Diagnosis and Management of VUR after first UTI

What is the evidence to support current model of diagnosing and treating VUR in children after UTI?

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Diagnosis and management of VUR after first UTI

1. Diagnosis and Management of VUR after first UTI

2. Case

• 2.5 year old old white girl with 3 days of:
–
–
–
–
Fever (Tmax = 40°C)
Poor appetite
Fussiness
2 loose stools a day
Urine dip shows moderate leukocyte esterase
Treatment with PO TMP/SMZ initiated
Urine culture (cath specimen) grows >105 E. coli
Child defervesces in 2 days and completely well in 3
days.
• Next steps?

3. Screening for VUR

• Infants and children 2 months to 2 years with initial
UTI should have either a VCUG or RNC performed to
detect the presence and severity of VUR. (Strength of
evidence: fair)
(AAP, Practice Parameter: The Diagnosis, Treatment, and Evaluation
of the Initial UTI in Febrile Infants and Young Children, Pediatrics,
103:4; 843-852, 1999)

4. Screening for VUR

• Infants and children 2 months to 2 years with initial
UTI should have either a VCUG or RNC performed
to detect the presence and severity of VUR. (Strength
of evidence: fair)
(AAP, Practice Parameter: The Diagnosis, Treatment, and Evaluation
of the Initial UTI in Febrile Infants and Young Children, Pediatrics,
103:4; 843-852, 1999)

5. Age at First UTI

0 - 2 years
39%
2 - 6 years
61%
Conway, P. H. et al. JAMA 2007;298:179-186.

6. Screening for VUR

• Infants and children 2 months to 2 years with initial
UTI should have either a VCUG or RNC performed
to detect the presence and severity of VUR. (Strength
of evidence: fair)
(AAP, Practice Parameter: The Diagnosis, Treatment, and Evaluation
of the Initial UTI in Febrile Infants and Young Children, Pediatrics,
103:4; 843-852, 1999)
No recommendations on
how to manage VUR

7. Management of VUR

Scarring at Dx
No
Age
Initial
Yes
F/U
Initial
F/U
<1
Proph Abx
III-V: Surgery
Proph Abx
III-V: Surgery
1-5
Proph Abx
B/L grade V:
Surgery
III-V: Surgery
V: Surgery
III-V: Surgery
6-10
Proph Abx
III-IV: Surgery Proph Abx
III-IV: Surgery
B/L grade III-IV or
B/L grade III-IV
U/L V: Surgery
or U/L V: Surgery
(AUA, Report on The Management of Primary VUR in Children, Journal of Urology,
May, 1997.)

8. Management of VUR

Scarring at Dx
No
Age
Initial
Yes
F/U
Initial
F/U
<1
Proph Abx
III-V: Surgery
Proph Abx
III-V: Surgery
1-5
Proph Abx
B/L grade V:
Surgery
III-V: Surgery
V: Surgery
III-V: Surgery
6-10
Proph Abx
III-IV: Surgery Proph Abx
III-IV: Surgery
B/L grade III-IV or
B/L grade III-IV
U/L V: Surgery
or U/L V: Surgery
“The recommendations, which generally lack empirical scientific
support, reflect the clinical experience and opinion of the panel.”
(AUA, Report on The Management of Primary VUR in Children, Journal of Urology,
May, 1997.)

9. Current Conceptual Model

Figure 3. Conceptual Model
Prophylactic
antibiotics prevent
recurrent UTI
End Stage Renal
Disease
UTI(s)
RENAL
SCARRING
Hypertension
Surgery
corrects VUR
Pre-eclampsia
VUR

10. What is the evidence to support current model of diagnosing and treating VUR in children after UTI?

11. Ecological Evidence

• Analyses of dialysis and transplant
registries
• Expect reduction in incidence of end
stage renal disease attributable to reflux
nephropathy following the diagnosis and
treatment of VUR started in the 1960’s
• Not there
Broyer M, Chantler C, Donckerwolcke R, Ehrich JH, Rizzoni G, Scharer K. The
paediatric registry of the European Dialysis and Transplant Association: 20 years'
experience. Pediatr Nephrol. Dec 1993;7(6):758-768.
Fenton S, Desmeules M, Copleston P, et al. Renal replacement therapy in Canada: a
report from the Canadian Organ Replacement Register. Am J Kidney Dis. Jan
1995;25(1):134-150.