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Актуальність. Везикоуретральний рефлюкс (ВУР) спостерігається в 1–2 % дитячої популяції, а його частота в дітей з інфекцією сечовивідних шляхів доcягає 70 %. Метою цього дослідження було визначення клінічного значення рівнів сечової екскреції біологічних маркерів фіброгенезу й ангіогенезу (TGF-b1, VEGF) у дітей з хронічним пієлонефритом і ВУР після ендоскопічної корекції. Матеріали та методи. Досліджені 54 дитини з III–V ступенем ВУР після ендоскопічної корекції в періоді клініко-лабораторної ремісії пієлонефриту. У дітей у добовій сечі методом імуноферментного аналізу визначали рівень екскреції TGF-b1 і VEGF за допомогою наборів Platinum ELISA (Австрія) відповідно до інструкцій виробника. Результати. При проведенні даного дослідження було виявлено вірогідно значуще підвищення показників екскреції TGF-b1 і VEGF в сечі всіх дітей з ВУР порівняно з відповідними показниками дітей контрольної групи (рк–1 = 0,000125 і рк–2 = 0,000081; рк–1 = 0,0000 і рк–2 = 0,000021 відповідно). Рівень екскреції TGF-b1 в сечі хворих з ВУР і ознаками склерозування ниркової паренхіми був вірогідно вище (р1–2 = 0,0269) порівняно з результатами пацієнтів з ВУР без ознак нефросклерозу. Рівень екскреції VEGF з сечею у пацієнтів з ВУР і ознаками склерозування ниркової паренхіми порівняно з показниками пацієнтів з ВУР без ознак нефросклерозу були вірогідно нижчими (р1–2 = 0,0163). При дослідженні показників сечової екскреції TGF-b1 і VEGF встановлено, що критерій Краскела — Уолліса був високо статистично значимий, отже статистичні характеристики відповідних показників різних груп значимо відрізнялися між собою. Висновки. Таким чином, рівні екскреції з сечею біомаркерів фіброгенезу й ангіогенезу можуть бути використані як маркери розвитку рубцювання ниркової паренхіми у дітей з ВУР.

Urinary tract infections commonly occur in patients with spina bifida and pose a risk of renal scarring. Routine antibiotic prophylaxis has been utilized in newborns with spina bifida to prevent urinary tract infections. We hypothesized that prophylaxis can safely be withheld in newborns with spina bifida until clinical assessment allows for risk stratification.Newborns with myelomeningocele at 9 institutions were prospectively enrolled in the UMPIRE study and managed by a standardized protocol with a strict definition of urinary tract infection. Patient data were collected regarding details of reported urinary tract infection, baseline renal ultrasound findings, vesicoureteral reflux, use of clean intermittent catheterization and circumcision status in boys. Risk ratios and corresponding 95% confidence intervals were calculated using log-binomial models.From February 2015 through August 2019 data were available on 299 newborns (50.5% male). During the first 4 months of life, 48 newborns (16.1%) were treated for urinary tract infection with 23 (7.7%) having positive cultures; however, only 12 (4.0%) met the strict definition of urinary tract infection. Infants with grade 3-4 hydronephrosis had an increased risk of urinary tract infection compared to infants with no hydronephrosis (RR=10.1; 95% CI=2.8, 36.3). Infants on clean intermittent catheterization also had an increased risk of urinary tract infection (RR=3.3; 95% CI=1.0, 10.5).The incidence of a culture positive, symptomatic urinary tract infection among newborns with spina bifida in the first 4 months of life was low. Patients with high grades of hydronephrosis or those on clean intermittent catheterization had a significantly greater incidence of urinary tract infection. Our findings suggest that routine antibiotic prophylaxis may not be necessary for most newborns with spina bifida.

Objective: To evaluate the association of vesicoureteral reflux (VUR) in comparison with the development of renal scarring in child patients with urinary tract infection (UTI). Methods: This study involved a retrospective review. Patients under 14 years old with a diagnosis of UTI with a positive urine culture and who had a voiding cystourethrogram (VCUG) and technetium 99 m dimercaptosuccinic acid (Tc-99m_DMSA) renal scintigraphy performed within 4-6 months after acute UTI were included in the study. The VCUG results were classified as positive or negative for vesicoureteral reflux (VUR). If reflux was present, the severity was graded according to the recommendation of the International Reflux Study in children.1 The Tc-99m DMSA results were interpreted as positive or negative for renal scarring. Statistical analysis was performed using the χ2 test or Fisher’s exact test and Mann–Whitney test to compare the presence of VUR and renal scarring as well as the grading of the VUR and renal scarring. Positive and negative likelihood ratios (LR) were calculated. Results: In total, 185 patients (74 girls and 111 boys; mean age, 3.5 years old) were included in the study. There were five children with only a single kidney, resulting in 365 kidneys for analysis. Vesicoureteral reflux was found in 203 (55.6%) kidneys, classified as grades 1, 2, 3, 4, and 5 in 19, 31, 81, 38, and 34 kidneys, respectively. Scarring was found in 110 of 203 kidneys (54.2%) with VUR and in 18 of 162 kidneys (11.1%) without VUR (p < 0.0001). The LR positive was 2.2 (95%CI, 1.9–2.5) and LR negative was 0.23 (95% CI, 0.1-0.4). Conclusion: There was a significant correlation between positive VUR and the development of renal scarring. Patients with positive VUR should be considered for a Tc99m-DMSA scan to evaluate them for the development of renal scarring.

Objective To assess the accuracy of renal ultrasound (RUS) in detecting renal scarring (RS). Methods All initial DMSA scans performed from 2006 to 2009 for history of urinary tract infection (UTI) or vesicoureteral reflux (VUR) in patients under 14 years old were identified, and clinical history obtained via chart review. Patients who had RUS within 4 months of DMSA scan and no documented UTI during that interval were included. Decreased uptake of tracer associated with loss of contours or cortical thinning defined a positive DMSA study. Increased echogenicity/dysplasia, cortical thinning, atrophic kidney and/or abnormal corticomedullary differentiation defined a positive RUS. The sensitivity and specificity of RUS in identifying RS were calculated using DMSA scan as the gold standard. Results A total of 144 patients had initial DMSA scans performed for UTI or VUR, with a RUS within 4 months, and no UTI between the 2 studies. Ninety-five of 144 (66%) had RS on DMSA and 49/144 (34%) did not. Patients with or without RS on DMSA were not different in gender (P = .073), age (P = .432), insurance (P = 1.000) or VUR grade (P = .132). Only 39/144 (27.1%) patients had positive RUS. The sensitivity of RUS for RS was 35.8% and the specificity was 89.8%, leading to an accuracy of 54.2% (95%CI; 45.7-62.5%, P = .999). Conclusion RUS demonstrated poor sensitivity for RS visualized on DMSA scan. This suggests that RUS is a poor screening test for RS or indicators of future renal scar. A normal ultrasound does not rule out RS or risk of future renal scar. Specificity of RUS was excellent.

Objective The aim of this study was to investigate the relation between urinary TGF-β1, urinary VEGF and renal scarring resulted from VUR. Patients and methods Materials and methods: This study included 141 patients with VUR and 34 healthy sex and age matched children. The statistical analysis consisted of descriptive statistical parameters, KruskalWallis, Mann-Whitney tests and ROC analysis. Results Results: The urine levels of TGF-β1 and VEGF were significantly increased in children with VUR, compared to the controls. The levels of TGF-β1 urine excretion in children with renal scarring were higher compared children no renal scarring. The indicators of VEGF urine excretion in children with renal scarring compared to indicators in children no renal scarring, were lower, however exceeded the indicators in children of control group. The area under the ROC curve for TGF-β1 was 109.9, for VEGF was 207.6. Conclusion Conclusions: The study allowed to substantiate and propose non-invasive methods for early diagnosis of renal scarring in children with VUR.

UTI (urinary tract infection) is a leading case of renal scarring. Most of nephrons are found in kidney cortex, so it is important for early diagnosis of scarring. In this study, we investigated if scarring affects GFR (glomerular filtration rate) and serum level of creatinine through dual multipurpose 99mTc-GH (99mTc-Glucoheptonate) scintigraphy in patients with UTI. Methods: During this study 21 patients with UTI were studied by 99mTc-GH scan. For performing scintigraphy, the patient was injected by 370-555 MBq of 99mTc-GH and studied through two steps including dynamic (immediately after injection) and static (2-3h after injection) phases. The results were evaluated by appropriate analytical methods. Moreover, five patients were studied by both 99mTc-DMSA/GH (99mTc-dimercaptosuccinic acid and 99mTc-Glucoheptonate) to show 99mTc-GH scan is beneficial for detection of additional problems. Results: The results showed that there is an association between right/left kidney scarring and related GFR. Furthermore, the odds of decreased right and left kidney GFR with scarring is 12.64 and 11.89 times more than normal kidney respectively. Also, there is a significant association between renal scarring and serum level of creatinine. The study showed that the odds of increased serum level of creatinine in patients with scarring are 6.75 times more than patients without scarring. Moreover, the survey of five patients with both 99mTc-DMSA/GH scans showed 99mTc-GH could be helpful with diagnosis of some renal problems as well as scarring. Conclusion: Through this study by 99mTc-GH, it was demonstrated that kidney glomerular filtration rate and serum level of creatinine are associated with renal scarring. Furthermore, it was shown that 99mTc-GH scintigraphy could detect dilatation and abstraction of collection system in addition to renal scarring through static/dynamic renal scintigraphy.

Summary Introduction Urinary tract infection is one of the most common diseases in childhood, and can lead to severe complications such as renal scarring in case of lack of diagnosis and timely treatment. Objective The aim of this study was to investigate the prevalence of kidney scarring caused by urinary tract infection in Iranian children by meta-analysis. Study design English -language databases including Science Direct, PubMed, Scopus, Web of Science, and Springer, and Persian -language sites including SID, Magiran, Iranmedex, and Medlib, and the Google Scholar search engine were searched by in March 2018 using MeSH keywords. The heterogeneity of studies was studied using the I2 index. Data were analyzed using STATA software, version 15.1. Results In 18 studies, the prevalence of kidney scarring from urinary tract infections in Iranian children was 31% (95% confidence intervalCI: 22%–39%), (which was 14% in girls and 23% in boys. Also, the prevalence of kidney scar in children with urinary reflux was 47% and in children without urinary reflux was 12%. The most common symptom of the renal scar was fever in 61%, followed by urinary reflux in 45% (unilateral in 42% and bilateral in 30%). Also, the prevalence of mild, moderate, and severe reflux, respectively, was 31%, 27%, and 13%. Meta-regression also showed that the prevalence of kidney scar due to urinary tract infections had no significant relationship with the number of samples and years of research (P > 0.05). Discussion and Conclusion About one-third of Iranian children suffering from urinary tract infections had kidney scarring, so that the prevalence is lower in girls than in boys. Also, the prevalence of renal scarring in children with urinary reflux is about four times higher than that in children without urinary reflux.

Bacterial urinary tract infections (UTIs) are one of the most common reasons for children to be admitted to hospital. Bacteria infect and invade the bladder (the lower urinary tract) and if the infection disseminates to the upper urinary tract, significant inflammation in the kidneys may arise. Inflammation is a double-edged sword: it is needed to clear bacteria, but if excessive, kidney tissue is injured. During injury, nephrons are destroyed and replaced with deposition of extracellular matrix and a renal scar. In this review, we explore the pathogenesis of UTIs and discuss the risk factors that result in dissemination of bladder infection to the kidneys. Three major risk factors predispose to kidney infections: the presence of vesicoureteric reflux, the presence of bladder and bowel dysfunction, and defects in the ability of the host immune response to clear bacteria. In this review, we will discuss these factors, their relationship to renal scarring, and potential treatments that might be beneficial to prevent renal scar formation in children.

Background Midregional-proadrenomedullin (MR-proADM) is a useful prognostic peptide in severe infectious pathologies in the adult population. However, there are no studies that analyze its utility in febrile urinary tract infection (fUTI) in children. An accurate biomarker would provide an early detection of patients with kidney damage, avoiding other invasive tests like renal scintigraphy scans. Our objective is to study the usefulness of MR-proADM as a biomarker of acute and chronic renal parenchymal damage in fUTI within the pediatric population. Methods A prospective cohort study was conducted in pediatric patients with fUTI between January 2015 and December 2018. Plasma and urine MR-proADM levels were measured at admission in addition to other laboratory parameters. After confirmation of fUTI, renal scintigraphy scans were performed during the acute and follow-up stages. A descriptive study has been carried out and sensitivity, specificity and ROC curves for MR-proADM, C-reactive protein, and procalcitonin were calculated. Results 62 pediatric patients (34 female) were enrolled. Scintigraphy showed acute pyelonephritis in 35 patients (56.5%). Of those patients, the median of plasmatic MR-proADM (P-MR-proADM) showed no differences compared to patients without pyelonephritis. 7 patients (11.3%) developed renal scars (RS). Their median P-MR-proADM levels were 1.07 nmol/L (IQR 0.66–1.59), while in patients without RS were 0.48 nmol/L (0.43–0.63) (p Conclusion MR-ProADM has demonstrated a poor ability to diagnose pyelonephritis in pediatric patients with fUTI. However, P-MR-proADM proved to be a very reliable biomarker for RS prediction.

Background: Urinary tract infection (UTI) is commoner in children with Congenital anomalies of the kidney and urinary tract (CAKUT) than in the general paediatric population. Recurrent UTI as a result of CAKUT may predispose children to renal scarring, hypertension and CKD. Prevention of UTI in this group of patients is advocated, but achieving this has become a medical challenge in view of the controversy surrounding use of prophylactic antibiotic. Methods: This was a 10 year retrospective review of Children with CAKUT who were placed on prophylactic antibiotics over a certain period, at an Academic Hospital in Johannesburg. The rate of UTI, the types of causative organisms isolated and the efficacy of prophylactic antibiotics in preventing UTI were documented. Results: One hundred and thirty four (134) patients with CAKUT were analyzed. Thirty six (36) of them 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 < 0.001). Patients who were not on a prophylactic antibiotic were five times more likely to have a UTI than those who were on a prophylactic antibiotic (OR = 5.21, P = 0.001, 95% CI: 1.9906 – 13.6277). Patients who were on prophylactic antibiotics showed an altered pattern of isolated bacteria, with Klebsiella pneumoniae being the most common organism isolated, rather than E. coli, when compared to the group that were not on prophylactic antibiotics. There was a statistically significant association between the type of bacteria isolated and the use of antibiotic prophylaxis (p= 0.031). Conclusion: Antibiotic prophylaxis was very effective in decreasing the rate of UTI in our cohort of patients with CAKUT.

Maysoun Al Rushood,1 Amal AL-Eisa,1 Rajaa’ AL-Attiyah2 1Department of Pediatrics, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait; 2Department of Microbiology, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait City, KuwaitCorrespondence: Maysoun Al RushoodDepartment of Pediatrics, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait City, KuwaitTel +965-25319486Fax +965-25338940Email maysounrushood@hsc.edu.kwBackground: Urinary tract infection (UTI) is common in pediatrics. Infection of the upper urinary tract may cause renal scarring, and subsequently renal failure and hypertension. Permanent renal damage has been suggested to be caused by the host inflammatory response. Therefore, it is crucial to understand the host defense mechanisms against such infection in order to make timely diagnosis. The aim of this study was to evaluate interleukin-6 (IL-6) and IL-8 as potential biomarkers in differentiating acute pyelonephritis (AP) from cystitis (Cys) in children.Methods: Forty-three children (21 with AP and 22 with Cys) were included. Serum and urinary IL-6 and IL-8 were measured during the acute phase (within 12 hours of presentation) and the convalescent phase (8 weeks post-infection). Thirty-eight healthy children were included as controls.Results: During the acute phase, the mean urinary IL-6 level in the Cys group was significantly higher than that in the controls (17.8 pg/mL vs 14.8 pg/mL, P=0.03), while the serum levels were significantly higher in both the Cys and AP groups than in the controls (19.5 pg/mL, 19.4 pg/mL, 15 pg/mL, P=0.005 and 0.02, respectively). During the convalescent phase, serum and urinary IL-6 levels were higher in patients than in controls. Urinary IL-8 levels were significantly higher in both the AP and Cys groups compared to controls (206.5 pg/mL, 291.8 pg/mL, 89.4 pg/mL, P=0.05 and 0.02, respectively) during the acute phase. Serum IL-8 was not significantly different between the 3 groups. Nonetheless, no significant differences were found between the AP and Cys groups, in urinary or serum levels of IL-6 or IL-8, during both phases.Conclusion: IL-6 and IL-8 levels are elevated in patients with UTI. However, the levels did not differentiate between AP and cystitis. Further studies are warranted to evaluate their roles as indicators of the site of UTIs.Keywords: cystitis, IL-6, IL-8, pyelonephritis, UTI

BACKGROUND Renal scarring is a serious complication in recurrent urinary tract infections (UTIs). Vitamin D deficiency has also been reported to be a risk factor for UTIs although, to date, no association between vitamin D deficiency and renal scarring has yet been identified. In the present study, it was investigated whether vitamin D deficiency may be a risk factor for renal scarring in patients with recurrent UTIs. METHODS The study included patients between the ages of 1 and 18 years who were admitted to the pediatric nephrology department of the center between November 1, 2018 and November 1, 2019 and who were diagnosed with recurrent UTIs. The medical records of the patients were reviewed for the collection of demographic data, vitamin D levels, ultrasonography results and scintigraphic investigations with 99m-technetium dimercaptosuccinic acid (99m Tc-DMSA). The patients were divided into two groups: those with and without renal scarring, diagnosed via 99m Tc-DMSA. The vitamin D levels and other parameters of the two groups were compared. RESULTS Vitamin D deficiency (

Renal scarring after pyelonephritis is linked to long‐term health risks for hypertension and chronic kidney disease. Androgen exposure increases susceptibility to, and severity of, uropathogenic Escherichia coli (UPEC) pyelonephritis and resultant scarring in both male and female mice, while anti‐androgen therapy is protective against severe urinary tract infection (UTI) in these models. This work employed androgenized female C57BL/6 mice to elucidate the molecular mechanisms of post‐infectious renal fibrosis and to determine how these pathways are altered by the presence of androgens. We found that elevated circulating testosterone levels primed the kidney for fibrosis by increasing local production of TGFβ1 before the initiation of UTI, altering the ratio of transcription factors Smad2 and Smad3 and increasing the presence of mesenchymal stem cell (MSC)‐like cells and Gli1 + activated myofibroblasts, the cells primarily responsible for deposition of scar components. Increased production of TGFβ1 and aberrations in Smad2:Smad3 were maintained throughout the course of infection in the presence of androgen, correlating with renal scarring that was not observed in non‐androgenized female mice. Pharmacologic inhibition of TGFβ1 signaling blunted myofibroblast activation. We conclude that renal fibrosis after pyelonephritis is exacerbated by the presence of androgens and involves activation of the TGFβ1 signaling cascade, leading to increases in cortical populations of MSC‐like cells and the Gli1 + activated myofibroblasts that are responsible for scarring., Circulating androgens prime the kidney for fibrosis upon infectious injury (Escherichia coli pyelonephritis) by enhancing local TGFβ1 production and myofibroblast activation.

Urinary tract infections (UTIs) are one of the most common childhood bacterial infections. Recurrent UTIs can lead to renal scarring. Compared to boys, girls are more likely to develop scars as a result of recurrent UTIs. Therefore, there is a need to identify girls at high risk for recurrent UTIs and develop interventions to decrease the risk of recurrent UTIs. In this commentary, we will review the hypothesized pathophysiology of recurrent UTIs, explore the literature on the role of the microbiome in recurrent UTIs, focusing on female pediatric patients when able, and highlight the need for future research in this area.

Vesicoureteral reflux (VUR) is the most common congenital urological abnormality in children and is most often diagnosed after an episode of urinary tract infection (UTI). Reflux nephropathy (RN) is the renal scarring associated with VUR. VUR may be congenital, a result of abnormal renal development leading to focal renal dysplasia, or acquired, from pyelonephritis-induced renal injury. The overriding hypothesis about the VUR-UTI link has been that VUR increases the risk of recurrent UTIs and renal scarring and the associated subsequent morbidity, although the exact mechanism for renal scarring following UTI is not known. The complications of renal scarring are more common in adults. Complications include proteinuria, hypertension, pre-eclampsia, and ESRD. The recently completed RIVUR trial was designed to investigate whether antimicrobial prophylaxis prevents UTI in children with VUR, or leads to a reduction in renal scarring. The trial results should enhance our understanding of VUR and the risk for RN, and lead to appropriately tailored management of individuals with VUR.

Ureteroceles can be associated with many potential complications to the lower and upper urinary tracts, and both the surgical and conservative management aim to avoid recurrent UTIs, renal scarring and to achieve renal function preservation. Several anatomical factors affect the outcomes and morbidities associated with ureteroceles, and they must be taken into consideration in the short- and long-term care of the patient. The key anatomical features that influence these potential complications include the positioning of the ureterocele within the lower urinary tract and whether or not there is ureteral duplication present. The management of ureterocele can be challenging and this chapter addresses the possible long-term complications.

Recurrent urinary tract infection (rUTI) continues to challenge pediatric care providers. The diagnosis of an rUTI can be difficult, especially in young febrile children. Antibiotic resistance rates continue to rise, which limits oral treatment options. Prophylactic antibiotics are used commonly to manage rUTI, but their use increases the risk of rUTI with antibiotic-resistant strains without significantly reducing renal scarring. Alternative therapies for rUTI include probiotics and anthocyanidins (eg, cranberry extract) to reduce gut colonization by uropathogens and prevent bacterial adhesion to uroepithelia, but efficacy data for these treatments are sparse. The future of rUTI care rests in addressing the following contemporary issues: best diagnostic practices, risk factors associated with rUTI, and the prevention of recurrent infection. In this review, we summarize the state of the art for each of these issues and highlight future studies that will aim to take an alternative approach to managing rUTI.

Objective Multiple imaging techniques may be used to evaluate the development of progressive renal damage in children with urinary tract infections (UTIs). The aim of this study was to compare the efficacy of Tc-99m dimercaptosuccinic acid (DMSA) scintigraphy and renal ultrasonography (USG) in detecting renal scars in children with UTIs. Methods A total of 630 kidneys from 364 children were included in the study and the results of DMSA and USG of children with UTIs were evaluated retrospectively between January 2016 and October 2017. DMSA scintigraphy is accepted as the gold standard and it was compared with USG results. Results The sensitivity, specificity, positive predictive value, and negative predictive value for USG in the detection of renal scarring was found as 57.1, 89.6, 40.8, and 94.4%, respectively. Conclusions Although USG is known to be safe, readily available, and relatively inexpensive, the sensitivity of USG does not seem to be sufficient to identify the renal parenchymal damage. We concluded that USG cannot replace DMSA in the evaluation of renal scarring.

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.

Background: The aim of the study was to determine the risk factors for renal scarring detected by DMSA (dimercaptosuccinic acid) scan in children with culture-proven urinary tract infection (UTI).Methods: A hospital based observational case-control study was conducted from 2018 June to 2020 June in children aged between 1 month to 5 years who underwent a DMSA scan following culture-proven UTI (N=72). Of the children fulfilling the criteria, 43 had renal scarring in the DMSA scan as a case group and the remaining 29 children who had no renal scarring were taken as a control group.Results: Of the total 72 cases with culture-positive UTI, 59% of patients had renal scarring and the rest and 40% were scar negative. There was no significant difference in the renal scarring observed with respect to age in the two groups. There was significant (p0.05). In DMSA positive group, circumcision was not a significant risk factor for scarring.Conclusions: VUR and recurrent UTI were significant risk factors for renal scarring in children with culture-proven UTI as detected by DMSA scan. The other risk factors like age, sex, fever, leucocytosis and circumcision were not found to be significant.

Recent advances in pediatric urinary tract imaging include development of alternative imaging methods without use of ionizing radiation; evolving understanding of the relationship of urinary tract infection, vesicoureteral reflux, and renal scarring, including the important role of dysfunctional voiding; development of a consensus nomenclature and risk-based classification for fetal and antenatal urinary tract dilation; advances in the understanding of sporadic and inherited renal cystic disease; and a proposed modification of the Bosniak criteria for distinguishing complex renal cysts from cystic renal tumors in children.

Urinary tract infection (UTI) is the most common bacterial infection seen in younger age group children. The most common risk factor for renal scarring in children with post-UTI is vesicoureteral reflux (VUR). This study looked at renal scarring following UTI in children by dimercaptosuccinic acid (DMSA) scan. It is a cross-sectional time bound study done among 40 infants and children with UTI for a period of 24 months. Their clinical presentation and laboratory data, including micturating cystourethrogram, were documented. DMSA scan, done during the follow-up, established the presence of renal scars if any. UTI was more common in males. Children with history of recurrent UTI had renal scarring. Statistical significance was noted when first and recurrent attacks of UTI were compared for clinical and diagnostic characteristics like Escherichia coli UTI (p = 0.007), increasing grades of VUR (p = 0.006) and renal scar formation (p = 0.041). The study concluded that the high grades of antenatal hydroureteronephrosis (100%), febrile UTI (34%), younger age group (67.5%) and E. coli UTI (86%) were more associated with recurrent attacks of UTI and renal scarring. DMSA, being the non-invasive test, is better proven to be an investigation of choice than other invasive modalities for follow-up of children with recurrent attacks of UTI.

Summary In this edition of Mythbusters we critically examine the premise that, because women with history of vesicoureteric reflux (VUR) are at higher risk of urinary tract infection (UTI) and other morbidity during pregnancy, persistent VUR in older girls should be considered an indication for surgical correction. The literature is very limited in that there are essentially no methodologically robust comparisons of pregnancy outcomes among women whose childhood VUR was or was not surgically repaired. Most of the case series and cohorts find relatively high incidence of UTI and pyelonephritis among pregnant women with a history of VUR, but there is very little to suggest that persistent VUR is itself a risk factor for infection during pregnancy. Indeed, some studies suggest that UTI risk is actually higher among women who previously underwent anti-reflux surgery compared to those who did not, although these data are compromised by significant selection bias. In contrast, there is relatively strong evidence that maternal and fetal morbidity is higher when the mother is known to have renal scarring; such women probably merit close surveillance during pregnancy for infection, hypertension and pre-eclampsia, and other problems. Overall, current evidence is insufficient to support routine anti-reflux surgery in girls with the sole purpose of decreasing complications during future pregnancy, particularly for girls with lower-grades of VUR and no renal scarring. The verdict for this urolegend: it contains a a “teeny, tiny nugget of truth.”

The RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial reported that antibiotic prophylaxis reduced recurrent urinary tract infection but antibiotic prophylaxis was not associated with decreased new renal scarring. However, the original reports did not assess the relationship among recurrent urinary tract infection, new renal scarring and antibiotic prophylaxis in detail. Therefore, we investigated the relationship among these issues.We included subjects with dimercaptosuccinic acid scan within 6 months of enrollment and at least 1 followup dimercaptosuccinic acid scan from the RIVUR trial. The primary outcome was recurrent urinary tract infection associated new renal scarring, defined as recurrent urinary tract infection and new changes on dimercaptosuccinic acid scan. Due to a low number of events, propensity score was used to adjust for confounders. Multivariate logistic regression was fitted to investigate the associations between the covariates and the outcome.A total of 489 patients (91% female, mean age 20.3 months) were included in the study. Any new renal scarring was more common among those with recurrent urinary tract infection (OR 4.1, 95% CI 2.0-8.5, p0.01) after adjusting for age, sex, index urinary tract infection, duplication, bowel bladder dysfunction and antibiotic prophylaxis. Recurrent urinary tract infection associated new renal scarring occurred in 5 of 244 (2%) patients on antibiotic prophylaxis and 13 of 245 (5%) on placebo. Compared to antibiotic prophylaxis, placebo was associated with a higher risk of recurrent urinary tract infection associated new renal scarring (OR 3.1, 95% CI 1.0-8.8, p=0.04) after adjusting for age, sex, race, index urinary tract infection, bowel bladder dysfunction, duplication, hydronephrosis, vesicoureteral reflux grade and baseline renal scarring. There were no differences in scar severity at final dimercaptosuccinic acid scan (p=0.88) or change from baseline (p=0.53) between antibiotic prophylaxis and placebo.Recurrent urinary tract infection was associated with new renal scarring in the RIVUR trial. When limited to recurrent urinary tract infection associated new renal scarring, antibiotic prophylaxis was associated with a decreased risk of this outcome. It remains unclear why new renal scarring developed in a proportion of subjects without recurrent urinary tract infection. The results should be carefully interpreted due to the inherent limitations.

Investigation of children with urinary tract infection (UTI) or other renal disease ofteninvolvesa combination of dimercaptosuccinic acid (DMSA) imaging and ultrasound (US) imaging to identify structural and functional defects. DMSA imaging provides information on the relative function of the right and left kidneys and is considered the gold-standard imaging modality for the detection of renal scarring. DMSA imaging requires anintravenous injection of a radioactive agent and often requires sedationin babies and young children. DMSA imaging takes more than two hours to complete and is not suitable for frequent repeat studies. US imaging provides information on renal size, parenchymal appearance and structural abnormalities such as calyceal and/or renal pelvic dilatation. US imaging is non-invasive, does not involve ionising radiation and can be performed in most children without sedation or anaesthetic. US imaging takes less than 30 minutes to complete and can be repeated easily for follow up. We have obtained ethical approval to investigate the associations between DMSA-assessed renal function discrepancy with US assessment of renal length, renal volume, renal length discrepancy and renal volume discrepancy. Image data will be captured and analysed from children who underwent both DMSA imaging and renal US imaging in our hospital between 2015 and 2018. The analytical group (n=200) has been limited to those who underwent imaging as part of investigation of UTI or other renal disease who had DMSA and ultrasound scanning within six months of each other and whose images are adequate to obtain the relevant measurements. Finding strong associations and sufficient diagnostic accuracy may mean that the non-invasive and more easily performed US examination, which does not involve ionising radiation, may reduce the need for DMSA scanning in some children.

Purpose Acute pyelonephritis (APN) is a serious bacterial infection that can cause renal scarring in children. Early identification of APN is critical to improve treatment outcomes. The neutrophil-lymphocyte ratio (NLR) is a prognostic marker of many diseases, but it has not yet been established in urinary tract infection (UTI). The aim of this study was to determine whether NLR is a useful marker to predict APN or vesicoureteral reflux (VUR). Methods We retrospectively evaluated 298 pediatric patients (age≤36 months) with febrile UTI from January 2010 to December 2014. Conventional infection markers (white blood cell [WBC] count, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]), and NLR were measured. Results WBC, CRP, ESR, and NLR were higher in APN than in lower UTI (P

Current management of vesicoureteral reflux (VUR) in children is the result of a steady albeit controversial evolution of data and thinking related to the clinical impact of VUR and urinary tract infection (UTI) in children, the value of clinical screening, and the relative impact of testing and interventions for VUR. While controversy continues, there is consensus on the importance of bladder dysfunction on VUR outcomes, the likelihood of VUR resolution, and the fact that not all children with VUR require active treatment. Early efforts to define risk stratification hold the most promise to provide more patient-specific treatment of UTI and VUR in children.

AmaçArtmış idrar ürik asit atılımının vezikoüreteral reflü (VUR) ile ilşkiliolduğu gösterilmiştir. Bu çalışmanın amacı idrar ürik asit/kreatinin oranınınVUR hastalığında renal skar için bir gösterge olup olamayacağının araştırılmasıdır.Materyal– MetodBu çalışma için VUR tanısı konmuş hastaların dosyaları geriye dönük olarak taranmıştır.Sekonder VUR, 3 yaş altındakiler ve yetersiz değerlendirmesi olan hastalarçalışma dışı bırakılmıştır. Yaş, cinsiyet, VUR durumu, dimerkaptosüksinik asit(DMSA) sintigrafi bulguları, hipertansiyon varlığı, mikroalbuminuri, vücutkitle indeksi sonuçları kaydedilmiştir. Serum ve idrar ürik asit, kalsiyum vekreatinin değerleri ölçülmüştür. İdrar ürik asit/kreatinin ve idrarkalsiyum/kreatinin oranları yaşa gore hesaplanmıştır. Herhangi bir predikteedici faktörü değerlendirmek için geriye dönük regresyon analizi yapıldı.Bulgular Çalışmaya toplam 76 hasta dahi edilmiştir. Ortalama yaş 8.2±3.7 olarakbulunmuştur. Hastalardan 49’u kız ve 27’si de erkektir. Toplamda 51 hastadarenal skar saptanmış olup 25 hastada renal skar saptanmamıştır. Çalışma grubunda22 hastada mikroalbuminüri mevcut iken 5 hastada hipertansiyon bulunmuştur.Hiperürikozüri 23 hastada (%30.7) var iken yalnızca 1 hastada (%1.3)hiperkalsiüri vardı. İdrar ürik asit/kreatinin oranı ile renal skar,mikroalbminüri ve hipertansiyon arasında ilişki saptanmamıştır (p değeri tümüiçin >0.05) . Ayrıca idrarkalsiyum/kreatinin oranı da bahsedilen parametrelerle ilişkili bulunmamıştır.Sonuçlar Çalışmamızınsonuçlarına göre ürik asit/kreatinin oranının vezikoüreteral reflülü hastalardarenal skarı gösteren bir bulgu olmadığı saptanmıştır., Objective: Increased urinary excretion of uric acid has been shown to be associated with vesicoureteral reflux (VUR). The aim of this study is evaluate if urinary uric acid/creatinine ratio can be used as a surrogate for renal scarring in VUR.Method: Retrospective chart analysis was made to identify patients who were diagnosed with VUR. Those with secondary VUR, 0.05, for all). Conclusions: Our results indicate that urinary uric acid/creatinine ratio would not be used as surrogate for renal scarring in VUR.

Objectives To identify factors associated with delayed antimicrobial treatment in febrile children with urinary tract infection (UTI). Study design We reviewed data from 802 children with UTI enrolled in 2 previously conducted prospective studies (Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation) and extracted data on possible predictors of delayed treatment including age, sex, history of UTI, ethnicity, race, primary caregiver's education level, insurance, and income. We used univariate and multivariable analyses to investigate the relationship between these predictors and treatment delay. Results We included 660 febrile patients with a mean age of 17.0 months old. Older age and commercial insurance were associated with delayed treatment on univariate analysis. Compared with younger children, treatment was delayed by an average of 26.2 hours in children ≥12 months of age. This relationship remained significant on multivariable analysis. Treatment also was delayed by an average of 12.6 hours in patients with commercial insurance. Race, ethnicity, primary caregiver's education level, and income were not associated with delayed treatment. Conclusions Older age was a consistent predictor of delayed antimicrobial treatment. Delays in the initiation of antimicrobial therapy for UTI has previously been associated with renal scarring. Educating parents with older children regarding the management of fever as well as providers regarding prompt evaluation and management may help to reduce renal scarring.

Introduction: Cystinuria is an autosomal recessive disorder due to intestinal and renal transport defects in cystine and dibasic amino acids, which result in recurrent urolithiasis and surgical interventions. This study aimed to assess the impact of surgical interventions on renal function by analyzing estimated glomerular filtration rates. Methods: Thirteen pediatric patients with cystinuria, who were followed-up in a single tertiary institution between 2004 and 2016, were included in the study. Medical records were reviewed to collect data on clinical presentation of patients, urine parameters, stone formation, medical treatment, surgical intervention, stone recurrence after surgical procedure, stone analysis, ultrasonography, 99m-technetium dimercaptosuccinic acid (99mTc-DMSA) radionuclide imaging results, and follow-up time. Creatinine clearances estimated by modified Schwartz (eGFR) formula before and after surgery were used to assess renal function and compared statistically. Results: Nine patients (69.2%) had renal scarring which were detected with 99mTc-DMSA radionuclide imaging. In ten patients (76.9%), open surgical intervention for stones were needed during follow-up. Significant difference was not detected between eGFR before and after surgical intervention (mean 92 versus 106, p = 0.36). Nine of the patients (69.2%) were stone free in the last ultrasonographic examination. Relapses of stone after surgery were seen in 66.6% of patients who underwent surgical intervention. Conclusions: Surgical interventions for urinary stones are commonly required in patients with cystinuria. Renal scarring is a prevalent finding in cystinuric patients. Surgical interventions have no negative impact on eGFR in patients with cystinuria according to the present study.

Background To report the long-term outcomes of endoscopic surgery (ES) in pediatric patients with vesicoureteral reflux in terms of success rate, urinary tract infection, and renal function. Methods We retrospectively reviewed the records of 73 pediatric patients (110 ureters) who underwent ES for vesicoureteral reflux. Ultrasonography was performed 1, 3, and 12 months postoperatively. Voiding cystourethrography was performed 3 months postoperatively and repeated after 1 year if vesicoureteral reflux persisted. Success was defined as the absence of reflux at the first voiding cystourethrography. Renal scans were performed at least 12 months postoperatively. Renal function deterioration was defined as a new scar or a greater than 5% decrease in function. Results The median follow-up duration was 24 (12-118) months. The overall success was 65.6%, while it was 78.9%, 87.0%, 62.5%, 37.5%, 66.7% for grades I, II, III, IV, and V, respectively. In multivariate analyses, significant predictive factors for success were vesicoureteral reflux grade (odds ratio [OR], 0.28; P < 0.001) and mound detection at the first postoperative ultrasonography (OR, 13.53; P < 0.001). Renal function deterioration was found in 8 (15.3%) ureters and was less common in those with successful surgeries than in those with failures (9.5% vs. 40.0%; P = 0.035). No significant predictive factor for renal function deterioration or urinary tract infection was found. Conclusion Successful short-term outcomes of ES are expected in low-grade vesicoureteral reflux, especially when a mound is detected by postoperative ultrasonography. However, unpredictable long-term renal deterioration warrants continued follow-up.

WOS: 000439814600014, PubMed: 30016028, Introduction. The aim was to investigate the relationship between vesicoureteral reflux (VUR) and renal damage in non-febrile, febrile for the first time and recurrent urinary tract infection (UTI) patients. The secondary aim was to determine whether C-reactive protein (CRP) in febrile UTIs could be a predictor of renal scarring. Population and methods. This prospective study included non-febrile, febrile for the first time and recurrent pediatric UTI cases. The routine lab analyses comprised a complete blood count, urea, creatinine, fully automated urinalysis, urine culture and CRP analyses. All the participants were examined using urine ultrasonography subsequent to their UTI diagnosis, voiding cystourethrography (VCUG) after six weeks and Tc-99m dimercaptosuccinic acid (DMSA) static renal scintigraphy after six months. Results. There were included 47 children with non-febrile UTIs, 48 with fist febrile UTIs and 61 with recurrent UTIs. A statistically significant difference was found among the groups in terms of VUR and renal scarring (p = 0.001 and p = 0.011, respectively). A statistically significant difference was also found in terms of renal scarring between patients with and without VUR (p = 0.001). Moreover, a statistically significant difference was also present in relation to renal scarring (p

La infeccion del tracto urinario (ITU) es una patologia frecuente en la infancia, reconocida como precipitante de enfermedades agudas y cronicas con un gran indice de morbilidad. Es importante el diagnostico apropiado para minimizar la instauracion de cicatrices renales, falla renal e hipertension arterial en la edad adulta. Las indicaciones de profilaxis han cambiado en los ultimos anos. Objetivo: Dar a conocer los conocimientos actuales en patogenesis diagnostico y manejo posterior en ITU. Metodologia: Se realizo una revision bibliografica entre los anos 1995 al 2016, en las bases de datos de Scielo, Elsevier, Pubmed, Redalyc, ScienceDirect, Medwave, Nature Reviews, EBSCO, Naxos, Bases de datos que ofrece la Universidad del Cauca. Se utilizo los terminos MeSH y DeSC -“Urinary Tract Infection, Risk factor, children, diagnostic, treatment”, en ingles y espanol con un total de 276 documentos. Posteriormente fueron evaluados con los respectivos instrumentos de lectura critica de articulos asi: Consort para ensayos clinicos, Strobe, para estudios observacionales, Prisma para meta-analisis y Agree para guia de practica clinica, filtrando un total de 58 documentos. Para la gestion de la informacion se utilizo el programa Mendeley de libre acceso. Resultados: Los conocimientos en ITU en pediatria han avanzado mas hacia la prevencion de cicatrices y prevencion de enfermedades en la etapa adulta. Las indicaciones de profilaxis han cambiado y son mas escuetas. Conclusiones: La ITU es frecuente en pediatria. Han cambiado los manejos, por ahora se necesitan mas estudios en nuestra poblacion.

Vesicoureteral reflux [VUR] remains a common problem seen by pediatric providers. Despite a great deal of research, the debate regarding how to screen and treat patients reremains tense and controversial. This review seeks to summarize the management of VUR with emphasis on recent published findings in the literature and how they contribute to this debate. The goals of managing VUR include preventing future febrile urinary tract infections [FUTI], renal scarring, reflux nephropathy and hypertension. The topdown approach with upper tract imaging and selective vesicocystourethrogram [VCUG] is an emerging alternative approach in the evaluation of children after their first FUTI. The elimination of bladder and bowel dysfunction [BBD] is an important management strategy to prevent further FUTIs, regardless of treatment choice. Antibiotic prophylaxis is a safe and effective modality to sterilize the urinary tract. Endoscopic treatment of VUR is an attractive modality in select patients, although some concerns remain regarding its effectiveness and durability as compared to to the gold standard of open or laparoscopic ureteroneocystostomy. Lastly, further research is required to determine the most effective algorithm to evaluate the pediatric patient after the first febrile UTI.

The 2011 American Academy of Pediatrics (AAP) Urinary Tract Infection (UTI):Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2-24 Months guideline addressed “areas for research” identifying multiple areas where evidence at the time of the publication was lacking. This review discussed the evidence development in those identified areas. In this paper, I will review the latest literature on UTI in children and focus on those areas of research suggested in these guidelines. I will also summarize the related literature since September 2011. Literature related to first UTI in children have contributed important new knowledge since the publication of the 2011 AAP guideline; 1) additional research has failed to clarify the relationship between childhood UTI and adult renal function. 2) High grade vesicoureteral reflux (VUR) has been established as a clear risk factor for scarring, but the condition is rare. Abnormal ultrasound, and fever in combination with non-E coli infection are other important predictors of scarring. 3) Antimicrobial prophylaxis appear to decrease UTI recurrences, but a large amount of antibiotics has to be administrated to prevent one UTI and the prevention works best in children with low grade, not high grade, VUR, 4) cranberry juice may prevent UTI, and 5) new, less aggressive guidelines, seem not to have negative consequences for pediatric patients measured as missed true pathology. Future guidelines would benefit from incorporating this new information.

Objective: Urinary tract infection (UTI) is the most common bacterial infection in childhood. UTI may be the sentinel event for underlying renal abnormality. There are still many controversies regarding proper management of UTI. In this review article, the authors discuss recent recommendations for the diagnosis, treatment, prophylaxis, and imaging of UTI in childhood based on evidence, and when this is lacking, based on expert consensus. Sources: Data were obtained after a review of the literature and a search of Pubmed, Embase, Scopus, and Scielo. Summary of the findings: In the first year of life, UTIs are more common in boys (3.7%) than in girls (2%). Signs and symptoms of UTI are very nonspecific, especially in neonates and during childhood; in many cases, fever is the only symptom. Conclusions: Clinical history and physical examination may suggest UTI, but confirmation should be made by urine culture, which must be performed before any antimicrobial agent is given. During childhood, the proper collection of urine is essential to avoid false-positive results. Prompt diagnosis and initiation of treatment is important to prevent long-term renal scarring. Febrile infants with UTIs should undergo renal and bladder ultrasonography. Intravenous antibacterial agents are recommended for neonates and young infants. The authors also advise exclusion of obstructive uropathies as soon as possible and later vesicoureteral reflux, if indicated. Prophylaxis should be considered for cases of high susceptibility to UTI and high risk of renal damage. Resumo: Objetivo: A infecção do trato urinário (ITU) é a infecção bacteriana mais comum na infância. A ITU pode ser o evento sentinela para alteração renal subjacente. Ainda há muitas controvérsias com relação ao tratamento adequado da ITU. Neste artigo de revisão, discutimos as últimas recomendações para diagnóstico, tratamento, profilaxia e imagiologia da ITU na infância, com base em comprovação e, na sua ausência, com base no consenso de especialistas. Fonte de dados: Os dados foram coletados após uma revisão da literatura e pesquisa no Pubmed, Embase, Scopus e Scielo. Resumo dos dados: No primeiro ano de vida, as ITUs são mais comuns em meninos (3,7%) que em meninas (2%). Os sinais e sintomas da ITU são muito inespecíficos, principalmente em neonatos e durante a infância, sendo a febre o único sintoma em muitos casos. Conclusões: O histórico clínico e exame físico podem sugerir ITU, porém a confirmação deve ser feita por urocultura. Antes da administração de qualquer agente antimicrobiano, deve ser feita coleta de urina. Durante a infância, a coleta de urina adequada é essencial para evitar resultados falso-positivos. O diagnóstico e início do tratamento imediatos são importantes na prevenção de cicatriz renal de longo prazo. Neonatos febris com ITUs devem ser submetidos a ultrassonografia renal e da bexiga, Agentes antibacterianos intravenosos são recomendados para neonatos e neonatos jovens. Recomendamos também a exclusão de uropatias obstrutivas o mais rápido possível e posterior refluxo vesico-ureteral, caso indicado. A profilaxia deve ser considerada em casos de elevada susceptibilidade a ITU e risco elevado de danos renais. Keywords: Urinary tract infection, Renal scarring, Ultrasonography, CAKUT, Hydronephrosis, Obstructive uropathy, Palavras-chave: Infecção do trato urinário, Cicatriz renal, Ultrassonografia, CAKUT, Hidronefrose, Uropatia obstrutiva

We report on a 11 year old boy who was treated for bilateral vesicoureteral reflux grade II at our department by the age of 12 months by bilateral endoscopic injection with dextranomer / hyaluronic acid (Deflux). Because of reflux persistence on the right side an open antireflux surgery (Lich Gregoir) was performed. 10 years after initial treatment he developed serious deterioration of the left kidney function after three febrile urinary tract infections within one month. Diagnostic re-evaluation revealed bilateral recurrence of grade II reflux, which was corrected consequently by open bilateral ureteral reimplantation (Cohen technique). We discuss the available literature as to renal scarring in older children and adults after initial reflux therapy in childhood and conclude that there is no age limit to possible scar formation and that there are possible implications on follow up after “curative” therapy of vesicoureteral reflux in childhood. key words: paediatric urology, vesicoureteral reflux, endoscopic reflux therapy, Deflux, renal scarring

The role of antimicrobial prophylaxis for the prevention of recurrent urinary tract infections in children with vesicoureteral reflux that was identified following a urinary tract infection has been the source of considerable debate. Prior studies had failed to show a benefit in the prevention of recurrent infection. The National Institutes of Health funded the Randomized Intervention for Vesicoureteral Reflux (RIVUR) study to determine if there was a benefit to the use of prophylaxis. Results of the RIVUR study indicated that there was a 50% reduction in the risk of recurrent urinary tract infection in those children on the prophylaxis arm. Adverse events with the use of prophylaxis were noted to be few. Renal scarring was noted in only a small number of children at study entry and no reduction in scarring was noted between the placebo and the treated groups. The impact of the RIVUR study on the current evaluation and management of children with urinary tract infections and vesicoureteral reflux is detailed.

Urinary tract infection (UTI) is a common problem during childhood and around 40% of these children have associated vesico ureteric reflux and renal scarring. Identification of an anatomical or physiological predisposition to urinary infection is an integral part of the comprehensive management of pediatric UTI. Voiding dysfunction is one of the leading causes of UTI in children. 1-5 Voiding dysfunction is defined as any disturbance in bladder filling or voiding after toilet training. It is seen in children without anatomical or neurological problems. 6,7 The etiology of voiding dysfunction is still unknown and its incidence varies from 20 to 50% among children. Frequency, urgency and urge incontinence are the main symptoms of voiding dysfunction. 8 Farhat et al described a dysfunctional voiding symptom score (DVSS) and Babu has used it earlier in identification of voiding dysfunction in children. 9,10 In this study, we have used DVSS in children with UTI to identify their association. Several authors have stressed the importance of identifying and treating voiding dysfunction to prevent recurrent UTI and promote resolution of associated vesico ureteric reflux (VUR). 11-16 ABSTRACT

Normal 0 false false false MicrosoftInternetExplorer4 Background: The goal of treatment in vesicoureteral reflux (VUR) is to reduce the risk of reflux-associated pyelonephritis. Medical versus surgical treatment for VUR is still controversial, with surgery successful in majority of cases. There are not enough data available in literature on long-term incidence of urinary tract infection (UTI) after reimplantation. The aim of the study was to determine the long-term outcome after reimplantation with respect to UTI, renal scarring and potential risk factors for post-reimplant UTI. Methods: It is a retrospective review of 106 consecutive cases who underwent reimplantation for primary VUR. Results: Incidence of post-reimplant UTI is 12.8%. Majority of our patients were females and showed high grade reflux. Median age at surgery was 32 months. Thirteen patients had post-reimplant UTI. Of this, 12/13 were females, 12/13 had pre-reimplant febrile UTI, 10/13 had high grade VUR, 7/13 had urge incontinence and dysfunctional voiding, and 3/13 had constipation. Only two patients showed new scarring/worsening scarring. Conclusions: It is an established fact that ureteric reimplantation is effective in preventing UTI. Some continue to develop UTI even after successful correction of VUR and it is unclear as to why it happens. Various rates of post-reimplant UTI have been quoted in literature with non-febrile UTI of 40% and febrile UTI of 14%. In our study, febrile UTI rate was 4.9% and non-febrile UTI rate was 7.9%. Post-reimplant UTI resulting in new renal scars is rare. There are some possible risk factors for recurrent UTI after reimplantation, but unfortunately only few of them are reversible (bowel bladder dysfunction). Reimplantation for VUR is a very effective treatment. Incidence of post-reimplant UTI is 12.8% with development of new scars after such UTI is rare. Several risk factors contribute to such UTI. World J Nephrol Urol. 2016;5(1):1-3 doi: http://dx.doi.org/10.14740/wjnu237w

Background Urinary Tract Infection (UTI) is a common cause of bacterial infection in young children, and accounts for a significant number of pediatric hospitalizations. Objective To review recent publications focusing on the care of children hospitalized with their first febrile UTI. Methods A PubMed search was performed including publications from 2011-2016 on first febrile UTI in childhood. Abstracts were reviewed for being relevant to the care of hospitalized children and their follow-up. Relevant articles underwent full review by all authors and articles excluded from results included those without novel data analysis, primary improvement-based reports and studies with poor design or analysis. Included articles were categorized as "diagnosis", "management", "imaging" or "follow-up". Results Of 406 articles initially identified, 40 studies were included. One technical report with a systematic review was also included. Major topics addressed included the role of urinalysis in screening for UTI, use of parenteral antimicrobial therapy, the role of antimicrobial prophylaxis in prevention of recurrent UTI, and ideal follow-up and imaging approach following diagnosis of febrile UTI. Conclusion Recent literature on first febrile UTI addresses a broad range of areas regarding the care of hospitalized children, though some questions remain unanswered. Overall, studies support increased attention to the potential risks, expense and invasiveness of various approaches for evaluation. Proposed updates to practice included: utilization of urinalysis for screening and diagnosis, transitioning to oral antimicrobials based on clinical improvement and limiting the routine use of voiding cystourethrogram and antimicrobial prophylaxis.

Commentary on: Hewitt IK, Pennesi M, Morello W, et al . Antibiotic prophylaxis for urinary tract infection-related renal scarring: a systematic review. Pediatrics 2017;139:e20163145. Renal scarring is a potentially serious long-term complication of acute pyelonephritis, and the risk increases significantly in children with high-grade vesicoureteral reflux (VUR) and recurrent urinary tract infection (UTI).1 For decades it has been a common practice to use antimicrobial prophylaxis or surgical correction to prevent recurrent UTI and renal scarring in children with VUR. Some recent studies have shown that antimicrobial prophylaxis significantly decreases the risk of UTI recurrence in children with VUR but does not significantly impact the risk of renal scarring when compared with placebo or no treatment.2 3 A review of the literature and a meta-analysis were done …

Aim: We assessed the urinary and serum levels of IL-32 in pediatric patients with acute pyelonephritis (APN) with and without renal scarring. Results: We enrolled children aged 2 months to 16 years with APN. Dimercaptosuccinic acid scans and ultrasonography studies were ordered for all patients, and a voiding. A total of 86 children (aged 57 ± 39 months, 74 [86%] female) were enrolled in this study. Group 1 was composed of 19 (16 female) patients, group 2 of 38 (35 female) patients and group 3 of 29 (23 female) patients. There were no significant differences in the serum and absolute urinary levels of IL-32 (UIL-32) between groups, but the urinary IL-32/creatinine ratio (UIL-32/Cr) was significantly higher in children with pyelonephritis than controls., Lay abstract Acute pyelonephritis (APN) is a serious infection for its effects on kidney structure and function. Dimercaptosuccinic acid scan is the gold standard for diagnosis of APN. The scan exposes patients to radiation and needs 6-month time to diagnosis of scar. We assessed the role of urinary and serum level of IL-32 in diagnosis of APN and anticipation of scarring. We showed that the serum and absolute urinary level of IL-32 are not helpful tools, however, urinary ratio of IL-32 to creatinine is significantly higher in pyelonephritic patients than healthy children, and could be useful. There was no difference between APN in children with scar and those without scar.

Febrile urinary tract infection (fUTI) in children may cause renal scarring. This study aimed to investigate the usefulness of urinary biomarkers for diagnosing renal scarring after fUTI. Thirty-seven children (median age: 1.36 years, range: 0.52–12.17 years, 25 boys) with a history of fUTI, who underwent renal scintigraphy for 4 months or longer after the last episode of fUTI, were analyzed. A spot urine sample was obtained on the day of renal scintigraphy to measure levels of total protein, N-acetyl-β-D-glucosaminidase (NAG), β2-microglobulin (BMG), neutrophil gelatinase-associated lipocalin (NGAL), liver-type fatty acid binding protein (L-FABP), and C-megalin (full-length megalin). Results were corrected for urinary creatinine (Cr) and compared between the group with renal scarring (n=23) and that without scarring (n=14). Urinary levels of C-megalin were also measured in healthy control subjects. No significant differences in total protein, NGAL, L-FABP, NAG, and BMG levels were found between the groups. However, C-megalin levels were significantly higher in the renal scarring group than in the non-renal scarring group and healthy controls (P

Background and aims Urinary tract infections in infants are important because of the severity and sequel potential. The aim of the study was to analyse the etiologic, clinical, demographic and evolutionary aspects of the urinary tract infections in infants admitted in Paediatric Clinic from Oradea during 5 years. Methods We performed a retrospective study on a sample of 56 infants admitted in Paediatric Clinic from Oradea during 2012–2016 and diagnosticated with urinary tract infections. There were performed a complete anamnesis, clinic examination, laboratory tests, imagistic investigations. All the medical documentation of the patients was thorough studied. Results From the 56 infants with urinary tract infections, 46 were full-term born, 10 were prematures. The predominance was at males: 34, 22 were females. Depending on the age-it had been noticed 11 newborns, 18 had between 1–3 months, 10 between 3–6 months and 17: 6–12 months. The aetiology of urinary tract infections was dominated by E.Coli and Klebsiella-77%. Comorbidityes were present in 49 situations. Most frequent was anemia-21 cases, dyspepsia 13 situations, malnutrition 5 infants, prolonged jaundice 3 subjects, other in 5 cases. Chronic renal failure was detected in one case. Recurrences appeared in 34% from the patients. Vesico-ureteral reflux was diagnosticated in 9 infants, urinary tract and renal abnormalities were detected in 17 situations. Surgical treatment was performed in 5 situations. Conclusions The early diagnosis and treatment of the urinary tract infections in infants have an important role in reducing complications and the risk of renal scarring.

We present a new preclinical model to study treatment, resolution, and sequelae of severe ascending pyelonephritis. Urinary tract infection (UTI), primarily caused by uropathogenic Escherichia coli (UPEC), is a common disease in children. Severe pyelonephritis is the primary cause of acquired renal scarring in childhood, which may eventually lead to hypertension and chronic kidney disease in a small but important fraction of patients. Preclinical modeling of UTI utilizes almost exclusively females, which (in most mouse strains) exhibit inherent resistance to severe ascending kidney infection; consequently, no existing preclinical model has assessed the consequences of recovery from pyelonephritis following antibiotic treatment. We recently published a novel mini-surgical bladder inoculation technique, with which male C3H/HeN mice develop robust ascending pyelonephritis, highly prevalent renal abscesses, and evidence of fibrosis. Here, we devised and optimized an antibiotic treatment strategy within this male model to more closely reflect the clinical course of pyelonephritis. A 5-day ceftriaxone regimen initiated at the onset of abscess development achieved resolution of bladder and kidney infection. A minority of treated mice displayed persistent histologic abscess at the end of treatment, despite microbiologic cure of pyelonephritis; a matching fraction of mice 1 month later exhibited renal scars featuring fibrosis and ongoing inflammatory infiltrates. Successful antibiotic treatment preserved renal function in almost all infected mice, as assessed by biochemical markers 1 and 5 months post treatment; hydronephrosis was observed as a late effect of treated pyelonephritis. An occasional mouse developed chronic kidney disease, generally reflecting the incidence of this late sequela in humans. In total, this model offers a platform to study the molecular pathogenesis of pyelonephritis, response to antibiotic therapy, and emergence of sequelae including fibrosis and renal scarring. Future studies in this system may inform adjunctive therapies that may reduce the long-term complications of this very common bacterial infection.

Urinary tract infections (UTIs) represent an important cause of febrile illness in young children and can lead to renal scarring and kidney failure. However, diagnosis and treatment of recurrent UTI in children is an area of some controversy. Guidelines from the American Academy of Pediatrics, National Institute for Health and Clinical Excellence and European Society of Paediatric Radiology differ from each other in terms of the diagnostic algorithm to be followed. Treatment of vesicoureteral reflux and antibiotic prophylaxis for prevention of recurrent UTI are also areas of considerable debate. In this review, we collate and appraise recently published literature in order to formulate evidence-based guidance for the diagnosis and treatment of recurrent UTI in children.

Objective To compare the childhood urinary tract infection (UTI) guidelines from the Royal College of Physicians (RCP) in 1991 and from National Institute of Health and Care Excellence (NICE) (CG54) in 2007 by measuring their efficiency at detecting urinary tract abnormalities. Design Children with UTIs within the Newcastle Primary Care Trust (population 70 800 children) were referred and imaged according to the RCP guidelines during 2008, and these were compared to the activity that would have been undertaken if we had implemented the CG54 guidelines, including following them through 2011 to identify those with recurrent UTIs. Main outcome measures The numbers of children imaged, the imaging burden and efficiency, and urinary tract abnormalities detected by each guideline. Results Fewer children would have been imaged by CG54 than RCP (150 vs 427), but its sensitivity was lower, at 44% for detecting scarring, 10% for identifying vesicoureteric reflux and 40% for other abnormalities. Overall, it would have only detected one-quarter of the abnormal cases (8 vs 32) and would have missed five of nine children with scarring, including three with multiple lesions and one with renal impairment. Imposing an age restriction of