Over 4 decades ago, Hodson & Edwards11. Hodson CJ, Edwards D. Chronic pyelonephritis and vesico-ureteric
reflex. Clin Radiol 1960;11:219-31. PMID: 13714877 DOI:
http://dx.doi.org/10.1016/S0009-9260(60)80047-5
http://dx.doi.org/10.1016/S0009-9260(60)...
described the association between chronic pyelonephritis and vesicoureteral reflux
(VUR). Soon after, the term "reflux nephropathy" started to be used. Since then, urinary
tract infection (UTI) and VUR are considered as risk factors for the development of
renal scars - which cause hypertension in 10% to 20% of patients and chronic kidney
disease (CKD) if the lesions are bilateral. Based on these concepts, urological studies
have been recommended at the time of the first acute pyelonephritis in recurrent UTI in
children of any age.
In the last decade, NICE22. National Institute for Health and Clinical Excellence. Urinary tract
infection in children. London: NICE, 2007 [Cited 2014 Feb 3]. Available from:
http://guidance.nice.org.uk/CG054
http://guidance.nice.org.uk/CG054...
(National Institute for
Health and Clinical Excellence) and the AAP33. Subcommittee on Urinary Tract Infection, Steering Committee on
Quality Improvement and Management.; Roberts KB. Urinary tract infection: clinical
practice guideline for the diagnosis and management of the initial UTI in febrile
infants and children 2 to 24 months. Pediatrics 2011;128:595-610. PMID: 21873693 DOI:
http://dx.doi.org/10.1542/peds.2011-1330
http://dx.doi.org/10.1542/peds.2011-1330...
(American Academy of Pediatrics) published their guidelines, with stringent protocols in
relation to investigation, prioritizing young children. There have been several
Publications44. Lytzen R, Thorup J, Cortes D. Experience with the NICE guidelines for
imaging studies in children with first pyelonephritis. Eur J Pediatr Surg
2011;21:283-6. DOI: http://dx.doi.org/10.1055/s-0031-1277212
http://dx.doi.org/10.1055/s-0031-1277212...
5. La Scola C, De Mutiis C, Hewitt IK, Puccio G, Toffolo A, Zucchetta P,
et al. Different guidelines for imaging after first UTI in febrile infants: yield,
cost, and radiation. Pediatrics 2013;131:e665-71. DOI:
http://dx.doi.org/10.1542/peds.2012-0164
http://dx.doi.org/10.1542/peds.2012-0164...
6. Pennesi M, L'erario I, Travan L, Ventura A. Managing children under
36 months of age with febrile urinary tract infection: a new approach. Pediatr
Nephrol 2012;27:611-5. DOI:
http://dx.doi.org/10.1007/s00467-011-2087-3
http://dx.doi.org/10.1007/s00467-011-208...
7. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring
in children with a first urinary tract infection: a systematic review. Pediatrics
2010;126:1084-91. DOI: http://dx.doi.org/10.1542/peds.2010-0685
http://dx.doi.org/10.1542/peds.2010-0685...
-88. Round J, Fitzgerald AC, Hulme C, Lakhanpaul M, Tullus K. Urinary
tract infections in children and the risk of ESRF. Acta Paediatr 2012;101:278-82.
PMID: 22122273 DOI:
http://dx.doi.org/10.1111/j.1651-2227.2011.02542.x
http://dx.doi.org/10.1111/j.1651-2227.20...
in order to demonstrate that the injudicious application of these
protocols can induce a failure in prevention, since a significant number of children
would be without a VUR and scarring diagnosis that can occur after the first UTI in
5%-15% of cases.
If investigation and antibiotic prophylaxis are still controversial nowadays, even more are the indications of conservative, surgical or endoscopic treatment for VUR. In the absence of international consensus, today we try to stratify risk factors according to family history, gender, age, laterality, UTI recurrence, VUR grade, scars and association with lower urinary tract dysfunction (LUTD). In this sense, it is interesting to notice the current trend to separate two groups of patients:
a) Boys with more hydronephrosis, UTI and higher grade VUR in the neonatal period, often
with congenital kidney lesion by dysplasia (10%) and which may also include acquired
scarring lesions, are best suited to surgical treatment.99. Paintsil E. Update on recent guidelines for the management of urinary
tract infections in children: the shifting paradigm. Curr Opin Pediatr 2013;25:88-94.
DOI: http://dx.doi.org/10.1097/MOP.0b013e32835c14cc
http://dx.doi.org/10.1097/MOP.0b013e3283...
b) Girls with higher recurrence of febrile UTI and renal scarring acquired after the
neonatal period and related to LUTD. Forty to sixty percent of children with VUR have
LUTD and prevalence of renal scarring reaches 30%.1010. Tekgül S, Riedmiller H, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C,
et al.; European Association of Urology. EAU guidelines on vesicoureteral reflux in
children. Eur Urol 2012;62:534-42. LUTD presents symptoms of urine urgency or postponement, daytime and/or
nighttime incontinence, changes in urine flow, post-void residual volume, urethra
deformations (spindle-shaped) and recurrent UTI; there may be chronic and severe
constipation (eliminations syndrome). The American Urological Association (AUA) in their
guidelines,1111. Peters CA, Skoog SJ, Arant BS Jr, Copp HL, Elder JS, Hudson RG, et
al. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in
Children. J Urol 2010;184:1134-44. DOI:
http://dx.doi.org/10.1016/j.juro.2010.05.065
http://dx.doi.org/10.1016/j.juro.2010.05...
emphasizes the need to
investigate these symptoms early on in the first UTI episode, and thus, the focus should
be the treatment of LUTD, stating "A happy bladder is an empty bladder and an empty
rectum."
Infants also have VUR-related LUTD. In a recently-published paper1212. Sillén U, Brandström P, Jodal U, Holmdahl G, Sandin A, Sjöberg I, et
al. The Swedish reflux trial in children: v. Bladder dysfunction. J Urol
2010;184:298-304. (Swedish Reflux Trial), including 203 infants with III-IV grade
VUR, 34% had LUTD with a negative effect on VUR resolution and renal scarring in two
years of follow up. Noninvasive bladder function assessment in infants is possible and
has been applied in this study through the 4-hour voiding observation test,1313. Holmdahl G, Hanson E, Hanson M, Hellström AL, Hjälmås K, Sillén U.
Four-hour voiding observation in healthy infants. J Urol 1996;156:1809-12. PMID:
8863622 DOI: http://dx.doi.org/10.1016/S0022-5347(01)65543-5
http://dx.doi.org/10.1016/S0022-5347(01)...
enabling an early selection of these
patients.
Conservative treatment is based on the fact that spontaneous VUR resolution occurs mainly in young patients with low-grade VUR, reaching 80% in I- II VUR and 30%-50% in the III-IV VUR in 4-5 years of follow up.1010. Tekgül S, Riedmiller H, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C, et al.; European Association of Urology. EAU guidelines on vesicoureteral reflux in children. Eur Urol 2012;62:534-42.
In the present issue of the Brazilian Journal of Nephrology, Teixeira et al.1414. Teixeira CBB, Cançado MAP, Carvalhaes JTA. Refluxo Vesicoureteral primário na infância: tratamento conservador versus intervenção cirúrgica. J Bras Nefrol 2014;36:10-7 described a group of patients with VUR maintained on conservative treatment or referred for surgical treatment and, despite the limited number of patients and its retrospective character, the study confirms literature findings regarding age, gender, UTI recurrence and the high rate of renal scarring (37.2%), reinforcing the need for seriousness in the implementation of investigation and treatment protocols in children with UTI and bringing to discussion current points concerning the stratification of risk groups.
The heterogeneity of the various studies hinders comparative analysis and most recommendations are based on consensus. While primary VUR receives conservative treatment or prophylaxis with endoscopic or open surgery, cases secondary to LUTD benefit from urotherapy, antibiotic prophylaxis, pelvic floor biofeedback, anticholinergics and parasacral transcutaneous electrical stimulation, according to the type of dysfunction, with high resolution of VUR. In our experience,1515. Meneses RP, Braga D, Melamed SCV, Andrade L. Tratamento das disfunções do trato urinário inferior. J Parana Pediatr 2010;11:76-81. among 402 children with LUTD, 73% females with mean age of 7.3 ± 2.8 years, 29% had VUR - and among these 39% had renal scarring. LUTD treatment brought about cure and reduction in VUR grade in 56% and 24%, respectively.
In Brazil , in addition to a few specialized centers to cater for the large number of
patients, social difficulties often hinder the maintenance of antibiotic prophylaxis and
monitoring, and these cases end up being taken to surgical treatment, but we should bear
in mind that in the presence of LUTD, surgical procedures are often doomed to failure.
Many studies are yet to come; and sayings like "an ounce of prevention is better than a
pound of cure"99. Paintsil E. Update on recent guidelines for the management of urinary
tract infections in children: the shifting paradigm. Curr Opin Pediatr 2013;25:88-94.
DOI: http://dx.doi.org/10.1097/MOP.0b013e32835c14cc
http://dx.doi.org/10.1097/MOP.0b013e3283...
or 'scars may develop in infant
kidneys quicker than urine culture can confirm the diagnosis, and that reflux
nephropathy has no age limit"88. Round J, Fitzgerald AC, Hulme C, Lakhanpaul M, Tullus K. Urinary
tract infections in children and the risk of ESRF. Acta Paediatr 2012;101:278-82.
PMID: 22122273 DOI:
http://dx.doi.org/10.1111/j.1651-2227.2011.02542.x
http://dx.doi.org/10.1111/j.1651-2227.20...
demonstrate the
concern of pediatric nephrologists vis-à-vis recurrent UTI and VUR in childhood.
Referências
-
1Hodson CJ, Edwards D. Chronic pyelonephritis and vesico-ureteric reflex. Clin Radiol 1960;11:219-31. PMID: 13714877 DOI: http://dx.doi.org/10.1016/S0009-9260(60)80047-5
» http://dx.doi.org/10.1016/S0009-9260(60)80047-5 -
2National Institute for Health and Clinical Excellence. Urinary tract infection in children. London: NICE, 2007 [Cited 2014 Feb 3]. Available from: http://guidance.nice.org.uk/CG054
» http://guidance.nice.org.uk/CG054 -
3Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management.; Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128:595-610. PMID: 21873693 DOI: http://dx.doi.org/10.1542/peds.2011-1330
» http://dx.doi.org/10.1542/peds.2011-1330 -
4Lytzen R, Thorup J, Cortes D. Experience with the NICE guidelines for imaging studies in children with first pyelonephritis. Eur J Pediatr Surg 2011;21:283-6. DOI: http://dx.doi.org/10.1055/s-0031-1277212
» http://dx.doi.org/10.1055/s-0031-1277212 -
5La Scola C, De Mutiis C, Hewitt IK, Puccio G, Toffolo A, Zucchetta P, et al. Different guidelines for imaging after first UTI in febrile infants: yield, cost, and radiation. Pediatrics 2013;131:e665-71. DOI: http://dx.doi.org/10.1542/peds.2012-0164
» http://dx.doi.org/10.1542/peds.2012-0164 -
6Pennesi M, L'erario I, Travan L, Ventura A. Managing children under 36 months of age with febrile urinary tract infection: a new approach. Pediatr Nephrol 2012;27:611-5. DOI: http://dx.doi.org/10.1007/s00467-011-2087-3
» http://dx.doi.org/10.1007/s00467-011-2087-3 -
7Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics 2010;126:1084-91. DOI: http://dx.doi.org/10.1542/peds.2010-0685
» http://dx.doi.org/10.1542/peds.2010-0685 -
8Round J, Fitzgerald AC, Hulme C, Lakhanpaul M, Tullus K. Urinary tract infections in children and the risk of ESRF. Acta Paediatr 2012;101:278-82. PMID: 22122273 DOI: http://dx.doi.org/10.1111/j.1651-2227.2011.02542.x
» http://dx.doi.org/10.1111/j.1651-2227.2011.02542.x -
9Paintsil E. Update on recent guidelines for the management of urinary tract infections in children: the shifting paradigm. Curr Opin Pediatr 2013;25:88-94. DOI: http://dx.doi.org/10.1097/MOP.0b013e32835c14cc
» http://dx.doi.org/10.1097/MOP.0b013e32835c14cc -
10Tekgül S, Riedmiller H, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C, et al.; European Association of Urology. EAU guidelines on vesicoureteral reflux in children. Eur Urol 2012;62:534-42.
-
11Peters CA, Skoog SJ, Arant BS Jr, Copp HL, Elder JS, Hudson RG, et al. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children. J Urol 2010;184:1134-44. DOI: http://dx.doi.org/10.1016/j.juro.2010.05.065
» http://dx.doi.org/10.1016/j.juro.2010.05.065 -
12Sillén U, Brandström P, Jodal U, Holmdahl G, Sandin A, Sjöberg I, et al. The Swedish reflux trial in children: v. Bladder dysfunction. J Urol 2010;184:298-304.
-
13Holmdahl G, Hanson E, Hanson M, Hellström AL, Hjälmås K, Sillén U. Four-hour voiding observation in healthy infants. J Urol 1996;156:1809-12. PMID: 8863622 DOI: http://dx.doi.org/10.1016/S0022-5347(01)65543-5
» http://dx.doi.org/10.1016/S0022-5347(01)65543-5 -
14Teixeira CBB, Cançado MAP, Carvalhaes JTA. Refluxo Vesicoureteral primário na infância: tratamento conservador versus intervenção cirúrgica. J Bras Nefrol 2014;36:10-7
-
15Meneses RP, Braga D, Melamed SCV, Andrade L. Tratamento das disfunções do trato urinário inferior. J Parana Pediatr 2010;11:76-81.
Publication Dates
-
Publication in this collection
Jan-Mar 2014
History
-
Received
25 Oct 2013 -
Accepted
03 Jan 2014