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1.
Eur J Pediatr ; 178(4): 525-531, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30706159

RESUMO

Severe (grades IV and V) vesicoureteral reflux (VUR) is a risk factor for acute pyelonephritis, renal scars, and renal failure. This study evaluates albumin and N-acetylglucosaminidase (NAG) urinary excretion, and renal concentrating ability as screening tools to select patients for voiding cystourethrogram (VCUG). Children (111 M, 52 F) aged 10.97 ± 21.17 months (mean + SD), diagnosed with UTI, and who had undergone renal ultrasound and a VCUG, underwent a desmopressin test and had albumin/creatinine and NAG/creatinine urinary excretion measured. Urine osmolality was significantly lower in 27 children with severe VUR (375.3 ± 171.8 mOsm/kg; mean + SD) compared to 100 patients with normal VCUG (611.5 ± 175.8 mOsm/kg), p < 0.001, and to 36 patients with VUR grades I to III (636.2 ± 180.2 mOsm/kg), p < 0.001. NAG/creatinine ratio was significantly elevated in 20 children with severe VUR (26.4 (28.3) U/g); median and interquartile range compared to 67 children with normal VCUG (10.8 (17.9) U/g), p = 0.003, and to 20 patients with VUR grades I to III (7.6 (21.1) U/g), p = 0.009.Conclusions: Urinary osmolality is significantly decreased and urinary excretion of NAG is significantly increased in patients with severe VUR. These tests could select patients for VCUG to assess for severe VUR. What is Known: • Severe vesicoureteral reflux (SVUR) may contribute to renal damage. Severe vesicoureteral reflux is diagnosed by voiding cystourethrogram and represents about 10% of all patients with VUR. Currently, there are no reliable tests used prior to VCUG to help on the decision of obtaining a VCUG to diagnose SVUR. What is New: • This study shows that renal tubular markers (concentrating ability and N-acetylglucosaminidase (NAG) excretion) are useful tests prior to voiding cystourethrogram to screen for severe vesicoureteral reflux. • This study suggests the use of renal concentrating ability and urinary N-acetylglucosaminidase (NAG) excretion to screen for severe vesicoureteral reflux before requesting a voiding cystourethrogram.


Assuntos
Acetilglucosaminidase/urina , Lesão Renal Aguda/etiologia , Albuminúria/diagnóstico , Creatinina/urina , Pielonefrite/etiologia , Refluxo Vesicoureteral/diagnóstico , Biomarcadores/urina , Estudos de Casos e Controles , Pré-Escolar , Feminino , Humanos , Lactente , Túbulos Renais/diagnóstico por imagem , Masculino , Concentração Osmolar , Refluxo Vesicoureteral/complicações
2.
PLoS One ; 13(12): e0209595, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30576373

RESUMO

OBJECTIVE: Urinary tract infection (UTI), one of the most common bacterial infections occurring during infancy and early childhood, is frequently associated with vesicoureteral reflux (VUR). Although several guidelines recommend performing ultrasonography as a screening test, its utility is not adequate and appropriate screening tests are strongly desirable. In this study, we evaluate the use of magnetic resonance imaging (MRI) as a screening test for VUR in children with UTI. METHODS: We prospectively studied 108 patients with suspected UTI between April 2014 and March 2016. UTI was diagnosed on the basis of diffusion-weighted MRI (DW-MRI) and urine culture findings. We measured ureteral dilatation using MRI in 96 patients with UTI and assessed the relationship between ureteral dilatation in MRI and VUR in 46 patients who underwent voiding cystourethrography (VCUG). RESULTS: Among 108 patients, 88 and 8 were diagnosed with upper and lower UTI, respectively. Among 46 patients who underwent VCUG, 23 had VUR (14 low grade and 9 high grade). Patients with ureteral dilatation detected on MRI had VUR more frequently than those without ureteral dilatation (any grades VUR, 71% vs. 32%; P = 0.02; high-grade VUR, 38% vs. 2%, P = 0.007). Overall, ureteral dilatation findings on MRI achieved sensitivity 65.2% and specificity 73.9% as a screening test for VUR. In addition, DW-MRI achieved sensitivity 100% and specificity 81.8% in the diagnosis of upper UTI. CONCLUSION: These findings suggested that MRI is a valuable tool for screening of VUR as well as diagnosis of upper UTI.


Assuntos
Uretra/diagnóstico por imagem , Infecções Urinárias/diagnóstico por imagem , Refluxo Vesicoureteral/diagnóstico , Pré-Escolar , Imagem de Difusão por Ressonância Magnética , Dilatação/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Imagem por Ressonância Magnética , Masculino , Ultrassonografia , Uretra/patologia , Urinálise , Infecções Urinárias/diagnóstico , Infecções Urinárias/urina , Urografia/métodos , Refluxo Vesicoureteral/diagnóstico por imagem , Refluxo Vesicoureteral/urina
3.
Actas urol. esp ; 42(5): 331-337, jun. 2018. ilus, tab, graf
Artigo em Espanhol | IBECS | ID: ibc-174719

RESUMO

Introducción: Los resultados del tratamiento endoscópico del reflujo vesicoureteral (RVU) a corto plazo son excelentes. No obstante, con el paso de los años se ha identificado un número de pacientes en quienes el RVU que fue resuelto mediante esta técnica vuelve a aparecer. El objetivo de este trabajo es analizar los factores relacionados con este evento. Material y métodos: Se ha realizado un estudio analítico retrospectivo tipo caso-control incluyendo 395 unidades ureterales con RVU primario tratadas con éxito en nuestro centro, con seguimiento mínimo de 3 años. Se han identificado los casos en los que el RVU reapareció y se han analizado variables demográficas, variables relativas al RVU (grado, lateralidad, estudio inicial) y a la intervención (material utilizado). Resultados: Se identificaron 77 unidades ureterales con recidiva de las 395 incluidas (19,5%). La incidencia de recidiva fue del 29,7% en los pacientes tratados con dextranómero/ácido hialurónico (Dx/HA), del 20,2% en los tratados con polidimetilxilosano (MP) y del 12,2% en el caso de politetrafluoroetileno (PTFE). La aparición de recidiva se eleva hasta el 35% en el caso de pacientes tratados antes del año de edad y aquellos con RVU de gradoV. La clínica de disfunción miccional también eleva la incidencia de recidiva al 34,9%. Conclusión: El uso del material reabsorbible Dx/HA está relacionado con la recidiva del tratamiento endoscópico del RVU. Los reflujos de alto grado, junto con el tratamiento en edades precoces, así como la presencia de disfunción miccional, también son factores asociados a la recurrencia


Introduction: The short-term results of endoscopic treatment of vesicoureteral reflux (VUR) are excellent. Over time, however, a number of patients have been identified for whom VUR reappeared after being resolved with this technique. The aim of this study was to analyse the factors related to this event. Material and methods: A retrospective, analytical, case-control study included 395 ureteral units with primary VUR treated successfully at our centre, with a minimum follow-up of 3 years. We identified cases in which VUR reappeared and analysed the demographic variables, those related to VUR (grade, laterality, initial study) and those related to the operation (materials used). Results: We identified 77 ureteral units with recurrence in the 395 included uni:ts (19.5%). The recurrence rate was 29.7% for the patients treated with dextranomer/hyaluronic acid (Dx/HA), 20.2% for those treated with polydimethylsiloxane (MP) and 12.2% for polytetrafluoroethylene (PTFE). The onset of recurrence rose to 35% for patients treated before 1 year of age and those with gradeV VUR. Urinary dysfunction symptoms also increased the recurrence rate to 34.9%. Conclusion: The use of resorbable dextranomer/hyaluronic acid material was related to recurrence in the endoscopic treatment of VUR. The high-grade reflux and treatment at an early age, as well as the presence of urinary dysfunction, are also factors associated with recurrence


Assuntos
Humanos , Masculino , Feminino , Criança , Falha de Tratamento , Refluxo Vesicoureteral/terapia , Ureteroscopia/métodos , Seguimentos , Refluxo Vesicoureteral/diagnóstico , Estudos Retrospectivos , Transtornos Urinários/complicações , Transtornos Urinários/terapia , Procedimentos Cirúrgicos Urológicos/métodos
4.
Eur Radiol ; 28(1): 66-73, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28755057

RESUMO

OBJECTIVE: To evaluate superb microvascular imaging (SMI) for the detection of high-grade vesicoureteral reflux (VUR). METHODS: We reviewed the patients with urinary tract infection who underwent renal US with SMI and VCUG. The subjects were divided into a VUR group, which included 17 patients (20 kidney units, KU) with high-grade reflux (grade 4 or 5) on VCUG, and a group without VUR including the same numbers of subjects. The direction of urine movement at the distal ureter and the renal pelvis was reviewed on SMI. SMI and VCUG results were compared. RESULTS: Urinary flow "jets" into the bladder and direction of the flow were detectable on all SMI examinations in both groups. In the group with VUR, 20 KUs had grade 4 (n = 11) or grade 5 (n = 9) reflux (bilateral VUR in 3 patients). Among 20 KUs with VUR, 15 (75%) showed a reversed ureteral jet and/or renal pelvic swirl sign on SMI. None of the patients in the group without VUR showed those findings on SMI. CONCLUSION: SMI enables detection of the direction of urinary flow. The presence of a reversed ureteral jet and/or renal pelvic swirl sign correlates with high-grade VUR with 75% accuracy. KEY POINTS: • Superb microvascular imaging is feasible in children with urinary tract infection. • SMI enables detection of the direction of urinary flow. • Presence of reversed flow correlates with high-grade vesicoureteral reflux.


Assuntos
Capilares/diagnóstico por imagem , Pelve Renal/irrigação sanguínea , Microcirculação , Ureter/irrigação sanguínea , Infecções Urinárias/diagnóstico , Refluxo Vesicoureteral/diagnóstico , Criança , Pré-Escolar , Estudos de Viabilidade , Feminino , Humanos , Lactente , Pelve Renal/diagnóstico por imagem , Masculino , Ureter/diagnóstico por imagem , Infecções Urinárias/complicações , Refluxo Vesicoureteral/complicações
5.
Urologiia ; (4): 107-112, 2017 Sep.
Artigo em Russo | MEDLINE | ID: mdl-28952702

RESUMO

Vesicoureteral reflux (VUR) is the most common type of obstructive uropathy in children. Reflux nephropathy (RN) is one of the most common complications of VUR that inevitably leads to chronic kidney disease. Patients with end-stage kidney disease require costly treatment, and the only way to cure them is kidney transplantation. A timely institution of renoprotective therapy is a key factor helping to preserve the function of the native kidneys. Hence, it is necessary to devise new highly sensitive and minimally invasive methods for early diagnosis of RN. The purpose of this article is to review the molecular mechanisms of initiation and progression of kidney fibrosis and the opportunities of instrumental and non-instrumental methods for its diagnosis. Special attention is paid to highly specific and highly sensitive non-invasive methods for the detection of minimal changes in the renal parenchyma. The authors discuss the promising biomarkers for the diagnosis and prediction of RN.


Assuntos
Refluxo Vesicoureteral/diagnóstico , Refluxo Vesicoureteral/fisiopatologia , Criança , Diagnóstico Precoce , Humanos , Refluxo Vesicoureteral/etiologia
6.
Urology ; 108: 96-101, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28666792

RESUMO

OBJECTIVE: To report our experience with robot-assisted ureteral anastomosis for kidney graft. Kidney graft complex ureteral strictures or symptomatic vesicoureteral reflux may require complex reconstruction. This is classically done through an open surgical access, which adds to the morbidity of kidney transplantation. The da Vinci robot enables performance of complex laparoscopic procedures and may hence be used for such reconstructions. PATIENTS AND METHODS: We retrospectively reviewed all patients undergoing robotic surgical revision for stricture or reflux disease over a 3-year period. Contemporary patients who underwent open surgery were used as a control group. RESULTS: Ten patients underwent a robotic attempt, of whom 4 needed conversion to open surgery. Seven patients underwent an open surgery. Preoperative demographics were similar in both groups. The median operative time was 293 minutes, with a shorter operative time in the open group. The group of patients who could be completed robotically had a significantly lower postoperative length of stay (5 vs 9 days), quicker return to normal food intake (postoperative day 1 vs 3), and quicker control of pain without opiates (postoperative day 1 vs 4) than the converted or open group. Morbidity was comparable with 1 late Clavien IIIb complication in each subgroup (open, converted, and robotic group). After a median follow-up of 43 months, renal function was stable and there were no recurrent graft infections. CONCLUSION: Robotic ureteral reconstruction for kidney graft patients is feasible and efficient, and offers the classical advantages of minimally invasive surgery with outcomes comparable with open series.


Assuntos
Transplante de Rim/efeitos adversos , Laparoscopia/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Ureter/cirurgia , Obstrução Ureteral/cirurgia , Refluxo Vesicoureteral/cirurgia , Adulto , Idoso , Anastomose Cirúrgica , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Ureter/diagnóstico por imagem , Obstrução Ureteral/diagnóstico , Obstrução Ureteral/etiologia , Urografia , Refluxo Vesicoureteral/diagnóstico , Refluxo Vesicoureteral/etiologia
7.
J Pediatr Urol ; 13(4): 378-382, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28630017

RESUMO

We performed a review of the recent literature concerning urinary tract infection (UTI) evaluation and management. In modeling options for management, one overriding conclusion became apparent: in most affected children, the presence of vesicoureteral reflux (VUR) is inconsequential since it has no bearing on optimal management or outcome. In fact, knowing that a child does not have reflux might bias the provider to withhold potentially helpful therapeutic modalities to decrease UTI morbidity, such as antibiotic prophylaxis. In this review, we will propose that evaluation for VUR is not necessary or helpful except in the small subset of children whose UTIs have proven refractory to management of their other risk factors.


Assuntos
Infecções Urinárias/diagnóstico , Infecções Urinárias/etiologia , Refluxo Vesicoureteral/diagnóstico , Refluxo Vesicoureteral/etiologia , Criança , Pré-Escolar , Humanos , Lactente , Fenótipo , Infecções Urinárias/terapia , Refluxo Vesicoureteral/terapia
9.
Indian J Pediatr ; 84(7): 540-544, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28477320

RESUMO

The primary goal in the management of a child with urinary tract infection (UTI) is to prevent recurrence of UTI and acquired renal damage. Approximately 15% of children develop renal scarring after a first episode of febrile UTI. Vesico-ureteric reflux (VUR) is diagnosed in 30-40% of children imaged after first febrile UTI. The 'top-down' approach involving ultrasound and dimercaptosuccinic acid scan (DMSA) first after an appropriate interval following UTI, can help in avoiding voiding cystourethrogram (VCUG), an invasive test with higher radiation exposure. The majority view remains that VCUG should be done after the second attack of UTI in girls and first attack of UTI in boys. Although the evidence in favour of antibiotic prophylaxis remains doubtful in preventing renal scars associated with VUR, it remains the first line treatment for high-grade reflux (grade 3-5) with an aim to prevent UTI and allow spontaneous resolution of VUR. Early identification and appropriate treatment of associated bowel bladder dysfunction is an essential part of successful medical management of VUR. Endoscopic treatment of VUR, using a bulking agent, is useful in grade 3 VUR. The main controversy regarding intervention (endoscopic/open surgical intervention) involves absence of strong evidence for these interventions in reducing renal scarring on randomized controlled trials. However, several recent trials have found the surgical interventions to be effective in reducing recurrent pyelonephritis and repeated hospital admissions.


Assuntos
Refluxo Vesicoureteral/terapia , Antibioticoprofilaxia , Criança , Humanos , Remissão Espontânea , Refluxo Vesicoureteral/diagnóstico
10.
J Pediatr Urol ; 13(5): 507.e1-507.e7, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28434635

RESUMO

INTRODUCTION/BACKGROUND: The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial. OBJECTIVE: To compare postoperative outcomes of EI vs UNC. STUDY DESIGN: This study reviewed linked inpatient (SID), ambulatory surgery (SASD), and emergency department (SEDD) data from five states in the United States (2007-10) to identify pediatric patients with primary VUR undergoing EI or UNC as an initial surgical intervention. Unplanned readmissions, additional procedures, and emergency room (ER) visits were extracted. Statistical analysis was performed using multivariate logistic regression using generalized estimating equation (GEE) to adjust for hospital-level clustering. RESULTS: The study identified 2556 UNC and 1997 EI procedures. Compared with patients undergoing EI, those who underwent UNC were more likely to be younger (4.6 vs 6.0 years, P < 0.001), male (30 vs 20%, P < 0.001), and publicly insured (34 vs 29%, P < 0.001). As shown in Summary Figure, compared with EI, UNC patients had lower rates of additional anti-reflux procedures within 12 months (25 (1.0) vs 121 (6.1%), P < 0.001), but a higher rate of 30-day and 90-day readmissions and ER visits. On multivariate analysis, patients treated by UNC remained at higher odds of being readmitted (OR = 4.45; 2.69 in 30 days; 90 days, P < 0.001) and to have postoperative ER visits (OR = 3.33; 2.26 in 30 days; 90 days, P < 0.001); however, EI had significantly higher odds of repeat anti-reflux procedures in the subsequent year (OR = 7.12, P < 0.001). DISCUSSIONS: Endoscopic injection constituted nearly half of initial anti-reflux procedures in children. However, patients treated with UNC had significantly lower odds of requiring re-treatment in the first year relative to those treated with EI. By contrast, patients treated with UNC had more than twice the odds of being readmitted or visiting an ER postoperatively. Although the available data were amongst the largest and most well validated, the major limitation was the retrospective nature of the administrative database. The practice setting may not be generalizable to states not included in the analysis. CONCLUSIONS: Postoperative readmissions and ER visits were uncommon after any surgical intervention for VUR, but were more common among children undergoing UNC. The EI patients had a more than seven-fold increased risk of surgical re-treatment within 1 year.


Assuntos
Cistostomia/métodos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Ureterostomia/métodos , Refluxo Vesicoureteral/diagnóstico , Refluxo Vesicoureteral/cirurgia , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Cistostomia/efeitos adversos , Bases de Dados Factuais , Endoscopia/métodos , Seguimentos , Humanos , Injeções Intralesionais , Análise Multivariada , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Ureterostomia/efeitos adversos
11.
Arch Dis Child ; 102(9): 804-808, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28408468

RESUMO

BACKGROUND AND OBJECTIVE: Urinary tract infection (UTI) represents the most common bacterial infection in infants, and its prevalence increases with the presence of high-grade vesicoureteral reflux (VUR). However, voiding cystourethrography (VCUG) is invasive, and its indication in infants <3 months is not yet defined. This study aims to investigate, in infants aged 0-3 months, if the presence of Escherichia coli versus non-E. coli bacteria and/or normal or abnormal renal ultrasound (US) could avoid the use of VCUG. METHOD: One hundred and twenty-two infants with a first febrile UTI were enrolled. High-grade VUR was defined by the presence of VUR grade ≥III. The presence of high-grade VUR was recorded using VCUG, and correlated with the presence of E. coli/non-E. coli UTI and with the presence of normal/abnormal renal US. The Bayes theorem was used to calculate pretest and post-test probability. RESULTS: The probability of high-grade VUR was 3% in the presence of urinary E. coli infection. Adding a normal renal US finding decreased this probability to 1%. However, in the presence of non-E. coli bacteria, the probability of high-grade VUR was 26%, and adding an abnormal US finding increased further this probability to 55%. CONCLUSIONS: In infants aged 0-3 months with a first febrile UTI, the presence of E. coli and normal renal US findings allow to safely avoid VCUG. Performing VCUG only in infants with UTI secondary to non-E. coli bacteria and/or abnormal US would save many unnecessary invasive procedures, limit radiation exposure, with a very low risk (<1%) of missing a high-grade VUR.


Assuntos
Infecções por Escherichia coli/etiologia , Rim/diagnóstico por imagem , Infecções Urinárias/etiologia , Refluxo Vesicoureteral/complicações , Refluxo Vesicoureteral/diagnóstico , Fatores Etários , Algoritmos , Bacteriúria/diagnóstico , Bacteriúria/microbiologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Ultrassonografia , Procedimentos Desnecessários , Bexiga Urinária/diagnóstico por imagem , Infecções Urinárias/microbiologia , Micção , Urografia
12.
J Pediatr Urol ; 13(5): 500.e1-500.e5, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28412102

RESUMO

INTRODUCTION: The likelihood of detecting vesicoureteral reflux (VUR) after febrile urinary tract infections (UTI) in children logically should correlate with the correct diagnosis of the UTI. Beneath the unspecific symptoms of fever urine analysis is the main diagnostic criterion for the exact diagnosis of febrile UTIs in children. Use of inadequate urine sampling techniques during diagnosis may lead to impaired accuracy in UTI diagnosis. This could lead to the assumption that children, having diagnosed their UTI by the use of possibly inadequate urine sampling techniques should not be evaluated as consequently compared to those, where the diagnosis relied on sterile urine sampling techniques. We hypothesized that children with possibly contaminated urine samples during the initial diagnosis may show a lower rate of VUR in subsequent VCUGs because of a wrong diagnosis initially compared to children, where accurate urine sampling techniques were used. PATIENTS: Between 2009 and 2014, a total of 555 patients underwent a primary VCUG at our department indicated because of febrile UTIs. Patients with urine collection methods other than bag urine and catheter/suprapubic aspiration (SPA) were excluded from this study (mid-stream urine, potty urine, n = 149). We evaluated 402 patients (male/female 131/271, mean age 1.91 years), VUR rates and grades were compared between patients where urine was sampled by the use of a urine bag only at the time of diagnosis (n = 296, 73.6%) and those where sterile urine sampling (catheter, suprapubic puncture) was performed (n = 106, 26.3%). 4 patients were excluded due to equivocal data on urine sampling. RESULTS: VUR rate in children after sterile urine sampling using a catheter or SPA accounted to 31.1%. In those where urine samples acquired by the use of urine bags were used, 33.7% showed VUR on subsequent VCUG (p = 0.718). There were no significant differences as to VUR grades or gender, although VUR was much more commonly diagnosed in female patients (37.0% vs 28.2%, p = 0.227) (Figure). CONCLUSION: Children diagnosed with their UTI by use of bag urine in our experience carried the same risk of showing a VUR in a subsequent VCUG compared to those, where the initial diagnosis relied - beneath clinical criteria - on urine samples acquired by suprapubic puncture or catheterization. Consequently urine-sampling technique during initial UTI diagnosis alone should not be used as predictor for the reliability of UTI diagnosis and should not influence the further management after UTI.


Assuntos
Febre/complicações , Cateterismo Urinário/métodos , Infecções Urinárias/diagnóstico , Coleta de Urina/métodos , Refluxo Vesicoureteral/diagnóstico , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Febre/diagnóstico , Humanos , Lactente , Masculino , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Urinálise/métodos , Infecções Urinárias/complicações
13.
J Pediatr Urol ; 13(4): 383.e1-383.e6, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28256423

RESUMO

INTRODUCTION AND OBJECTIVE: Management of primary vesicoureteral reflux (VUR) remains controversial, and reflux grade currently constitutes an important prognostic factor. Previous reports have demonstrated that distal ureteral diameter ratio (UDR) may be more predictive of outcome than vesicoureteral reflux (VUR) grade. We performed an external validation study in young children, evaluating early spontaneous resolution rates relative to reflux grade and UDR. STUDY DESIGN: Voiding cystourethrograms (VCUGs) were reviewed. UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between the L1 and L3 vertebral bodies (Figure). VUR grade and UDR were tested in univariate and multivariable analyses. Primary outcome was status of VUR at last clinical follow-up (i.e. resolution, persistence, or surgical intervention). Demographics, VUR timing, laterality, and imaging indication were also assessed. RESULTS: One-hundred and forty-seven children (98 girls, 49 boys) were diagnosed with primary VUR at a mean age of 5.5 ± 4.7 months. Sixty-seven (45.6%) resolved spontaneously, 55 (37.4%) had persistent disease, and 25 (17%) were surgically corrected. Patients who spontaneously resolved had significantly lower VUR grade, refluxed later during bladder filling, and had significantly lower UDR. In a multivariable model, grade of VUR (p = 0.001), age <12 months (p = 0.008), ureteral diameter (p = 0.02), and UDR (p < 0.0001) achieved statistical significance. For every 0.1 unit increase in UDR, there was a 2.6 (95% CI 1.58-4.44) increased odds of persistent VUR, whereas a 1.6 (95% CI 0.9-3.0) increased odds was observed for every unit increase in grade. DISCUSSION: Both grade of reflux and UDR were statistically significant in a multivariable model; however, UDR had a higher likelihood ratio and was more predictive of early spontaneous resolution than grade alone. Furthermore, unlike traditional VUR grading where children with grade 1-5 may outgrow reflux depending on other factors, there appears to be a consistent UDR cutoff whereby patients are unlikely to resolve. In the present study, no child with a UDR greater than 0.43 experienced early spontaneous resolution, and only three (4.5%) of those with spontaneous resolution had a UDR above 0.35. CONCLUSIONS: UDR correlates with reflux grade, and is predictive of early resolution in children with primary VUR. UDR is an objective measurement of VUR, and provides valuable prognostic information about spontaneous resolution, facilitating more individualized patient care.


Assuntos
Remissão Espontânea , Ureter/patologia , Refluxo Vesicoureteral/diagnóstico , Pré-Escolar , Cistografia , Feminino , Humanos , Lactente , Masculino , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Ureter/diagnóstico por imagem , Refluxo Vesicoureteral/etiologia , Refluxo Vesicoureteral/terapia
14.
Int Urol Nephrol ; 49(5): 741-745, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28243965

RESUMO

Primary vesicoureteral reflux (VUR) is a controversial pathology. Current management of VUR is ruled by EAU guidelines elaborated in 2012. They defined and analyzed the risk factors and enunciated three risk groups, developing the initial treatment indications. Continuous antibiotic prophylaxis (CAP) is recommended as the initial treatment option in patients classified in moderate-risk group without low urinary tract disorder. The compliance with medication use is a concern for using CAP. The aim of the present study is to quantify the compliance of the parents of VUR patients, to analyze its impact on treatment and the applicability of EAU guidelines in our patients. This is a 4-year prospective study, which includes 202 patients aged between 1 and 174 months, diagnosed with primary VUR without LUTD. To quantify parent compliance with treatment, an algorithm was developed. Out of 202 children, 60.9% were girls. A rate of 54% patients was declared cured. In terms of compliance, incompliant patients tend toward worsening (p = 0.0001), most of them being unfollowed. Logistic regression demonstrated that the evolution of children with VUR is dependent on compliance. In conclusion, parent's compliance must be considered in EAU guidelines application, being a negative predictive factor in VUR resolution.


Assuntos
Pais , Cooperação do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Infecções Urinárias/terapia , Refluxo Vesicoureteral/terapia , Fatores Etários , Antibacterianos/uso terapêutico , Pré-Escolar , Estudos de Coortes , Progressão da Doença , Europa (Continente) , Feminino , Humanos , Lactente , Modelos Logísticos , Masculino , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Resultado do Tratamento , Infecções Urinárias/etiologia , Infecções Urinárias/fisiopatologia , Urografia/métodos , Procedimentos Cirúrgicos Urológicos/métodos , Refluxo Vesicoureteral/complicações , Refluxo Vesicoureteral/diagnóstico
15.
Urologe A ; 56(2): 247-262, 2017 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-28154883

RESUMO

Urinary tract infections (UTI) are the most common bacterial infections in children. The symptoms are not very specific and range from abdominal pain, poor feeding to nocturnal urinary incontinence. The technique of collecting urine plays an important role for securing the diagnosis. The best way to obtain urine in non-toilet-trained children is catheterization or suprapubic bladder aspiration. In toilet-trained children midstream urine is an acceptable alternative after cleaning the foreskin or labia. In the case of an infection a prompt empirical antibiotic therapy is necessary to reduce the risk of parenchymal scarring of the kidneys. There are different approaches to diagnose vesicoureteral reflux in different countries. The commonly used standard approach in Germany is voiding cystourethrography. In the case of reflux dimercaptosuccinic acid (DMSA) scintigraphy should be performed additionally to exclude renal scarring (bottom-up approach).


Assuntos
Infecções Bacterianas/diagnóstico , Infecções Bacterianas/microbiologia , Infecções Urinárias/diagnóstico , Infecções Urinárias/microbiologia , Coleta de Urina/métodos , Refluxo Vesicoureteral/diagnóstico , Refluxo Vesicoureteral/microbiologia , Infecções Bacterianas/urina , Criança , Pré-Escolar , Diagnóstico Diferencial , Medicina Baseada em Evidências , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Resultado do Tratamento , Infecções Urinárias/urina
16.
Arch Pediatr ; 24(3): 249-253, 2017 Mar.
Artigo em Francês | MEDLINE | ID: mdl-28161229

RESUMO

Endoscopic management is the gold standard for symptomatic low-grade vesicoureteral reflux (VUR) in children. Deflux® (hyaluronic acid/dextranomer) injection is highly effective and has very few complications. We report on two cases of secondary megaureter after Deflux® injections. In the first case, a boy presented with Grade 4 VUR. He received a bilateral Deflux® injection with a total of three syringes. The postoperative ultrasound was normal. However, a check-up ultrasound 3 years later showed a significant ureteropyelocalyceal dilatation, with stasis and decreased renal function on scintigraphy, the reason why antireflux surgery (Cohen procedure) was performed. In the second case, a girl diagnosed with bilateral VUR at birth received bilateral injections with one syringe on each side at the age of 12 months. One month later, the ultrasound showed a dilation of the distal ureters (diameter of the right ureter, up to 10mm; left ureter, up to 6.7mm). The child underwent surgery 8 months later (Cohen procedure) because of iterative pyelonephritis and persistent ureter dilatation. Only one previous case has been described in the literature. In our experience, this complication has occurred only twice in 452 injections (4‰). In conclusion, endoscopic treatment with hyaluronic acid/dextranomer injection is a minimally invasive procedure that improves the situation in cases of VUR. It has few complications. Other than failure, there is a low risk of secondary expansion requiring, in our opinion, ultrasound verification over the long term.


Assuntos
Dextranos/efeitos adversos , Ácido Hialurônico/efeitos adversos , Ureter/efeitos dos fármacos , Refluxo Vesicoureteral/terapia , Criança , Pré-Escolar , Cistografia , Dextranos/administração & dosagem , Dilatação Patológica/induzido quimicamente , Dilatação Patológica/diagnóstico , Feminino , Seguimentos , Humanos , Ácido Hialurônico/administração & dosagem , Injeções , Masculino , Ultrassonografia , Ureteroscopia , Refluxo Vesicoureteral/diagnóstico
17.
J Pediatr Urol ; 13(1): 67.e1-67.e6, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28087230

RESUMO

INTRODUCTION: It has become clear that obesity is associated with a variety of infectious diseases, including urinary tract infection (UTI) and renal scarring. OBJECTIVE: The aim of this study was to evaluate the association between obesity and the degree of febrile UTI (fUTI) and renal scarring in children with vesicoureteral reflux (VUR), and to stratify the results into obesity subcategories. STUDY DESIGN: A total of 186 patients were diagnosed with VUR between January 2002 and December 2008. This study retrospectively reviewed the medical records of 72 children with primary VUR who had recurrent fUTI (more than twice). Overweight or obese status of the patients aged <2 years was defined using weight-for-length (WFL) measurements. For 2-5 year old children, body mass index (BMI) percentile-for-age was used. They were divided into three groups as follows; standard (<85%), overweight (85-95%), and obese (≥95%). The following clinical variables were compared: age at diagnosis of primary VUR (months), sex, VUR grade, hydronephrosis grade, presence of renal scarring, surgical treatment, and degree of inflammation during fUTI. RESULTS: In the overweight and obese groups, VUR was diagnosed at a young age (P = 0.05), the degree of renal scarring was more severe (P = 0.006), and serum white blood cell count, C-reactive protein, and erythrocyte sedimentation rate (ESR) levels were significantly higher (P < 0.001, P < 0.001, and P < 0.001, respectively). Abnormal focal dimercaptosuccinic acid (DMSA) defects were present in 25 of the 72 children (35%). Cortical defects occurred more frequently in children with obesity, and they were associated with a higher grade of reflux and serum ESR levels (P = 0.007, P = 0.042, and P = 0.021, respectively). Among these risk factors, high-grade VUR (OR = 9.93, 95% CI = 1.13-86.71), and being overweight and obese (OR = 5.26, 95% CI = 1.75-15.82) were associated with increased renal scarring. However, ESR was not associated with renal scarring (OR = 1.01, 95% CI = 0.95-1.07). DISCUSSION: The relationships between obesity and UTI are controversial. Some studies have shown positive results; however, other studies have shown opposite results. The main limitations of this study were the retrospective data collection via electronic medical records, and the small number of subjects. CONCLUSIONS: This study showed that obesity in patients with VUR has an effect on fUTI and renal scar formation. If the patients with VUR have obesity, close follow-up should be performed, and VUR patients should be started on a weight-loss program, which could reduce the number of patients with chronic kidney disease in the future.


Assuntos
Cicatriz/epidemiologia , Febre/fisiopatologia , Hidronefrose/epidemiologia , Obesidade/epidemiologia , Infecções Urinárias/epidemiologia , Refluxo Vesicoureteral/epidemiologia , Fatores Etários , Análise Química do Sangue , Proteína C-Reativa/análise , Criança , Pré-Escolar , Cicatriz/patologia , Comorbidade , Intervalos de Confiança , Bases de Dados Factuais , Feminino , Humanos , Hidronefrose/diagnóstico , Incidência , Contagem de Leucócitos , Masculino , Obesidade/diagnóstico , Razão de Chances , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Infecções Urinárias/diagnóstico , Refluxo Vesicoureteral/diagnóstico
18.
Genet Med ; 19(4): 412-420, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27657687

RESUMO

PURPOSE: To investigate the utility of whole-exome sequencing (WES) to define a molecular diagnosis for patients clinically diagnosed with congenital anomalies of kidney and urinary tract (CAKUT). METHODS: WES was performed in 62 families with CAKUT. WES data were analyzed for single-nucleotide variants (SNVs) in 35 known CAKUT genes, putatively deleterious sequence changes in new candidate genes, and potentially disease-associated copy-number variants (CNVs). RESULTS: In approximately 5% of families, pathogenic SNVs were identified in PAX2, HNF1B, and EYA1. Observed phenotypes in these families expand the current understanding about the role of these genes in CAKUT. Four pathogenic CNVs were also identified using two CNV detection tools. In addition, we found one deleterious de novo SNV in FOXP1 among the 62 families with CAKUT. The clinical database of the Baylor Miraca Genetics laboratory was queried and seven additional unrelated individuals with novel de novo SNVs in FOXP1 were identified. Six of these eight individuals with FOXP1 SNVs have syndromic urinary tract defects, implicating this gene in urinary tract development. CONCLUSION: We conclude that WES can be used to identify molecular etiology (SNVs, CNVs) in a subset of individuals with CAKUT. WES can also help identify novel CAKUT genes.Genet Med 19 4, 412-420.


Assuntos
Variações do Número de Cópias de DNA , Predisposição Genética para Doença/genética , Anormalidades Urogenitais/diagnóstico , Refluxo Vesicoureteral/diagnóstico , Sequenciamento Completo do Exoma/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Fatores de Transcrição Forkhead/genética , Fator 1-beta Nuclear de Hepatócito/genética , Humanos , Lactente , Peptídeos e Proteínas de Sinalização Intracelular/genética , Masculino , Proteínas Nucleares/genética , Fator de Transcrição PAX2/genética , Linhagem , Polimorfismo de Nucleotídeo Único , Proteínas Tirosina Fosfatases/genética , Proteínas Repressoras/genética , Anormalidades Urogenitais/genética , Refluxo Vesicoureteral/genética , Adulto Jovem
19.
Pediatr Nephrol ; 32(3): 477-484, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-27744618

RESUMO

OBJECTIVES: This study was designed to compare the diagnostic accuracy of plasma neutrophil gelatinase-associated lipocalin (NGAL) with procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBCs) for predicting acute pyelonephritis (APN) in children with febrile urinary tract infections (UTIs). MATERIALS AND METHODS: In total, 138 children with febrile UTIs (APN 59, lower UTI 79) were reviewed retrospectively. Levels of NGAL, PCT, CRP, and WBCs in blood were measured on admission. The diagnostic accuracy of the biomarkers was investigated. Independent predictors of APN were identified by multivariate logistic regression analysis. RESULTS: Receiver operating curve (ROC) analyses showed good diagnostic profiles of NGAL, PCT, CRP, and WBCs for identifying APN [area under the curve (AUC) 0.893, 0.855, 0.879, and 0.654, respectively]. However, multivariate analysis revealed only plasma NGAL level was an independent predictor of APN (P = 0.006). At the best cutoff values of all examined biomarkers for identifying APN, sensitivity (86 %), specificity (85 %), positive predictive value (81 %), and negative predictive value (89 %) of plasma NGAL levels were the highest. The optimal NGAL cutoff value was 117 ng/ml. The positive likelihood ratio [odds ratio (OR) 5.69, 95 % confidence interval (CI) 3.56-8.78], and negative likelihood ratio (OR 0.16, 95 % CI 0.08-0.29) of plasma NGAL for APN diagnosis also showed it seemed to be more accurate than serum PCT, CRP, and WBCs. CONCLUSION: Plasma NGAL can be more useful than serum PCT, CRP, and WBC levels for identifying APN in children with febrile UTIs.


Assuntos
Biomarcadores/sangue , Lipocalina-2/sangue , Pielonefrite/sangue , Pielonefrite/diagnóstico , Proteína C-Reativa/análise , Calcitonina/sangue , Feminino , Humanos , Hidronefrose/sangue , Hidronefrose/diagnóstico , Lactente , Recém-Nascido , Contagem de Leucócitos , Masculino , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Reprodutibilidade dos Testes , Estudos Retrospectivos , Infecções Urinárias/sangue , Infecções Urinárias/diagnóstico , Refluxo Vesicoureteral/sangue , Refluxo Vesicoureteral/diagnóstico
20.
Urology ; 101: 63-66, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27687330

RESUMO

Dextranomer/hyaluronic acid copolymer (Deflux) first received Food and Drug Administration approval in 2001 for endoscopic injection in children with grade II-IV vesicoureteral reflux VUR. As experience has grown, Deflux has been used more liberally with encouraging results. We report 3 cases where Deflux was used in off-label fashion, resulting in delayed ureteral obstruction and loss of renal function (range 18-52 months postoperatively). We now place increased emphasis on the need for long-term follow-up after Deflux in both routine and complex cases, particularly in situations of off-label use.


Assuntos
Dextranos/efeitos adversos , Endoscopia/métodos , Ácido Hialurônico/efeitos adversos , Obstrução Ureteral/etiologia , Refluxo Vesicoureteral/terapia , Doenças Assintomáticas , Criança , Pré-Escolar , Dextranos/administração & dosagem , Endoscopia/efeitos adversos , Feminino , Humanos , Ácido Hialurônico/administração & dosagem , Lactente , Injeções Intralesionais/efeitos adversos , Testes de Função Renal , Masculino , Próteses e Implantes , Obstrução Ureteral/diagnóstico , Obstrução Ureteral/cirurgia , Urografia , Procedimentos Cirúrgicos Urológicos/métodos , Refluxo Vesicoureteral/diagnóstico
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