Renal Transplants Due to Congenital Anomalies of the Kidney and Urinary Tract (CAKUT) Have Better Graft Survival Than Non-CAKUT Controls: Analysis of Over 10,000 Patients.

OBJECTIVE: To determine whether graft survival for patients with congenital anomalies of the kidney and urinary tract (CAKUT) is impaired compared to non-CAKUT counterparts. METHODS: The United States Renal Data System (USRDS) is a national data system that has collected information about end stage renal disease (ESRD) and renal transplantation since 1995. We identified 10,635 first-time renal transplant patients with ESRD attributed to a CAKUT diagnosis transplanted between 1995 and 2018, with follow-up of 7.9 ± 5.8 years. We matched 1:1 with non-CAKUT transplant recipients, using age at transplant, sex, race, year of transplant, and donor-type. We compared renal transplant death-censored graft survival between CAKUT vs non-CAKUT controls, with further stratification for age at transplant and lower urinary tract malformations (LUTM) vs upper urinary tract malformations (UUTM). RESULTS: Graft survival was better in CAKUT patients with a 5-year survival of 83.3% vs 79.3% (P< .001), and CAKUT status infers a hazard ratio of 0.878 for graft failure on multivariable analysis with Cox regression. Favorability of CAKUT status persisted when stratifying for both pediatric (80.3 vs 77.6% P< .001) and adult (84.5 vs 81.4% P< .001) age groups. Looking within the CAKUT population: comparison of LUTM to UUTM yielded no difference, implying that LUTM is not a risk factor for graft failure. Examining pediatric LUTM alone, graft survival was not better than matched non-CAKUT counterparts with 5-year graft survival of 69%-75% for LUTM adolescents. CONCLUSION: Renal transplant graft survival is better overall in CAKUT patients as opposed to non-CAKUT counterparts. Pediatric LUTM patients have similar graft survival to controls.

Utility of Urine Interleukines in Children with Vesicoureteral Reflux and Renal Parenchymal Damage.

PURPOSE: Vesicoureteral reflux (VUR) is the most common risk factor of urinary tract infection in children. Currently, diagnosis of VUR depends on invasive imaging studies, with a high radiologic burden. Therefore, different biomarkers have been introduced for the evaluation of these patients. The objective of this study was to identify alteration of urinary interleukins (ILs) excretion in children with primary VUR and renal parenchymal damage, for further clinical application. MATERIALS AND METHODS: Urinary concentrations of IL-1α, IL-1ß, IL-6, and IL-8 were evaluated in 34 children with VUR (cases) and 36 without VUR (control), during 2018-2019. Urinary concentrations of IL-1, IL-1, IL-6 and IL-8 were measured, using polyclonal antibody ELISA kit, and standardized to urine creatinine (Cr). Patients with infectious or inflammatory disorders, urolithiasis, immune deficiency, acute or chronic kidney disease, and secondary VUR were excluded from the study. RESULTS: Mean age of cases (36.00 ± 27.66) had no significant difference with the control (32.86±29.31) group (p=0.44). The majority of patients had moderate VUR (58.8%), followed by severe (35.3%) and mild (5.9%) grades. Urinary concentration of all ILs/Cr were significantly higher in patients with VUR, compared with those without VUR. There was no significant correlation between urine ILs/Cr with age, gender, serum electrolytes, urine specific gravity, renal ultrasound, laterality or severity of VUR, and DMSA renal scan. All urine ILs/Cr had acceptable sensitivity and accuracy for workup of children with primary VUR. CONCLUSION: Urine IL-1α, IL-1ß, IL-6 and IL-8/Cr were sensitive and accurate additionary screening biomarkers in children with primary VUR.

Frequency of urinary tract infection in children with antenatal diagnosis of urinary tract dilatation.

BACKGROUND: Neonates with congenital urinary tract dilatation (UTD) may have an increased risk of urinary tract infections (UTI). At present, the management of these patients is controversial and the utility of continuous antibiotic prophylaxis (CAP) remains uncertain as the literature presents contradicting evidence. The aim of this observational study was to assess UTI occurrence in children with prenatal diagnosis of urinary collecting system dilatation without antibiotic prophylaxis. METHODS: Between June 2012 and August 2016, we evaluated the incidence of UTI and the clinical and ultrasonography evolution in 407 children with a prenatally diagnosed UTD. All subjects underwent two prenatal ultrasounds scans (USs) at 20 weeks and 30 weeks of gestation and within 1 month of birth. Patients with a confirmed diagnosis of UTD underwent US follow-up at 6, 12 and 24 months of life. According to the UTD classification system stratify risk, after birth UTD were classified into three groups: UTD-P1 (low risk group), UTD-P2 (intermediate risk group), and UTD-P3 (high risk group). Voiding cystourethrogram was performed in all patients who presented a UTI and in those with UTD-P3. No patient underwent CAP. RESULTS: Postnatal US confirmed UTD in 278 out of 428 patients with the following rates: UTD-P1 (126), UTD-P2 (95) and UTD-P3 (57). During postnatal follow-up, 6.83% patients presented a UTI (19 out of 278). Eleven out of 19 had vesicoureteral reflux (VUR), and other four were diagnosed with obstructive uropathy and underwent surgical correction. Five patients presented a UTI reinfection. CONCLUSION: The occurrence of UTI in patients with urinary collecting system dilatation was low. The recent literature reports an increased selection of multirestistant germs in patients with VUR exposed to CAP. This study constitutes a strong hint that routine continuous antibiotic prophylaxis could be avoided in patients with UTD.

Common clinical markers predict end-stage renal disease in children with obstructive uropathy.

BACKGROUND: Obstructive uropathy (OU) is a common cause of end-stage renal disease (ESRD) in children. Children who escape the newborn period with mild-to-moderate chronic kidney disease (CKD) continue to be at increased risk. The predictive ability of clinically available markers throughout childhood is poorly defined. METHODS: Patients with OU were identified in the Chronic Kidney Disease in Children Study. The primary outcome of interest was renal replacement therapy (RRT) (cases). Controls were age matched and defined as patients within the OU cohort who did not require RRT during study follow-up. RESULTS: In total, 27 cases and 41 age-matched controls were identified. Median age at baseline and age at outcome measurement were 10 vs. 16 years, respectively. First available glomerular filtration rate (GFR) (36.9 vs. 53.5 mL/min per 1.73 m2), urine protein/creatinine (Cr) (0.40 vs. 0.22 mg/mg) and microalbumin/Cr (0.58 vs. 0.03 mg/mg), and serum CO2 (20 vs. 22 mmol/L) and hemoglobin (12.4 vs. 13.2 g/dL) differed significantly between cases and controls, respectively. GFR declined 3.07 mL/min per 1.73 m2/year faster in cases compared to that in controls (p < 0.0001). Urine protein/Cr and microalbumin/Cr increased by 0.16 and 0.11 per year more in cases compared to those in controls, respectively (p ≤ 0.001 for both). Serum phosphate increased by 0.11 mg/dL and serum albumin and hemoglobin decreased by 0.04 (g/dL) and 0.14 (g/dL) per year more for cases compared to those for controls, respectively (p < 0.05 for all). CONCLUSIONS: Age-specific baseline and longitudinal measures of readily available clinical measures predict progression to ESRD in children with mild-to-moderate CKD from OU.

Primary vesicoureteral reflux; what have we learnt from the recently published randomized, controlled trials?

In recent years, progress has been made on understanding the relationship between vesicoureteral reflux (VUR) and urinary tract infection (UTI). The findings on recent prospective, randomized, controlled studies have questioned the conventional VUR clinical significance and, therefore, have challenged the traditional diagnostic and therapeutic recommendations. These new studies have redefined the pathogenic role of vesicoureteral reflux in UTI as well as have disputed the routine use of urinary antibiotic prophylaxis to prevent UTI and renal damage in VUR patients. The time to overinvestigate and treat the vast majority of otherwise healthy children who have an uncomplicated UTI with long-term antibiotic prophylaxis seems to be over. Is there a role of severe VUR in the development of chronic renal disease and renal failure? New ideas are needed to answer these questions with the goal to avoid repeating past mistakes when therapeutic choices were based on expert opinions rather than facts.

Paediatric Urology and the Dilemma of Low-quality Evidence for the Management of Common Urological Conditions (Vesicoureteral Reflux, Lower Urinary Tract Dysfunction, Undescended Testis) in Children.

We have to strive for a more prospective scientific approach to every specific urological condition in children, with contributions from all parties involved and an emphasis on proper outcome research.

Incidence of urinary tract infections in infants with antenatally diagnosed hydronephrosis-A retrospective single center study.

OBJECTIVE: To evaluate the incidence of urinary tract infections (UTIs) in infants with antenatal hydronephrosis (AHN). MATERIALS AND METHODS: A cohort of AHN patients admitted to our institution between 2003 and 2013 were identified. Altogether 192 patients with nonrefluxing hydronephrosis (HN, n=135), nonrefluxing hydroureteronephrosis (HUN, n=21), or vesicoureteral reflux (VUR, n=36) were identified. Patients with complex anomalies or neonatal decompression of the urinary tract were excluded. Information about UTIs diagnosed among the AHN patients was collected and compared with data from 58 controls. RESULTS: During the median follow-up time of 2.6 (0.3-11.2) years, 24 (13%) patients (15 (10%) males and 9 (19%) females) and 2 (3%) controls experienced at least one UTI (p=0.033). Eighteen (69%) UTIs were febrile. The males had the first UTI at significantly younger age than the females (0.3, 0.0-1.7years vs. 1.0, 0.4-4.8years, p=0.010). UTI was detected in 15 (63%) patients with grade 4-5 VUR, in 8 (6%) patients with HN, and in one (5%) patient with HUN (p-values <0.001, 0.726 and >0.999 against the controls). None of the patients with grade≤3 VUR had UTI. Fifty-eight percent of the patients with UTI were on antimicrobial prophylaxis. In five (12%) cases UTI appeared within one week after voiding cystourethrography (VCUG). CONCLUSIONS: Infants with AHN and grade 4-5 VUR had the highest risk of UTI. UTIs tented to be more common in females than in males; however, males experienced UTI at younger age than females. VCUG caused UTI in 2.3% in our material. LEVEL OF EVIDENCE: III.

[Imaging strategy for children after a first episode of pyelonephritis]. / Explorations morphologiques après un premier épisode de pyélonéphrite chez l'enfant.

Pyelonephritis is a common bacterial disease in young children and is a serious infection because of its potential to produce renal scarring. One of the concerns of physicians is therefore the diagnosis of uropathy at risk for recurrence of pyelonephritis, especially high-grade reflux. There are no French recommendations on imaging evaluation after a first episode of pyelonephritis. Voiding cystography was systematically proposed years ago and recommended by the American Academy of Pediatrics until 1999. This systematic strategy exposed all children to a painful, irradiating exam, and exposed them to urinary tract infection. The American recommendations changed in 2011 and cystography is now only proposed to children with recurrence of pyelonephritis or with ultrasound abnormalities. A collaborative review of the literature involving the Pediatric Emergency, Nephrology and Surgery Departments at Necker-Enfants-Malades Hospital led us to propose an algorithm for imaging after the first episode of pyelonephritis in children. This algorithm was based on data from the past medical history (results of prenatal ultrasonography or recurrence of pyelonephritis), the results of the ultrasound exam at the time of diagnosis, and the procalcitonin concentration, to limit the indications for voiding cystography, limiting risk for delaying high-grade reflux diagnosis. Children with low risk for high-grade reflux can be followed up with an ultrasound exam 6 months after acute infection.

What is the risk of urinary tract infection in children with antenatally presenting dilating vesico-ureteric reflux?

INTRODUCTION: The incidence of recurrent urinary tract infection (UTI) in children with primary vesico-ureteric reflux (VUR) presenting symptomatically is well documented. The risk of UTI in asymptomatic primary VUR diagnosed on investigation of antenatal hydronephrosis (ANH) is less clear. Paradoxically, several previous studies have suggested a lower risk (1-25%). We ascertain the incidence of UTI amongst antenatally-presenting primary VUR and explore risk factors. STUDY DESIGN: All patients <16 years managed for primary VUR between 1997 and 2013 were retrospectively reviewed. Patients were identified by searching 'VUR, vesicoureteric reflux' and 'vesico' in the clinical database. Sex, follow up, antibiotic prophylaxis, age at UTI, grade of VUR, radioisotope imaging findings (CRN-congenital reflux nephropathy, NRD-new renal defects), evidence of bladder dysfunction, surgical intervention and resolution were recorded. UTI diagnosis was based on positive urine culture with symptoms including fever. SPSS statistical package and Pearson's Chi-squared test were used to explore significance. RESULTS: Of 308 patients with primary VUR aged <16 years treated, 242 were diagnosed following presentation with UTI. The remaining 66 (21%) were initially asymptomatic, and VUR was diagnosed on investigation of ANH. All were given prophylaxis from birth. Six months to 16years (median 6years) follow-up was available for 54 (42 males, 12 females). All but two patients had grade III-V VUR (96%), bilaterally in 41 (76%). CRN was evident in 30 (56%; all male) and bladder dysfunction in 12 (22%; 10 males). Twenty-eight patients (52%) developed a UTI. The risk of UTI was 58% in girls, 33% in boys without CRN and 57% in boys with CRN (p = 0.17). Bladder dysfunction was a significant risk factor for UTI (p = 0.03). All 8 (15%; 7 males) with NRD had had a UTI. A single UTI appeared responsible for the majority of NRD (6/8; 75%). UTI occurred in 6/27 (22%) boys after circumcision compared to 17/25 (68%) prior/without circumcision (p < 0.05). CONCLUSIONS: The incidence of UTI in VUR detected after presentation with ANH was 52%. CRN and bladder dysfunction were risk factors for developing a UTI. Circumcision appears to significantly reduce the risk of infection. Antenatal presentation of primary VUR does not carry a reduced risk of UTI. A single UTI, in half before the age of six months, seemed responsible for the majority of NRD. In boys, the highest risk of UTI is in the first few months of infancy, despite antibiotic prophylaxis, and other interventions, particularly circumcision, should therefore be considered as early as possible.

Misdiagnoses caused by use of indwelling urethral catheters in children with ureterovesical junction anomalies.

PURPOSE: Children commonly undergo vesicograms for diagnosing vesicoureteral reflux (VUR). This requires urethral catheterization with transurethral replacement. We report misdiagnosed or related complications due to indwelling urethral catheters unintentionally placed in the ureter. METHODS: From our computerized urology records over an 18-year period from January 1995 to May 2013, we retrospectively identified nine cases of 1850 vesicograms that had misdirection of a urethral catheter placed in a ureter. Foley catheters with inflating balloons were used to obtain the vesicograms. RESULTS: In all, 1850 vesicograms were performed (746 males, 1104 females; age 1 week to 14 years, mean age 3.8 years) using standard radiological techniques. Size 6-10 Fr indwelling urethral catheters were used, depending on the patient's age and gender. In nine cases (five females, four males), a misdirected urethral catheter was discovered in one of the ureters. The urethral catheter was in the left ureter in four patients and in the right ureter in five patients. Cystoscopic examination found ectopic ureteral openings in six patients: at the bladder neck in four and just below the bladder trigone in two. Three patients in this group with ectopic ureters were followed due a misdiagnosis of VUR. The remaining three patients had grade 3 or 4 VUR. In this group, the catheter passed into the ureter because of the enlarged ureterovesical junction. In one patient with VUR, intraparenchymal fluid leakage and transient hematuria occurred due to the rapid tension increase following the fast injection of contrast with liquid to one ureter. CONCLUSION: Although placing an indwelling urethral catheter is a relatively safe procedure, complications can occur, particularly in patients with ureterovesical anomalies, such as high-grade VUR or an ectopic ureter. Using catheters with inflating balloons can cause rapid increases in tension in the ureter, and related complications.

[MODIFIED Politano-Leadbetter REIMPLANTATION FOR TREATMENT OF CONGENITAL MALFORMATION OF VESICOURETERAL JUNCTION IN CHILDREN].

UNLABELLED: Corresponding author: HUANG Lugang, E-mail: lugang992001@aliyun.com OBJECTIVE: To explore the effectiveness of modified Politano-Leadbetter reimplantation for the treatment of congenital malformation of the vesicoureteral junction in children. METHODS: A retrospective analysis was made on the clinical data of 53 patients with congenital malformation of the vesicoureteral junction treated with modified Politano-Leadbetter reimplantation between June 2000 and October 2014. Of 53 cases, there were 24 boys and 29 girls, aged from 8 months to 7 years (mean, 2.1 years); 23 had congenital vesicoureteral junction obstruction (14 left, 5 right, and 4 bilateral), and 30 had vesicoureteral reflux (12 unilateral, 18 bilateral), which were verified by voiding cystourethrography. The disease duration was from 1 month to 1 year (mean, 5 months). RESULTS: All of the patients underwent modified Politano-Leadbetter reimplantation successfully. The mean operation time was 74 minutes (range, 65-85 minutes) for unilateral cases and 105 minutes (range, 98-130 minutes) for bilateral cases. There was no dysuria, infection of incision, or incision dehiscence after urinary catheter removal. The follow-up time was 6 months to 14 years (median, 28 months); all patients were free from complications of fistula, vesicoureteral reflux, vesicoureteral junction obstruction, or hypertension. The new ureteral orifices had good appearance at 1 month after operation. Urologic ultrasound showed that hydronephrosis relieved at 3 months after operation. Urinary tract infection rate was 13.2% (7/53) during 6 months after operation, which was cured by antibiotics. Voiding cystourethrography showed no vesicoureteral reflux in 32 cases at 6 months after operation. CONCLUSION: The modified Politano-Leadbetter reimplantation simplifies he operation course, which has the longitudinal ureter after operation and is similar to physiological state. It is a safe and effective option for congenital malformation of vesicoureteral junction in children with few complications, especially for patients with unilateral megaloureter.

Rapid and sustained recovery of renal function with transient placement of an intrauretral nephrostomy catheter in an infant with ureteropelvic junction obstruction and acute renal failure.

Ureteropelvic junction obstruction (UPJO) is a common, congenital urinary malformation in the pediatric age group. In most cases the diagnosis is made antenataly and resolves spontaneously. Postnatal diagnosis is made when symptoms of urinary tract infection or abdominal pain occur. We report a six-month-old girl with single kidney and known vesicoureteral reflux grade IV presenting with severe acute renal failure (ARF), requiring acute peritoneal dialysis (PD).After diagnosis of decompensated UPJO, a nephrostomy was performed, and renal function restored within seven days. UPJO was subsequently treated by open pyeloplasty. To our knowledge, this is the first case of UPJO requiring PD due to severe renal failure in a child. Children with UPJO and major morbidity of the contralateral kidney are at risk of renal failure and should therefore be followed carefully to prevent serious complications.

[Recent advances in the diagnosis of vesicoureteral reflux in children]. / Diagnosi di reflusso vescico-ureterale in età pediatrica.

Primary vesicoureteral reflux is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal treatment, which necessitates identification of patients requiring early intervention. The aim of this review is to evidence the recent advances in the diagnosis of this congenital abnormality and to indicate the guidelines for its diagnostic management.

Large spectrum of complete urinary collecting system duplication exemplified by cases. Pictorial essay.

Urinary collecting system duplication is a congenital anomaly and can associate various types of urinary tract pathologies. Authors will illustrate by cases some of associated anomalies such as ureterocele, extravesical ectopic ureter, vesicoureteral reflux or reflux nephropathy; one case presented an association between posterior urethral valve and bilateral collecting system duplication.

Renal ultrasound volume in children with primary vesicoureteral reflux allows functional assessment.

OBJECTIVE: Renal scintigraphy represents the current diagnostic standard to assess split kidney function. We tested the hypothesis that the relative renal volume assessed by ultrasound provides an equally reliable but less invasive tool for assessment of kidney function as compared to renal scintigraphy in patients with primary vesicoureteral reflux. METHODS: Renal ultrasound and renal scintigraphy were performed in 85 patients (median age 4.5 years, range 0.25-7.7) and repeated in 74 patients after 2-13 months (mean 7) of the primary investigation. Renal size was measured by ultrasound, and relative renal volume was calculated for each kidney by using the formula of a prolate ellipsoid. Renal function was estimated for each side (split renal function) by scintigraphy with (99m)Tc MAG3. RESULTS: The mean difference between relative renal volume measured by ultrasound and split renal function determined by renal scintigraphy was 2.8% (standard deviation ± 4.1%; 95% confidence interval 10.8/-5.2%). There was a statistically significant correlation between relative renal volume estimated by ultrasound and split renal function estimated by renal scintigraphy at first examination (r = 0.98; p < 0.001) and at follow-up (r = 0.91; p < 0.001). CONCLUSION: We conclude that ultrasound measurement of relative renal volume is capable of assessing split renal function in children with primary vesicoureteral reflux and, thus, should be considered instead of the more invasive MAG3 scintigraphy.

Single trocar retroperitoneoscopic assisted ipsilateral ureteroureterostomy for ureteral duplication.

The aim of this study is to present the technique and early outcomes of single trocar retroperitoneoscopic assisted ureteroureterostomy for ureteral duplication. The patient was placed in a lateral decubitus position. A skin incision of 11 mm width was made above the iliac crest. The operation was performed through single trocar with operating laparoscope. The two ureters were encircled with a vessel loop and exteriorized outside the retroperitoneal space via trocar incision. The pathologic ureter was divided as low as possible. The recipient ureter was opened longitudinally. End-to-side ureteroureterostomy anastomosis was performed extracorporeally with two running 6/0 PDS sutures. From December 2010 to July 2011, nine patients were operated on using the same technique. Patient's ages ranged from 2 to 72 months. Mean operative time was 78 ± 21 min. There were no intra or postoperative complications. Postoperative stay was 2.6 ± 1.0 days. Follow-up revealed that two renal moieties preserved their functions in all patients. The diameter of involved ureters and pelvises was significantly reduced in all patients. Single trocar retroperitoneoscopic assisted ureteroureterostomy is safe and effective procedure for ureteral duplication.

Do infants with mild prenatal hydronephrosis benefit from screening for vesicoureteral reflux?

PURPOSE: Screening for vesicoureteral reflux in asymptomatic infants with low grade hydronephrosis is unjustified if this condition is benign. We present a cohort with prenatally detected hydronephrosis, some observed without voiding cystourethrography, and compare outcomes to a classic, screened group. MATERIALS AND METHODS: A total of 206 consecutive children presenting with postnatally confirmed prenatally detected hydronephrosis (47% bilateral) were included in the study. Cases with associated renal or bladder anomalies were excluded. Children with low grade hydronephrosis either underwent screening voiding cystourethrography or did not, largely based on whether care was managed by a urologist or a nephrologist. Patients with high grade hydronephrosis routinely underwent voiding cystourethrography. Primary outcome was a symptomatic or febrile urinary tract infection. We used Mantel-Haenszel analysis to determine urinary tract infection risk factors during the first 2 years of life. RESULTS: No urinary tract infection was observed in patients with grade I hydronephrosis. Urinary tract infections in low grade hydronephrosis were only seen in the voiding cystourethrogram group (7 patients), including 1 infection following voiding cystourethrogram. Urinary tract infection rate was 3.52 infections per 100 patient-years in children with low grade hydronephrosis and 11.1 infections per 100 patient-years in those with high grade hydronephrosis (p = 0.02). This increased risk of urinary tract infection in high grade hydronephrosis persisted after correcting for gender and circumcision status (IRR 3.17, p = 0.01). The association remained strong (IRR 2.48, 95% CI 0.96-6.44) but was not statistically significant (p = 0.053) after additionally correcting for vesicoureteral reflux status. CONCLUSIONS: Our data suggest that children with low grade hydronephrosis and otherwise normal kidneys and bladder do not benefit from voiding cystourethrographic screening. Interestingly high grade hydronephrosis appears to carry a threefold greater risk of urinary tract infection compared to low grade hydronephrosis.

Assessing urinary tract defects in mice: methods to detect the presence of vesicoureteric reflux and urinary tract obstruction.

Congenital Anomalies of the Kidney and Urinary Tract (CAKUT) encompass a spectrum of kidney and urinary tract disorders. Here, we describe two assays that can be used to determine if a mouse has vesicoureteric reflux (VUR) or urinary tract obstruction, two urinary tract defects observed in CAKUT. To test for VUR, dye is injected into the mouse bladder and then monitored to determine if it passes retrogradely from the bladder towards the kidneys, indicating the presence of VUR. To test for urinary tract obstruction, the renal pelvis is microinjected with dye and its passage along the urinary tract is monitored to determine if there is evidence of impaired flow along the tract. These methods will facilitate the analysis of CAKUT phenotypes in the mouse.

Candidiasis caused by Candida kefyr in a neonate: case report.

BACKGROUND: Systemic Candidia infections are of major concern in neonates, especially in those with risk factors such as longer use of broad spectrum antibiotics. Recent studies showed that also term babies with underlying gastrointestinal or urinary tract abnormalities are much more prone to systemic Candida infection. We report a very rare case of candidiasis caused by Candida kefyr in a term neonate. CASE PRESENTATION: Renal agenesis on the left side was diagnosed antenatally and anal atresia postnatally. Moreover, a vesico-ureteral-reflux (VUR) grade V was detected by cystography. The first surgical procedure, creating a protective colostoma, was uneventful. Afterwards our patient developed urosepsis caused by Enterococcus faecalis and was treated with piperacillin. The child improved initially, but deteriorated again. A further urine analysis revealed Candida kefyr in a significant number. As antibiotic resistance data about this non-albicans Candida species are limited, we started liposomal amphotericin B (AMB), but later changed to fluconazole after receiving the antibiogram. Candiduria persisted and abdominal imaging showed a Candida pyelonephritis. Since high grade reflux was prevalent we instilled AMB into the child's bladder as a therapeutic approach. While undergoing surgery (creating a neo-rectum) a recto-vesical fistula could be shown and subsequently was resected. The child recovered completely under systemic fluconazole therapy over 3 months. CONCLUSIONS: Candidiasis is still of major concern in neonates with accompanying risk factors. As clinicians are confronted with an increasing number of non-albicans Candida species, knowledge about these pathogens and their sensitivities is of major importance.

Urinary tract anomalies associated with high grade primary vesicoureteral reflux.

BACKGROUND: Few studies have evaluated the significance of associated urological anomalies in vesicoureteral reflux (VUR). The aim of our study was to determine the incidence of associated urological anomalies in patients with high grade VUR and to assess their impact on renal parenchymal scarring. METHODS: We retrospectively reviewed the hospital records of 1,765 consecutive cases diagnosed with high grade VUR (Grade III-V) at our hospital between 1998 and 2010. The diagnosis of VUR was made by a voiding cystourethrogram (VCUG). Renal scarring was evaluated by dimercapto-succinic acid (DMSA) scintigraphy and classified into three groups: mild (focal defects in uptake between 40 and 45%), moderate (uptake of renal radionuclide between 20 and 40%), and severe (shrunken kidney with relative uptake <20%). All associated urological anomalies were diagnosed by ultrasound or VCUG or DMSA scan. RESULTS: Associated urological anomalies were present in 229 (13%) children. There were 87 boys and 142 girls. Duplex kidney was the main associated anomaly occurring in 148 (64.6%) of the 229 patients. Other anomalies were: bladder diverticulum in 29, solitary kidney in 12, ureterocele in 13, hypospadiasis in 11, pelviureteric junction obstruction in 9, malrotated kidney in 3, horseshoe kidney in 2, crossed fused ectopia in 1 and renal cyst in 1. DMSA scan revealed renal scarring in 105 (47.7%) of the 220 children who had a DMSA scan. 75 (50.7%) children with duplex kidneys showed renal scarring. CONCLUSION: Associated urological anomalies occur commonly in patients with high grade VUR. Our data shows that nearly half of the patients with VUR and associated urological anomalies have renal scarring. Early recognition and treatment of VUR patients with associated urological anomalies may decrease the risk of renal parenchymal damage.