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Aim: There are scanty data on the rate of abnormal Tc-99 m dimercaptosuccinic acid (DMSA) renal scintigraphy and associated factors in children older than 5 years with diagnosis of VUR. We do not have knowledge about which older children should undergo DMSA after VUR diagnosis. This study aims to assess the rate of abnormal DMSA findings and associated factors in children older than 5 years of age diagnosed with VUR., Materials and Methods: We retrospectively reviewed the medical records of 258 children with VUR diagnosed at or older than 5 year age. 179 children [42 (23.5%) males and 137 (76.5%) females] with complete data were included. 268 reflux units were compared according to gender, bilaterality, grade, reflux phase at voiding cystourethrography, febrile urinary tract infection (fUTI), lower urinary tract dysfunction (LUTD), and DMSA findings with uni- and multivariate analysis., Results: The median age was 110 (60-216) months. VUR grades were I, II, and III in 197 (73.6%) units and IV-V in 71 (26.4%). 138 (51.5%) renal units had abnormal DMSA. VUR grade (p < 0.01), unilaterality (p = 0.048), and fUTI (p = 0.031) in univariate but only grade and unilaterality in multivariate analysis are significantly associated with abnormal DMSA. Although reflux at filling phase was predominant in high-grade VUR group, reflux at voiding phase (p = 0.006) in low-medium-grade (1-3) VUR was associated with abnormal DMSA., Conclusion: Children older than 5 years of age diagnosed with VUR should be regarded as a high-risk group for abnormal DMSA regardless of gender, unilaterality, grade, reflux phase, fUTI, and LUTD., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Background Acute pyelonephritis (AP) is a common bacterial infection in childhood. Follow-up guidelines on these children are controversial. This study aimed to identify risk factors for kidney scarring and vesicoureteral reflux (VUR). Furthermore, international follow-up guidelines were used for simulation to evaluate sensitivity and specificity. Methods Urinary culture-confirmed first-time AP patients (aged 0-14 years) were enrolled (n = 421) from review of patient charts. All underwent kidney ultrasound (US) and a technetium-99m-dimercaptosuccinic acid (DMSA) scan or technetium-99m-mercaptoacetyltriglycine scinti-renography (MAG3) at 4-6 months of follow-up. The international guidelines used for simulation were from the National Institute of Health UK (NICE), the American Association of Paediatrics (AAP) and the Swedish Paediatric Society (SPS). Results 17.8% presented with an abnormal DMSA/MAG3 at follow-up, 7.1% were diagnosed with VUR grades III-V and 4.7% were admitted for surgery. Non-Escherichia coli infections, abnormal kidney US, elevated creatinine and delayed response to treatment (>48 h) were risk factors for abnormal DMSA findings and VUR grades III-V. NICE and SPS guidelines showed best sensitivity in diagnosing VUR grades III-V (75%) compared with AAP (56%). Conclusions Risk factors are helpful in identifying the children in need of further investigations and minimizing invasive work-up for the rest. International guidelines on follow-up detect a varying number of children with kidney damage and/or significant VUR. Future work must focus on identifying more specific risk factors, better imaging, or specific biomarkers, to enhance sensitivity and specificity in detecting the children at high risk for developing recurrent infections and/or nephropathy., Author(s): Anders Breinbjerg [sup.1] , Cecilie Siggaard Jørgensen [sup.1] , Jørgen Frøkiær [sup.2] , Kjell Tullus [sup.3] , Konstantinos Kamperis [sup.1] , Søren Rittig [sup.1] Author Affiliations: (1) grid.154185.c, 0000 [...]

Background This study investigated whether performing kidney ultrasound (KUS) only in children presenting either a pathogen other than E. coli at their first febrile urinary tract infection (fUTI) or experiencing fUTI recurrence would increase missed diagnoses of kidney anomalies. Methods Patients aged 2-36 months with fUTI who underwent KUS evaluation from 2 January 2013 to 31 June 2018 were enrolled. Cystourethrography was performed after pathological KUS or recurring fUTIs. Thereafter, we retrospectively assessed the detection rate of kidney anomalies through performing KUS only in patients with atypical pathogen at first fUTI or with recurring fUTIs. Results In 263 patients included, the isolated pathogen was E. coli in 223 cases (84.8%) and atypical in 40 cases (15.2%). KUS detected kidney anomalies in 14/223 (6.3%) of fUTIs caused by E. coli and in 11/40 (27.5%) of fUTIs caused by an atypical pathogen (OR 5.5, 95%CI 2.5-14.5). Cystourethrography was performed in 40 patients and vesicoureteral reflux (VUR) found in 20 cases. None of the high grade VUR diagnoses or other kidney anomalies would have been lost through a different diagnostic protocol that required the presence of an atypical pathogen at the first fUTI or a fUTI recurrence to perform the KUS. Conclusions A diagnostic protocol that requires presence of an atypical pathogen at the first fUTI or a second episode of fUTI to perform the KUS would allow a reduction in the number of negative ultrasounds with a negligible risk of missed diagnoses of kidney anomalies., Author(s): Marco Pennesi [sup.1] , Stefano Amoroso [sup.2] , Giulia Pennesi [sup.3] , Manuela Giangreco [sup.1] , Elisabetta Cattaruzzi [sup.1] , Marco Pesce [sup.2] , Marina Busetti [sup.4] , Egidio [...]

Vesico-ureteral reflux (VUR) has long been recognized as associated with urinary tract infections (UTIs), renal scarring, and chronic kidney disease (CKD). The concept of 'reflux nephropathy' was born, whereby the VUR was considered the culprit, predisposing to recurrent UTIs and providing a conduit whereby the infection could ascend to the kidneys resulting in scarring and destruction. The more severe grades of reflux were thought to place the young child at particular risk of CKD. The question being asked in this pro/con debate is whether VUR is indeed the culprit responsible for a significant proportion of children with CKD, a number of whom progress to end-stage kidney failure (ESKF), and is thus important to find and treat, or is it an innocent bystander associated with CKD and ESKF but not the cause. We believe the latter and will present convincing evidence supported by large scale prospective randomized controlled trials that VUR is not the ogre it was thought to be and is not important to find following a UTI (with some exceptions)., Author(s): Ian Hewitt [sup.1] , Giovanni Montini [sup.2] [sup.3] Author Affiliations: (1) grid.410667.2, 0000 0004 0625 8600, Department of Pediatric Nephrology, Perth Children's Hospital, , Perth, Australia (2) Pediatric Nephrology, [...]

In recent years, progress has been made on understanding the relationship between vesicoureteral reflux (VUR) and urinary tract infection (UTI). The findings on recent prospective, randomized, controlled studies have questioned the conventional VUR clinical significance and, therefore, have challenged the traditional diagnostic and therapeutic recommendations. These new studies have redefined the pathogenic role of vesicoureteral reflux in UTI as well as have disputed the routine use of urinary antibiotic prophylaxis to prevent UTI and renal damage in VUR patients. The time to overinvestigate and treat the vast majority of otherwise healthy children who have an uncomplicated UTI with long-term antibiotic prophylaxis seems to be over. Is there a role of severe VUR in the development of chronic renal disease and renal failure? New ideas are needed to answer these questions with the goal to avoid repeating past mistakes when therapeutic choices were based on expert opinions rather than facts., Author(s): Eduardo H. Garin [sup.1] Author Affiliations: (Aff1) 0000 0004 1936 8091, grid.15276.37, Pediatric Nephrology, University of Florida, , Gainesville, FL, USA Definition Vesicoureteral reflux (VUR) is defined as the [...]

Randomised controlled trials (RCTs) provide the most reliable way to evaluate the benefits and harms of interventions. Participants are divided into groups using methods that balance the characteristics (both known and unknown) of the participants between treatment groups; thus, differences in outcomes are due to the interventions administered. From Cochrane Kidney and Transplant's Specialised Register, a comprehensive registry of trials in kidney disease, we identified 482 trials involving children. The vast majority concerned urinary tract infection (UTI; 134) and nephrotic syndrome (136). Most were small, with a median enrolment of 46 children, with only 26 trials enrolling 200 or more participants, and of these, 18 involved children with UTI. We discuss a number of important advances in the care of children with UTI with or without vesico-ureteric reflux, nephrotic syndrome, chronic kidney disease (CKD) and kidney transplantation that have been driven largely by trials in these conditions., Author(s): Elisabeth M. Hodson[sup.1] [sup.2] , Jonathan C. Craig[sup.1] [sup.2] Author Affiliations: (1) Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, 2145, Sydney, NSWAustralia (2) [...]

Background Antimicrobial prophylaxis is recommended for the prevention of urinary tract infections (UTI) in high-risk children. However, there is growing concern about the use of [beta]-lactams as prophylaxis and subsequent development of antibiotic resistance. Methods In this prospective, randomized, crossover controlled trial we compared cotrimoxazole (SXT) and second-generation cephalosporins (2GC) as UTI prophylaxis in children ranging in age from 1 to 60 months. Eligible patients were 1:1 randomized to receive either SXT or 2GC for the initial 6-month period (1 course), then switched to the other antimicrobial agent class for the subsequent course, with switching continuing after each course until the end of the study. Urethral orifice cultures (UOCs) were obtained at the time of switching antimicrobial prophylaxis. Results Among 97 children (mean age 13.6 months) on prophylaxis, breakthrough UTIs occurred during 13.3 % (10/75) of SXT courses and 10.3 % (8/78) of 2GC courses (p = 0.62). 2GC failed earlier than SXT (mean ± standard error: 0.81 ± 0.1 vs. 2.37 ± 0.36 months, respectively; p = 0.028). Pseudomonas aeruginosa and Enterococcus spp. were more frequently isolated after 2GC courses than after SXT courses [22.6 vs. 4.8 % (p = 0.02) and 20.7 vs. 4.8 % (p = 0.035), respectively]. Prophylaxis with 2GC significantly increased resistance to both 2GC and SXT, while SXT prophylaxis did not affect susceptibility to 2GC. Conclusions While SXT and 2GC appear to be equally efficacious as UTI prophylaxis in children, the latter exert a broader effect on patients' flora and development of bacterial resistance, suggesting that SXT may be more appropriate for UTI prophylaxis than 2GC., Author(s): Charalampos Antachopoulos[sup.1] , Maria Ioannidou[sup.1] , Athanasios Tratselas[sup.1] , Elias Iosifidis[sup.1] , Aspasia Katragkou[sup.1] , Paschalis Kadiltzoglou[sup.1] , Konstantinos Kollios[sup.1] , Emmanuel Roilides[sup.1] Author Affiliations: (1) 3rd Department of [...]

Author(s): William Morello [sup.1] , Claudio La Scola [sup.1] , Irene Alberici [sup.1] , Giovanni Montini [sup.2] Author Affiliations: (1) Nephrology and Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria [...]

Background The conclusion drawn by the authors of the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial is that antimicrobial prophylaxis reduces the risk of recurrent urinary tract infection (UTI)-but not of renal scarring-in patients with vesicoureteral reflux (VUR). Results A review of the findings showed that the decreased recurrent UTI rate was only present at the end of the 2-year follow-up period and was only slightly increased (12.3 %) above the 10 % cutoff for statistical significance. The difference was not observed in children younger than two years of age with VUR grade III and IV. In addition, the rate of new renal scarring was not statistically different between the prophylaxis and placebo groups (8.2 vs. 8.4 %, respectively). A high rate of uropathogen antibiotic resistance was observed in the prophylaxis group (68.4 vs. 24.6 %, respectively). Conclusion The analysis of the RIVUR findings questions the validity of its authors suggestion that the results may warrant reconsideration of the current recommendations by the American Academy of Pediatrics on obtaining a voiding cystourethrogram after the first febrile UTI and the use of urinary antibiotic prophylaxis in VUR patients., Author(s): Gabriel Cara-Fuentes[sup.1] , Nirupama Gupta[sup.1] , Eduardo H. Garin[sup.1] Author Affiliations: (1) Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd., HD214, 32610, Gainesville, [...]

Vesicoureteral reflux (VUR) increases the risk of urinary tract infection (UTI) and renal scarring. Many prospective studies have evaluated the role of antimicrobial prophylaxis in the prevention of recurrent UTI and renal scarring in children with VUR. Of these, the RIVUR trial was the largest, randomized, placebo-controlled, double blind, multicenter study, involving 607 children aged 2-72 months with grade I-IV VUR and a first or second symptomatic UTI. The median age of children in the RIVUR trial was 12 months, 92 % were female, 91 % were randomized after a first UTI, 86 % had a febrile index UTI, and 71 (56 %) of 126 toilet-trained children had bladder bowel dysfunction. Trimethoprim/sulfamethoxazole reduced the risk of UTI recurrences by 50 % (hazard ratio 0.50; 95 % confidence interval 0.34-0.74) as compared to placebo. No significant difference was seen in renal scarring between the two groups. However, this does not invalidate the role of prophylaxis in preventing renal scars because RIVUR and other recent prospective studies were not designed to address renal scarring as a primary study endpoint. In view of the RIVUR Trial and other studies that showed similar results, albeit in selected groups of patients, the debate on antimicrobial prophylaxis should shift from 'no prophylaxis' to 'selective prophylaxis' in children with VUR., Author(s): Tej K. Mattoo[sup.1] , Myra A. Carpenter[sup.2] , Marva Moxey-Mims[sup.3] , Russell W. Chesney[sup.4] , For The RIVUR Trial Investigators Author Affiliations: (1) Division of Pediatric Nephrology and Hypertension, [...]

Background The benefits of long-term low-dose antibiotics in preventing urinary tract infection (UTI) and renal damage in children with primary vesicoureteric reflux (VUR) are unclear. Methods Children aged between 1 and 12 years with VUR grade I-IV and a microbiologically proven UTI were randomized into two groups to receive either antibiotic prophylaxis [2 mg/kg trimethoprim + sulfamethoxazole (TMP-SMX)] daily or placebo, respectively, for 12 months. Primary outcome was microbiologically confirmed symptomatic UTI. Intention-to-treat analysis using time-to-event data was performed. Results A total of 93 children (66.7% boys) with a median age of 4.6 years were enrolled in this study; VUR grade III--IV was present in 73.1% of these children. At least one symptomatic UTI occurred in ten (21.3%) patients receiving antibiotic prophylaxis and in three (6.5%) patients receiving placebo [hazard ratio in antibiotic group 3.9; 95% confidence interval (CI) 1-14; log rank test P = 0.02). Compared to the group receiving placebo, the antibiotic group had a 14.8% increased risk for developing UTI (95% CI 1-28; P = 0.03). Of the total number of episodes of UTI, 58 3% of those in the antibiotic group were caused by TMP-SMX-resistant bacteria compared to 20% in the placebo group (P = 0.15). A renal scan at 12 months revealed that six of 37 (16.2%) patients in the antibiotic group and seven of 43 (16.3%) patients in the placebo group had new or worsening of pre-existing scar. Conclusions Long-term antibiotic prophylaxis with TMP-SMX is associated with increased risk of symptomatic UTI compared to placebo in children with grade I--IV VUR. Keywords Urinary tract infection * Trimethoprim-sulphamethoxazole * Asymptomatic bacteriuria * Bacterial resistance * DMSA scan * Renal scar, Introduction Urinary tract infection (UTI) occurs in about 2% of boys and 8% of girls [1], and one-third of children with proven UTI have vesicoureteric reflux (VUR) [2]. Data from [...]

Urinary tract infection (UTI) affects about 2% of boys and 8% of girls during the first 6 years of life with Escherichia coli as the predominant pathogen. Symptomatic UTI causes discomfort and distress, and carries a risk of inducing renal damage. The strong correlation between febrile UTI, dilating vesicoureteral reflux (VUR), and renal scarring led to the introduction of antibiotic prophylaxis for children with VUR to reduce the rate of UTI recurrence. It became common practice to use prophylaxis for children with VUR and other urinary tract abnormalities. This policy has been challenged because of a lack of scientific support. Now, randomized controlled studies are available that compare prophylaxis to no treatment or placebo. They show that children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. Dilating VUR may still be an indication for prophylaxis in young children. After the first year of life, boys have very few recurrences and do not benefit from prophylaxis. Girls with dilating VUR, on the other hand, are more prone to recurrences and benefit from prophylaxis. There has been a decline in the use of prophylaxis due to questioning of its efficacy, increasing bacterial resistance, and a propensity to low adherence to medication. Alternative measures to reduce UTI recurrences should be emphasized. However, in selected patients carefully followed, prophylaxis can protect from recurrent UTI and long-term sequelae. Keywords Urinary tract infection * Vesicoureteral reflux * Renal scarring * Antibiotic prophylaxis * Trimethoprim * Nitrofurantoin * Multi-resistance, Epidemiology By the age of 6 years, 2% of boys and 8% of girls will have experienced a urinary tract infection (UTI) [1]. Most infections occur during the first 2 [...]

Background Shigatoxin-associated hemolytic uremic syndrome (STEC-HUS) is a common thrombotic microangiopathy (TMA) in which central nervous system (CNS) involvement is responsible for the majority of deaths and for severe long-term sequelae. We have analyzed the role of hemoconcentration in disease severity. Methods This was a retrospective review of the records and laboratory data at presentation of all patients with STEC-HUS cases (n = 61) over a 10-year period. The patients were grouped into three severity classes: group A, comprising patients who did not require dialysis; group B, patients who were dialyzed without CNS involvement; group C, patients with CNS involvement. Results Patients with CNS involvement (group C) had a higher mean hemoglobin level (11.2 [+ or -] 2.3 g/dL) than those of group A or B (9.4 [+ or -] 2.1 and 7.5 [+ or -] 1.9 g/dL, respectively; p < 0.0001). We also observed that the higher the initial hemoglobin level, the more severe the long-term renal damage (p < 0.007). Conclusions In patients with STEC-HUS, hemoconcentration and hypovolemia may be responsible for more severe ischemic organ damage (both short and long term) at disease onset, and these signs should be regarded as risk factors for CNS damage and formore severe TMA. Therefore, we recommend that hydration status should be actively monitored in HUS patients and that dehydration, when diagnosed, should be promptly corrected. Keywords Diarrhea * Neurological involvement * Shigatoxin * Children * Hemolytic uremic syndrome, Introduction Hemolytic uremic syndrome (HUS), which is one of the most frequent causes of acute renal failure in children [1], is classically defined as the simultaneous occurrence of microangiopathic hemolytic [...]

Background Although erythropoietin (EPO) deficiency has been reported in children with post-diarrheal hemolytic uremic syndrome (D+HUS), very limited clinical data on EPO use in this disease are currently available. In this case-control study we examined whether EPO administration would reduce the number of red blood cell (RBC) transfusions in D+ HUS patients under our care. Methods Data from children treated exclusively with RBC transfusions (controls; n = 21) were retrospectively compared with data on those who also received EPO for the treatment of anemia (cases; n = 21). Results Both patient groups were similar in age (p = 0.9), gender (p = 0.12), weight (p = 1.00) and height (p = 0.66). Acute phase severity was also comparable, as inferred by the need for dialysis (p = 0.74), the duration of dialysis (p = 0.3), length of hospitalization (p = 0.81), presence of severe bowel (p = 1.00) or neurological injury (p = 0.69), arterial hypertension (p = 1.00) and death (p = 1.00). No differences in the hemoglobin level at admission (p = 0.51) and discharge (p = 0.28) were noted. Three children treated with EPO and two controls did not require any RBC transfusion (p = 1.00). Median number of RBC transfusions needed by cases and controls was 2 (p = 0.52). Conclusion Treatment with EPO did not reduce the number of RBC transfusions in D+HUS children. Assessment of EPO efficacy in D+HUS merits further studies. Keywords Hemolytic uremic syndrome * Anemia * Erythropoietin * Red blood cell transfusion * Hemoglobin * Children, Introduction Microangiopathic hemolytic anemia is a hallmark of postdiarrheal hemolytic uremic syndrome (D+HUS) [1,2]. Inappropriately low levels of erythropoietin (EPO) relative to the severity of anemia have been demonstrated in [...]

Shiga toxin-associated haemolytic uraemic syndrome (Stx HUS) is the leading cause of paediatric acute kidney injury. This toxin-mediated disease carries a significant morbidity and mortality but has no direct treatments. Rare familial atypical HUS (aHUS) is now understood to result from over-activation of the alternative complement pathway causing glomerular endothelial damage. By understanding the pathogenic mechanisms of this disease, the monoclonal antibody eculizumab, which blocks the final common pathway of complement, is now being used to treat aHUS. For this reason, clinicians and scientists are studying the role of the alternative complement pathway in Stx HUS with the aim of targeting treatment in a similar way. There is some evidence suggesting that complement plays a role in the pathogenesis of Stx HUS, but other mechanisms may also be important. Clinically, modulating the complement system using plasma exchange provides no proven benefit in Stx HUS, and the use of eculizumab has provided conflicting results. Understanding the local effect of Stx on the glomerulus, in particular regulation of the complement and coagulation systems, may lead to advances in defining the precise pathogenesis of this disease. Then, targeted treatment strategies could be devised and clinical trials undertaken. Keywords Shiga toxin Complement* Haemolytic uraemic syndrome * Thrombotic microangiopathy * Eculizumab, Introduction Haemolytic uraemic syndrome (HUS) is a multi-system disease classically characterised by microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury [1-3]. Among the paediatric patient population, 90 % ofHUS cases [...]

Background Children with a solitary kidney (SK) have an increased long-term risk of hypertension, albuminuria and glomerulosclerosis. In this study, we assessed the early signs of impaired glomerular filtration in children with a SK from birth or from early infancy. Methods Renal growth and function at ages 4-15.5 years were studied in 38 children with SK and 40 matched control subjects in terms of accelerated growth. Results The systolic/diastolic blood pressure Z-scores (p = 0.01/< 0.05) and the resistance index (RI) of the arcuate arteries (p = 0.05) were higher in the children with SK. Creatinine clearance and 24-h protein and albumin urinary excretion showed no difference. All but seven children with SK had 99mTc diethylene-triamine pentaacetic acid glomerular filtration rate values of > 80 ml/min/1.73 [m.sup.2]. An independent positive correlation was found between length of the follow-up time and 24-h albumin urinary excretion (β = 0.54, p < 0.01). Accelerated postnatal growth was positively related with kidney volume (β = 0.35, p < 0.05). Conclusions Among our patient cohort, renal function was well preserved at ages 4-15.5 years in children who were born with a SK. However, both their higher blood pressure and RI and the correlation of 24-h albumin urinary excretion with length of follow-up time underline the need for monitoring to detect early signs of glomerular hyperfiltration and, if necessary, implement timely intervention. SK hypertrophy was found to be correlated with postnatal growth. Keywords Solitary kidney * Unilateral renal agenesis * Uninephrectomy * Glomerulosclerosis * Resistance index * Microalbuminuria, Introduction An apparently normal solitary kidney (SK), resulting from unilateral renal agenesis, unilateral non-functioning kidney or uninephrectomy, is typically associated with increased renal growth in childhood [1-6]. The increased growth [...]

Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) is an important cause of acute kidney injury (AKI). The outcomes of STEC HUS have improved, and the acute mortality rate in children is 1-4%. About 70 % of patients recover completely from the acute episode and the remainder have varying degrees of sequelae. Only a few retrospective studies have reviewed these patients over long periods. Methodological flaws include a lack of strict definitions, changing modes of treatment, ascertainment bias and loss of subjects to follow-up. The kidneys bear the brunt of the long-term damage: proteinuria (15-30 % of cases); hypertension (5-15 %); chronic kidney disease (CKD; 9-18 %); and end-stage kidney disease (ESKD; 3%). A smaller number have extra-renal sequelae: colonic strictures, cholelithiasis, diabetes mellitus or brain injury. Most renal sequelae are minor abnormalities, such as treatable hypertension and/or variable proteinuria. Most of the patients who progress to ESKD do not recover normal renal function after the acute episode. Length of anuria (more than 10 days) and prolonged dialysis are the most important risk factors for a poor acute and long-term renal outcome. After the acute episode all patients must be followed for at least 5 years, and severely affected patients should be followed indefinitely if there is proteinuria, hypertension or a reduced glomerular filtration rate (GFR). Keywords Hemolytic uremic syndrome * Long-term outcomes * Prognosis STEC HUS * D+HUS, Introduction The hemolytic uremic syndromes (HUS) are a major cause of acute kidney injury (AKI) in childhood and adults [1]. Before any causes were known, HUS was divided into diarrhea-associated [...]

Background The purpose of this study was to assess the prevalence and outcome of newborns with bilateral mild isolated antenatal hydronephrosis managed with neither antibiotic prophylaxis nor voiding cystourethrography (VCUG). Methods Inclusion criteria were ultrasonographic evidence of an anterior-posterior pelvic diameter (APPD) of 5-15 mm at the third trimester of gestation and on the first postnatal ultrasound sonogram. Exclusion criteria were an APPD > 15 mm, calyectasis, hydroureteronephrosis, or renal or bladder abnormalities. Ultrasound follow-up was performed. Parents were familiarized with the signs of urinary tract infection (UTI). If UTI was confirmed, VCUG was performed. The outcome was assessed as intrauterine resolution of hydronephrosis, total or partial resolution, stability, or progression. Results Hydronephrosis was bilateral in 98 of the 236 newborns (196 hydronephrotic kidneys) with mild isolated antenatal hydronephrosis enrolled in this study. Nine patients had UTI, and none showed reflux. After a mean follow-up of 15 months, 74 kidneys showed intrauterine resolution (38%), 82 (42%) showed total resolution, 13 showed partial resolution, 24 were stable, and 3 showed progression. Bilateral cases represented 42% of mild isolated antenatal hydronephrosis. During the first year of life, 80% of the kidneys showed total hydronephrosis resolution, 9% of patients had UTI, and none of the patients showed reflux. Conclusions Antibiotic prophylaxis and VCUG are not mandatory in newborns with bilateral mild isolated antenatal hydronephrosis, but clinical and ultrasound follow-up are recommended during the first year of life. Keywords Bilateral mild isolated antenatal hydronephrosis * Prevalence * Voiding cystourethrography * Urinary tract infection * Outcome, Introduction Mild isolated antenatal hydronephrosis is the most frequent urinary tract abnormality detected intra-utero. It is being diagnosed with increasing frequency due to the routine use of ultrasonography (US) in [...]

Background Recent guidelines on urinary tract infection (UTI) agree on reducing the number of invasive procedures. None of these has been validated by a long-term study. We describe our 11-years experience in the application of a diagnostic protocol that uses a reduced number of invasive procedures. Methods We reviewed retrospectively the records of 406 children aged between 1 and 36 months at their first UTI. All patients underwent renal ultrasound (RUS). Children with abnormal RUS and those with UTI recurrences underwent voiding cystourethrography (VCUG) and dimercaptosuccinic acid (DMSA) renal scans. Results RUS after the first UTI was pathological in 7.4% children; 4.4 % had a second UTI. We performed 48 VCUG: 14 patients (29%) had vesicoureteral reflux (VUR), 12 of which showed an abnormal RUS while 2 had recurrent UTI. After DMSA renal scan renal damage appeared in only 6 of them (12.5%); all these children showed grade IV VUR. Conclusions The application of our guidelines leads to a decrease in invasive examinations without missing any useful diagnoses or compromising the child'shealth. Keywords Urinary tract infection * Renal scars * Vesicoureteral reflux * Antibiotic prophylaxis, Introduction The National Institute for Health and Clinical Excellence (NICE) guidelines on urinary tract infections (UTI) in childhood, published in 2007 [1], may lead to an epochal change in the [...]

Vesicoureteral reflux (VUR) is a heterogeneous disease and its management remains one of the most controversial topics in pediatrics. Management options include surveillance, antibiotics, and surgery. The approval of dextranomer/hyaluronic acid (DHA) as a bulking agent by the Food and Drug Administration was followed by wide acceptance of endoscopic techniques as a major tool in the management of reflux. Pyelonephritis rather than VUR is the most common cause of kidney damage in children. It should be emphasized that the primary goal of diagnosing and treating VUR should be preventing this complication. There are no sufficient data in the literature to address the impact of the different treatment modalities on the incidence of febrile urinary tract infections (feb-UTIs) denoting pyelonephritis, with very few studies evaluating endoscopic treatment in light of this clear and well-defined outcome. The fact that we can correct the anatomy at the vesicoureteral junction with a simple and relatively safe outpatient procedure does not justify offering it to all patients. In this review, we attempt to critically evaluate the available literature pertaining to the impact of different treatment modalities on reducing the incidence of febrile UTIs and kidney damage, with a special emphasis on endoscopic treatment. Keywords Urinary tract infection. Vesicoureteral reflux. Deflux[R]. Endoscopic treatment. Renal scaring. Reflux nephropathy, Introduction Vesicoureteral reflux (VUR) is a common pediatric urological anomaly [1] and is defined as the retrograde flow of urine from the bladder into the ureter and renal pelvis. Its [...]

Vesicoureteral reflux (VUR) is commonly diagnosed in children presenting with urinary tract infections. Antibiotic prophylaxis and ureteric surgery are standard treatments for these children. Our aim was to investigate whether health-related quality of life (HRQOL) was altered in children treated for VUR. Children aged 1-5 years with grade III or higher VUR were identified through electronic records at the Stollery Children's Hospital. Parents of these children were mailed the TNO-AZL Netherlands Organisation for Applied Scientific Research Academic Medical Centre Quality of Life (TAPQOL) questionnaire. QOL scores for this group were compared with normative controls from the instrument's creators using the Mann-Whitney U test. Thirty-two of the 96 (33%) mailed surveys were returned. Eight children had surgery, and 19 were treated with antibiotic prophylaxis. When comparing the VUR group with the control group, we found that anxiety and social functioning scores were significantly better in patients with VUR (p < 0.01). The VUR group had worse scores in problem behavior, stomach complaints, and communication (p < 0.01). This study reveals that children with VUR have a reasonable QOL when compared with controls. However, the diagnosis of VUR and its management does have an impact on gastrointestinal complaints, behavior, and communication, which may occur as a result of chronic medical intervention. Keywords Vesicoureteral reflux * Quality of life * Urinary tract infections, Introduction Vesicoureteral reflux (VUR) is a common condition in children presenting either prenatally with hydronephrosis or postnatally with a febrile urinary tract infection (UTI) [1, 2]. Children with a UTI [...]

Urinary tract infections (UTI) are common in childhood. Presence of pyuria and bacteriuria in an appropriately collected urine sample are diagnostic of UTI. The risk of UTI is increased with an underlying urological abnormality such as vesicoureteral reflux, constipation, and voiding dysfunction. Patients with acute pyelonephritis are at risk of renal scarring and subsequent complications such as hypertension, proteinuria with and without FSGS, pregnancy-related complications and even end-stage renal failure. The relevance and the sequence of the renal imaging following initial UTI, and the role of antimicrobial prophylaxis and surgical intervention are currently undergoing an intense debate. Prompt treatment of UTI and appropriate follow-up of those at increased risk of recurrence and/or renal scarring are important., Author(s): Sermin A. Saadeh [sup.1] , Tej K. Mattoo [sup.2] Author Affiliations: (1) grid.414154.1, 0000000091441055, Pediatric Nephrology and Hypertension, Children's Hospital of Michigan, Wayne State University, , Detroit, MI, USA [...]

Urinary tract infections (UTIs) in children appear to be simple and straightforward matters, but there is as yet no consensus on UTIs in this patient group, and it remains one of the most--if not the most--controversial fields in paediatric medicine. Controversy and the lack of consensus can be found in many areas, including the diagnosis and management of UTIs in paediatric patients. Consequently, children with a UTI are investigated and treated quite differently in different parts of the world and also within different parts of the same country. One factor contributing to the current situation is the unexpected difficulty in diagnosing a UTI in children. This difficulty has implications not only for clinical work but also for scientific studies. Substantial over- and under-diagnosing can result from practical difficulties in at least three areas, including problems with collecting urine samples, in interpreting bacterial numbers correctly, and in confusing infantile asymptomatic bacteriuria and a true symptomatic febrile UTI. In this review, these problems will be discussed in detail as well as the implications they have had on clinical practice and research on UTIs. Keywords urine tract infection * bacterial numbers * contamination * asymptomatic bacteriuria, Introduction On the face of it, urinary tract infections (UTI) in children seem to be a simple and straightforward matter, and yet the treatment of UTI is one of the [...]

This study evaluates the impact of pediatric uninary tract infection (UTI)s on the economy and inpatient healthcare utilization in the USA. A retrospective analysis of patient demographics and hospital economics was performed on children less than 18 years of age admitted with a UTI between 2000 and 2006 using the Healthcare Cost and Utilization Project Kids' Inpatient Database. Our results were stratified as follows. Hospital admissions--nearly 50,000 children/year were admitted with a UTI. Pediatric UTIs represented 1.8% of all pediatric hospitalizations. Seventy-three percent of patients were female and 40% were under 1 year of age. Payer information--from 2000 to 2006, pediatric insurance coverage shifted from the private sector to the public sector. Hospital cost--in 2000, estimated hospital costs for UTIs were $2,858 per hospitalization and rose to $3,838 by 2006. Mean hospital charges increased from $6,279 to $10,489 per stay. By 2006, aggregate hospital charges exceeded $520 million. Our results indicate that UTIs are among the most common pediatric admission diagnoses. Hospitalization is more common in females and younger children. Since 2000, hospital charges for UTIs increased disproportionately to hospital costs. Over time, more children hospitalized with a UTI depend on public agencies to cover healthcare expense. More efforts are needed to evaluate cost-effective strategies for evaluation and treatment of UTIs. Keywords Urinary tract infection * Pediatrics * Epidemiology. Economics * Utilization review, Introduction Urinary tract infections (UTI) are one of the most common and most serious bacterial infections in children [1-3]. Estimates on the cumulative incidence of UTIs in American children indicate [...]

The role of antimicrobial prophylaxis in vesicoureteral reflux (VUR) has come under increasing scrutiny because of better analytical methods in the published literature, knowledge gained from VUR and renal scars diagnosed without preceding urinary tract infection (UTI), and better renal imaging modalities for diagnosing renal scars. A meta-analysis of the five recent randomized studies with a total of 809 patients with VUR diagnosed after UTI reveals a relative risk of UTI recurrence of 0.82 [95% confidence interval (CI) 0.62-1.08; p=0.16) with prophylaxis. A meta-analysis of the four studies with a total of 662 patients with UTI with and without VUR evaluated for renal scarring reveals a relative risk of 1.04 (95% CI: 0.84-1.30; p=0.69) with prophylaxis. However, these observations need to be interpreted with caution because of the limitations with these studies and their heterogeneity for meta-analysis, particularly for renal scarring. More research is needed to validate the role of prophylaxis in VUR diagnosed after UTI, and even more research is warranted to answer the questions regarding antimicrobial prophylaxis across the spectrum of VUR in different clinical settings. Keywords Vesicoureteral reflux * Prophylaxis * Reflux nephropathy. Renal scarring, Introduction About 45 years ago, antimicrobial prophylaxis was introduced as a measure for preventing recurrent urinary tract infection (UTI) in children. The concept of prophylaxis in vesicoureteral reflux (VUR) was [...]

We conducted a retrospective multicenter review to estimate the prevalence of urological abnormalities in Chinese children with first febrile urinary tract infection (UTI) and to evaluate the selective imaging strategy recommended by the NICE guideline for detecting underlying abnormalities. Atypical UTI was defined as in the NICE UTI guideline. Overall, 576 boys and 244 girls aged below 24 months were reviewed. All underwent ultrasound (US) and micturating cystourethrogram (MCUG) and 612 underwent DMSA scans. US was abnormal in 73 (8.9%) and vesicoureteral reflux was shown in 195 patients (23.8%). A total of 126 patients were considered to have remediable urological abnormalities requiring additional surgical or medical interventions. The NICE guideline yielded excellent negative predictive values (NPV) of 100-94.4% in girls but 91% in boys. If all boys underwent US and DMSA and only those with atypical UTI or abnormal US or DMSA proceeded to MCUG, then the NPV increased to 95.2% and 97.4% for boys aged below and above 6 months, respectively. These revised strategies would substantially save invasive studies-DMSA and MCUG in 27 and 74% of girls aged below and above 6 months, respectively, or MCUG in 23 and 59% of boys aged below and above 6 months, respectively. Keywords Children. Chinese * Imaging strategies * NICE guideline * Urinary tract infection, Introduction Urinary tract infection (UTI) is common in young children, reaching a cumulative prevalence of 2% in boys and 8% in girls in the first 8 years of life [1]. [...]

Data reported in this issue of Pediatric Nephrology suggest that the ureteric jet Doppler waveform can predict the occurrence of vesicoureteric reflux (VUR). Many different methods are currently used to detect VUR, including traditional X-ray micturating cystourethrogram, indirect and direct nuclear imaging and contrast enhanced ultrasonography. These methods are invasive, do have some radiation burden and are also quite uncomfortable to paediatric patients. This relatively new non-invasive method is therefore of interest, but its efficacy needs to be confirmed in further studies and, in particular, in babies and infants before it can possibly be considered as a good method to provide clinical information on VUR. Once such studies have been performed, this method may also prove to be a useful approach to obtain modern knowledge on the occurrence of VUR in healthy children. Keywords Vesicoureteric reflux * VUR * MCUG * Prophylactic antibiotics * Kidney scarring * Ultrasonography * Ureteric jet Doppler waveform, Introduction The clinical importance of vesicoureteric reflux (VUR) has, during the last decade, become a highly debated issue. Most older guidelines recommend a micturition cystography (MCUG) for children who have [...]