Vesicoureteral reflux in infants with isolated antenatal hydronephrosis

Standardized evaluation of all newborns with antenatally recognized hydronephrosis (ANH) at The Hospital for Sick Children (HSC) has included voiding cystourethrography (VCUG). This paper reviews this protocol to determine: (1) the prevalence of vesicoureteral reflux (VUR) in isolated ANH and (2) the value of performing VCUG in cases of mild hydronephrosis, defined as renal pelvis dilatation <10 mm on postnatal ultrasonography (US). A retrospective chart review was performed on infants referred with ANH. The inclusion criterion was isolated ANH. Exclusion criteria were (1) presence of additional genitourinary abnormalities and (2) no VCUG. Pelviectasis was categorized according to the anteroposterior diameter of the renal pelvis. There were 111 infants with isolated ANH. All except 3 underwent VCUG. There were 68 children (63%) with normal postnatal US or mild pelviectasis (<10 mm). VUR was detected in 16 patients, of whom 10 had mild or absent pelvic dilatation. There was no correlation between the degree of pelviectasis on postnatal US and the presence or severity of VUR (P=0.567 and P=0.802). VUR was detected in 15% of children with isolated ANH, many of whom had normal postnatal US or mild postnatal pelviectasis. VCUG is the only reliable test for detecting postnatal VUR.     

Outcome of isolated antenatal hydronephrosis: a systematic review and meta-analysis

Idiopathic antenatal hydronephrosis (IAHN), defined as antenatal hydronephrosis not associated with other morphologic renal tract abnormalities, is the most common abnormality detected by antenatal ultrasound. We performed a systematic review and meta-analysis to determine the outcome of IAHN. We screened three databases and bibliographies to identify English-language original peer-reviewed papers that reported serial postnatal renal ultrasonography in children with IAHN. Patients who stabilized and/or improved were extracted and pooled according to the individual grading systems used by each study. A systematic analysis of data extracted from 25 articles revealed overall resolution of pelviectasis in milder cases of IAHN (Society of Fetal Urology [SFU] grade 1–2; anterior posterior pelvic diameter [APPD]<12 mm). In contrast, IAHN of higher severity (grades 3–4; APPD>12 mm) resolved with a lower frequency. Meta-analysis of data extracted from seven papers showed stabilization of pelviectasis in 98% of patients with grades 1–2 (95% confidence interval [CI] 0.93–1.0; p =0.0008) and in 51% of patients with grades 3–4 (95% CI 0.34–0.68; p <0.00001). Grades 1–2 pelviectasis was five times more likely to stabilize than grades 3–4 pelviectasis (odds ratio [OR] 4.69; 95% CI 1.73–12.76; p =0.002). We conclude that in patients with IAHN and lesser degrees of pelvic dilatation, pelvic diameter decreases to the normal range or does not worsen with the vast majority of patients. Further studies are needed to define outcomes, particularly in more severe forms of IAHN.     

Current management of infants with fetal renal pelvis dilation: a survey by French-speaking pediatric nephrologists and urologists

To analyze the current management recommendations among French-speaking physicians treating infants with antenatal renal pelvis dilatation, we surveyed 83 pediatric nephrologists and 68 pediatric urologists by questionnaire. A total of 45 (54%) pediatric nephrologists and 38 (56%) pediatric urologists responded. The threshold for the diagnosis of abnormal fetal renal pelvis dilatation was significantly higher among pediatric urologists than nephrologists. All responders perform renal ultrasound examinations after birth. Postnatal renal pelvis dilatation was considered abnormal if the anteroposterior diameter was 11±1.9 mm by the pediatric urologists and 9±2.9 mm by the pediatric nephrologists (P=0.003). Pediatric urologists were more likely than nephrologists to recommend routine voiding cystourethrography [41% versus 20% (P=0.04)]. Mercaptoacetyl-triglycine renography was the most routinely used tool to achieve functional evaluation during follow-up among the responders. Pediatric urologists were more likely to recommend surgical treatment in dilated kidneys with initial function <40%. In conclusion, pediatric urologists had significantly higher thresholds for the detection of prenatal and neonatal renal pelvis dilatation. They also more frequently recommended routine voiding cystourethrography and surgical therapy of dilated kidneys with low function than pediatric nephrologists. The variability in attitudes is most probably due to the absence of clear guidelines based on prospective and controlled trials.The following workers contributed to this study. For the French-speaking Society of Pediatric Nephrology (SNP): J. Al Hosri (Hôpital Nord, Amiens, France), J.L. André (Hôpital dEnfants, Nancy, France), A. Bensman (Hôpital Trousseau, Paris, France), E. Berard (LArchet II, Nice, France), J.P. Bertheleme (Centre Hélio Marin, Roscoff, France), F. Bouissou (Hôpital des Enfants, Toulouse, France), G. Bourdat-Michel (CHU, Grenoble, France), G. Champion (CHU, Angers, France), S. Cloarec (Hôpital Clocheville, Tours, France), L. Collard (Hôpital E. Herriot, Lyon, France), J.C. Davin (Emma Childrens Hospital, Amsterdam, Holland), L. de Parscau (Hôpital Augustin Morvan, Brest, France), S. Decramer (Hôpital des Enfants, Toulouse, France), V. Desvignes (CH, Clermont Ferrand, France), R. Donckerwolcke (AZ, Maastricht, Holland), J. Ehrich (MHH, Hannover, Germany), M. Fischbach (Hôpital de Hautepierre, Strasbourg, France), M. Foulard (Hôpital Jeanne de Flandre, Lille, France), M.S. Ghuysen (CHU Sart Tilman, Liège, Belgium), J.B. Gouyon (Hôpital dEnfants, Dijon, France), J.P. Guignard (CHUV, Lausanne, Switzerland), C. Guyot (CHU, Nantes, France), P. Hansen (Hôpital Tivoli, La Louvière, Belgium), J.P. Hehunstre (Hôpital Pellegrin, Bordeaux, France), F. Janssen (Hôpital Universitaire des Enfants, Brussels, Belgium), M.J. Krier (Hôpital dEnfants, Nancy, France), A. Lahoche-Manucci (Hôpital Jeanne de Flandre, Lille, France), H. La Selve (Centre Hélio Marin, Roscoff, France), M.P. Lavocat (Hôpital Nord, Saint Etienne, France), C. Loirat (Hôpital Robert Debré, Paris, France), J. Lombet (CHR La Citadelle, Liège, Belgium), A. May (CH Sud Francilien, Evry, France), D. Morin (Hôpital Arnaud de Villeneuve, Montpellier, France), J.B. Palcoux (Hôtel Dieu, Clermont Ferrand, France), S. Palomera (CTMR, Bordeaux, France), C. Pietrement (American Memorial Hospital, Reims, France), S. Ploos van Amstel (Emma Childrens Hospital, Amsterdam, Holland), W. Proesmans (UZ Gasthuisberg, Leuven, Belgium), N. Ranguelov (CHU, Charleroi, Belgium), B. Roussel (American Memorial Hospital, Reims, France), M.H. Said (Hôpital E. Herriot, Lyon, France), A. Taque (Hôpital de Pontchaillou, Rennes, France), M. Tsimaratos (Hôpital La Timone, Marseille, France). R. Van Damme-Lombaerts (UZ Gasthuisberg, Leuven, Belgium)For the French-speaking Pediatric Urology Study Group (GEUP): T. Aivazoglou (Aglaia Kyriakou Hospital, Athens, Greece), J.L. Alain (CHU Dupuytren, Limoges, France), P. Alessandrini (Hôpital Nord, Marseille, France), G. Audry (Hôpital Trousseau, Paris, France), M. Avérous (Hôpital Lapeyronie, Montpellier, France), R. Besson (Hôpital Jeanne de Flandre, Lille, France), J. Biserte (Hôpital Huriez, Lille, France), B. Boillot (CHU Albert Michallon, Grenoble, France), J.M. Bondonny (Hôpital des Enfants, Bordeaux, France), J.P. Bonnet (Hôpital Simone Veil, Montmorency, France), P. Bugmann (Hôpital des Enfants, Geneva, Switzerland), F. Collier (Hôpital Universitaire des Enfants, Brussels, Belgium), J.F. Colombani (CHU, Fort-de-France, France), H. Dodat (Hôpital E. Herriot, Lyon, France), B. Dore (CHU, Poitiers, France), A. El Ghoneimi (Hôpital R. Debré, Paris, France), C. Esposito (Universitary Hospital, Naples, Italy), B. Fremond (Clinique Chirurgicale infantile, Rennes, France), P. Frey (CHUV, Lausanne, Switzerland), S. Geiss (Centre de la Mère et lEnfant, Colmar, France), I. Germouty (CHU, Brest, France), Y. Heloury (CHU, Nantes, France), A. Lacombe (Hôpital Clocheville, Tours, France), S. Lortat-Jacob (Hôpital Necker-Enfants Malades, Paris, France), T. Merrot (Hôpital Nord, Marseille, France), R. Moog (Hôpital de Hautepierre, Strasbourg, France), G. Morisson-Lacombe (Hôpital Saint Joseph, Marseille, France), J. Moscovici (Hôpital des Enfants, Toulouse, France), P. Mouriquand (Hôpital Debrousse, Lyon, France), E. Sapin (CHU, Dijon, France), A. Savanelli (Universitary Hospital, Catanzaro, Italy), M. Schmitt (Hôpital dEnfants, Nancy, France), H. Steyaert (Fondation Lenval, Nice, France), C. Tölg (CHU, Fort-de-France, France), J.S. Valla (Fondation Lenval, Nice, France), F. Varlet (Hôpital Nord, Saint Etienne, France), P. Wallon (Centre de Chirurgie de lEnfant, Bordeaux, France), D. Weil (Centre Hospitalier, Le Mans, France)     

First urinary tract infection in neonates, infants and young children: a comparative study

In an attempt to evaluate first urinary tract infection (UTI) in neonates and infants, we estimated retrospectively in 296 patients (62 neonates and 234 infants) clinical and laboratory findings, occurrence of vesicoureteral reflux (VUR), urinary tract abnormalities and pyelonephritis. First UTI occurred more often in male than female neonates, whereas male and female infants/young children were affected at an equal rate. The pathogens isolated in urine cultures of neonates and infants did not statistically significantly differ (P>0.05); Escherichia coli predominated. Gram-negative bacteria other than E. coli affected boys more often than girls (P=0.0022). Fever was the most frequent symptom. Neonates had lower-grade fever of shorter duration than infants (P<0.05). The incidence of reflux and urinary tract abnormalities did not differ between neonates and infants, male and female neonates and infants (P>0.05). Pyelonephritis affected neonates and infants at an equal rate; it was more prevalent among female patients (P=0.038) and patients with VUR or urinary tract abnormalities other than VUR (P<0.0001). Neonates with reflux were more often affected by Gram-negative bacteria other than E. coli than were neonates without reflux (P=0.0008).     

Natural history of neonatal reflux associated with prenatal hydronephrosis: long-term results of a prospective study

PURPOSE: We have previously reported on patients with neonatal vesicoureteral reflux followed conservatively. The current study is a long-term followup of our prospective expectant management protocol for the overall cohort. MATERIALS AND METHODS: Between 1993 and 1998, 31 of 260 patients with prenatal hydronephrosis had vesicoureteral reflux and were followed prospectively. Outcome analysis was done on 25 patients, excluding 6 who underwent surgery, with the end point of complete resolution or improvement of reflux using our previously reported Kaplan-Meier survival curve, urinary tract infection, dysfunctional voiding, and changes in renal function or growth, somatic growth and hypertension. RESULTS: Of the 25 cases reflux was grades I to V in 7%, 20%, 34%, 16% and 23%, respectively. Reflux resolved in 13 patients (52%) and improved in 6 (24%). Grades I to V disease resolved in 100%, 77%, 53%, 28% and 40% of refluxing units, respectively. The improvement rate for grades III to V reflux was 13%, 14% and 30%, respectively. Breakthrough urinary tract infection occurred in 4 patients with grades IV and V reflux, and dysfunctional voiding developed in 5. Followup renal scans showed 19% and 17% decreased differential function in 2 units without new scars. There was no difference in renal length in patients with resolved versus persistent reflux or low versus high grade reflux. All patients had normal somatic growth at the 4-year followup and none had hypertension. CONCLUSIONS: Expectant management was effective in the majority of cases and associated with a low urinary tract infection rate. Neonatal vesicoureteral reflux resolved or improved in 76% of our patients by age 4 years without somatic growth retardation or hypertension. High grade reflux resolved or improved in 59% of the units and showed normal renal growth with expectant management.     

Clinical course of prenatally detected primary vesicoureteral reflux

The purpose of this study was to report the clinical course of medium-long-term follow-up of children with prenatally detected vesicoureteral reflux (VUR). Between 1986 and 2004, 53 (41 males) children with VUR detected by investigation of prenatal hydronephrosis were followed up for a mean time of 66 months (range: 6–200 months). Newborns were investigated by ultrasound, voiding cystourethrogram (VCUG) and DMSA scan. Follow-up clinical visits were performed at 6-month intervals. After 24 months patients were investigated by conventional VCUG or direct isotope cystogram. Survival analysis was performed in order to evaluate the resolution of the reflux. Differences between subgroups (mild vs moderate/severe reflux) were assessed by the two-sided log rank test. Thirty (58%) infants presented bilateral VUR, for a total of 83 renal units. There was a predominance of severe reflux (54%). Renal damage was detected in 33.7% of the units on first renal scan. There was a significant correlation between severe reflux and renal damage scars (RR=3.4, 95% confidence interval [CI], 1.4–8, p=0.002). Forty-seven patients were treated with continuous prophylaxis. One patient developed systolic hypertension. Urinary tract infection occurred in 12 (25%) children conservatively managed. VUR resolution was evaluated in 56 renal units. Spontaneous resolution was observed in 25 units (45%). At 48 months after diagnosis, 75% of the cases of mild reflux (I–III) and 37% of severe reflux (IV–V) had resolved (log-rank, 5.6, p=0.017). There was an improvement of nutritional parameters between admission and the end of follow-up. In conclusion, the clinical course of prenatally detected VUR followed up on a medium-long-term basis is relatively benign. Our study corroborates the results obtained in other series of infants with reflux that emphasized the heterogeneity of this disorder.     

Mild hydronephrosis in newborns and infants: can ultrasound predict the presence of vesicoureteral reflux

The objective of our study was to determine the significance of mild hydronephrosis in newborns and infants as an indicator of vesicoureteral reflux (VUR). The voiding cystourethrography (VCUG) of 573 patients aged 0–18 months with mild, sonographically detected hydronephrosis were reviewed for VUR. Patients with secondary reflux or anomalies making an exact reflux grading impossible were excluded. Normal kidneys, contralateral to hydronephrotic ones, were included. Each kidney was considered separately, forming a total of 1,146 renal units. Mild hydronephrosis was defined as an anteroposterior diameter of the renal pelvis of 0.5–1.5 cm without caliectasis. The International Grading System was used to grade VUR. Seven hundred and thirty-six kidneys had mild hydronephrosis. VUR occurred in 189 out of 736 (25.7%) of these kidneys, and in 108 out of 410 (26.3%) non-distended kidneys, contralateral to hydronephrotic ones (p=0.806). No statistical differences in the frequency of VUR and dilatation were found between the subgroups of patients with and without infection, except for a higher grade of reflux in the group with infection. The frequency of VUR in mildly dilated kidneys was not significantly different from that in non-distended ones. There was a poor correlation between VUR and mild hydronephrosis. The latter should not be considered in itself an indication for VCUG in asymptomatic neonates and infants.     

Vesicoureteral reflux, a benign condition

The combination of urinary tract infection (UTI) and vesicoureteral reflux (VUR) is commonly thought to predispose the child to pyelonephritis, renal scarring and, later in life, to hypertension or end-stage renal disease (ESRD). This paradigm has led to the active search, follow-up and treatment of VUR, and also prevention of recurrent UTI in children. The causality of VUR and ESRD is controversial, however. According to recent meta-analyses it is uncertain whether we can prevent renal scarring or ESRD by treating VUR. Studies on VUR are abundant, but the findings and conclusions are confounding. Because of the lack of evidence of the role of VUR, reasonable doubt has recently been presented on the rationale of imaging all children with UTI and treating the children with VUR. The overall importance of VUR is confounded because of the natural tendency of VUR to resolve spontaneously, its dynamic nature, and its different grades in children. The historical studies showing that VUR is much more common, even among healthy children, than usually claimed, have been forgotten. Since it seems that we are referring too many healthy children to unpleasant and possibly unnecessary imaging tests for VUR, we are uncertain when and what kind of VUR—if any—we should treat, and whether our present rationale of addressing VUR truly makes any difference to renal scarring or ESRD in children, we should critically revisit the subject of VUR.     

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)     

Summary of recent AUA guidelines for the management of vesicoureteral reflux in children

VUR is a common condition and it is a predisposing factor for pyelonephritis, and reflux nephropathy, which can cause end stage renal disease in children. Given the consequences and sequelae of UTI and VUR, and due to lack of consensus regarding management of this common condition, the American Urological Association (AUA) developed treatment guidelines for children with VUR in 1997 and 2012 to help physicians better manage children with VUR. In this review, the summary of the 1997 and 2012 AUA guidelines are discussed with a focus on the 2012 report. Recommendations about evaluation and management of children under and above one year with VUR, with and without bladder/bowel dysfunction, screening of siblings of patients with VUR, screening of the neonate/infant with prenatal hydronephrosis, and follow up of the children with VUR are discussed in this review. The identification and management of VUR in these groups, provide the potential opportunity to prevent renal damage and decrease the risk of UTI and pyelonephritis. According to these guidelines, risk assessment of renal injury/scarring in the individual patient based upon clinical factors is critical, and interventions should be appropriate to the risk profile. Informing families and healthcare providers of the potential risk of pyelonephritis and renal scarring and allowing them to participate in decision making is considered important.     

Timing of voiding cystourethrography in infants with first time urinary infection

The aim of the study was to evaluate whether the timing of performing a voiding cystourethrography (VCUG) following a first urinary tract infection (UTI) in infants is related to the presence or the severity of vesicoureteral reflux (VUR). A total of 411 children (male 230, female 181) with a first-recognised UTI between ages 15 days and 12 months (median 3 months) underwent a VCUG within 4-81 days (median 9 days) following diagnosis. The presence and the grade of the VUR were compared in two groups: an "early" group in which the VCUG was performed during the first week of the start of treatment and a "late" group in which the examination was performed during the second week or thereafter. The prevalence of VUR in the study cohort was 23.3% (96/411 infants). A VUR was diagnosed in 44 infants in the early group (28%) and in 52 in the late group (21%). Reflux of grade III or higher was seen in 25/44 (57%) of the infants in the early group and in 27/52 (52%) infants in the late group. These differences were not significant. Our results suggest that neither the presence nor the grade of VUR in infants is influenced by the timing of the examination following diagnosis. We therefore recommend that it is better to perform VCUG as soon as possible, provided the inflammation has subsided.     

Resolution of vesicoureteral reflux during medical management in children

A retrospective study was performed to evaluate the results of medical management of primary vesicoureteral reflux (VUR) in infants and children. The charts of 105 patients (74 boys, 31 girls) with 167 refluxing ureters were reviewed. The age at diagnosis ranged from 3 days to 9.2 years (mean 1.3±1.9 years). The mean duration of follow-up was 2.4±1.5 years. We found that the patient's sex did not influence the fate of VUR and its complications. Patients whose reflux improved while being managed medically were younger than those who did not improve, and the younger the patient the sooner the reflux resolved. Improvement and resolution of reflux were also related to grade, and the lower the initial grading the sooner the reflux resolved. Spontaneous resolution rates of reflux were 92.3%, 76.2%, 61.7%, and 32.0% for grades I, II, III, and IV, respectively. No ureters with grade V reflux resolved without complications. The most common complications in our series were renal scarring and secondary obstructive uropathy.     

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.     

Vesicoureteral reflux and febrile urinary tract infections in anorectal malformations: A retrospective review

Background

Multiple studies document a correlation between anorectal malformations (ARMs) and vesicoureteral reflux (VUR), development of urinary tract infections (UTIs), and subsequent renal disease. We aimed to determine which patient characteristics are associated with VUR and UTI in this population.

Methods

A retrospective review of ARM patients at a free-standing children’s hospital from January 1996 to December 2011 was performed. Logistic regression was used to investigate the associations between VUR and UTI and ARM classification and co-morbid diagnoses.

Results

Of 190 patients, 41 (31%) received a diagnosis of VUR. Thirty-one of the 190 patients had at least one febrile UTI (16%). Of these, only 16 (51%) had a diagnosis of VUR. On multivariable logistic regression, the only patient variable associated with VUR was having an ectopic kidney (p = 0.026). Similarly, the presence of GU malformations was the closest variable associated with developing a UTI (p = 0.073).

Conclusions

In ARM patients, VUR as well as UTIs are associated with the presence of GU malformations. Thus, voiding cystourethrogram (VCUG) testing should be pursued when there are other caudal and GU abnormalities, regardless of fistula location. Antibiotic prophylaxis for UTI should be considered in children with ARM and any GU malformation, not only VUR.     

Intermittent trimethoprim-sulfamethoxazole in children with vesicoureteral reflux

The effectiveness of intermittent low-dose trimethoprim-sulfamethoxazole (TMP-SMZ) for the prophylaxis of recurrent urinary infection is well established in adults. The present study assessed the effectiveness and safety of intermittent low-dose TMP-SMZ in 35 children (24 boys, 11 girls, aged 1 month to 9 years, median age 5 months) with vesicoureteral reflux; 18 children had bilateral reflux. A total of 53 refluxing ureters were graded as I in 2, II in 16, III in 19, IV in 14, and V in 2 cases. The children were given 1 mg/kg body weight of trimethoprim together with 5 mg/kg of sulfamethoxazole at bedtime every other day for 6 – 50 months (mean±SD, 22.9±11.7 months). None of the boys had a recurrence of urinary infection, while 2 of the 11 girls had a total of 7 recurrences during the prophylaxis period, with a recurrence rate of 0.027 per patient month in girls. Both girls were over 3 years and had a mildly unstable bladder. Transient neutropenia (<1,000/μl) developed in 2 infants during the prophylaxis period, but disappeared spontaneously. Intermittent low-dose TMP-SMZ seemed very effective for the prevention of recurrent urinary infection in children with ureteral reflux even of higher grades. Received September 11, 1996; received in revised form and accepted December 11, 1996     

Asymptomatic vesicoureteral reflux detected by neonatal ultrasonographic screening

Renal ultrasonography was performed in 2,384 healthy and asymptomatic neonates. The definition and grading of hydronephrosis was according to the system of the Society for Fetal Urology. Voiding cystourethrography was performed in the cases with moderate to severe hydronephrosis or persistent mild hydronephrosis. In cases with vesicoureteral reflux (VUR), a dimercaptosuccinic acid (DMSA) renal scan was arranged immediately to evaluate the renal parenchyma. VUR was diagnosed in 30 infants with a prevalence of 1.26%; 7 had bilateral VUR. The male/female ratio was 4:1 and the right/left ratio was 1.85:1. Comparing with the abnormal ultrasonographic findings, VUR appeared ipsilaterally in 23 ureters and contralaterally in 14 ureters. Using ultrasonography for diagnosing VUR, the sensitivity, specificity, positive predictive value, and negative predictive value were 62.2%, 36.1%, 11.0%, and 88.2%, respectively. DMSA renal scan was perfomed in 31 refluxing kidneys, and congenital renal scarring was found in 9 (29.0%) kidneys. Six neonates underwent reimplantation surgery. We conclude that although ultrasonography is not a reliable tool for diagnosing VUR, it can detect many cases of VUR during the newborn stage using our screening program, which thus makes early treatment from the neonatal period possible. Whether our screening program can improve the outcome of VUR will require further follow-up. Received January 10, 1997; received in revised form September 2, 1997; accepted September 3, 1997     

Postnatal management of infants with antenatally detected hydronephrosis

With the increasing use of antenatal sonography, fetal hydronephrosis has been reported more frequently. Because of the lack of consensus regarding treatment of these infants, the postnatal approach toward fetal renal pelvis enlargement remains controversial. The aim of this prospective study is to demonstrate the postnatal investigation, treatment, and outcome of infants with prenatally diagnosed hydronephrosis. Infants whose antenatal ultrasound scan showed a fetal renal pelvis of 5 mm or greater were investigated postnatally using ultrasound (US) and voiding cystourethrography. When indicated, isotope studies and intravenous urograms were also performed. We followed prospectively neonates with antenatally diagnosed hydronephrosis and recommended management guidelines on the basis of our findings. In 156 neonates (193 kidney units) that were found to have hydronephrosis, the average gestational age at which the diagnosis was made was 32.94±5.10 weeks. The mean duration of postnatal follow-up was 26.3±13.56 months (range 3–60 months). The mean APPD of the fetal renal pelvis was 10.35±3.24 mm (5–9 mm in 84 kidneys, 10–14 mm in 96 kidneys and 15 mm in 13 kidneys). Of the 193 kidney units, 145 units were found to be pathological. The most common detected underlying abnormalities were ureteropelvic junction obstruction (in 91 kidneys; 62.7%) and vesicoureteral reflux (in 24 kidneys; 16.6%). Postnatally, 23 (45%) of 51 patients whose first US was normal were diagnosed postnatally as having urinary tract abnormality. There was a negative correlation between APPD and the rate of spontaneous resolution and positive correlation between APPD and the rate of surgery (P<0.01). In conclusion, because it is not possible to determine an upper limit of normal for the antenatal renal pelvis, any baby with AH should not be considered clinically insignificant. Infants with antenatal renal pelvis measurements 5 mm should be investigated postnatally. A normal postnatal ultrasound scan does not preclude the presence of urinary tract abnormality.     

Predictive value of clinical and laboratory variables for vesicoureteral reflux in children

We aimed to determine the predictability of clinical and laboratory variables for vesicoureteral reflux (VUR) in children with urinary tract infection (UTI). Data of children with febrile UTI who underwent voiding cystoureterography between 2002 and 2005 were evaluated retrospectively for clinical (age, gender, fever ≥38.5°C, recurrent UTI), laboratory [leukocytosis, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), pyuria, serum creatinine (S_Cr)] and imaging (renal ultrasonography) variables. Children with VUR (group 1) vs. no VUR (group 2) and children with high-grade (III–V) VUR (group 3) vs. no or low-grade (I–II) VUR (group 4) were compared. Among 88 patients (24 male), 38 had VUR and 21 high-grade VUR. Fever ≥38.5°C was associated with VUR [odds ratio (OR): 7.5]. CRP level of 50 mg/l was the best cut-off level for predicting high-grade VUR (OR 15.5; discriminative ability 0.89 ± 0.05). Performing voiding cystourethrography based on this CRP level would result in failure to notice 9% of patients with high-grade VUR, whereas 69% of children with no/low-grade VUR would be spared from this invasive test. In conclusion, fever ≥38°C and CRP >50 mg/l seem to be potentially useful clinical predictors of VUR and high-grade VUR, respectively, in pediatric patients with UTI. Further validation of these findings could limit unnecessary voiding cystourethrography.