尿路感染与原发性膀胱输尿管反流

目的 了解儿童尿路感染中原发性膀胱输尿管反流的发生情况。方法 62例尿路感染患儿行排泄性膀胱尿路造影，诊断原发性膀胱输尿管反流并分级，以做相应治疗。结果 膀胱输尿管反流在尿路感染住院患儿中比例为40.32％。结论 儿童尿路感染的住院患儿，尤其反复发作者，存在原发性膀胱输尿管反流比例较大。     

儿童尿路感染及原发性膀胱输尿管反流临床诊治的专家共识(2007 上海)

尿路感染是儿科常见的感染性疾病之一,原发性膀胱输尿管反流(VUR)在健康儿童中发病率为1%,而在尿路感染患儿中可高达20%~50%.VUR和反复尿路感染可导致持续性的肾脏损害和疤痕化,从而可能引起高血压和慢性肾损害.     

降钙素原对尿路感染儿童膀胱输尿管反流的诊断价值及其关联性

目的 探讨降钙素原（PCT）对儿童尿路感染伴膀胱输尿管反流（VUR）的诊断价值及其关联。 方法 纳入2012年1月1日至2015年12月31日湖南省儿童医院首次诊断为尿路感染且住院期间进行了PCT、CRP检测、排尿期膀胱尿道造影（VCUG）检查和尿液细菌定量培养的患儿,排除医院获得性尿路感染者和进行过尿道外科手术者。以VCUG作为金标准,以PCT和CRP为待测标准,将诊断为VUR的患儿分为无反流组和反流组（轻度反流亚组和重度反流亚组）。采集性别、月龄和VCUG信息,仅截取入院后24 h内行PCT和CRP检测的结果。比较PCT和CRP对VUR的诊断参数。 结果 进入本文分析的尿路感染患儿156例,经VCUG确诊的VUR （反流组）58例,其中轻度反流亚组38例,重度反流亚组20例;无反流组98例。无反流组与反流组患儿月龄、男女比例差异无统计学意义（Z=-1.667, P=0.096;χ2=0.291,P=0.590）。PCT(ng·mL-1)和CRP(mg·L-1)反流组高于无反流组［1.01（0.78,1.28）vs 0.40（0.10,0.60）和14.2（8.9,31.1）vs 11.0（6.6,19.5）］,差异有统计学意义（Z=-7.863, P=0.000;Z=-2.327, P=0.02）。PCT无反流组与轻度反流亚组［0.99（0.68,1.16）］和重度反流亚组［1.57（0.93,1.96）］、CRP无反流组与重度反流亚组［28.9（12.7,45.2）］、PCT与CRP轻度反流亚组及重度反流亚组,差异均有统计学意义。CRP无反流组与轻度反流亚组［12.6（8.5,19.5）］,差异无统计学意义。PCT区分有无反流的最佳截值为0.77 ng·mL-1,敏感度为77.6%,特异度90.8%,ROC曲线下面积0.877（95％CI：0.811~0.943）。在控制了性别和CRP等因素的情况下,PCT≥0.77 ng·mL-1的尿路感染患儿VUR的风险是PCT＜0.77 ng·mL-1的3.604倍。 结论 PCT对于判断尿路感染患儿是否存在VUR具有一定的临床价值,可作为预测VUR的独立指标。     

小儿尿路感染与膀胱输尿管反流

膀胱输尿管反流(vesicoureteral reflux, VUR)是由于膀胱输尿管连接部瓣膜作用不全以致尿液自膀胱反流入输尿管、肾盂的疾病.     

排尿性膀胱尿路造影术在诊断儿童膀胱输尿管反流中的意义

目的 探讨排尿性膀胱尿路X线造影术(MCU)在尿路感染患儿中的检查时机,为早期诊断膀胱输尿管反流提供依据.方法 分析2003年1月-2007年12月我院住院患尿路感染并行排尿期膀胱尿路X线造影术检查的患儿,分析相关的B超,放射性核素肾静态扫描,肾功能(血尿素氮、血肌酐),尿常规,尿微量蛋白(尿IgG、Alb、TRF、RBP、NAG、a1-MG),中段尿培养等检查.结果 [1]进行MCU检查的患儿共392例,年龄1个月-14岁,平均年龄(2.43±3.10)岁.无膀胱输尿管反流者230例;有膀胱输尿管反流者162例;其中原发性膀胱输尿管反流150例,男女比为1.23:1.[2]原发性膀胱输尿管反流阳性、阴性两组患儿间,放射性核素肾静态扫描(DMSA)中表现为急性期放射稀疏、肾疤痕、尿微量蛋白,差异有统计学意义(P<0.05).[3]原发性膀胱输尿管反流患儿年龄分布为<2岁93例(62%),2-7岁39例(26%),>7岁18例(12%).结论 对尿路感染伴随DMSA异常,尿微量蛋白明显增高的患儿应提高警惕,积极行MCU检查,特别是<2岁的男童更应重视.     

儿童膀胱输尿管反流的转归预后探讨

膀胱输尿管反流 (vesicouretericreflux ,VUR)是指排尿时尿液从膀胱反流至输尿管和肾盂 ,是婴幼儿反复泌尿道感染的常见原因。部分VUR患儿可自行缓解 ,但是 ,也有部分VUR患儿可引起反流性肾病 (refluxnephropathy ,RN) ,表现为肾脏瘢痕形成、肾生长迟缓、肾功能不全。VUR患儿因反复泌尿道感染常常导致肾功能受损 ,估计 15岁以下儿童每年有 0 3～ 0 4人 / 10 0万人口因RN导致肾衰竭 ,每年有 5～ 10名女孩 / 10 0万人口因RN而进入终末期肾病[1] ,但也有研究认为无症状VURⅠ度及Ⅱ度可能为一生理现象[2 ] 。所以 ,很有必要进一步研…     

儿童泌尿道感染中膀胱输尿管反流发生率的临床研究

目的回顾性分析儿童泌尿道感染中膀胱输尿管反流(VUR)的发生情况,以加强对VUR的认识,提高检出率。方法选择2000年1月到2006年11月因泌尿道感染收治入院的患儿106例,根据年龄分为≤2岁组、～5岁组、>5岁组三组,通过排泄性膀胱尿道造影(VCUG)和直接放射性核素造影诊断VUR;通过肾皮质静态显像(DMSA)检查,了解肾疤痕的形成情况。分析不同年龄组的VUR发病情况、不同等级VUR的程度和肾疤痕的形成分布情况。结果106例中VUR共40例,不同年龄组VUR的所占比例分别是77.78%、46.67%、27.90%(χ2=12.994,P=0.002),差异具有统计学意义。106例中有40例作了DMSA检查,14例形成肾疤痕,三组间肾疤痕的分布情况依次是66.7%、30.77%、28.57%,≤2岁组肾疤痕发生率高。另外,从VUR的等级分布和单、双侧VUR发生的情况来看,≤2岁组中VUR患儿主要是Ⅲ、Ⅳ、Ⅴ级,而～5岁组和>5岁组则随着年龄的逐渐增加Ⅰ、Ⅱ级的例数增加,Ⅲ、Ⅳ、Ⅴ级的例数减少;而且≤2岁组的VUR患儿双侧VUR的例数也较后两组多。结论≤2岁的泌尿道感染患儿最易形成肾疤痕,VUR的发病率高,且高级别、双侧VUR的发生率高,应及时行VCUG和DMSA,及早发现VUR和肾疤痕。     

血清降钙素原对膀胱输尿管反流的诊断价值

目的探讨降钙素原(PCT)在膀胱输尿管反流诊断中的应用价值。方法对第一次发热的尿路感染患儿进行血清PCT检测,并对所有患儿进行排尿性膀胱尿道造影(VCUG)以确定是否存在膀胱输尿管反流,从而评估PCT对膀胱输尿管反流诊断的预测作用。结果膀胱输尿管反流组血清PCT值为(1.26±0.07)ng/ml,明显高于无膀胱输尿管反流组[(0.57±0.08)ng/ml],差异有非常显著性(P<0.01)。13例轻度膀胱输尿管反流患儿血清PCT水平为(1.02±0.14)ng/ml,6例重度膀胱输尿管反流患儿PCT水平为(1.79±0.20)ng/ml,差异有非常显著性(P<0.01)。血清PCT≥0.5ng/ml对所有膀胱输尿管反流患儿诊断的敏感度为84%,特异度为64%,对重度膀胱输尿管反流诊断的敏感度为100%,特异度为64%。结论血清PCT值可用于鉴别是否存在膀胱输尿管反流,且与反流程度相关。     

Age at diagnosis of vesicoureteric reflux after urinary infections: historical changes

AIM: Efforts are currently made to detect vesicoureteric reflux (VUR) early after urinary infections in order to limit secondary renal damage. This study investigated the extent to which recommendations for the detection of VUR are put into practice, and their influence on the age at diagnosis. METHODS: The age at diagnosis of VUR after urinary tract infections was analysed in 126 patients (48M, 78F) referred to a tertiary centre in Milan between 1976 and 1999. RESULTS: The median age at diagnosis was 34 mo in subjects born before and 8 mo (p < 0.001) in those born after 1988. The difference was statistically significant in female but not in male subjects. The figures from Milan were compared with those for 102 patients (35M, 65F) born between 1946 and 1970, treated in Melbourne and reported in 1976. In Melbourne the median age at diagnosis was 1-2 y for boys and 5-6 y for girls; in Milan, the corresponding figures were <1 y and 1-2 y. The difference between Melbourne and Milan was statistically significant for both genders. CONCLUSION: In Milan VUR is now detected earlier than in the past. This trend is more marked in females than in males, but reflux is still detected earlier in boys.     

Surgical treatment of vesicoureteric reflux

Vesicoureteric reflux (VUR), the retrograde flow of urine from the bladder into the upper tracts, is a common finding during investigation of the urinary tract. It is a risk factor for urinary tract infection (UTI). The gold standard for diagnosis is a direct micturating cystourethrogram (MCUG). VUR may resolve spontaneously, and in recent years the trend has been towards conservative management to lower the risk of UTI. However, in some circumstances for example when conservative treatment fails, surgery may be required. Surgery for VUR is reliable at downgrading the extent of VUR, and lowers the frequency of UTI but probably does not influence the outcome of the kidneys. For this reason, patients and their families must be selected and counselled carefully. As with many surgical procedures there has been interest in minimal access although the fundamental principles of abolishing reflux remain the same. This article briefly reviews the roles of medical and surgical treatment in the management of VUR.     

Risk factors for recurrent urinary tract infection in preschool children

OBJECTIVE: Children with urinary tract infections (UTI) are at risk of renal scarring which may lead to impaired renal function and hypertension. This study examines the risk factors that predispose to recurrent UTI in children and the role of recurrent UTI in renal scarring. METHODOLOGY: A group of 290 children under 5 years of age with a first symptomatic UTI were studied. Micturating cystourethrogram and dimercaptosuccinic acid (DMSA) renal scintigraphy were performed at entry, and DMSA was repeated 1 year later. Two hundred and sixty-one children (90%) were followed up at 1 year. RESULTS: There were 46 confirmed recurrent infections in 34 children, a recurrence rate of 12%. Multiple recurrence occurred in 14/34 (34%) children. Age of less than 6 months on entry independently predicted for recurrent UTI (odds ratio (OR): 2.9)). Compliance with prophylactic antibiotics fell throughout the year of follow up. Vesicoureteric reflux (VUR) was present in 14/34 (34%) of the group with recurrent UTI, 69/256 (27%) without recurrence. Urinary tract infection was significantly associated with bilateral and intrarenal reflux; grade 3-5 reflux independently predicted for recurrent UTI (OR: 3.5). Recurrent UTI was significantly associated with high grade DMSA defects on entry, renal parenchymal defects at 1 year follow up, and new defects at 1 year. CONCLUSION: The independent risk factors for recurrent UTI identified by this study were an age of less than 6 months at the index UTI and grade 3-5 VUR. These findings suggest more selective targeting may minimize problems associated with prophylaxis and improve outcomes for children with urine infection.     

膀胱输尿管反流90例临床回顾分析

目的探讨输尿管膀胱反流(VUR)的临床特征。方法回顾分析2012年1月至2017年12月期间因发热性尿路感染住院治疗并经排泄性尿路造影(MCU)确诊VUR的患儿的临床资料。结果 90例患儿中男41例、女49例,中位年龄0.90岁;双侧反流46例,其中神经源性膀胱4例。51例1岁以下患儿中,男性28例、女性23例;10例5岁以上患儿中,仅1例男性患儿。6例手术治疗,其余84例内科保守治疗,其中随访到48例。随访患儿中,15例尿路感染复发,5例因肾瘢痕、患侧肾小球滤过率下降转为手术治疗;25例于一年后复查MCU,1例反流级别加重、12例无变化、5例减轻、7例消失。8例患儿首次肾静态显像(DMSA)发现肾脏缩小、肾瘢痕形成,36例患儿半年后复查DMSA发现10例出现肾瘢痕。结论婴儿期发热性尿路感染患儿,尤其是男孩应注意是否存在VUR。DMSA、MCU等检查不能相互取代。双侧VUR患儿应排除神经源性膀胱及合并其他畸形。     

Prediction of vesico-ureteric reflux in childhood urinary tract infection: a multivariate approach

In this study, independent predictors obtained from patient history, physical examination and laboratory results for vesico-ureteric reflux (VUR) in children of 0-5 y with a first urinary tract infection (UTI) were assessed and the added value of renal ultrasound (US) investigated. Information was collected from children visiting the paediatric outpatient department with a first proven UTI, defined as a urine monoculture with ≥105 organism/ml, with clinical symptoms and possible white cell count ≥20 per high-power field of spun fresh urine. Children with neurologic bladder dysfunction were excluded. VUR was determined by voiding cystourethrography (VCUG) and graded from I to V. The diagnostic value of predictors was judged using multivariate logistic modelling with the area under the receiver operating characteristic (ROC area). A risk score was derived based on the regression coefficients of the independent predictors in the logistic model. In 140 children (51 boys and 89 girls) VUR was diagnosed in 37. Independent predictors for VUR were male gender, age, family history for uropathology, serum C-reactive protein level (CRP) and dilatation of the urinary tract on US. The ROC area of this model was 0.78 (95% CI: 0.69-0.87). This prediction model identified 12% (95% CI: 7-18) of the patients without VUR without missing one case of VUR. If we used VUR ≥ grade 3 as a threshold, the model assessed VUR to be absent in 34% (95% CI: 26-42). Conclusion: A prediction rule based on age, gender, family history, CRP and US results is useful in assessing the probability of VUR in the individual child with a first UTI and may help the physician to make decisions about performing additional imaging techniques. Prospective validation of the model in future patients, however, will be necessary before applying the rule in practice.     

Urinary tract infections in children below two years of age: a quality assurance project in Sweden. The Swedish Pediatric Nephrology Association

The objective of this study was to evaluate the basis for diagnosis and assessment of children <2 y of age with urinary tract infections (UTI) and to describe their subsequent management as currently practised in Sweden. The study was a prospective, multicentre project as part of a programme for quality assurance. A total of 2309 children (1111M, 1198F) was studied during a 2-y period. Of the population at risk, 1.6% of both boys and girls were diagnosed with a UTI. This represents a minimum figure. Suprapubic bladder aspiration was mainly used during the first year of life, with the highest frequency in the youngest infants. Adhesive bags were used in half of the children, and the frequency increased with age. Imaging of the urinary tract was performed in 97% of the children. Vesicoureteric reflux was the most common finding, occurring in 36% of the girls and 24% of the boys. The presence of dilatation of the upper urinary tract correlated significantly to the presence and grade of reflux. Initial intravenous therapy was given to 31% of the children and long-term antibacterial prophylaxis to 20%. Major differences were found between centres in diagnostic rate, urine sampling technique and the use of parenteral therapy. In conclusion, this study showed a high diagnostic rate of urinary infections in children below 2 y of age. The urine sampling technique was optimal (suprapubic aspiration) in half of the infants, but less reliable in the children above 1 y of age. The frequency of imaging investigations of the urinary tract was high. The strategies for diagnosis and treatment varied considerably among centres.     

Outcome of primary vesicoureteric reflux detected following fetal renal pelvic dilatation

OBJECTIVE: Postnatal investigation of mild degrees of fetal hydronephrosis has allowed subsequent detection of infants with vesicoureteric reflux (VUR). This study was designed to provide short to medium term information on such infants who had primary VUR, the rates of renal damage and progression over time, the risk factors for such damage and to compare the characteristics of those who had mild dilatation of the fetal renal pelvis (4-9 mm) with those who had moderate-severe dilatation (> or = 10 mm). METHODOLOGY: Since June 1989, infants whose antenatal sonography had identified a fetal renal pelvis with an anteroposterior diameter of > 4 mm were investigated postnatally with renal ultrasonography and micturating cystourethrogram (MCU), and placed on antimicrobial prophylaxis. Those with VUR received 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy. Infants were followed until discharge based on resolution of VUR, surgery, or low grade VUR. A 5.5 year cohort between June 1989 and December 1994 formed the study population. A review of notes and clinical review (if still under follow up) was undertaken. Vesicoureteric reflux on MCU was regraded according to the International Classification, and reflux nephropathy on DMSA scans was regraded according to criteria proposed by Goldraich. Regression analysis was used to assess risk factors for renal damage. RESULTS: There were 69 infants (37 girls, 32 boys) who were identified with primary VUR, with 37/69 having bilateral reflux. Eight had a urinary tract infection during the follow-up period. There was a broad distribution of grades of reflux detected (Grades I-3, Grades II-23, Grades III-19, Grades IV - 17, Grades V-7). 99m-Tc-dimercaptosuccinic acid scans on 57/69 (83%) demonstrated renal damage in eight infants (14%). This was predominantly global contraction of function. No progression of renal damage was seen over 2-7 years. Regression analysis showed a strong association between Grades IV, V reflux and the presence of renal damage (P < 0.001). Review of the degrees of fetal renal pelvic dilatation showed that 60/69 infants were detected because of mild (4-9 mm) dilatation. The majority (43/60) had lower grades of reflux (Grades I, II, 3), but there was no obvious cut-off between 4 and 9 mm that could predict high grade VUR (Grades IV, V). CONCLUSIONS: The use of 4 mm to define an abnormal fetal renal pelvis allows a much larger group of infants with high grade primary VUR to be detected than if a higher cut-off measurement is used. Although it also detects many more infants with low grade primary VUR, there is no obvious cut-off point at which this effect predominates. Progressive renal damage was not seen in follow up of up to 7 years of age. Renal damage on DMSA scanning in this group is almost exclusively a pattern of global contraction of function. The presence of high-grade VUR appears to be the only important factor in predicting the presence of renal damage.