A Study of Fifty-eight Patients with Renal Scarring Associated with Urinary Tract Infection

Fifty-eight patients, three male and 55 female, with radiologicallyapparent renal scarring together with urinary tract infectionhave been followed for periods from five to 13 years. Controlof urinary infection has been attempted by antibacterial treatmentand prophylaxis, and radiological appearances, renal functionand blood pressure have been monitored. Urinary infection waseliminated in 50 patients (86 per cent), all of whom becamesymptom-free. Evidence of new renal scarring was not seen, butthree patients showed contraction of kidney size and three developedradio-opaque renal calculi. Vesico-ureteric reflux was demonstratedin 20 patients; surgical re-implantation of ureters was carriedout in four patients and the indications for this operationare discussed. Of the 12 patients who had a raised serum creatinineat some time during the study only three showed progressivedecline in renal function; the serum creatinine returned tonormal in seven patients when infection was controlled. Hypertensionwas more common in patients with bilateral than in those withunilateral scarring, and all patients with evidence of impairedfunction at any time developed hypertension. We conclude thatmost patients with scarred kidneys and urinary infection canbe rendered symptom-free by control of infection, and that thereis some evidence that renal function can be preserved in thisway.     

Diagnosis and treatment of urinary tract infections in children

Acute urinary tract infections are relatively common in children, with 8 percent of girls and 2 percent of boys having at least one episode by seven years of age. The most common pathogen is Escherichia coli, accounting for approximately 85 percent of urinary tract infections in children. Renal parenchymal defects are present in 3 to 15 percent of children within one to two years of their first diagnosed urinary tract infection. Clinical signs and symptoms of a urinary tract infection depend on the age of the child, but all febrile children two to 24 months of age with no obvious cause of infection should be evaluated for urinary tract infection (with the exception of circumcised boys older than 12 months). Evaluation of older children may depend on the clinical presentation and symptoms that point toward a urinary source (e.g., leukocyte esterase or nitrite present on dipstick testing; pyuria of at least 10 white blood cells per high-power field and bacteriuria on microscopy). Increased rates of E. coli resistance have made amoxicillin a less acceptable choice for treatment, and studies have found higher cure rates with trimethoprim/sulfamethoxazole. Other treatment options include amoxicillin/clavulanate and cephalosporins. Prophylactic antibiotics do not reduce the risk of subsequent urinary tract infections, even in children with mild to moderate vesicoureteral reflux. Constipation should be avoided to help prevent urinary tract infections. Ultrasonography, cystography, and a renal cortical scan should be considered in children with urinary tract infections.     

Is serum procalcitonin able to predict long-term kidney morbidity from urinary tract infections in children?

A new diagnostic strategy for children with febrile urinary tract infections could be the routine use of procalcitonin assessment to identify children requiring closer follow-up since being at risk for kidney damage. A total of 11 studies were published between 1998 and 2007. Children with very high procalcitonin levels during urinary tract infections are likely to be at risk of renal damage and vesico-ureteral reflux. Therefore, the prediction of long-term renal damage showed contradictory results. However, high procalcitonin values at diagnosis and positive scintigraphic scans may suggest the need to investigate for vesico-ureteral reflux. Consequently, procalcitonin levels should be included in follow-up protocols for urinary tract infections to aid in decision making concerning scintigraphic scans and voiding cystourethrograms.     

Vesico-ureteral reflux, reflux nephropathy and terminal renal failure

Vesicoureteric reflux is subcategorized into primary and secondary. Secondary vesicoureteric reflux results from increased bladder pressure duo to anatomic outlet obstruction or neuropathic disturbances. Primary vesicoureteric reflux was felt to result from a congenitally short mucosal tunnel length but this concept has been thrown into question. Recent studies suggest an association between lower urinary tract dysfunction and primary vesicoureteric reflux. Primary vesicoureteric reflux is often associated with kidney damage. It has been traditionally assumed that in children with primary vesicoureteric reflux kidney damage results from reflux of infected urine into the renal tissue. While there is unarguable proof that kidney damage can be acquired by the reflux of infected urine, the extent of reflux nephropathy explained by this mechanism has been overemphasized. Recent observations indicate that there are two categories of primary reflux disorder: a mild reflux associated with an acquired renal scarring secondary to infections which affects most females and a proportion of males; and a prenatal high-grade vesicoureteric reflux with a congenital nephropathy characterized by generalized hypodysplastic features which almost exclusively affects boys. Treatment options of primary vesicoureteric reflux range from surgical ureteric reimplantation to antimicrobial prophylaxis. Findings from comparative trials of prophylactic antibiotics and surgical management of children with high-grade vesicoureteric reflux do not show difference in renal growth and acquisition of new scars or renal function for 10 years. The factors accounting for the outcome in the mentioned studies are that most damage occurs at a very early stage and that severely damaged kidneys will either remain stable or progress to end-stage kidney disease, despite all efforts to cure the reflux.     

The characteristics and outcome of primary vesicoureteric reflux diagnosed in the first year of life

A retrospective trial was performed to study presentation, evaluation, management, complications and outcome of 186 infants with vesicoureteral reflux (VUR). Medical records of 103 male and 83 female infants with mean age at entry 5.97 months were reviewed. Diagnosis was established using radiographic voiding cystourethrogram. At diagnosis, a renal ultrasound and dimercaptosuccinic acid renal scintigraphy were performed in all children. The follow-up included blood pressure measurements, serial urine cultures, haematological and biochemical tests, radionuclide cystography, renal ultrasounds and renal scintigraphy. The majority of infants with reflux, 176/186, presented with one or more episodes of urinary tract infections. In 113 children, reflux resolved spontaneously, 27 underwent surgical or endoscopic correction and 46 are being followed-up to date. Spontaneous resolution after prophylaxis was more frequent in boys (p < 0.0001), in children with grade I or II (p < 0.0001) and unilateral reflux at diagnosis (p = 0.0215). No significant difference could be established with respect to the presence of scars (p = 0.1680) and the number of breakthrough urinary tract infections (p = 0.1078). The data of the present study indicate that spontaneous resolution rate is high in infants, and therefore, early antireflux     

Urinary tract infections in infants and children. Guidelines for averting permanent damage

Urinary tract infection (UTI) is common in childhood and, early in life, is often associated with vesicoureteral reflux or other urinary tract anomalies. Since the combination of reflux and infection can cause renal scarring and impaired renal function, identification of children at risk and provision of close follow-up are important. Diagnosis in the first year of life relies on a high index of suspicion on the part of the clinician, as signs and symptoms are nonspecific. Reliable cultures are the cornerstone of accurate diagnosis and will be the basis for selection of acute and long-term management. Vigilant follow-up of all children with UTI can prevent ultimate morbidity.     

Management of acute uncomplicated urinary tract infection in adults

Acute uncomplicated UTI is one of the most common problems for which young women seek medical attention, and it accounts for considerable morbidity and health care costs. Acute cystitis is a superficial infection of the bladder mucosa, whereas pyelonephritis involves tissue invasion of the upper urinary tract. Localization tests suggest that as many as one third of episodes of acute cystitis are associated with silent upper tract involvement. Acute cystitis or pyelonephritis in the adult patient should be considered uncomplicated if the patient is not pregnant or elderly, if there has been no recent instrumentation or antimicrobial treatment, and if there are no known functional or anatomic abnormalities of the genitourinary tract. Most of these infections are caused by E. coli, which are susceptible to many oral antimicrobials. Because of the superficial nature of cystitis, single-dose and 3-day regimens have gained wide acceptance as the preferred methods of treatment. Review of the published data suggests that a 3-day regimen is more effective than a single-dose regimen for all antimicrobials tested. Regimens with trimethoprim-sulfamethoxazole appear to be more effective than those with beta-lactams, regardless of the duration. Acute pyelonephritis does not necessarily imply a complicated infection. Upper tract infection with highly virulent uropathogens in an otherwise healthy woman may be considered an uncomplicated infection. The optimal treatment duration for acute uncomplicated pyelonephritis has not been established, and 14-day regimens are often used. We prefer to use antimicrobials that attain high renal tissue levels, such as trimethoprim-sulfamethoxazole or quinolones, for pyelonephritis. Women with frequently recurring infections can be successfully managed by continuous prophylaxis, either daily or thrice-weekly, by postcoital prophylaxis, or, in compliant patients, by early self-administration of single-dose or 3-day therapy as soon as typical symptoms are noted. Our drug of choice for all these regimens is trimethoprim-sulfamethoxazole. Acute uncomplicated cystitis in adult men is very uncommon, but it is occasionally noted in homosexual men who practice insertive and intercourse or in heterosexual men whose partners have vaginal colonization with E. coli.     

Surgical management of vesicoureteral reflux

Vesicoureteral reflux (VUR) is a urologic condition in which there is a retrograde flow of urine from the bladder through the ureter back up to the upper urinary tract. The condition may be classified as primary or secondary and is more often identified in Caucasian females. The primary goal in the management of VUR is the prevention of pyelonephritis and subsequent renal scarring.     

Pyelonephritis and female urinary tract infection

Urinary tract infections are a common problem for women and frequently result in a visit to the Emergency Department. Most of these infections are easily diagnosed and treated; however, subclinical pyelonephritis is a recently recognized entity and signs of upper tract involvement should always be sought, especially in compromised hosts and patients who are at risk for developing complicated infections. Each of these situations demands a more thorough evaluation and more prolonged and aggressive treatment to minimize the possibility of renal damage. Fortunately, there is a narrow spectrum of organisms responsible for most urinary tract infections, and they respond well to a wide range of commonly used antibiotics. Newer diagnostic techniques, the acceptance of short-course therapy for lower tract infections, and the development of new antibiotics have increased our diagnostic and therapeutic options. Further developments in these areas, as well as the possibility of nonantibiotic prevention of urinary tract infections, predict a brighter future for patients with complicated or frequently recurring urinary tract infections.     

Lump type crossed fused renal ectopia with bilateral vesicoureteral reflux: A case report

BACKGROUND Crossed fused renal ectopia is a rare congenital anomaly of the ascent of the kidney. This anomaly may be observed as a solitary kidney during initial evaluation. A solitary kidney must be evaluated for associated anomalies such as duplication,horseshoe kidney,or crossed renal ectopia.CASE SUMMARY An anomaly was observed in a 9-mo-old male child who was subsequently diagnosed with crossed fused renal ectopia and vesicoureteral reflux(VUR). In this condition,recurrent febrile urinary tract infection can be a serious problem,and can easily cause renal damage due to relatively short ureters and high pressure in the kidney.CONCLUSION To prevent urosepsis and preserve renal function,early diagnosis and proper management including surgical correction should be considered for the management of renal ectopia with VUR.     

肾移植术后患者泌尿道医院感染现状及影响因素研究

目的研究肾移植术后患者发生泌尿道医院感染现状及其影响因素,提出相应干预措施。方法采用前瞻性目标监测的方法,对某医院同种异体肾移植手术患者发生泌尿道医院感染的临床资料进行研究和分析。结果共研究了某医院肾移植手术患者329例,发生泌尿道感染92例,感染率为27.96%。肾移植患者术后留置尿管时间越长,泌尿道感染发生率越高。结论肾移植术后泌尿道感染率较高,患者术后泌尿道长时间留置尿管构成医院感染的最危险因素,可采取有效的干预措施加以控制。     

A Rapid Quality Control Initiative to reduce the incidence of urinary tract infection in the paediatric intensive care patient--Part one

Urinary tract infection is one of the common bacterial infections in children and can lead to substantial morbidity. If the infection results in renal scarring, various long-term risks include hypertension and renal insufficiency. Nosocomial urinary tract infections (NUTI) in children occur with varying frequency with approximately 60–80% of these infections being strongly correlated with urethral instrumentation. This paper presents stage one of a Rapid Quality Control Initiative to reduce the incidence of NUTI in the paediatric patient at King Faisal Specialist Hospital and Research Centre.     

The treatment of urinary tract infection.

Urinary infections are due to organisms gaining entry from the genital area and are therefore much commoner in females than in males. In male patients of any age urinary infection is often associated with some underlying abnormality and warrants full investigation. Recurrent infections in girl children may lead to renal scarring and later impairment of function and require careful management. Occult infections occur. The majority of patients with urinary symptoms are adult women, and symptoms tend to recur. These can produce great distress but in this age-group they do not lead to renal scarring. When symptoms occur for the first time during pregnancy they are associated with a high prevalence of underlying radiological abnormalities and should be investigated after the pregnancy. Care should be taken to ensure that apparent uprinary symptoms due to other causes are not mistakenly treated with antibiotics. The immediate management of patients with urinary symptoms consists in relief of discomfort, combined with treatment by an antibacterial drug appropriate for the infecting organism. The urine culture should be repeated after the course of treatment. Simple measures can prevent or reduce recurrences in adult women.     

Cranberry for prevention of urinary tract infections

Traditionally, cranberry has been used for the treatment and prophylaxis of urinary tract infections. Research suggests that its mechanism of action is preventing bacterial adherence to host cell surface membranes. Systematic reviews have concluded that no reliable evidence supports the use of cranberry in the treatment or prophylaxis of urinary tract infections; however, more recent, randomized controlled trials demonstrate evidence of cranberry's utility in urinary tract infection prophylaxis. Supporting studies in humans are lacking for other clinical uses of cranberry. Cranberry is a safe, well-tolerated herbal supplement that does not have significant drug interactions.     

Diagnosis and management of uncomplicated urinary tract infections

Most uncomplicated urinary tract infections occur in women who are sexually active, with far fewer cases occurring in older women, those who are pregnant, and in men. Although the incidence of urinary tract infection has not changed substantially over the last 10 years, the diagnostic criteria, bacterial resistance patterns, and recommended treatment have changed. Escherichia coli is the leading cause of urinary tract infections, followed by Staphylococcus saprophyticus. Trimethoprim-sulfamethoxazole has been the standard therapy for urinary tract infection; however, E. coli is becoming increasingly resistant to medications. Many experts support using ciprofloxacin as an alternative and, in some cases, as the preferred first-line agent. However, others caution that widespread use of ciprofloxacin will promote increased resistance.     

The natural history of urinary infection in adults

The vast majority of otherwise healthy adults with anatomically and functionally normal urinary tracts experience few untoward long-term consequences from symptomatic or asymptomatic UTIs. Effective early treatment of symptomatic infection rapidly curtails bacterial invasion and the resulting inflammatory response. Rarely, uncomplicated acute pyelonephritis causes suppuration and renal scarring. Urinary infections in patients with renal calculi, obstructed urinary tract, neurogenic bladder, or diabetes are frequently much more destructive and have ongoing sequelae. Strategies to treat both the infection and the complications are often necessary to alter this outcome.     

脊柱裂患者的影像尿动力学特点分析

目的分析脊柱裂患者的影像尿动力学特点，探讨其发生上尿路损害的尿动力学危险因素。方法33例脊柱裂患者采用非完全同步影像尿动力学方法评估患者的膀胱尿道功能，了解膀胱的感觉、稳定性、顺应性、相对安全容量、逼尿肌漏尿点压力、有无膀胱输尿管返流等储尿功能参数，以及排尿期逼尿肌压力、有无逼尿肌内外括约肌协同失调（DSD）等排尿功能参数。将患者按照有无肾积水或返流、肾功能损害分为上尿路损害组和非损害组，统计比较各组中尿动力学参数的差异。结果脊柱裂患者上尿路损害的发生率约为51％（17／33），其中膀胱输尿管返流发生率为33％（11／33），无返流性肾积水发生率为18％（6／33）。在肾积水患者中，64．7％具有膀胱输尿管返流。上尿路损害组的膀胱顺应性和相对安全容量等参数与非损害组相比差异具有显著性（P〈0．05）。结论脊柱裂患者具有较高的上尿路损害发生率，其中膀胱输尿管返流占较大比例。膀胱顺应性下降及相对安全容量小可能是患者发生上尿路损害的主要尿动力学危险因素。     

排尿性膀胱尿道造影筛查儿童原发性膀胱输尿管反流的意义

目的探讨排尿性膀胱尿道造影(micturating cystourethrography,MCU)筛查儿童原发性膀胱输尿管反流(vesi-coureteric reflux,VUR)的意义。方法选择40例经99Tcm-二巯基丁二酸(DMSA)显像后肾脏放射性摄取缺损或减少的尿路感染(urinary tract infection,UTI)患儿行MCU检查,依据国际反流性肾病协会提出的VUR分级标准评价MCU诊断结果。结果 40例MCU检查诊断原发性VUR 16例,检出率为40.0%,其中双侧9例,单侧7例;男8例,女8例;年龄<1岁13例。MCU检查共检出VUR 25个肾输尿管单位,其中Ⅱ级反流2支(8.0%),Ⅲ级反流5支(20.0%),Ⅳ级反流12支(48.0%),Ⅴ级反流6支(24.0%)。结论对UTI患儿进行规范的MCU检查可为原发性VUR诊断和治疗提供客观依据。     

Bacterial fimbriae in the pathogenesis of urinary tract infection

Escherichia coli is the most frequent cause of pyelonephritis. A possible virulence factor includes the ability to adhere to and colonize the urinary tract which is an important initiating factor in all urinary tract infections. The importance of P-fimbriae and type 1 fimbriae in this adhesion and inflammatory process are emphasized and evidence for their importance in pyelonephritis is presented in epidemiologic studies of patients, as well as in animal studies. It is widely accepted that uropathogens possess definite determinants of virulence which enable them to survive and multiply in vivo. Among these pathogen,E. coli has the capability of provoking tissue damage and scar formation in the parenchyma, with scarring the major pathologic feature of chronic pyelonephritis. The mechanisms involved in renal scarring are still poorly understood, but some investigators have noted that renal scarring is related to an acute inflammatory process due to the respiratory burst of phagocytosis and renal ischemia as a consequence of the release of superoxide. Vaccination with P-fimbriae has been shown to experimentally prevent the initiation of the disease. However, since vaccines are not clinically available, clinical and animal studies on the therapy of acute disease are presented. The prevention of end-stage renal disease that may occur from acute pyelonephritis during infancy depends on early diagnosis, age, and effective antibiotic treatment.     

Cytokines and cell adhesion molecules in the inflammatory response during acute pyelonephritis

Urinary tract infection is a common bacterial infection of childhood. Renal parenchymal scarring, a recognised complication of urinary tract infection, is responsible for up to 24% of children entering end-stage renal failure. Why acute inflammation results in renal scarring in some children whilst in others complete resolution occurs without scarring is at present poorly understood. This article reviews the role of the cytokines, adhesion molecules and growth factors in the inflammatory response during acute pyelonephritis and renal parenchymal scarring. We hypothesize that inter-individual variability in cellular response may in part be responsible for this variable clinical outcome.