jornal club pediatric nephrology

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Slide 1 : Jornal Club Nephrology Virender Verma MD Pediatrics PGIMS Rohtak
Slide 2 : Do systemic symptoms predict the risk of kidney scarring after urinary tract infection. Coulthard MG, Lambert HJ, Keir MJ Royal Victoria Infirmary. Newcastle, UK
Slide 3 : Archives of Diseases in Childhood 2009;94:278-81
Slide 4 : Background and aims: In the National Institute for Health and Clinical Excellence(NICE) guidelines, it is assumed that the presence of severity of systemic symptoms especially fever, predicts the renal scarring and different management is recommended accordingly. The aim of the study was to test this hypothesis by retrospective case note analysis.
Slide 5 : What is already known: Young children presenting with UTIs and high grade fever are assumed to have “UPPER URINARY TRACT” infection and hence increased risk of scarring The NICE guidelines advise treating children with UTIs more assiduously, if they are febrile, although they acknowledge that this is no evidence base.
Slide 6 : NICE guidelines for treating children with age 3m to 3y.
Slide 7 : Design Retrospective Case Note Analysis
Slide 8 : Subjects Children of <5y of age who were referred following their first UTI ( more than equal to 100000 CFU/ml) during 1992-95 from a child population of 15400. This population included children referred acutely and those sent for assessment after their treatment in community and all had a DMSA scan in Royal Victoria Infirmary.
Slide 9 : Method Scar was defined as a focal defect on DMSA scan performed at least 5 months after an episode of UTI and it was noted whether it was single or multiple. The control group consisted of up to three of the next children to have a normal post UTI DMSA scan.
Slide 10 : A review of referral letters and clinical notes was taken to see whether child was febrile or had vomiting, malaise or anorexia at presentation or required hospital admission.
Slide 11 : It was tested that whether these presenting symptoms were associated with age or scarring using statistical method.
Slide 12 : Statistical method: Univariate or multiple regression and by logistic regression
Slide 13 : Results 51 children with scars of whom 55% (28) with multiple scars and 140 unscarred controls In both groups the predominance was of girls (scarred 65%, unscarred 69%) Boys were common among the younger age group.(p=0.015) Younger children were more likely to present with fever, vomiting, anorexia, malaise or required hospitalization.(p<0.001) Vomiting, anorexia and malaise at presentation predict for scarring (p=0.02), but this only refined the scarring risk by 2.7% (R2=0.03)
Slide 14 : No other variable had any associated risk with scarring. (sex p=0.7 , age p=0.9, fever 0.6, hospitalization p=0.06). Comparing only children with multiple scarring had similar pattern of results (vomiting p=0.02, sex p=1.0, age p=0.9, fever p=0.8, hospitalization p=0.8)
Slide 15 : Fever vomiting, Hospitalization anorexia, malaise
Slide 16 : Sensitivities and specificities for predicting renal scarring in children with UTI according to fever vomiting, anorexia and malaise or being hospitalized. According to age groups.
Slide 17 : Discussion This study takes a large number of children in the account but it entirely depends upon the retrospective data which could introduce bias. It demonstrate that while very young children with UTI are more likely to have fever, vomiting, anorexia or malaise or to be admitted to hospital than older children, these variable do not usefully predict for the risk of child having renal scarring. Neither the absence nor the presence of these symptoms has sufficient predictive power either for scarring or for multiple scarring to justify their alternate management. Fever is a common symptom of UTI but it is to be noted that scarring has been reported in the children who do not have fever at presentation, so non-febrile children should not be investigated less assiduously.
Slide 18 : It is evident that kidney scarring could sometime occur while a child has relatively mild symptoms. It has been noted that children may be afebrile immediately after acquiring UTI, all are afebrile and well at 3 days, despite having a persistent UTI and despite not receiving the antibiotics and being in the process of renal scarring. Clearly, great caution should be taken while dealing with a child with UTI and imaging studies should be provided due consideration.
Slide 19 : In summery, fever predicts either weekly or not at all for the risk of renal scarring, mild or severe, among young children with a first UTI, and should not be used to guide management. NICE’s opinion that it should be used to decide which children‘s urine to culture and which antibiotics to use and for how long is not justified.
Slide 20 : What this study adds Systemic symptoms with UTI, including fever do not predict for scarring. If children with afebrile UTI are managed less assiduously about 30% of kidney scars would be missed in infants and 60% in older children.
Slide 21 : Other Related Studies: Development of new renal scars: a collaborative study. J M Smellie etal, Br Med J (Clin Res Ed) 1985;290:1957-1960 In study of the factors surrounding the development of renal scars clinical data and serial radiographs were analyzed in 74 infants and children (66 girls and eight boys) without duplex kidney or obstruction. The development of new scars was seen radiologically in 87 kidneys (74 previously normal and 13 previously scarred). New scarring was extensive in 16 kidneys. Thirty four children were aged 5 or over when scarring occurred.
Slide 22 : Urinary infection occurred in all the children. Diagnosis and effective treatment were delayed in 45 of them; 58 suffered further UTIs between the baseline IVP and the first showing new scarring. Vesicoureteric reflux was seen in 67 of the children. Investigation and treatment varied widely, and few children received long term prophylaxis. Social problems interfered with the management of 22 children. Early diagnosis, prompt effective treatment, investigation, and long term supervision of children with urinary infection are essential if renal scarring is to be reduced; those over the age of 5 are still vulnerable.
Slide 23 : THANKS

 


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