排泄性尿路超声造影评估儿童膀胱输尿管反流及肾内反流

目的 探讨排泄性尿路超声造影(CeVUS)在诊断儿童膀胱输尿管反流(VUR)及肾内反流(IRR)中的价值，评估IRR与年龄、性别和VUR分级之间的关系。方法 回顾性收集怀疑VUR行CeVUS检查的患儿。所有患儿均行CeVUS检查，分析造影图像，记录反流级别、有无IRR、年龄和性别等资料。结果 在319例患儿中CeVUS检出VUR 138例，其中IRR有59例(42.8%)。IRR患儿年龄中位数为7(2～84)个月，而无IRR年龄中位数为16(1～108)个月(P<0.05)。共有VUR肾输尿管单位202个，其中IRR 77个，IRR在各级别VUR的检出率分别为Ⅱ级5.0%(2/40)、Ⅲ级34.7%(26/75)、Ⅳ级66.2%(43/65)、Ⅴ级40.0%(6/15)。结论 CeVUS可用于儿童VUR及IRR的诊断，IRR多见于Ⅳ级VUR和1岁以内的患儿。     

41例膀胱输尿管反流患儿临床特征及预后研究

目的探讨患儿膀胱输尿管反流(VUR)的临床特点及其转归,为临床诊治提供指导。方法回顾分析该院VUR患儿临床经过特点、影像学改变、排泄性尿路造影检查(MCU)及其分级,并随访其预后。结果本研究共纳入VUR患儿41例,其中≤1岁31例(75.6%),男27例,女14例。MCU分级轻度反流组(Ⅰ、Ⅱ级)9例,中度反流组(Ⅲ级)16例,重度反流组(Ⅳ、Ⅴ)16例。3组间性别、年龄、反流状况(单侧/双侧)、≥2次泌尿道感染率、合并其他结构异常比较,差异无统计学意义(P0.05)。确诊6个月至3年后进行MCU复查,MCU反流完全缓解12例,部分缓解9例,无改变15例,加重5例。随着反流级别升高,缓解率呈下降趋势(P=0.008)。24例在预防剂量中或停药后出现感染复发。随着反流级别升高,感染复发率呈上升趋势(P=0.014)。结论婴儿泌尿道感染易发生VUR。反流程度与预后关系密切,应根据反流程度采取相应的诊治措施。     

降钙素原对儿童膀胱输尿管反流的预测价值

目的初步探讨降钙素原对儿童尿路感染伴膀胱输尿管反流(VUR)的诊断价值及其与反流严重程度的关系。方法收集2011年1月至2012年3月该院所有连续就诊并诊断为首次发生尿路感染的患儿的降钙素原(PCT)、C反应蛋白(CRP)、尿液细菌培养、泌尿系统B超、排尿期膀胱尿道造影(VUCG)等结果。以VUCG作为VUR与非VUR的分组标准及VUR分级标准。结果共146例尿路感染患儿纳入研究,其中VUR患儿51例(占34.9%),VUR患病年龄、性别比例差异无统计学意义(P>0.05)。VUR组的PCT、CRP水平高于非VUR组(P<0.05),ROC曲线显示PCT诊断性能优于CRP。高PCT水平(≥0.5ng/mL)与VUR的级别密切相关(优势比为5.5,95%置信区间2.3～12.9),且与轻度、中度VUR均密切相关(优势比分别为4.6、9.1,95%置信区间分别为1.8～11.7、1.4～61.7)。结论 PCT对于判断是否存在膀胱输尿管反流具有一定的临床价值,可作为预测反流级别的独立指标,可能有助于减少不必要的VUCG。     

膀胱输尿管反流患儿的临床分析和随访

膀胱输尿管反流（VUR）是一种常见的尿路畸形,严重者可致肾脏损害。重度反流以手术纠正为主,轻、中度反流以低剂量抗生素预防尿路感染为主。本研究对膀胱输尿管反流患儿进行临床分析和随访,现报告如下。1资料与方法选取2009年1月—2011年12月本院尿路感染控制后行X线排尿期膀胱尿路造影（MCU）诊断为VUR的患儿42例,其中首次发生尿路感染者19例,反复尿路感染者37例。     

首诊泌尿道感染患儿影像学检查评价与分析

目的通过对首次就诊的UTI患儿核素肾皮质显像、肾脏B超等影像检查结果进行分析比较,从而探讨小儿UTI影像学检查的策略。方法研究对象为224例首次就诊的UTI患儿,在1周内进行99Tcm-DMSA肾皮质显像及肾脏超声检查评价是否有肾实质感染,一到两周内进行膀胱输尿管显像以评价VUR。结果经DMSA显像证实121例(54%)存在肾实质感染,其中8人伴肾瘢痕形成;103例(46%)DMSA显像正常。以DMSA肾显像为诊断标准,B超检查评价肾实质感染的灵敏度为53.72%。在肾实质感染患儿中,41%存在膀胱输尿管返流。100个发生损害的肾脏,48%存在膀胱输尿管返流;而92个未发生损害的肾脏,有1个存在中度VUR。在有肾瘢痕的UTI患儿中,75%存在膀胱输尿管返流。对VUR分度及肾损害分级进行等级相关分析,发现肾损害分级程度越重,VUR分度越高。结论对首诊的UTI患儿,临床上怀疑肾实质感染者,应行DMSA显像以准确评价肾损害程度,B超检查可作为筛查及补充手段;DMSA显像提示肾损害或有反复尿路感染者,尤其是有瘢痕形成的UTI患儿,行VUR检测十分必要,并建议3~6个月后随访DMSA显像,以检测是否发生肾瘢痕。     

超声造影对小儿膀胱输尿管反流诊断价值的初步探讨

目的 评价排尿膀胱尿道超声造影检查对小儿膀胱输尿管反流(VUR)的诊断价值.方法 应用对比脉冲序列超声造影技术对53例反复尿路感染的患儿进行超声造影检查,观察膀胱、输尿管及肾的声像图表现,用五级法分析评价,并以排尿膀胱尿道造影术(VUCG)对照.结果 53例患者中超声造影检出19例(36个肾输尿管单位),VCUG检出18例(34个肾输尿管单位),超声造影及VCUG对VUR的分级检出一致性为31个肾输尿管单位,阴性检出一致性为69个肾输尿管单位.超声造影和VCUG对VUR的检查有很高的一致性(Kappa值=0.909).结论 超声造影能敏感检测出VUR,同时无放射性,重复性好,可作为VUR的首选检查方法之一.     

几种膀胱输尿管返流诊断方法的评价

本文在56例成年反复尿感病人进行了排尿期膀胱尿路造影(MCU)及同位索间接法膀胱输尿管造影(IVRC)检测膀胱输尿管返流(VUR)的比较,结果发现两者符合率为71.4％,而在RN病人中IVRC及MCU显示返流阳性率分别为59.4％及40.6(P<0.05)。在17只实验性VUR小猪共98侧输尿管进行了MCU及同位素直接法胱输尿管造影(DRC)检测VUR的研究。结果显示两者诊断VUR的总符合率为91.8％。DRC诊断VUR的特异性为92.3％。以上结果提示:IVRC是一种简单、易行、安全的VUR筛选方法;DRC作确诊VUR的新方法,有较大实用价值。     

儿童膀胱输尿管反流29例临床分析

回顾性分析我院2004年1月-2012年12月收治的29例经排泄性膀胱尿路造影确诊的膀胱输尿管反流患儿临床资料。29例膀胱输尿管反流患儿中, MCU显示单侧异常25例,双侧均异常4例。经过治疗,25例好转出院,3例治疗后要求出院,1例放弃,随访6个月及以上,22例预后好,7例仍有反复泌尿系感染发生。男性患儿,反复泌尿系感染,年龄〈3岁者发生VUR的可能性大,婴幼儿VUR发生级别相对较高,双侧出现率高,无创性B超可作为常规筛查手段,3岁以下泌尿系感染患儿应及时行MCU,级别低VUR可内科保守治疗,级别高VUR应早期手术。     

小儿膀胱输尿管反流与尿路感染

膀胱输尿管反流(VUR)在小儿的尿路感染(UTI)中发生率较高。患者常无自我感觉,往往在无症状中经过。VUR使尿液向上部尿路逆流,造成上部尿路扩张、变形,进而压迫肾实质;同时细菌易逆流而上,反复引起UTI,最后导致肾实质萎缩。一般文献通常把UTI复发和肾瘢痕形成归罪于VUR。     

儿童膀胱输尿管反流的诊疗研究现状及进展

原发性膀胱输尿管反流(vesicoureteral reflux,VUR)是儿童常见的先天性泌尿道异常,约30%~50%患病儿童合并泌尿系感染,反复的尿路感染可导致肾脏瘢痕形成、肾实质损害及肾衰竭。然而膀胱输尿管反流在儿童中的严重程度表现不一,大部分儿童有自愈趋势。目前膀胱输尿管反流的诊断、治疗方法和治疗时机仍存在极大的争议,需要更为精确的研究方法进一步实施以提高膀胱输尿管反流的诊断及治疗效果。     

小儿尿路感染与原发性膀胱输尿管反流的关系

目的探讨小儿尿路感染与原发性膀胱输尿管反流的关系。方法78例尿路感染患儿经肾脏超声、静脉肾盂造影及排泄性尿路造影检查明确诊断，并给予相应治疗。结果膀胱输尿管反流在尿路感染患儿中占26％，在反复尿路感染患儿中占69％。结论原发性膀胱输尿管反流是小儿尿路感染的易感因素之一。     

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.     

Usefulness of echocystography in the study of vesicoureteral reflux.

The aim of our study was to assess the usefulness of contrast-enhanced sonography in detecting and staging vesicoureteral reflux in pediatric patients. Forty-nine children between birth and 5 years of age were studied for vesicoureteral reflux. Echocystography with the use of an endovesical signal enhancer was performed first, followed immediately by conventional voiding cystourethrography. The findings obtained by echocystography and voiding cystourethrography were consistent in 89 (90.8%) of 98 ureterorenal units (a ureterorenal unit is 1 kidney with its own ureter). Reflux was demonstrated by voiding cystourethrography in 13 cases; in 9 of these cases diagnosis had also been made by echocystography. Five cases of reflux detected by echocystography were not identified by voiding cystourethrography. With voiding cystourethrography as the standard of reference, sensitivity was 69%; specificity, 94%; positive predictive value, 64%; and negative predictive value, 95%. In conclusion, echocystography is a useful tool for the diagnosis of vesicoureteral reflux. Its ability to detect reflux is similar to that of cystography in cases of high-grade reflux, and it may be an appropriate complementary technique to voiding cystourethrography, because it avoids exposure to radiation.     

Kidney length and scarring in children with urinary tract infection: importance of ultrasound scans

Background Many studies have demonstrated that dimercaptosuccinic acid (DMSA) scintigraphy is the most sensitive diagnostic method in the identification of irreversible renal lesions (scars) in children with previous episodes of acute pyelonephritis (APN). This study assessed the reliability of ultrasound in identifying reflux nephropathy in children with acute pyelonephritis with or without vesicoureteric reflux (VUR). Methods Eighty children (45 female and 35 male, age range 5 months to 10 years, average age 2 years 1 month) with a positive history for at least one episode of APN participated in this study. All children underwent voiding cystourethrography, DMSA scintigraphy 4 to 8 months after the most recent episode of APN, and an ultrasound test evaluation less than 2 months after DMSA scintigraphy. Results Voiding cystourethrograms showed VUR in 52 children (68%); 13 of these were bilateral, for a total of 65 refluxing kidney units of the 154 (42%) evaluated; DMSA scintigram was normal for 108 of 154 kidneys (70%). Of the 65 kidneys with VUR, DMSA scintigram displayed normal findings in 29 cases (45%) and pathologic findings in 36 (55%). In the 79 nonrefluxing kidneys, DMSA scintigram was normal in 69 cases (87%). The relative risk of scarring in VUR kidneys is 2.6. The ultrasound study recorded a maximum longitudinal diameter between the 5th and 95th percentiles in 80 of 89 (81%) kidneys without VUR and in 21 of 65 (32%) with VUR. A significant correlation was found between maximum longitudinal diameters and DMSA scintigraphic findings in kidneys with VUR and those without VUR, respectively. Conclusion This study establishes that ultrasound scans, by means of a simple and reproducible measurement technique, maximum longitudinal diameter, have a predictive value with regard to the presence of scars, with few exceptions. This finding, in our opinion, could lead to a decrease in the number of invasive procedures, in particular DMSA scan, in patients with APN.     

Reflux nephropathy and primary vesicoureteric reflux in adults

We have studied the clinical features and course of adults with reflex nephropathy and/or primary vesicoureteric reflux, paying particular attention to the differences between males and females, and the presenting features that influence prognosis. In our series of 293 patients, females outnumbered males in the ratio 5:1 and most presented with urinary infection, whereas males most commonly presented with features of renal damage such as proteinuria, hypertension or renal failure. Males more commonly had bilateral scarring and persistent reflux. One hundred and forty-seven patients were followed for two years or more (range 2-19 years); deterioration in renal function occurred in 55 (37 per cent). Risk factors for a rise in plasma creatinine were, in descending order, the presence of proteinuria, an elevated plasma creatinine concentration, bilateral scarring, male sex and the presence of hypertension. Stepwise multiple regression analysis showed that the independent risk factors were proteinuria, elevated plasma creatinine concentration and hypertension; gender and the presence of persistent reflux had no independent influence on the course of renal failure.     

Childhood urinary infection associated with vesico-ureteric reflux.

Among 222 children investigated in hospital for urinary infection 98 had vesicoureteric reflux only, and of these a group of 59 has been followed at a special clinic for from three to 14 years (mean 5.4 years). Children with reflux had an earlier age of onset and a greater likelihood of a family history of urinary infection than those with other diagnoses. Fifty-five were conservatively treated, and more than half of these still had reflux at the end of the study. Children with severe grades of reflux and an early onset of symptoms had least chance of reacting favourably to medical treatment. Evidence of renal deterioration was exceptional and virtually confined to the pre-school age group. It is argued that severe grades of reflux in pre-school children should be treated surgically, and that voiding cystograms need only be part of routine investigation in two circumstances, namely when the patient is under five, and on the very rare occasion when an older child shows progressive renal damage in serial pyelograms.     

Childhood Urinary Infection Associated With Vesico-ureteric Reflux

Among 222 children investigated in hospital for urinary infection98 had vesicoureteric reflux only, and of these a group of 59has been followed at a special clinic for from three to 14 years(mean 5.4 years). Children with reflux had an earlier age ofonset and a greater likelihood of a family history of urinaryinfection than those with other diagnoses. Fifty-five were conservativelytreated, and more than half of these still had reflux at theend of the study. Children with severe grades of reflux andan early onset of symptoms had least chance of reacting favourablyto medical treatment. Evidence of renal deterioration was exceptionaland virtually confined to the pre-school age group. It is arguedthat severe grades of reflux in pre-school children should betreated surgically, and that voiding cystograms need only bepart of routine investigation in two circumstances, namely whenthe patient is under five, and on the very rare occasion whenan older child shows progressive renal damage in serial pyelograms.     

Reflux Nephropathy and Primary Vesicoureteric Reflux in Adults

We have studied the clinical features and course of adults withreflex nephropathy and/or primary vesicoureteric reflux, payingparticular attention to the differences between males and females,and the presenting features that influence prognosis. In ourseries of 293 patients, females outnumbered males in the ratio5:1 and most presented with urinary infection, whereas malesmost commonly presented with features of renal damage such asproteinuria, hypertension or renal failure. Males more commonlyhad bilateral scarring and persistent reflux. One hundred and forty-seven patients were followed for two yearsor more (range 2–19 years); deterioration in renal functionoccurred in 55 (37 per cent). Risk factors for a rise in plasmacreatinine were, in descending order, the presence of proteinuria,an elevated plasma creatinine concentration, bilateral scarring,male sex and the presence of hypertension. Stepwise multipleregression analysis showed that the independent risk factorswere proteinuria, elevated plasma creatinine concentration andhypertension; gender and the presence of persistent reflux hadno independent influence on the course of renal failure.     

Is the preliminary film necessary prior to the micturating cystourethrogram in children?

The aim of the study was to determine the value of the preliminary film in children undergoing a micturating cystourethrogram (MCU). The coded computer reports of 806 children undergoing MCUs in a 12-month period were retrospectively reviewed for abnormalities of the lumbar spine, hips, or for calcifications. Vesicoureteric reflux was present in 185 patients (23%). Four patients had renal calculi (0.5%), and in all cases the abnormality was evident on preceding imaging of the upper urinary tract. Spinal anomalies (other than known meningomyelocele) were present in four patients. The clinically obvious abnormalities present in these were a sacral teratoma, a sacral lipoma, scoliosis with tracheo-oesophageal fistula, and a cutaneous angioma with a sacral pit. No patients (other than those with known meningomyelocele) had dislocated hips diagnosed. If the preliminary film had not been performed in 806 patients, neither spinal anomaly, renal calculus, nor congenital dislocated hip would have been missed. The low incidence of plain film anomalies indicates that in our population a plain film is not justified routinely.