The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection.

BACKGROUND: Childhood urinary tract infection (UTI) with or without vesicoureteric reflux (VUR) may predispose to renal scarring. There is no clear consensus in the literature regarding imaging following UTI in infancy. AIMS: To define the role of cystography following a first UTI in children aged under 1 year, when urinary tract ultrasonography (US) is normal. METHODS: Retrospective data collection of 108 children (216 renal units) aged under 1 year at the time of a bacteriologically proven UTI. All had a normal US and underwent both catheter cystogram and DMSA test. Sensitivity, specificity, likelihood ratios positive and negative, and diagnostic odds ratio were calculated for VUR on cystography versus scarring on DMSA. RESULTS: VUR was shown in 25 (11.6%) renal units. Scarring on DMSA was seen in 8 (3.7 %) kidneys. Only 16% of kidneys with VUR had associated scarring; 50% of scarred kidneys were not associated with VUR. The likelihood ratio positive was 4.95 (95% CI 2.22 to 11.05) and the likelihood ratio negative was 0.56 (95% CI 0.28 to 1.11). The diagnostic odds ratio was 8.9, suggesting that cystography provided little additional information. CONCLUSION: Since only 16% of children with VUR had an abnormal kidney, the presence of VUR does not identify a susceptible population with an abnormal kidney on DMSA. In the context of a normal ultrasound examination, cystography contributes little to the management of children under the age of 1 year with a UTI. In this context, a normal DMSA study reinforces the redundancy of cystography.     

The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection

Background: Childhood urinary tract infection (UTI) with or without vesicoureteric reflux (VUR) may predispose to renal scarring. There is no clear consensus in the literature regarding imaging following UTI in infancy. Aims: To define the role of cystography following a first UTI in children aged under 1 year, when urinary tract ultrasonography (US) is normal. Methods: Retrospective data collection of 108 children (216 renal units) aged under 1 year at the time of a bacteriologically proven UTI. All had a normal US and underwent both catheter cystogram and DMSA test. Sensitivity, specificity, likelihood ratios positive and negative, and diagnostic odds ratio were calculated for VUR on cystography versus scarring on DMSA. Results: VUR was shown in 25 (11.6%) renal units. Scarring on DMSA was seen in 8 (3.7 %) kidneys. Only 16% of kidneys with VUR had associated scarring; 50% of scarred kidneys were not associated with VUR. The likelihood ratio positive was 4.95 (95% CI 2.22 to 11.05) and the likelihood ratio negative was 0.56 (95% CI 0.28 to 1.11). The diagnostic odds ratio was 8.9, suggesting that cystography provided little additional information. Conclusion: Since only 16% of children with VUR had an abnormal kidney, the presence of VUR does not identify a susceptible population with an abnormal kidney on DMSA. In the context of a normal ultrasound examination, cystography contributes little to the management of children under the age of 1 year with a UTI. In this context, a normal DMSA study reinforces the redundancy of cystography.     

Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials

Aims: To evaluate the benefits and harms of treatments for vesicoureteric reflux in children. Methods: Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate. Results: Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1–2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment. Conclusion: It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.     

Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials.

AIMS: To evaluate the benefits and harms of treatments for vesicoureteric reflux in children. METHODS: Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate. RESULTS: Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment. CONCLUSION: It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.     

Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department

OBJECTIVE: To assess the value of procalcitonin (PCT) and C-reactive protein (CRP), compared with that of total white-blood cell count (WBC) and absolute neutrophil count (ANC), in predicting severe bacterial infections (SBIs) in febrile children admitted to Emergency Department. METHODS: A prospective study was conducted in 408 children aged 7-days to 36-months, admitted with fever without source, at a tertiary care Pediatric Emergency Department. PCT, CRP, WBC, and ANC were determined upon admission and compared. Specificity, sensitivity, multilevel likelihood ratios, receiver operating characteristic (ROC) analysis, and multivariate stepwise logistic regression were carried out. RESULTS: SBI was diagnosed in 94 children (23.1%). PCT, CRP, WBC, and ANC were significantly higher in this group than in non-SBI patients. The area under the ROC (AUC) obtained was 0.82 (95% CI: 0.78-0.86) for PCT, 0.85 (95% CI: 0.81-0.88) for CRP (P = 0.358), 0.71 (95% CI: 0.66-0.75) for WBC, and 0.74 (95% CI: 0.70-0.78) for ANC. Only PCT (OR: 1.32; 95% CI: 1.11-1.57; P < 0.001) and CRP (OR: 1.02; 95% CI: 1.01-1.03; P < 0.001) were retained as significant predictors of SBI in a multiple regression model. For infants with fever <8 hours (n = 45), AUC for PCT and CRP were 0.92 (95% CI: 0.80-0.98) and 0.75 (95% CI: 0.60-0.87), respectively (P = 0.056). CONCLUSION: Both PCT and CRP are valuable markers in predicting SBI in children with fever without source and they perform better than WBC and ANC. PCT appears more accurate at the beginning of infections, but overall CRP may be the most convenient marker for its better sensitivity and feasibility.     

Unilateral vesicoureteric reflux: Low prevalence of contralateral renal damage

OBJECTIVE: We assessed the risk for the occurrence of renal damage in children with vesicoureteric reflux (VUR). STUDY DESIGN: We reviewed the records of 187 consecutive children, aged 3.8 +/- (SD) 2.8 years, with unilateral primary VUR diagnosed after urinary tract infection (UTI). Dimercaptosuccinic acid renal scintigraphy was performed 4 to 6 months after the last UTI. Three patterns of renal damage were identified: global reduction (GR) of renal radionuclide uptake (20% to 40% of relative uptake), focal defects (FD) in uptake, and shrunken (relative uptake <20%) kidney (SK). We assumed that in these subjects FD indicated postpyelonephritic damage and that GR indicated congenital renal damage. RESULTS: Scintigraphic renal damage of any type was present in 36.9% of the refluxing and in 3.2% of the nonrefluxing kidneys (odds ratio [OR], 17.6; 95% CI, 7.4 to 41.9). FD were present in 15.5% and 2.7% (OR, 6.7; CI, 2.5-17.6), GR in 19% and 0.5% (OR, 44.3; CI, 6.1 to 327.2), and SK in 6.9% and 0%, respectively. Patients with severe VUR showed a higher probability of renal damage than those with nonsevere VUR. CONCLUSIONS: In children with UTI and VUR, the refluxing kidney is most at risk of both congenital and acquired renal damage, and this risk increases with severity of reflux.     

Can Procalcitonin Reduce Unnecessary Voiding Cystoureterography in Children with First Febrile Urinary Tract Infection?

Objective: Recently, new predictors of vesicoureteral reflux (VUR) in children with a first febrile UTI such as Procalcitonin (PCT) were introduced as selective approaches for cystography. This study wants to show the capability of PCT in predicting presence of VUR at the first febrile UTI in children. Methods: Patients between 1 month and 15 years of age with febrile UTI were included in this prospective study. PCT values were measured through a semi-quantitative method in four grades comprising values less than 0.5, 0.5-2.0, 2.0-10.0 and above 10.0 ng/ml. The independence of PCT levels in predicting VUR were assessed after adjustment for all potential confounders using a logistic-regression model. Findings: A total of 68 patients, 54 (79.4%) girls and 14 (20.6%) boys were evaluated. PCT level demonstrated a significant difference between patients with positive VUR and those with negative VUR (P=0.012). To calculate the independent factors that may predict the presence of VUR, all included variables were adjusted for age and sex. Results of logistic regression showed that a PCT level between 2.0 and 10.0 ng/mL could independently predict presence of VUR (Odds ratio=6.11, CI 95%= 1.22-30.77, P=0.03). Conclusion: Our finding in this study showed that readily available semi-quantitative measures for PCT are feasible for detecting patients with VUR. We suggest that in semi-quantitative measurements of PCT, levels between 2.0 and 10.0 ng/ml could be an independent predictor of positive VUR.Key Words: Urinary Tract Infection, Procalcitonin Levels, Vesicoureteral Reflux, Voiding Cystourethrogram     

Prediction of Vesicoureteral Reflux in Children with First Urinary Tract Infection by Dimercaptosuccinic Acid and Ultrasonography

Objective

Urinary tract infection (UTI) is one of the most common causes of febrile pediatric diseases. Also, vesicoureteral reflux (VUR) is a significant risk factor for UTI. Voiding cystourethrography (VCUG) is the method of choice for evaluation of VUR. This study was done to predict VUR by DMSA scan (technetium 99 m-labeled dimercaptosuccinic acid) and ultrasonography (US).

Methods

In a prospective study, all children with first time acute pyelonephritis were selected and evaluated by DMSA scan and US. Then VCUG was done with negative urine culture. All children with final diagnosis of obstructive congenital anomaly were excluded. The sensitivity, specifity, positive predictive values, negative predictive values, Confidence Interval of DMSA scan and US were calculated for prediction or exclusion of VUR.

Findings

Among 100 children with UTI diagnosis, VUR was detected in 39 children and 63 (31.5%) kidneys. DMSA scan was abnormal in 103 (51.5%) units, 45 units had VUR (PPV=44%), 79 units with normal DMSA scan had no VUR (NPV=81%). Of kidney units that were abnormal by DMSA or US, 51 units had VUR. PPV and NPV were 44% and 56%, respectively.

Conclusion

DMSA scan alone or with US cannot predict VUR (especially low grade VUR). But according to NPV, it seems that absence of VUR can be predicted. So, more studies are needed to determine the usefulness of DMSA scan and US instead of VCUG for detection of VUR.     

Imaging the urinary tract in children with urinary tract infection

Aim: To evaluate whether ultrasonography (US) alone is sufficient in imaging the urinary tract in 1185 children with urinary tract infection (UTI). Methods: The reports on US and voiding cystourethrography (VCUG) were reviewed. Results: Initial US was normal in 861/1185 patients (73%). VCUG revealed abnormal findings in 285/861 (33%), of which grade III–V vesicoureteral reflux (VUR) comprised 97 cases (11%). During follow‐up, VUR had resolved in 88/97 (91%) patients: in 50/57 (88%) patients without active treatment for VUR, in 27/29 (93%) with endoscopic and in 11/11 (100%) with open surgery for VUR. During follow‐up, 11/97 patients (11%) had developed new renal scarring detectable in US, but no renal impairment occurred. Except for VUR, VCUG showed nonobstructive urethral valves in two infant boys with normal initial US. Thus, in 861 children with normal initial US, 40 patients with grade III–V VUR and two patients with significant nonreflux pathology may have benefited from surgical treatment, giving the total number of possibly missed pathological finding in 42/861 (4.9%) cases if VCUG had not been performed. Conclusion: We suggest that children with UTI could be examined using US alone and to use VCUG only after additional indications.     

降钙素原对儿童急性肾盂肾炎的诊断价值

目的：探讨降钙素原（PCT）对儿童急性肾盂肾炎（APN）的诊断价值。方法：回顾性分析2011年9月至2012年2月诊断为初发的尿路感染（UTI）且年龄<3岁患儿的病例资料,以核素肾静态扫描（99mTc-DMSA）结果作为诊断APN的金标准,比较上尿路感染（APN）及下尿路感染（非APN）患儿血清PCT、CRP的水平,并绘制二者诊断APN的受试者工作特征曲线（ROC曲线）,判断其诊断性能。结果：共65例UTI患儿纳入研究,其中APN 39例,下尿路感染者26例,前者的血清PCT、CRP水平显著高于后者（分别 3.08 ng/mL vs 0.37 ng/mL;6.25 mg/L vs 3.01 mg/L;均P<0.01）。血清PCT诊断APN的敏感性为84.6%,特异性为88.5%,曲线下面积为0.873（95%可信区间为0.781~0.965）,最佳阈值为1.03 ng/mL;血清CRP诊断APN的敏感性为71.8%,特异性为69.2%,曲线下面积为0.735（95%可信区间为0.612~0.858）,最佳阈值为3.91 mg/L。结论：PCT对儿童APN的诊断具有较高的敏感性及特异性,有助于临床对APN的早期识别。     

Timing of voiding cystourethrogram in the investigation of urinary tract infections in children

OBJECTIVE: To determine whether the detection of vesicoureteral reflux (VUR) in children with a urinary tract infection (UTI) is more likely if the voiding cystourethrogram (VCUG) is performed early (within the first 7 days after diagnosis) or late (>7 days after diagnosis). STUDY DESIGN: We conducted a retrospective case review of children <5 years of age admitted with a first episode of UTI to a tertiary care pediatric hospital over a 2-year period. Timing of the VCUG was at the discretion of the attending pediatrician. Differences in age, sex, mean time to performing the VCUG, and incidence of VUR between the 2 groups (VCUG performed early vs late) were compared by using Student t test (for age) and chi(2) test (for sex and incidence of VUR). Potential confounders (age and sex) were included in a multiple logistic regression analysis. RESULTS: A total of 162 patients were eligible for inclusion. Mean age was 181 days, and 43.8% were female. The incidence of VUR was 21.6%. The early group consisted of 82 patients, and the late group consisted of 80. No significant difference was found for age or sex or for the incidence of reflux (17.1% vs 26.3%, P =.219), with a crude odds ratio of.59 (95% CI 0.3-1.2, P >.05). CONCLUSION: The rate of detection of VUR in children with a first episode of UTI does not increase when the VCUG is done early (within the first 7 days of diagnosis) rather than later.     

Prognostic factors in prenatally-detected posterior urethral valves: a multivariate analysis

To identify prognostic factors associated with chronic renal insufficiency in children with posterior urethral valves (PUV), 22 children with PUV were submitted to a systematic protocol and prospectively followed. Prognostic factors associated with fetal echography and clinical and laboratory findings were studied on admission. Median follow-up was 76 months. The analysis was conducted in two steps: in univariate analysis, variables associated with adverse outcome were identified by the Kaplan-Meier method. The variables that were significantly associated with adverse outcome were then included in a multivariate analysis using the Cox model. Eleven patients (50%) developed chronic renal failure (CRF) during follow-up. After adjustment by the multivariate model, four factors were identified as independent predictors of adverse outcome: oligohydramnios (relative risk [RR] = 10.6, 95% CI = 2.7 - 77, P = 0.02), ventilatory support (RR = 6, 95% CI = 2 - 24, P = 0.01), urea higher than 40 mg/dl (RR = 3.7, 95% CI = 0.92 - 15.0, P = 0.06), and bilateral vesicoureteral reflux (VUR) (RR = 6.1, 95% CI = 1.25 - 30, P = 0.02). On the other hand, the presence of unilateral VUR was a protective factor against the development of CRF or death during follow-up (RR = 0.92, 95% CI = 0.87 - 0.98, P = 0.05).     

Urinary tract infection and vesicoureteral reflux in children with mild antenatal hydronephrosis

ObjectiveThe postnatal management of mild antenatal hydronephrosis (ANH) remains controversial. The purpose of this study was to evaluate the incidence of UTI and VUR in children with mild ANH in order to determine the necessity of antibiotic prophylaxis (ABP) and VCUG.MethodThe data of 1511 patients with various grades of ANH who were referred to Department of Urology, Boston Children's Hospital between January 1998 and January 2010 were reviewed and 760 patients who had mild ANH were identified. The inclusion criteria were:1) A confirmed report of ANH or actual prenatal ultrasound (US) images.2) Postnatal evaluation and management conducted at the hospital.3) Persistent mild hydronephrosis on the first US done between two weeks and three months of age.4) No other US findings such as ureteral dilatation, duplication anomalies or bladder abnormalities.5) At least one three-month follow up.Univariate statistical analysis was performed using a Student's t test.ResultsOf the 760 patients who were identified, 608 (80%) were males, and 225 (30%) had bilateral mild hydronephrosis. Of these, 475 patients (63%) underwent an initial screening VCUG. VUR was identified in 13 patients (1.7%) with grades varying from 1 to 5. At follow up, hydronephrosis resolved in 67% of the renal units and worsened in 3.3%. Among the 692 patients with available follow-up data, 23 (3.3%) had a documented UTI. Twelve of these children had an initial screening VCUG that was negative for VUR. Of these 12 patients, seven underwent a subsequent RNC with none having VUR; five of the 12 patients did not undergo a repeat evaluation for VUR (four had a UTI after the screening VCUG and one had an afebrile UTI). Eleven of the 23 children with mild ANH did not have an initial screening VCUG, and all underwent a subsequent VCUG/RNC. Only two children were then found to have VUR Grade 4–5.ConclusionThe incidence of UTI and VUR in children with mild ANH is low. Consequently, routine VCUG screening for VUR and the use of long-term ABP is not necessary for all patients with asymptomatic mild AHN. Evaluation for VUR in children with mild ANH should be reserved for those who subsequently present with a UTI.     

Vesicoureteral reflux: subpopulations of patients defined by clinical variables

Background. The first imaging evaluation of the child with urinary tract infection (UTI) is often the same for all children, regardless of the child's clinical presentation. However, this approach is simplistic and ignores considerable differences in the frequency of abnormal pathophysiology in different subpopulations of children with UTI.¶Objective. Six clinical variables are evaluated as predictors of vesicoureteral reflux (VUR) in a large series of girls with UTI.¶Materials and methods. Data were collected from a consecutive series of 919 girls undergoing a first imaging evaluation for UTI. Six input variables were used: age, maximum body temperature (T _max), number of UTIs, hospitalization, family history of childhood UTI, and rapidity of response to antibiotic therapy. The dependent variable was VUR. Data were enumerated and analyzed by logistic regression and the chi-square test.¶Results. VUR was present in 28.8 %. The percentage with VUR varied from 56.1 % for age < 6 months and T _max L 38.5 °C to 13.0 % for age L 10 years and T _max < 38.5 °C. The frequency of VUR was significantly lower in girls with T _max < 38.5 °C in most age groups. Logistic regression demonstrated, when all clinical variables were taken together, that only age and T _max were independent predictors of VUR.¶Conclusions. Girls with UTI should not be considered to be a homogeneous group. The frequency of VUR is related to T _max and inversely to age. Data about these subpopulations should be used in deciding which girls should undergo cystography.     

Short compared with standard duration of antibiotic treatment for urinary tract infection: a systematic review of randomised controlled trials.

AIMS: To compare the effectiveness of short course (2-4 days) with standard duration oral antibiotic treatment (7-14 days) for urinary tract infection (UTI). METHODS: Meta-analysis of randomised controlled trials using a random effects model. Ten trials were eligible, involving 652 children with lower tract UTI recruited from outpatient or emergency departments. Main outcome measures were UTI at the end of treatment, UTI during follow up (recurrent UTI), and urinary pathogens resistant to the treating antibiotic. RESULTS: There was no significant difference in the frequency of positive urine cultures between the short (2-4 days) and standard duration therapy (7-14 days) for UTI in children at 0-7 days after treatment (eight studies: RR 1.06; 95% CI 0.64 to 1.76) and at 10 days to 15 months after treatment (10 studies: RR 1.01; 95% CI 0.77 to 1.33). There was no significant difference between short and standard duration therapy in the development of resistant organisms in UTI at the end of treatment (one study: RR 0.57, 95% CI 0.32 to 1.01) or in recurrent UTI (three studies: RR 0.39, 95% CI 0.12 to 1.29). CONCLUSION: A 2-4 day course of oral antibiotics is as effective as 7-14 days in eradicating lower tract UTI in children.     

Downgrading of high-grade vesicoureteral reflux is a reliable option in the treatment of children with grade IV‒V reflux accompanied by breakthrough infections

PurposeTo evaluate incidence of urinary tract infection (UTI) and natural history of downgraded vesicoureteral reflux (VUR) in children with high-grade VUR following endoscopic correction.Materials and methodsWe retrospectively studied 54 children (13 males and 41 females) with a mean age of 1.8 years who underwent endoscopic correction of Grade IV‒V VUR due to breakthrough infections while on antibiotic prophylaxis.Reflux was Grade IV in 40 (74%) and V in 14 (26%) patients comprising 95 renal refluxing units (RRU). Reflux was corrected in 72 (76%) RRU. 18 (34%) patients/23 (24%) RRU demonstrated downgrading of VUR. 21 of the 23 RRU showed Grade II and 2 Grade III VUR, and were taken off antibiotic prophylaxis and allocated to observation. Patients were followed for 2–22 years (median 14 years).ResultsTechnetium 99m dimercaptosuccinic acid renal scan demonstrated preoperative renal scarring in 21 (78%) of the 23 RRU with downgraded VUR. None of the children developed febrile UTI after surgery. 1 RRU showed renal function deterioration. 8 (44%) of the 18 patients underwent follow-up voiding cystourethrogram, and in 7 (88%) there was either spontaneous resolution of VUR or downgrade to Grade I VUR.ConclusionsDowngrading of VUR is a reasonable option in patients with high-grade VUR suffering from breakthrough infections while on antibiotic prophylaxis. It leads to the cessation of febrile UTIs, further spontaneous resolution of VUR and may potentially avoid renal damage.     

小儿遗尿与膀胱输尿管反流的相关性研究

目的 探讨小儿遗尿与膀胱输尿管反流(vesicoureteral reflux,VUR)的关系,筛选小儿VUR的高危因素为临床诊治提供依据.方法 选取郑州大学第一附属医院小儿尿动力学中心以遗尿为主诉就诊并且神经功能正常的儿童和青少年83例(男36例,女47例),年龄5～16岁,平均(9.42±3.21)岁.所有患儿进行排尿性膀胱尿道造影(VCUG)检查以评估VUR情况,并进行尿常规、尿培养、肾脏和膀胱超声检查.尿动力学检查包括尿流率、盆地肌电图和膀胱压力容积测定.泌尿系检查的准入标准包括泌尿系超声异常、白天尿失禁、尿动力学检查异常、尿路感染或者同胞兄妹中有VUR病史等.结果 48例(57.8％)出现单症状性夜遗尿(MNE),35例(42.2％)非单症状性夜遗尿(NMNE).13例(15.7％)出现VUR.t检验结果显示,白天尿失禁患儿、女性患儿和当前伴有尿路感染的患儿VUR发病率明显升高(P＜0.05);多自变量logistic回归分析结果显示,只有性别、白天尿失禁和当前尿尿路感染的回归系数检验有统计学意义(P＜0.05),VUR与患儿年龄、遗尿类型(原发性、继发性)、遗尿频率、有无遗尿家族史、尿路感染病史、有无排便异常和除白天尿失禁外的白天尿路症状无统计学意义(P＞0.05).结论 VUR明显常见于白天尿失禁的遗尿患儿,建议存在白天尿失禁的遗尿患儿进一步进行相关检查.当前尿路感染是遗尿患儿发生VUR的高危因素.     

Urinary tract infections in pediatric renal transplant recipients – a two center risk factors study

Abstract:  UTI are common in renal Tx recipients and may significantly impact on the graft function. The aim of our study was to evaluate the prevalence, risk factors, and significance of UTI in Tx children. We performed a retrospective cross-sectional study of 76 Tx patients, median age at Tx was 13.4 yr. Twenty-one of 76 (28%) patients developed at least one UTI during the mean follow-up time of 3.3 ± 2.0 yr post-Tx. The first UTI occurred at a median of 160 days post-Tx. The RR of having UTI was significantly higher in patients with the primary diagnosis of obstructive uropathy (RR = 2.6, 95th CI = 1.1–6.0, p = 0.032), history of PN pre Tx (RR = 2.7, 95th CI = 1.3–5.4, p = 0.009) and pre Tx VUR (RR = 2.2, 95th CI = 1.1–4.5, p = 0.045). These three factors also significantly decreased the infection-free survival time to the first UTI. Most UTI caused reversible acute allograft dysfunction, but the long-term graft function could not be reliably assessed with SCr. In conclusion, UTI occurred in 28% of pediatric Tx recipients, mostly during the first year post-Tx despite antibiotic prophylaxis. The diagnosis of obstructive uropathy, history of UTI and VUR prior to Tx were significant risk factors.     

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。     

The impact of therapeutic delay time on acute scintigraphic lesion and ultimate scar formation in children with first febrile UTI

We assessed the role of therapeutic delay time (TDT) in acute renal cortical scintigraphic lesion (ASL) and ultimate scar formation (USF) in children with first febrile UTI and whether it is affected by the presence of vesico-ureteral reflux (VUR). 230 children, 90 girls and 140 boys with first febrile UTI were included. Radiologic (USG, DMSA, and VCUG), clinical (age, gender, peak fever, therapeutic delay time) and laboratory (CBC with differential count, ANC (absolute neutrophil count), BUN, Creatinine, urine analysis, gram stain, culture, CRP and ESR) variables were analysed. DMSA was performed within 5 days and after six months. VCUG was performed after acute phase of UTI. The differences in TDT according to the presence of ASL, USF and VUR were assessed. And the correlation between ASL or USF with the duration of TDT was assessed. Of 230 patients enrolled, 142 patients had refluxing UTI and 88 patients had non-refluxing UTI. TDT was the risk factor associated with ASL and USF along with presence of VUR. TDT was longer in ASL positive group compared with the ASL negative group. Also USF group showed longer TDT compared with those without USF in both refluxing UTI and non refluxing UTI. The TDT was significantly shorter in USF group with the presence of VUR. Positive linear association was noted between prevalence of ASL and USF and duration of TDT. In conclusion, the impact of UTI on formation of USF may be enhanced by the presence of VUR with shorter duration of TDT.