Vesicoureteral reflux increases the risk of renal scars: a study of unilateral reflux

The aim of this study was to assess the impact of vesicoureteral reflux (VUR) on renal scar following acute pyelonephritis by comparing the refluxing renal units with nonrefluxing renal units in children with unilateral primary VUR. Forty-eight children with unilateral primary VUR diagnosed after the first pyelonephritis were enrolled. Mean age of patients was 1.0±1.6 years (29 boys and 19 girls). All patients underwent renal ultrasonography and renal 99 m-technetium dimercaptosuccinic acid (DMSA) scan within three days following the diagnosis of pyelonephritis, and voiding cystourethrography (VCU) was performed soon after fever subsided and the infection was controlled. The DMSA scan was rechecked six months after the initial study when the first scan showed a renal defect. The first DMSA showed renal defects in 34 (70.8%) out of 48 of the refluxing renal units and in 13 (27.1%) out of 48 of the nonrefluxing renal units (P<0.01, OR: 6.54). At six months after the infection, 23 (47.9%) out of 48 refluxing renal units and seven (14.6%) out of 48 nonrefluxing renal units had renal scars on DMSA scan (P<0.01, OR: 5.39). The prevalence of renal scars did not vary significantly according to the grade of VUR. The CRP level on admission was significantly higher in patients with acute renal defect and scar. In conclusion, VUR increases the risk of post-pyelonephritic renal scars in children.     

Dimercaptosuccinic acid (DMSA) renal scan in the evaluation of hypertension in children

Renal scarring is known to be associated with hypertension. The primary objective of this study was to investigate the prevalence of renal scarring in children referred to our clinic with hypertension. The secondary objective was to compare renal ultrasound (US) examination with dimercaptosuccinic acid (DMSA) renal scan in diagnosing renal scars in these patients. The study included 159 patients who underwent DMSA renal scan as well as renal US for the evaluation of hypertension of unknown etiology. Thirty-three (21%) patients were found to have renal scars; their demographic details, including mean age and gender distribution, were not significantly different from those without renal scars. In comparison with the DMSA renal scan, sensitivity and specificity of renal US in diagnosing renal scars were 36% and 94%, respectively. In our study, in which the prevalence of scarring was 21%, this gave positive predictive and negative predictive values of 63% and 85%, respectively. In conclusion, our study indicates that renal scarring is present in 21% of otherwise healthy children who are evaluated for newly diagnosed hypertension, and renal US is not a sensitive imaging modality to rule out renal scarring.     

A Snapshot of the Guidelines on Vesicoureteral Reflux in Children

The main goal in the management of patients with vesicoureteral reflux (VUR) is the preservation of kidney function by minimizing the risk of pyelonephritis. By defining and analyzing the risk factors for each patient depending on age, sex, grade of reflux, lower urinary tract dysfunction, anatomic abnormalities, and kidney status, it is possible to identify those patients with a potential risk of upper urinary tract infection and resulting renal scarring. This paper gives a brief overview of the European Association of Urology guidelines for the management and treatment of VUR in children. These guidelines are based on the best currently available knowledge and evidence.     

New renal scars in children with severe VUR: a 10-year study of randomized treatment

The International Reflux Study in Children was set up to compare prospectively the outcome of medical or surgical management of children with grade III or IV vesicoureteral reflux and a history of symptomatic urinary tract infection. Development of new radiological scars was the main end point. Of the 306 children randomized, 302 (153 medical, 149 surgical) were available for radiological follow-up at 5 years. New scars had developed in 19 medically and 21 surgically treated children. Among 223 patients (113 medical, 110 surgical) who continued follow-up with urography at 10 years, only 2 further new scars developed. Overall, 47 new scars were acquired in 42 patients (20 medical, 22 surgical), 25 of them in children with unscarred kidneys at entry (13 medical, 12 surgical). New scars occurred mostly in children under 5 years of age and were observed more frequently in children with grade IV than grade III reflux. We conclude that with careful management, only a small proportion of children with severe reflux developed new scars and rarely after the first 5-year follow up period, and that there was no difference between children treated medically or surgically.The authors are the writing committee of the European arm of the International Reflux Study in Children. H. Olbing is deceased. Co-ordinating center, Essen, Germany: chairman H. Olbing, scientific co-ordinator T. Tamminen-Möbius, statistics H. Hirche, documentation H. Lax. Participating university hospitals and investigators: Bonn, Germany: R. Mallmann, D. Emons; Brussels, Belgium: M. Hall, A. Piepsz, C. Schulmann; Essen, Germany: H.J. Bachmann, W. Rascher, E. Brunier, C. Reiners, J. Behrendt, P. Mellin (deceased); Gothenburg, Sweden: U. Jodal, K. Hjälmås, E. Hanson, N. Nilsson, J. Bjure (deceased), R. Sixt; Hamburg, Germany: R. Busch, C. Montz; Helsinki, Finland: O. Koskimies, S. Wikström, E. Marttinen, A. Kivisaari, T. Korppi-Tommola; Oulu, Finland: J. Seppänen (deceased), N.P. Huttunen, U. Seppänen, J. Heikkilä; Stockholm, Sweden: A. Aperia, G. Löhr, P. Herin, U. Freyschuss, L. Blom, U. Erasmi, B. Söderborg. Consultants: I. Claesson, K.-D. Ebel, R.A. Lebowitz, K. Parkkulainen, J.M. Smellie, I. Wikstad, and J. Winberg (deceased)     

Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children

For the comparison of long-term outcome of the management of medical or surgical treatment of children with severe vesicoureteral reflux (VUR), children aged <11 years with non-obstructive grade III/IV reflux, previous urinary tract infection (UTI) and glomerular filtration rate (GFR) ≥70 ml/min per 1.73 m² body surface area were recruited, and 306 were randomly allocated to receive antimicrobial prophylaxis or ureteral reimplantation. Primary endpoints were new renal scars and renal growth. Follow up, originally planned for 5 years, was extended to 10 years for 252 children, 223 of whom had follow-up imaging. Up to 5 years, 40 new urographic scars (medical 19, surgical 21) were seen. Between 5 years and 10 years, only two further scars were observed. Renal growth and UTI recurrence rate were similar, except that medically treated patients had more febrile infections. There was no difference in somatic growth, radionuclide imaging or renal function. A GFR <70 ml/min per 1.73 m² was found in only one patient. Three patients developed hypertension requiring treatment. We conclude that, with close supervision and prompt treatment of recurrences, children entering the study with GFR ≥70 ml/min per 1.73 m² progressed remarkably well under either medical or surgical management, emphasizing the importance of continued supervision and the entry level of renal function.The authors are the writing committee of the European arm of the International Reflux Study in Children. Co-ordinating centre, Essen, Germany: chairman H. Olbing (deceased), scientific coordinator T. Tamminen-Möbius, statistics H. Hirche, documentation H. Lax.Participating university hospitals and investigators were Bonn, Germany: R. Mallmann, D. Emons; Brussels, Belgium: M. Hall, A. Piepsz, C. Schulmann; Essen, Germany: H.J. Bachmann, W. Rascher, E. Brunier, C. Reiners, J. Behrendt, P. Mellin (deceased); Göteborg, Sweden: U. Jodal, K. Hjälmås (deceased), E. Hanson, N. Nilsson, J. Bjure (deceased), R. Sixt; Hamburg, Germany: R. Busch, C. Montz; Helsinki, Finland: O. Koskimies, S. Wikström, E. Marttinen, A. Kivisaari, T. Korppi-Tommola; Oulu, Finland: J. Seppänen (deceased), N.P. Huttunen, U. Seppänen, J. Heikkilä; Stockholm, Sweden: A. Aperia, G. Löhr, P. Herin, U. Freyschuss, L. Blom, U. Erasmi, B. Söderborg. Consultants: I. Claesson, K.-D. Ebel, R.A. Lebowitz, K. Parkkulainen (deceased), J.M. Smellie, I. Wikstad, and J. Winberg (deceased). External Monitoring Committee: C. Meinert (chairman), H.-K. Selbmann, J.M. Smellie, J. Gillenwater, and H.J. Jesdinski (deceased).This paper is presented as a tribute to the late Professors Hermann Olbing and Paul Mellin of Essen, who conceived this study in 1978; to the late Dr. John Duckett of Philadelphia, who, with Professor Adrian Spitzer and Dr. Robert Weiss of New York, promoted and maintained the American limb; to Dr. Tytti Tamminen-Möbius, who coordinated the study, and to Herbert Hirche, statistician. Finally, we wish to acknowledge and thank all the children and their parents who agreed to participate in the study and adhere to the follow-up protocol, 252 of them for 10 years.     

Predictors of renal scar in children with urinary infection and vesicoureteral reflux

We evaluated the predictors of renal scar in children with urinary tract infections (UTIs) having primary vesicoureteral reflux (VUR). Data of patients who were examined by dimercaptosuccinic acid (DMSA) scintigraphy between 1995 and 2005 were evaluated retrospectively. Gender, age, reflux grade, presence/development of scarring, breakthrough UTIs, and resolution of reflux, were recorded. The relation of gender, age and VUR grade to preformed scarring and the relation of gender, age, VUR grade, presence of preformed scarring, number of breakthrough UTIs and reflux resolution to new scarring were assessed. There were 138 patients [male/female (M/F) 53/85]. Multivariate analysis showed that male gender [odds ratio (OR) 2.5], age ≥ 27 months in girls (OR 4.2) and grades IV–V reflux (OR 12.4) were independent indicators of renal scarring. On the other hand, only the presence of previous renal scarring was found to be an independent indicator for the development of new renal scar (OR 13.4). In conclusion, while the most predictive variables for the presence of renal scarring among children presenting with a UTI were male gender, age ≥ 27 months in girls, and grades IV–V reflux, the best predictor of new scar formation was presence of previous renal scarring.     

The etiology of renal scars in infants with pyelonephritis and vesicoureteral reflux

We aimed to investigate, by means of dimercaptosuccinic acid (DMSA) scan, the relations between vesicoureteral reflux (VUR) and its degree, pyelonephritis during infancy, and renal parenchymal findings. Seventy-four infants with pyelonephritis, 44 girls and 30 boys (mean age at their first pyelonephritic episode 4.12 months, median 3 months), were enrolled in the study. Voiding cystourethrography (VCU) and ultrasonography (US) were performed within 6 weeks following the infection. DMSA was performed at least 4 months after the urinary tract infection (UTI). The renal parenchymal pathology was defined as focal or multifocal defects or as a split renal uptake of less than 45%. DMSA scintigraphy revealed that 19% (14/74) of the children had renal damage. Renal parenchymal findings were observed only when VUR was present, and its grade was above 3/5. No abnormality was found in 51 renal units without reflux, 9 with VUR grade 1/5, and 54 with grade 2/5. Renal pathology was observed in 9/24 renal units with VUR grade 3, 3/8 with grade 4, and 2/2 with grade 5. No correlation was found between renal parenchymal defects and clinical presentation of the pyelonephritis, type of the microorganism, presence of bacteremia, or the number of recurrent infections. In adequately treated infants, renal damage is probably due to a reflux-associated, preexisting, congenital renal parenchymal pathology and not to the inflammatory process. We suggest that DMSA scintigraphy should not be performed routinely in every infant with UTI and should be reserved primarily for children with VUR grade 3 and above. Received: 17 February 1999 / Revised: 30 June 1999 / Accepted: 7 July 1999     

Urinary excretion of tubular proteins and the technetium-99m dimercaptosuccinic acid (DMSA) absolute renal uptake in partial ureteral obstruction in rats: a functional evaluation of hydronephrotic kidneys

The aim of this longitudinal study was to evaluate tubular proteinuria in rats with unilateral (UPO) and bilateral (BPO) partial ureteral obstruction with the dimercaptosuccinic acid (DMSA) scan as the gold standard for measuring renal tubular damage. We studied 70 female Wistar rats: 28 animals with UPO, 28 animals with BPO, 7 sham-operated animals, and 7 controls. All animals with obstructed ureters showed renal dilatation on the diethylenetriaminepentaacetic acid DTPA images 1 and 5 weeks postoperatively. One week following UPO and BPO, tubular proteinuria and urinary N-acetyl-beta-d-glucosaminidase (NAG) activity increased (P < 0.01) and the absolute DMSA uptake decreased (P < 0.01). Persistently (week 6) high tubular proteinuria was found in 29% of the animals and was related to severe damage on the DMSA scan (P < 0.01) and to albuminuria (P < 0.05). Renal tubular damage was demonstrated by measuring renal enzymes, tubular proteins, and DMSA uptake after UPO and BPO. Persistent elevated tubular proteinuria was related to severely damaged kidneys. Received: 18 June 1998 / Accepted: 20 October 1998     

五种常见病原体感染与紫癜性肾炎患儿肾小管-间质损伤的相关性研究

目的：比较起病时无感染的紫癜性肾炎患儿与发病时存在支原体、链球菌、腺病毒、合胞病毒及流感病毒这5种常见病原体感染的患儿在肾小管及肾间质的损伤程度上的区别以明确以上5种病原体是否在紫癜性肾炎的发病过程中对肾小管及肾间质造成进一步损伤.方法：按照实验室检查结果将患儿分为无感染组及支原体感染组、链球菌感染组、腺病毒感染组、合胞病毒感染组及流感病毒感染组,比较其肾小球、肾小管、肾间质损伤程度.将各感染组分别分为有症状组及隐性感染组,组间比较其肾小管、肾间质损伤程度.结果：各组间肾小球损伤情况无明显差别.支原体感染组患儿在肾小管及肾间质的损伤程度上与无感染组患儿相比无差别,而链球菌、腺病毒、合胞病毒及流感病毒感染组的肾小管及肾间质损伤比无感染组严重.将以上四组患者分别分为有症状组及隐性感染组,组间比较发现其肾小管及肾间质损伤程度无差别.结论：链球菌、腺病毒、合胞病毒及流感病毒感染可能在紫癜性肾炎的发病过程中对肾小管及肾间质造成进一步损伤,且这种损伤的严重程度与感染的严重程度不相关.     

Renal Function and Urine Drainage after Conservative or Operative Treatment of Primary (Obstructive) Megaureter in Infants and Children

We examined renal function and urinary drainage of children with primary megaureter (PMU) in dependence on conservative or operative treatment. Material and methods: The retrospective analysis covering the years 1994 to 2000 comprised children at an age of 0–7 years with 35 PMU. Sonography, dynamic MAG3 renography as well as endogenic creatinine clearance (GFR) were used to assess drainage and the renal function. Temporary urinary diversion was established in fourteen patients of both groups. In 14 children with 16 PMU a ureteroneocystostomy (UNC) was performed. The average observation period was 30 months (11–108). ResultsThe children of the UNC group differed from the non-neoimplanted group in the age at diagnosis (10.5 vs. < 1 months), higher degrees of hydronephrosis on average, a more distinct dilatation of the ureter as well as renographically significant obstruction. Children of the non-UNC group, including four children with a type B drainage curve (O’Reilly), had an unimpaired differential renal function or improved during the observation period (initially 51% vs. 50.5% at the end). In neoimplantation group the differential function improved from 32.5% to 38.5% (p<0.05) and obstruction resolved with one exception. Conclusion: Given a higher-grade PMU with a reduced function of the kidneys and a significant impaired drainage pattern and/or symptoms, neoimplantation without temporary diversion has proved to be an efficient renoprotective method. Furthermore, data clearly justify a conservative approach without urinary diversion in infants with large asymptomatic PMU.     

~(99m)Tc-MIBI乳腺显像与乳腺X线照相在乳腺癌诊断中的价值

目的　评价99mTc MIBI乳腺显像与乳腺X线照相检测乳腺癌的实用性。方法　对 10 0例10 6个经临床检查可疑乳腺病灶的妇女进行乳腺钼靶X线照相和99m Tc MIBI乳腺显像检查 ,并与病理学诊断结果进行对比。结果　与病理组织学诊断比较 ,钼靶照相检测乳腺癌特异性为 44 .6% ,阳性预测值为 3 1.7% ;99mTc MIBI乳腺显像检测乳腺癌的特异性为 87.8% ,阳性预测值为 76.9%。结论　99mTc MIBI乳腺显像对乳腺癌的诊断较乳腺X线照相具有较大的临床价值     

双波长强脉冲光联合30%超分子水杨酸治疗面部寻常痤疮的临床疗效及美容效果

目的 探究双波长强脉冲光（IPL）联合30%超分子水杨酸治疗面部寻常痤疮的临床疗效及美容效果。方法 以2020年1月-2021年8月南京医科大学附属江宁医院皮肤科接诊的60例面部寻常痤疮病例为研究对象,按照随机数字表法分为对照组（30例）与观察组（30例）,对照组行双波长IPL治疗,观察组采用双波长IPL联合30%超分子水杨酸治疗。比较两组临床疗效、痤疮综合分级系统（GAGS）评分、皮肤屏障功能[皮肤经皮水丢失(TEWL)、角质层含水量、pH值]、不良反应、痤疮瘢痕情况以及皮肤评分。结果 观察组治疗总有效率高于对照组（P＜0.05）。治疗后两组GAGS评分均有下降,且观察组低于对照组（P＜0.05）;治疗后,观察组TEWL、pH值低于对照组,角质层含水量高于对照组（P＜0.05）;两组不良反应总发生率比较,差异无统计学意义（P＞0.05）;两组痤疮瘢痕分级比较,差异有统计学差异（P＜0.05）;治疗后,两组皮肤毛孔、红斑、紫质评分均低于治疗前,且观察组低于对照组,差异有统计学意义（P＜0.05）。结论 双波长IPL联合30%超分子水杨酸治疗面部寻常痤疮疗效显著,可促进皮损消退,改善皮肤屏障,减轻痤疮瘢痕,且安全性好。     

板一根系统（PRSS）对生长中儿童和成人脊柱侧弯矫治的早期结果

目的研究新型脊柱侧弯矫正装置-板棍系统PRSS(Plate-RodSpinalSystem)对生长发育中儿童和成人的脊柱侧弯的矫治效果及治疗原理。方法从1998年9月～1999年6月对35例脊柱侧弯使用PRSS矫治。其中先天性脊柱侧弯10例,特发性脊柱侧弯22例,其它4例平均年龄15.6岁(3～34岁)。术前平均畸形为65.5°(40°～103°)。所有病例均进行术前后X线检查分析。PRSS矫正力由弹力板棍提供,不需植骨融合,允许矫正节段脊柱继续生长。结果平均随诊6.9个月,侧弯畸形度由术前平均68.6°矫正至31.7°,平均矫正率53.8%,最好者87.2%,平均身高增加5cm,矫正节段平均增高5mm。结论PRSS是新型有效的脊柱侧弯矫正装置,特别适于生长发育中儿童的脊柱侧弯,其矫正方式和原理均与国内外流行方法不同,具有不易发生截瘫和脱钩的优点,为脊柱侧弯的治疗开辟了一条新路。     

双核素免疫显像诊断大肠癌的临床研究

目的 探讨大砀癌及其复发、转移灶的诊断方法。方法 采用改良氯腕Ｔ法进行抗癌胚抗原（ＣＥＡ）单抗抗（Ｃ５０）＾１３１Ｉ票房，对２０例临床疑为大肠癌或其复发、转移的患者静注＾１３１Ｉ－Ｃ５０ ３７０～５５５ｍＢｑ后４８～７２小时进行放免显像（ＲⅡ）、显像前３小时财时静注＾９９ｍＴｃ－ＭＤＰ（亚甲基二膦酸盐（１８５～５５５ｍＢｑ。手术时取不同组织行放射计数检测。结果与手术、病理诊断进行对照。结果 显像阳     

动脉粥样硬化性肾动脉狭窄患者血MMP-9水平、血脂、肾动脉狭窄支数及其间关系的临床观察

目的探讨动脉粥样硬化性肾动脉狭窄患者血基质金属蛋白酶-9（MMP-9）及血脂水平、肾动脉狭窄支数以及三者之间的相关关系。方法将99例患者根据肾小球滤过率（GFR）分为：Ⅰ组GFR〈20ml/min组（n=26），Ⅱ组20ml/min〈GFR〈35ml/min组（n=33），Ⅲ组35ml/min〈GFR〈70ml/min组（n=20）和Ⅳ组GFR〉70ml/min组（n=20）。测定所有患者MMP-9以及血脂的浓度。所有病人均行肾动脉造影检查，据结果分为单侧或双侧肾动脉狭窄。结果①四组患者血MMP-9浓度随肾功能的进行性下降而逐渐减少。②四组患者主要冠脉狭窄支数比较：Ⅰ组高于Ⅳ组且差值比较有统计学意义，其余各组间差值比较均无统计学差异。③患者血TC与LDL-c呈现Ⅰ组〈Ⅱ组〈Ⅳ组〈Ⅲ组的规律，组间比较差别均具有统计学差异；而TG与HDL-c则未显示出明显的规律，组间比较差别无统计学意义。④患者血MMP-9水平与肾动脉狭窄支数之间无相关关系。⑤患者血MMP-9水平与血TC、LDL-c水平呈负相关，与TG，HDL-c无相关关系。⑥患者肾动脉狭窄支数与血脂水平无相关关系。结论MMP-9可作为动脉粥样硬化性肾动脉狭窄的炎症观察指标，是动脉粥样硬化肾动脉斑块不稳定的标记物，可作为动脉粥样硬化性肾动脉狭窄的发生及发病程度的一种重要的相关性指标。