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Saudi Journal of Kidney Diseases and Transplantation
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Year : 1996  |  Volume : 7  |  Issue : 1  |  Page : 24-26
Vesico Ureteric Reflux and Renal Scarring in Children with Urinary Tract Infection


Department of Pediatrics, King Hussein Medical Center, Amman, Jordan

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   Abstract 

To evaluate the presence of vesico ureteric reflux (VUR) and renal scarring in children with documented symptomatic urinary tract infection (UTI), and the importance of age at time of presentation, we studied 29 patients with UTI. Nineteen patients were females and 10 were males. Three patients were below one year of age, 13 were between one and five years, and 13 were above five years. None of the patients had systemic hypertension or renal insufficiency. All patients had renal ultrasound and renal scintigraphy with dimercapto succinic acid (DMSA). Micturating cystourethrogram was done in all children below age of five, and in patients above age of five if renal scintigraphy showed evidence of scarring. Of the 29 UTI patients 10 (34%) had VUR. Of the patients with VUR, seven were below age of five while three were above five. Renal scarring was found in 3/7 patients with VUR below age of five years, but was in all patients with VUR above age of five years. All patients with grade 3 and 4 reflux nephropathy had renal scarring, while it was found in half of the patients with grade 1 and 2 reflux. We conclude that in UTI patients VUR is not uncommon finding, which needs further investigations and follow-up.

Keywords: Urinary tract infection, Children, Reflux, Vesico ureteric.

How to cite this article:
Hazza I, Wahadeneh A, Qudah E, Ahmad M. Vesico Ureteric Reflux and Renal Scarring in Children with Urinary Tract Infection. Saudi J Kidney Dis Transpl 1996;7:24-6

How to cite this URL:
Hazza I, Wahadeneh A, Qudah E, Ahmad M. Vesico Ureteric Reflux and Renal Scarring in Children with Urinary Tract Infection. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Sep 26];7:24-6. Available from: http://www.sjkdt.org/text.asp?1996/7/1/24/39535

   Introduction Top


Pyelonephritis in children may lead to irreversible renal damage and eventually to systemic hypertension and renal insufficiency [1] . The incidence of urinary tract infection was reported to be 1.7/1000/year in boys and 3.1/1000/year in girls [1] . Although most of these children do not develop renal damage as a consequence of their infection, a significant minority does [2] . Vesico ureteric reflux (VUR) nephropathy represents a significant cause of chronic pyelonephritis, which may lead to renal scarring and failure [3],[4],[5] . The aim of our study was to evaluate the prevalence of VUR and renal scarring in children with urinary tract infection (UTI), and the importance of age at the time of presentation.


   Patients and Methods Top


We studied symptomatic children presenting to our hospital with proven UTI between July 1992 and July 1993. Twenty nine children were included in the study. The age and sex distributions are shown in [Table - 1]. All patients had physical examinations, and blood renal function tests including urea and creatinine.

Urine samples were taken either by midstream clean catch technique, catheterization or suprapubic method according to age. All children had renal ultrasound at time of presentation. All children below the age of five years with proved UTI, had micturating cystourethrogram (MCUG) after six weeks of presentation, and renal scintigraphy using dimercapto succinic acid (DMSA) at 12 weeks of presentation. All children above the age of 5 years with proven UTI under­went MCUG following the DMSA scan only if the latter showed evidence of renal scars.


   Results Top


All children had normal physical exami­nations including blood pressure, and normal external genitalia. Also all of them had normal blood renal function tests at the entry to the study.

Among the 29 children with UTI there were 10 patients who showed evidence of VUR (34%). Among children with VUR, seven were below age of five years (70%) while three were above age of five (30%). [Table - 2], shows the distribution of VUR and renal scarring among age groups. All children with VUR who were above the age of five years at the time of presentation had scarred kidneys in comparison with 3/7 (42.8%) of those under the age of five years. All patients with grade 3 and 4 reflux had renal scars in comparison to half the number of patients with grade 1 and 2 reflux. Renal ultrasound was not helpful in the diagnosis of VUR since it was reported as normal in 82.7% of the patients. None of our patients developed high blood pressure, or renal insufficiency during the study period.


   Discussion Top


Urinary tract infection is an important childhood condition which should be evaluated by imaging studies to screen the urinary tract for structural abnormalities, to detect renal scarring and to identify VUR [6] . It has been reported that long-term morbidity might be associated with reflux nephropathy due to the presence of renal scarring [7] . The majority of children with reflux nephropathy were noted to have scarred kidneys at the time of investigation of their initial UTI [7],[8],[9] , Our study was in accordance with previous reports showing significant prevalence of VUR and renal scars in children presenting with urinary tract infection. The relation between the grade of VUR and renal scarring was suggested by previous studies [10] . Our study also showed the presence of renal scarring with higher grade of VUR.

We were not surprised to find that the prevalence of renal scars was more common in the older age group, as many of our patients had histories of recurrent UTI. Proper investigations might have not been carried out at the time of their first episode of UTI. Nevertheless, despite the significant prevalence of VUR and renal scars in our study group, hypertension and renal insuffi­ciency were not apparent complications. This lack of correlation was suggested by other reports [11],[12],[13] . Management of VUR depends on the age of detection of this condition, which dictates the modality of therapy, whether surgical or non-surgical [8],[12],[13],[14],[15] . We conclude that in UTI patient VUR is not uncommon finding which need further investigations and follow-up.

 
   References Top

1.Spencer JR., Sohaeffer AJ. Pediatric urinary tract infections. Urol Clin North Am 1986;13:661-72.  Back to cited text no. 1    
2.Jacobson SH, Eklof O, Eriksson CG, Lins LE, Tidgren B, Winberg J. Development of hypertension and uremia after pyelonephritis in childhood: 27 year follow up. Br Med J 1989;299:703-6.  Back to cited text no. 2    
3.Heale WF. Hypertension and reflux nephropathy. Aust Pediatr J 1977;13:56.  Back to cited text no. 3    
4.Broyer M, Rizzoni G, Brunner FP, et al. Combined report on regular dialysis and transplantation of children in Europe XIV. Proc Eur Dial Transplant Assoc Eur Ren Assoc 1984;22:55-79.  Back to cited text no. 4    
5.Dickinson JA. Incidence and outcome of symptomatic urinary tract infection in children. Br Med J 1979;l:1330-2.  Back to cited text no. 5    
6.Haycock GB. A practical approach to evaluating urinary tract infection in children. Pediatr Nephrol 1991;5:401-2.  Back to cited text no. 6    
7.Gleeson FV. Gordon I. Imaging in urinary tract infection. Arch Dis Child 1991;66:1282-3.  Back to cited text no. 7    
8.Birmingham Reflux Study Group. Prospective trial of operative versus non­-operative treatment of severe vesicoureteric reflux: Two years' observation in 96 children. Br Med J Clin Res Ed 1983;287:171-4.  Back to cited text no. 8    
9.Blickman JG, Taylor GA, Lebowitz RL. Voiding cystourethrography: the initial radiologic study in children with urinary tract infection. Radiology 1985;156:659-­62.  Back to cited text no. 9    
10.Jakobsson B, Berg U, Svensson L. Renal Scarring after acute pyelonephritis. Arch Dis Child 1994;70:111-5.  Back to cited text no. 10    
11.Wolfish NM, Delbrouck NF, Shanon A, Matzinger MA, Stenstrom R, McLaine PN. Prevalence of hypertension in children with primary vesicoureteral reflux. J Pediatr 1993;123:559-63.  Back to cited text no. 11    
12.Scholtmeijer RJ. Treatment of vesicoureteric reflux. Results of a prospective study. Br J Urol 1993;71(3):346-9.  Back to cited text no. 12    
13.Smellie JM, Tamminen Mobius T, et al. Radiologic findings in the kidney of children with severe reflux. Five-year comparative study of conservative and surgical treatment. Urologe A 1993;32(l):22-9.  Back to cited text no. 13    
14.Saw AH. Management of urinary tract infection and vesico-ureteric reflux in children. Singapore Med J 1990;31(3):266-8.  Back to cited text no. 14    
15.Jansen H, Scholtmeijer RJ. Results of surgical treatment of severe vesicoureteric reflux. Retrospective study of reflux grade 4 and 5. Br J Urol 1990;65(4):413-7.  Back to cited text no. 15    

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Correspondence Address:
Issa Hazza
Department of Pediatrics, King Hussein Medical Center, PO Box 960955, Amman
Jordan
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PMID: 18417912

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    Abstract
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