More on the Long-Term Outcome of Children with UTI and Reflux
More on the Long-Term Outcome of Children with UTI and Reflux
ABSTRACT & COMMENTARY
Synopsis: The long-term prognosis of children with vesicouretic reflux is excellent, for fewer than 10% of these patients treated either medically or surgically have persistent hypertension or azotemia as adults.
Source: Smellie JM, et al. Childhood reflux and urinary infection: A follow-up of 10-41 years in 226 adults. Pediatr Nephrol 1998;12:727-736.
Smellie and colleagues determined the outcome of 226 patients with childhood vesicouretic reflux (VUR) and urinary tract infection followed for 10-35 years. As children, 30% had severe VUR (Grade III-V) and 38% had evidence of renal scarring. The age at presentation ranged from 5 days to 12 years (mean 5 years), but most had previous presumed or documented UTIs. The majority (193/226; 85%) were followed medically and treated with continuous low-dose antibiotic prophylaxis until VUR was demonstrated to have resolved on two cystograms. The other 15% of cases underwent surgical reimplantation of the ureters.
Follow-up in adulthood revealed that few had hypertension or azotemia (7.5%) and that these long-term sequelae occurred exclusively in those patients who had scarring, hypertension, and azotemia in childhood. Renal scarring occurred in 38% of cases, but this was not directly related to the severity of the reflux. No new scars developed after puberty. Smellie et al conclude that early recognition and medical management of children with UTI and VUR are important to limit the development of renal scars and prevent chronic renal disease.
COMMENT BY THOMAS KENNEDY, MD, FAAP
This is a wonderfully meticulous, perspective, long-term longitudinal study of the kind we have come to expect from Smellie et al in London. The duration of follow-up with minimal attrition (only 10 patients were lost to follow-up), the relatively large population studied, and the detailed data that were collected prospectively makes the report truly remarkable. Given the continued amount of confusion and contradictory data regarding the risk and relationship of childhood UTI, VUR, scarring, renal insufficiency, and progression to end-stage renal disease, the study is a welcome addition. The following points are supported by Smellie et al’s report. First, most children with UTI and VUR, even including the majority with scarring, have normal renal function as adults (at least if followed with careful medical management and antimicrobial prophylaxis). Second, in the few adults who develop either hypertension or renal insufficiency (7.5%), all had evidence of severe scarring with or without hypertension and azotemia in childhood, thus, providing no surprises. Third, renal scarring is common (38%) in children with UTI and VUR and is not directly related to the severity of reflux. Fourth, most scarring occurs in early childhood and is frequently present at the initial radiographic evaluation of the child. Fifth, it is unusual for new scars to develop after medical management is instituted and no new scars appear after puberty and, thus, supporting Smellie et al’s plea for prompt recognition and management. Sixth, VUR resolved in the majority (76%), including those with grades III-V, although cystograms were not repeated beyond childhood, and resolution of VUR did not appear to confer a better outcome. Seventh, although the overall size of scarred kidneys was smaller in the patients with renal scarring than those in the unscarred group, renal growth measured in both groups was not significantly different. Eighth, although the numbers treated surgically were very small, there appeared to be no difference between the children who had surgery and the majority of the children who were medically managed.
This is a great deal to conclude from a single study and helps to unmuddy the murky waters that currently surround this important and controversial aspect of pediatric medicine. Wouldn’t it be wonderful if many other investigators had the perseverance and foresight to begin and complete prospective studies that cover 35 years?
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