Evaluation of the Pediatric Patients with Primary Vesicoureteral Reflux- Single Center Study
Abstract
Objective: Vesicoureteral reflux (VUR) with bladder and bowel dysfunction (BBD) predispose to recurrent urinary tract infections (UTIs), thus increase the risk of kidney damage. In this study, we retrospectively evaluated the clinical characteristics and outcomes of children with primary VUR.
Methods: 115 patients diagnosed with primary VUR were enrolled. The patients were grouped according to VUR stages and demographic characteristics, laboratory and imaging studies, medical and surgical treatment options were evaluated.
Results: Majority of the patients were females (82.6%). Mean follow-up time was 3.6±1.1 years. At admission, 60% and 62.6% of the patients had recurrent UTIs and BBD, respectively. There was grade I-II VUR, grade III VUR and grade IV-V VUR in 26.8%, 51.7% and 21.5% of 149 renal units, respectively. Ultrasonographic abnormalities and scarring on technetium (Tc)-99m dimercaptosuccinic acid (DMSA) were significantly higher in high grade VUR (p=0.001 and p=0.04, respectively). Patients with scarring had significantly more recurrent UTIs, BBD and ultrasonographic abnormalities (p=0.03, for all). 22.6% of the patients underwent surgery. Control voiding cystourethrography (VCUG) of 67 renal units showed spontaneous resolution in 38.8%, whereas surgical correction/regression was detected in 53.7%. Patient outcomes were favorable with decreased recurrent UTIs (15.6%) and no progression into chronic kidney disease (CKD).
Conclusion: Risk of renal scarring, an important finding of reflux nephropathy and subsequent CKD, was significantly higher in patients with high grade VUR, recurrent UTIs and BBD. Urinary ultrasonography was reliable in predicting scarring. Children with recurrent UTIs and/or BBD as well as urinary ultrasonography (USG) abnormalities should be evaluated for VUR.
References
1. Park JM. Vesicoureteral reflux: Anatomic and functional basis of etiology. In: Docimo SG, editor. The Kelais-King-Belman Textbook of Clinical Pediatric Urology. Docimo SG, Canning DA, Khoury AC (eds). vol: 5, London: Informa Healthcare UK Ltd., 2007:655-662.
2. Ashcraft KW. Vesicoureteric reflux. In: Ashcraft KW: Pediatric Urology. Chap:7, Philadelphia: Saunders Company, 1990: 151-8.
3. Bundy DG. Vesicoureteral reflux. Pediatr Rev 2007; 28: e6-8; discussion e8.
4. Zerin JM, Ritchey ML, Chang AC. Incidental vesicoureteral reflux in neonates with antenatally detected hydronephrosis and other renal abnormalities. Radiology 1993; 187: 157-60.
5. Alsaywid BS, Saleh H, Deshpande A, Howman-Giles R, Smith GH. High grade primary vesicoureteral reflux in boys: Long-term results of a prospective cohort study. J Urol 2010; 184: 1598-1603.
6. Jerkins GR, Noe HN. Familial vesicoureteral reflux: A prospective study. J Urol 1982; 128: 774-8.
7. Cooper CS. Diagnosis and management of vesicoureteral reflux in children. Nat Rev Urol 2009; 6: 481-9.
8. Gökçe İ, Alpay H. Renal Parenchymal Scarring and Reflux Nephropathy. Turk Neph Dial Transpl 2012; 21: 21-7.
9. Dillon MJ, Goonasekera CD. Reflux nephropathy. J Am Soc Nephrol 1998; 9: 2377-83.
10. Mattoo TK. Medical management of vesicoureteral reflux. Pediatr Nephrol 2007; 22: 1113-
1120.
11. Jacobson SH, Eklöf O, Eriksson CG, Lins LE, Tidgren B, Winberg J. Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up. Br Med J 1989; 299: 703-706.
12. Noe HN. The long-term results of prospective sibling reflux screening. J Urol 1992; 148: 1739-42.
13. Sirin A, Emre S, Alpay H, Nayir A, Bilge I, Tanman F. Etiology of chronic renal failure in Turkish children. Pediatr Nephrol 1995; 9: 549-952.
14. Ander AH. Vesicoureteral reflux. Türkiye Klinikleri J Pediatr Sci 2005; 1: 5-11.
15. Yıldırım İ, Dayanç M. Vesicoureteral reflux. In: Güncel Çocuk Ürolojisi (Dayanç M, ed). Vol. 8. Ankara: Atlas Kitapçılık, 2004;145-88.
16. Elder JS. Vesicoureteral reflux. American Urological Association 2002;716-22.
17. Joana Dos Santos, Lopes RI, Koyle MA. Bladder and bowel dysfunction in children: An update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem. Can Urol Assoc J 2017;11(1-2Suppl1): S64-S72.
18. Piñeiro Pérez R, Cilleruelo Ortega MJ, Ares Álvarez J, Baquero-Artigao F, Silva Rico JC, Velasco Zúñiga R, et al. Recommendations on the diagnosis and treatment of urinary tract infection. An Pediatr (Barc) 2019; 90: 400.e1-400.e9.
19. Averbeck MA, Madersbacher H. Constipation and LUTS - how do they affect each other? Int Braz J Urol 2011;37: 16-28. Review.
20. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, et al. European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 2016; 34:1887-920.
21. Schwartz GJ, Muñoz A, Schneider MF, Mak RH, Kaskel F, Warady BA, et al. New equations to estimate GFR in children with CKD. J Am Soc Nephrol 2009; 20: 629-37.
22. Report of the International Reflux Study Committee: Medical versus surgical treatment of vesicoureteral reflux: a prospective international reflux study in children. Pediatrics 1981;) 67: 392-400.
23. Düzova A, Ozen S. Vesicoureteral reflux in childhood. Saudi J Kidney Dis Transpl 2003; 14: 290-5.
24. Acar C, Gürocak S: Current approaches and treatment alternatives in vesicoureteral reflux: review. Türkiye Klinikleri J Pediatr 2010; 19: 38-46.
25. Sargent MA. What is the normal prevalence of vesicoureteral reflux? Pediatr Radiol 2000; 30: 587-593.
26. Meena J, Hari P. Vesicoureteral reflux and recurrent urinary tract infections. Asian J Pediatr Nephrol 2019; 2: 61-70.
27. Shaikh N, Hoberman A, Keren R, Gotman N, Docimo SG, Mathews R, et al. Recurrent Urinary Tract Infections in Children with Bladder and Bowel Dysfunction. Pediatrics 2016; 137: e20152982.
28. Meena J, Mathew G, Hari P, Sinha A, Bagga A. Prevalence of Bladder and Bowel Dysfunction in Toilet-Trained Children with Urinary Tract Infection and/or Primary Vesicoureteral Reflux: A Systematic Review and Meta-Analysis. Front Pediatr 2020; 8: 84.
29. Kılıç N. Vesicoureteral reflux in children. Turk Pediatri Ars 2010; 45: 80-4.
30. Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunction elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol 1998; 160: 1019-1022.
31. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Pediatrics 1999; 103: 843-852.
32. NICE Clinical Guideline 2007. Urinary tract infection in children: diagnosis, treatment and long-term management.
33. Zamir G, Sakran W, Horowitz Y, Koren A, Miron D. Urinary tract infection: is there a need for routine renal ultrasonography? Arch Dis Child 2004; 89: 466–468.
34. Moore KL, Persaud TVN, Torchia MG. Before we are born: Essentials of Embryology and Birth Defects. Ninth Edition, Elsevier, 2015: Urogenital System: 161-170.
35. RIVUR Trial Investigators, Hoberman A, Greenfield SP, Mattoo TK, Keren R, Mathews R, Pohl HG, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 2014; 370: 2367-76.
36. Rushton Jr HG. Vesicoureteral reflux and renal scarring. In: Avner E, Harmon W, Niaudet P, Eds. Pediatric Nephrology, 5th Ed, Philedelphia: Lippincott, Williams & Wilkins Co, 2004:1027-48.
37. Gargollo PC, Diamond DA. Therapy Insight: what nephrologists need to know about primary vesicoureteral reflux. Nat Clin Pract Nephrol 2007; 3:551-63.
38. Elder JS, Peters CA, Arant BS Jr, Ewalt DH, Hawtrey CE, Hurwitz RS, et al. Pediatric Vesicoureteral Reflux Guidelines. Panel summary report on the management of primary vesicoureteral reflux in children. J Urol 1997; 157: 1846-51.
39. Aydın M, Şirin H, Karatağ T, Horasanlı K. Endoscopic subureteric injection in vesicoureteral reflux. ŞEH Tıp Bülteni 2008; 42: 2.
40. Oswald J, Riccabona M, Lusuardi L, Bartsch G, Radmayr C. Prospective comparison and 1-year follow-up of a single endoscopic subureteral polydimethylsiloxane versus dextranomer/ hyaluronic acid copolymer injection for treatment of vesicoureteral reflux in children. Urology 2002; 60: 894-7.
