.09). The pathogens of PNs in uropathic patients are different from those of community-acquired PNs, and clinicians should be aware of their peculiar antibiotic susceptibility. An empiric therapy based on the association ampicillin + ceftazidime is therefore suggested.

Clinical features of neurogenic bladder with vesicoureteral reflux in children

OBJECTIVE To study the clinical features of vesicoureteral reflux (VUR) in children with neurogenic bladder (NB), and to provide a reference for its early diagnosis and treatment. METHODS Clinical data were collected from 26 children with NB and urinary tract infection who were admitted to the Department of Pediatric Nephrology from January 2014 to December 2019. According to the presence or absence of VUR, the children were divided into a VUR group with 11 children and a non-VUR group with 15 children. Clinical features were compared between the two groups. RESULTS Compared with the non-VUR group, the VUR group had a significantly higher proportion of children with non-Escherichia coli urinary tract infection, hydronephrosis (the severity of hydronephrosis increased with the grade of VUR), abnormal 99mTc-DMSA renal scanning findings, elevated ratios of urinary albumin, urinary IgG and urinary transferrin to creatinine, increased residual urine volume, and increased detrusor leak point pressure (P < 0.05). CONCLUSIONS When NB children have the clinical manifestations of non-Escherichia coli urinary tract infection, hydronephrosis, abnormal 99mTc-DMSA renal scanning findings, glomerular proteinuria, increased bladder residual urine volume, and high detrusor leak point pressure, such children may already have VUR, and so diagnosis and intervention should be performed as early as possible.

An Important Risk Factor Affecting Hypercalciuria in Children: Vesicoureteral Reflux.

A large number of genes and environmental factors, like dietary habits, play a role in the development of hypercalciuria in children. In this study, we aimed to determine the effects of the presence and grade of vesicoureteral reflux (VUR) on hypercalciuria status in children. Data for 165 patients who admitted to the Pediatric Urology Department were retrospectively analyzed. The patients were composed of following four different groups: (1) urinary stone patients, (2) VUR patients under follow-up, (3) corrected VUR patients, and (4) control. The demographic features, clinical data, and laboratory tests for the groups were compared. The mean age of the patients was 100.6 ± 54.69 months and the female/male ratio was 79:86. The mean urinary calcium/creatinine (UCa/Cr) excretion and the frequency of high UCa/Cr ratios in the corrected VUR group were similar to those in the control group (p = 0.375 and 0.965, respectively). In contrast, the mean UCa/Cr excretion and frequency of high UCa/Cr ratios in the urinary stone and follow-up VUR groups were significantly higher than those in the corrected VUR group (p < 0.001, < 0.001, 0.003, and 0.029, respectively). The mean UCa/Cr excretion and frequency of high UCa/Cr ratios in the follow-up VUR group were similar to those in the urinary stone group (p = 0.323 and 0.425, respectively). In the follow-up VUR group, although reflux laterality had no effect on the UCa/Cr ratios (p = 0.180 and 0.108, respectively), the mean and frequency of high UCa/Cr ratios were higher in high-grade reflux cases (p < 0.001 and p = 0.042, respectively). Both the mean UCa/Cr ratio and the rate of hypercalciuria in the corrected reflux group were significantly lower than the corresponding values in the follow-up VUR and urinary stone groups. Further, the follow-up VUR patients had similar urinary calcium excretion levels as the stone patients. VUR treatment is associated with a decrease in urinary calcium excretion to the normal population level. A positive correlation between reflux degree and calcium excretion was observed.

Relationship between Vesicoureteral Reflux and Glomerular Filtration Rate in Children.

Vesicoureteral reflux (VUR) is one of the most common urinary tract anomalies in children and causes renal damage and studies focusing on the effect of VUR on renal function are rare. We recruited 35 primary VUR patients with recurrent urinary tract infection (UTI) and 10 non-VUR patients with recurrent UTI. Contrast-enhanced voiding urosonography (ceVUS) was performed for VUR grading, and renal dynamic imaging was used for evaluating glomerular filtration rate (GFR, mL/min). Standardized GFR (sGFR), namely GFR/BSA (mL·min-1·m-2), was calculated based on the body surface area (BSA). Total sGFR (tsGFR, mL·min-1·m-2) was obtained from the sum of sGFR on the left and right sides of all the children. The risk of renal regurgitation was equal in the unilateral reflux group. The sGFR of children with grade IV (45.74±18.05 mL·min-1·m-2) and grade V (49.67±23.63 mL·min-1·m-2) reflux was significantly lower than that in children with grade III (77.69 ±22.21 mL·min-1·m-2). The renal function compensation of contralateral non-reflux kidney increased in unilateral reflux group, which was higher than that in the control group and level II, IV and V of reflux group respectively. In VUR group of the same grade, sGFR decreased with the age at diagnosis. In unilateral grade V reflux group, the tsGFR was lower than that in the unilateral grade III reflux group (133.51±48.21 vs. 186.87±53.49 mL·min-1·m-2). The patients with VUR of unilateral grade II were significantly older than those with VUR of unilateral grades III and IV. This study indicates that severe VUR is significantly associated with decreased renal function. Therefore, VUR should be diagnosed early and managed individually.

Urinary excretion of pentraxin-3 correlates with the presence of renal scar following acute pyelonephritis in children.

Acute pyelonephritis is associated with considerable morbidity and potential for renal scarring. Pentraxin3 (PTX3) is a recently discovered mediator of inflammation. The objective of this study was to investigate the changes in serum and urine PTX3 levels in children who had a history of pyelonephritis and were diagnosed with renal parenchymal scar (RPS) and/or vesicoureteral reflux (VUR). The study included 88 children (31 males, 57 females) aged between 3months and 18years. The children included in the study were divided into four groups: VUR with RPS (Group 1), RPS without VUR (Group 2), VUR without RPS (Group 3), and healthy children without a history of hydronephrosis or UTI history (Group 4). After the initial evaluation, the participants were further divided into two more groups and re-evaluated: Children with RPS (Group 1 + 2), children without RPS (Group 3 + 4), children with VUR (Group 1 + 3), and children without VUR (Group 2 + 4). We found that urine pentraxin 3 (uPTX3) and uPTX3/Creatinine levels were significantly higher in the groups with renal scar with or without VUR than the ones without RPS [mean uPTX3, 3.5pg/ml (min-max 0.0022-12.3668) vs. 2.2pg/ml (min-max 0.0022-18.5868) and uPTX3/creatinine, 10.5pg/mg (min-max 0.0035-51.1) vs. 5.8pg/mg (min-max 0.0004-78.7), p < 0.01]. uPTX3 levels were not different among the groups with and without VUR. In addition, serum PTX3 levels were not different among the groups. We showed that urinary PTX3 increased only in patients with scarred kidneys. These results might be helpful to predict RPS due to past pyelonephritis.

Prediction of vesicoureteral reflux in children with febrile urinary tract infection using relative uptake and cortical defect in DMSA scan

Vesicoureteral reflux (VUR) is an important urologic anomaly that causes renal injury in children with febrile urinary tract infection (UTI). The present study aimed to evaluate the associations of abnormalities detected on technetium-99m-labeled dimercaptosuccinic acid (DMSA) scans, focusing on the association with VUR of the levels of relative decrease in kidney function and cortical defects after a first febrile UTI in children. All 171 children underwent ultrasonography, DMSA scan and voiding cystourethrography (VCUG). The features of ultrasound and DMSA scans were compared between patients with (n=48) and without VUR (n=123). The relative uptake (RU) by each kidney was derived from the absolute value of the differences between the value for RU of radionuclide in the right kidney and that in the left kidney. The extent of cortical defects (ECD) was graded according to the number of compartments that contained cortical defect in both kidneys (right upper/right lower, left upper/left lower). Receiver operating characteristic curves were constructed to examine the diagnostic value of these parameters of ultrasound and DMSA scans for predicting VUR. The ratio of patients having hydronephrosis on ultrasound or cortical defects on DMSA scan did not differ significantly between VUR and non-VUR groups. However, the absolute values of the RU and the scores for ECD were significantly higher in the VUR group than in the non-VUR group. The area under the curves for these two parameters were higher than those for the presence of hydronephrosis or the presence of cortical defects or both. Decreased relative function and increased extents of cortical defects on DMSA scan may be associated with the presence of VUR. These findings may assist pediatricians to decide whether febrile UTI children need to undergo VCUG.

Is vaginal reflux associated with urinary tract infection in female children under the age of 36 months?

PurposeTo determine the relationship between vaginal reflux (VR) and urinary tract infection (UTI) in female children aged <36 months.MethodsA single center retrospective study was performed for 191 girls aged <36 months, with a diagnosis of febrile UTI, who underwent a voiding cystourethrography (VCUG) for assessment of vesicoureteral reflux (VUR) at Sanggye Paik Hospital. Fifty-one girls, who underwent VCUG for assessment of congenital hydronephrosis or renal pelvis dilatation, without a UTI, formed the control group. The correlation between the presence and grade of VR and UTI was evaluated.ResultsThe prevalence rate of VR was higher in the UTI (42.9%) than control (13.7%) group (P<0.05), with a higher VR severity grade in the UTI (mean, 0.64) than control (mean, 0.18) group (P<0.05). On subanalysis with age-matching (UTI group: n=126, age, 5.28±2.13 months; control group: n=22, age, 4.79±2.40 months; P=0.33), both VR prevalence (43.65% vs. 18.18%, P<0.05) and grade (0.65 vs. 0.22, P<0.05) remained higher in the UTI than control group. Presence and higher grade of VR were associated with UTI recurrence (P<0.05). VR was correlated to urosepsis (P<0.05). The renal defect rate of patients with VR (VR [+]/VUR [+]) was not different from that of patients without VR (74% vs. 52%, P=0.143) in the VUR group; however, it was higher than that of VR (+)/VUR (−) patients (74% vs. 32%, P=0.001). If a child with VR (+)/VUR (+) is exposed to a UTI, the risk of renal defect increases.ConclusionOccurrence of VR is associated with UTI recurrence and urosepsis in pediatric female patients.

Feasibility of superb microvascular imaging to detect high-grade vesicoureteral reflux in children with urinary tract infection.

To evaluate superb microvascular imaging (SMI) for the detection of high-grade vesicoureteral reflux (VUR). We reviewed the patients with urinary tract infection who underwent renal US with SMI and VCUG. The subjects were divided into a VUR group, which included 17 patients (20 kidney units, KU) with high-grade reflux (grade 4 or 5) on VCUG, and a group without VUR including the same numbers of subjects. The direction of urine movement at the distal ureter and the renal pelvis was reviewed on SMI. SMI and VCUG results were compared. Urinary flow "jets" into the bladder and direction of the flow were detectable on all SMI examinations in both groups. In the group with VUR, 20 KUs had grade 4 (n = 11) or grade 5 (n = 9) reflux (bilateral VUR in 3 patients). Among 20 KUs with VUR, 15 (75%) showed a reversed ureteral jet and/or renal pelvic swirl sign on SMI. None of the patients in the group without VUR showed those findings on SMI. SMI enables detection of the direction of urinary flow. The presence of a reversed ureteral jet and/or renal pelvic swirl sign correlates with high-grade VUR with 75% accuracy. • Superb microvascular imaging is feasible in children with urinary tract infection. • SMI enables detection of the direction of urinary flow. • Presence of reversed flow correlates with high-grade vesicoureteral reflux.

Serum interleukin -8 is not a reliable marker for prediction of vesicoureteral reflux in children with febrile urinary tract infection.

ABSTRACTObjective:In view of the side effects of voiding cystourethrography (VCUG), identification of noninvasive markers predicting the presence of vesicoureteral reflux (VUR) is important. This study was conducted to determine the predictive value of serum interleukin-8 (IL-8) in diagnosis of VUR in children with first febrile urinary tract infection (UTI).Materials and Methods:Eighty children with first febrile UTI were divided into two groups, with and without VUR, based on the results of VCUG. The sensitivity, specificity, positive and negative predictive value positive and negative likelihood ratio, and accuracy of IL-8 for prediction of VUR were investigated.Results:Of the 80 children with febrile UTI, 30 (37.5%) had VUR. There was no significant difference between the children with and without VUR and also between low and high-grade VUR groups in terms of serum concentration of IL-8 (P>0.05). Based on ROC curve, the sensitivity, specificity, likelihood ratio positive, and accuracy of serum IL-8 was lower than those of erythrocyte sedimentation rate and C-reactive protein. Multivariate logistic regression analysis showed significant positive correlation only between erythrocyte sedimentation rate and VUR.Conclusions:This study showed no significant difference between the children with and without VUR in terms of the serum concentration of IL-8. Therefore, it seems that serum IL-8 is not a reliable marker for prediction of VUR.

Bioelectric Impedance Analysis in the Diagnosis of Vesicoureteral Reflux.

Background:Vesicoureteral reflux (VUR) is a common abnormality of the urinary tract in childhood.Objectives:As urine enters the ureters and renal pelvis during voiding in vesicoureteral reflux (VUR), we hypothesized that change in body water composition before and after voiding may be less different in children with VUR.Patients and Methods:Patients were grouped as those with VUR (Group 1) and without VUR (Group 2). Bioelectric impedance analysis was performed before and after voiding, and third space fluid (TSF) (L), percent of total body fluid (TBF%), extracellular fluid (ECF%), and intracellular fluid (ICF%) were recorded. After change of TSF, TBF, ECF, ICF (ΔTSF, ΔTBF%, ΔECF%, ΔICF%), urine volume (mL), and urine volume/body weight (mL/kg) were calculated. Groups 1 and 2 were compared for these parameters. In addition, pre- and post-voiding body fluid values were compared in each group.Results:TBF%, ECF%, ICF%, and TSF in both pre- and post-voiding states and ΔTBF%, ΔECF%, ΔICF%, and ΔTSF after voiding were not different between groups. However, while post-voiding TBF%, ECF% was significantly decreased in Group 1 (64.5 ± 8.1 vs 63.7 ± 7.2, P = 0.013 for TBF%), there was not post-voiding change in TSF in the same group. On the other hand, there was also a significant TSF decrease in Group 2.Conclusions:Bladder and ureter can be considered as the third space. Thus, we think that BIA has been useful in discriminating children with VUR as there was no decreased in patients with VUR, although there was decreased TSF in patients without VUR. However, further studies are needed to increase the accuracy of this hypothesis.

Diagnostic value of hydrodistention of the ureteral orifice

The dynamic hydrodistention (HD) classification is a basic and objective way of rating the ureteral orifice opening. This study evaluated the value of hydrodistention of the ureteral orifice in the diagnosis of vesicoureteral reflux (VUR). Between January 2012 and March 2013 the HD grade in 106 ureters was prospectively assigned. A 9.5-Fr rigid cystoscope with a 0-degree lens was used in all procedures. Warm saline was used and the irrigation bag was placed approximately 1m above the bladder level on full flow. The grading is as follows: H0 denotes absence of ureteral dilation; H1 indicates dilation of the ureteral orifice only; H2 allows visualization of the intramural ureter; and H3 allows visualization of the extramural ureter. Indications for cystoscopy were endoscopic and open surgical treatment of VUR, stent removal, and any other diagnostic reasons. Exclusion criteria were patients with: infravesical obstruction, neuropathic bladder, severe detrusor over activity/dysfunctional voiding, duplex system, paraureteral diverticulum, bladder exstrophy and grade-1 VUR. The 51 refluxing ureters (RUs) were compared with 55 non-refluxing ureters (NRUs). Finally, sensitivity, specificity, positive and negative predictive values, and accuracy rate of HD were evaluated. A total of 106 ureters in 61 patients with a mean age of 5.3±3.9 years (range 2 months-15 years, median 5 years) were prospectively assigned. The mean HD grade in the RUs was 2.17±0.55. The mean HD grades were 2.0±0.63, 2.07±0.53, 2.38±0.5 and 2.5±0.57 for VUR grades 2-5, respectively. The mean HD grade in the NRUs was 1.60±0.70. The HD grades were H0 to H3 in 7.3%, 30.9%, 56.4% and 5.4% of the NRUs, respectively. The RUs group (2.17±0.55) showed a statistically higher HD grade than the NRUs group (1.60±0.70) (P<0.005). Sensitivity, specificity, positive and negative predictive values, and accuracy rate of HD grading in the diagnosis of VUR were 92%, 38%, 58%, 84%, and 64%, respectively. The mean HD grade in contralateral ureters of unilateral VUR was 1.55±0.72 and HD grades were H0-H3 in 0%, 55.6%, 33.3% and 11.1% of these nine ureters, respectively. In these nine non-refluxing contralateral ureters, after endoscopic correction of ipsilateral VUR, new contralateral VUR did not occur. Even though HD grade was high in the VUR group and popularity of the HD grading is on the increase, HD grading by itself still has a low diagnostic value.

Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring.

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. 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. 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]). 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.