Nader Shaikh1, Jonathan C Craig2, Maroeska M Rovers3, Liviana Da Dalt4, Stefanos Gardikis5, Alejandro Hoberman6, Giovanni Montini7, Carlos Rodrigo8, Seppo Taskinen9, David Tuerlinckx10, Timothy Shope6. 1. Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania2Division of General Academic Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. 2. Department of Paediatric Nephrology, Children's Hospital at Westmead and Sydney School of Public Health, University of Sydney, Sydney, Australia. 3. Departments of Operating Rooms and Health Evidence, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands. 4. Department of Woman's and Child's Health, University of Padova, Padova, Italy. 5. Department of Pediatric Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece. 6. Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. 7. Dialysis Unit, Department of Pediatrics and Nephrology, Azienda Ospedaliero Universitaria Sant'Orsola-Malpighi Bologna, Bologna, Italy. 8. Department of Pediatrics, Germans Trias i Pujol University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain. 9. Department of Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland. 10. Service de Pédiatrie, Université Catholique de Louvain, University Medical Centre Mont-Godinne, Yvoir, Belgium.
Abstract
IMPORTANCE: No studies have systematically examined the accuracy of clinical, laboratory, and imaging variables in detecting renal scarring in children and adolescents with a first urinary tract infection. OBJECTIVES: To identify independent prognostic factors for the development of renal scarring and to combine these factors in prediction models that could be useful in clinical practice. DATA SOURCES: MEDLINE and EMBASE. STUDY SELECTION: We included patients aged 0 to 18 years with a first urinary tract infection who underwent follow-up renal scanning with technetium Tc 99m succimer at least 5 months later. DATA EXTRACTION AND SYNTHESIS: We pooled individual patient data from 9 cohort studies. MAIN OUTCOMES AND MEASURES: We examined the association between predictor variables assessed at the time of the first urinary tract infection and the development of renal scarring. Renal scarring was defined by the presence of photopenia on the renal scan. We assessed the following 3 models: clinical (demographic information, fever, and etiologic organism) and ultrasonographic findings (model 1); model 1 plus serum levels of inflammatory markers (model 2); and model 2 plus voiding cystourethrogram findings (model 3). RESULTS: Of the 1280 included participants, 199 (15.5%) had renal scarring. A temperature of at least 39°C, an etiologic organism other than Escherichia coli, an abnormal ultrasonographic finding, polymorphonuclear cell count of greater than 60%, C-reactive protein level of greater than 40 mg/L, and presence of vesicoureteral reflux were all associated with the development of renal scars (P ≤ .01 for all). Although the presence of grade IV or V vesicoureteral reflux was the strongest predictor of renal scarring, this degree of reflux was present in only 4.1% of patients. The overall predictive ability of model 1 with 3 variables (temperature, ultrasonographic findings, and etiologic organism) was only 3% to 5% less than the predictive ability of models requiring a blood draw and/or a voiding cystourethrogram. Patients with a model 1 score of 2 or more (21.7% of the sample) represent a particularly high-risk group in whom the risk for renal scarring was 30.7%. At this cutoff, model 1 identified 44.9% of patients with eventual renal scarring. CONCLUSIONS AND RELEVANCE: Children and adolescents with an abnormal renal ultrasonographic finding or with a combination of high fever (≥39°C) and an etiologic organism other than E coli are at high risk for the development of renal scarring.
IMPORTANCE: No studies have systematically examined the accuracy of clinical, laboratory, and imaging variables in detecting renal scarring in children and adolescents with a first urinary tract infection. OBJECTIVES: To identify independent prognostic factors for the development of renal scarring and to combine these factors in prediction models that could be useful in clinical practice. DATA SOURCES: MEDLINE and EMBASE. STUDY SELECTION: We included patients aged 0 to 18 years with a first urinary tract infection who underwent follow-up renal scanning with technetium Tc 99m succimer at least 5 months later. DATA EXTRACTION AND SYNTHESIS: We pooled individual patient data from 9 cohort studies. MAIN OUTCOMES AND MEASURES: We examined the association between predictor variables assessed at the time of the first urinary tract infection and the development of renal scarring. Renal scarring was defined by the presence of photopenia on the renal scan. We assessed the following 3 models: clinical (demographic information, fever, and etiologic organism) and ultrasonographic findings (model 1); model 1 plus serum levels of inflammatory markers (model 2); and model 2 plus voiding cystourethrogram findings (model 3). RESULTS: Of the 1280 included participants, 199 (15.5%) had renal scarring. A temperature of at least 39°C, an etiologic organism other than Escherichia coli, an abnormal ultrasonographic finding, polymorphonuclear cell count of greater than 60%, C-reactive protein level of greater than 40 mg/L, and presence of vesicoureteral reflux were all associated with the development of renal scars (P ≤ .01 for all). Although the presence of grade IV or V vesicoureteral reflux was the strongest predictor of renal scarring, this degree of reflux was present in only 4.1% of patients. The overall predictive ability of model 1 with 3 variables (temperature, ultrasonographic findings, and etiologic organism) was only 3% to 5% less than the predictive ability of models requiring a blood draw and/or a voiding cystourethrogram. Patients with a model 1 score of 2 or more (21.7% of the sample) represent a particularly high-risk group in whom the risk for renal scarring was 30.7%. At this cutoff, model 1 identified 44.9% of patients with eventual renal scarring. CONCLUSIONS AND RELEVANCE: Children and adolescents with an abnormal renal ultrasonographic finding or with a combination of high fever (≥39°C) and an etiologic organism other than E coli are at high risk for the development of renal scarring.
Authors: Nader Shaikh; Timothy R Shope; Alejandro Hoberman; Gysella B Muniz; Sonika Bhatnagar; Andrew Nowalk; Robert W Hickey; Marian G Michaels; Diana Kearney; Howard E Rockette; Martin Charron; Ruth Lim; Massoud Majd; Eglal Shalaby-Rana; Marcia Kurs-Lasky; Daniel M Cohen; Ellen R Wald; Greg Lockhart; Hans G Pohl; Judith M Martin Journal: Pediatr Nephrol Date: 2020-06-15 Impact factor: 3.714
Authors: Kevin Meesters; Robin Michelet; Reiner Mauel; Ann Raes; Jan Van Bocxlaer; Johan Vande Walle; An Vermeulen Journal: Antimicrob Agents Chemother Date: 2018-08-27 Impact factor: 5.191
Authors: Zachary N Gordon; Daryl J McLeod; Christina B Ching; Daniel B Herz; D Gregory Bates; Brian Becknell; Seth A Alpert Journal: J Pediatr Urol Date: 2016-05-27 Impact factor: 1.830