BMJ 1994;308:1193-1196 (7 May)

Papers

Retrospective study of children with renal scarring associated with reflux and urinary infection

J M Smellie, Department of Paediatrics, Rayne Institute, University College and Middlesex School of Medicine, London WC1E 6JJ.,a A Poulton, N P Prescod 

a Department of Paediatric Nephrology, Hospital for Sick Children, Great Ormond Street, London WC1N 3JH, Department of Paediatric Nephrology, Guy's Hospital, London SE1 9RT Correspondence to: Dr

Abstract

Objective : To review the histories of children with bilateral renal scarring and severe vesicoureteric reflux to determine whether an improvement in early management might reduce the risk of scarring.
Design : Retrospective study of medical records and discussion with parents.
Setting : Outpatient departments of two teaching hospitals.
Patients : 52 children aged 1-12 years participating in a randomised comparison of medical and surgical management. All had a history of symptomatic urinary tract infection. Two thirds presented with fever and two with hypertension or renal failure. In only one out of 32 children examined by antenatal ultrasonography was an abnormality suspected. Results - There was delay in diagnosis or appropriate imaging or effective treatment of urinary infection in 50 of the 52 children. In 41 there was delay in diagnosis; there was delay in treating a confirmed infection in 45; no antibacterial prophylaxis was prescribed before imaging in 28; and investigation of the urinary tract was delayed in 33. The severity of scarring was significantly related to delay in diagnosis (X2 for trend 7.43, P=0.01). Four children of mothers known to have reflux nephropathy were not investigated until they developed urinary tract infection.
Conclusions : Efforts to reduce the incidence and severity of renal scarring should be directed towards rapid diagnosis and effective early management of urinary tract infection in infancy and childhood. Stolings and offspring of known patients with severe reflux nephropathy should be investigated for reflux.

Clinical implications

  • Clinical implications

  • The renal scarring associated with vesicoureteric reflux and found in 10-20% of children with urinary infection is serious and can be followed by hypertension or renal failure

  • Clinical and experimental studies have established that delay in treatment of urinary infection is a factor in the development of scarring

  • Delay in diagnosis and treatment of urinary infection or identification of reflux was found in 50 out of 52 children with bilateral renal scarring and bilateral reflux studied retrospectively

  • The severity of the scarring was significantly related to the length of delay in diagnosis of infection

  • The possibility of urinary infection should be considered in any infant or child who is feverish or unwell


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Relevant Article

Urinary tract infection in children How vigorous should investigation be?
M Brindle and J A Holemans
BMJ 1994 309: 609. [Extract] [Full Text]

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