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UTI & VUR

in children
Dr. Issa Hazza.MD
Pediatric Nephrologist
KHMC

:Definition
UTI is defined by the presence of
a pure growth of >100,000
CFU/ml

The risk of developing symptomatic UTI


during childhood is :
2% for boys
8%for girls
3% of boys and 11% of girls will have UTI
by the age of 16 year
Of all children with UTI half are manifested
during the 1st. Year of life

5-15% will have scarring after their 1 st. UTI


32-70%of them will have the scar at the
time of initial assessment
50% of children with UTI will have a
further infection within the 1st.year and
75% within 2 years

Complications of renal scars

Hypertension
Poor renal growth
Recurrent adult pyelonephritis
Impaired GFR
ESRF

Risk factors for the development of


scarring

Urinary tract malformation


Obstruction
Renal dysplasia
VUR
Therapeutic delay
Young age <1year
Bacterial virulence
Host factors

Causes of CRF
UK

Obstructive uropathy 20.2


Reflux nephropathy
7.2
Hypo-dysplasia
25.5
Hereditary
17.6
Glomerulonephritis
10.3
Systemic disease
5.6

NAPRICS
16.1
5.4
15.8
13.3
22
6.8

Diagnosis
Congenital abnormalities
Reflux nephropathy
Neurogenic bladder
NB without neurological deficit
NB with spinal dysraphism
Obstructive uropathy
Renal dysplasia

Hereditary conditions
Oxalosis
ARPKD
Nephronephthesis
Cystinosis
Other

Glomerulopathy
Mesangio capillary GN
Henoch-Schonlein purpura
Focal segmental glomerulosclerosis
Crescentic GN
Diffuse mesangial nephritis
Post strept GN

Hemolytic uremic syndrome


Rhabdomyosarcoma
Total

Number

Percent

80

68.4

36
21
14
7
12
11

30.8
17.9
11.9
6
10.3
9.4

16

13.7

8
3
3
1
1

6.8
2.6
2.6
0.9
0.9

15

12.8

6
3
2
2
1
1

5.1
2.6
1.7
1.7
0.9
0.9

5
1
117

4.3
0.9
100

:APN is defined as
Fever >38
Positive acute phase reactants
ESR,CRP,Leukocytosis
Sensitivity 53-84%
Specificity 44-92%
Positive urine culture

Renal scarring in children during


and after APN
During APN
After 2 months
After 2 years

86%
59%
37%

DMSA &pyelonephritis
Normal DMSA scan with APN does not
exclude the risk of having VUR
Scarred kidneys without reflux represent
the majority
Renal scarring is associated more
frequently with gross reflux
Abnormal DMSA scan is higher in children
<1 year

APN common symptoms during


infancy

Fever
Poor feeding
FTT
Vomiting ,diarrhea
Irritability
sepsis

Signs and Symptoms of Urinary


Tract Infection in Children
Urinary tract signs and symptoms
Dysuria
Frequency
Dribbling/hesitancy
Enuresis after successful toilet training
Malodorous urine
Hematuria
Squatting
Abdominal/suprapubic pain
Systemic signs and symptoms
Fever
Vomiting/diarrhea
Flank/back pain

Criteria for the Diagnosis of UTI


Method of Collection (Pure Culture)

Probability of Infection (%)

SPA Gram-negative bacilli: any number > 99%


Gram-positive cocci: more than a few thousand
Transurethral catheterization>105
= 95%
Clean void Boy>104

Girls:
Three
Specimens
Specimens
105
90%
One Specimen
105

105
80%

2006 American Academy of Pediatrics.

95%

> 99%
Infection likely

Two

Sensitivity and Specificity of Components of the Urinalysis,


Alone and in Combination

Leukocyte esterase
Nitrite
Leukocyte esterase
nitrite positive
Microscopy:
WBCs
Bacteria
Leukocyte esterase , nitrite
microscopy positive

Sensitivity %
83 (67-94)
53 (15-82)

Specificity %
78 (64-92)
98 (90-100)

93 (90-100)

72 (58-91)

73 (32-100)
81 (16-99)

81 (45-98)
83 (11-100)

99.8 (99-100)

70 (60-92)

2006 American Academy of pediatrics

Some Antimicrobials for


Prophylaxis of UTI

TMP alone or in combination with SMX 2 mg of TMP, 10 mg of

SMX per kg as single bedtime dose or 5 mg of TMP, 25 mg of SMX per


kg twice per

Nitrofurantoin1-2 mg/kg as single daily dose

Nalidixic acid 30 mg/kg divided every 12 h

VUR IN CHILDREN
THE RETROGRADE PASSAGE OF
URINE FROME THE BLADDER INTO
.THE URETERS

INCEDENCE
IN INFANT 1%
18-40%IN CHILDREN EVALUATED FOR
THEIRE 1ST. UTI
WILL HAVE RENAL SCARRING 30%

93 CHILDREN WITH PRIMARY VUR


47 MALE/46 FEMALE
GROUP A:
34 patients
25M,9F.
ANTENATALLY Dx
GROUP B:
59 patients
22M,37F
Dx AFTER UTI

RESULTS
GROUP A:MILD VUR (1-3) 25%
SEVERE (4-5) 75%
SCARRING
85%
M>F

GROUP B:
MILD
SEVERE
SCARRING
F>M

70%
30%
63%

Signs and Symptoms of Urinary Tract Infection in Children

GRADING OF VUR
G 1 :REFLUX IN URETER ONLY
G 2:REFLUX EXTEND TO RENAL PELVIS
G3: REFLUX EXTEND TO RENAL PELVIS
WITH DILATED URETER
G4:BLUNTINGT OF THE CALYCES
G5:URETERAL TORTUOISITY

INTRODUCTION
HODSON&EDWARD:DEMONSTRATED
THE ASSOCIATION BETWEEN VUR AND
RENAL SCARRING .1960 .CLIN.RADIOL.11:219-231

BAILY : INTRODUCED THE TERM RN IN 1973


TO IMPHASIZE THE RELATION BETWEEN
RENAL DAMAGE AND VUR..
1973.CLIN.NEPH.1:132-141

DIAGNOSIS of VUR

WORKUP FOR UTI


ANTENATAL SCREENING

INITIAL WORKUP AT 1st


DIAGNOSED FEB. UTI
CHILD <1YR: U/S
ACUTE
MCUG
1-2MONTH
DMSA
2-3 MONTH
CHILD >1YR :U/S
DMSA
MCUG IF RENAL SCAR AT
ANY AGE OR FAMILY Hx OF VUR <4YR

PATHOGENESIS OF SCARRING
CHILDREN BORN WITH RENAL
SCARRING DUE TO DEVELOPMENTAL
HYPOPLASIA
POSTNATALLY ACQUIRED SCARRING IS
DUE TO INFECTION

PATHOGENESIS of VUR
AD PATTERN OF INHERETANCE
PREVELANCE AMONG SIBLINGS 32%
INTRAMURAL LENGTH
OBLIQUE ENTRY
LOCATION OF THE ORIFICE
URETHRAL OBSTRUCTION

.CONT
NEUROMUSCULAR DISEASE
ABNORMAL VOIDING PATTERN.

MANAGEMENT OF VUR
RN15-25% OF CHILDREN WITH ESRF
UK

10% HYPERTENSION IN
CHILDREN

MEDICAL MANAGEMENT
FOR VUR GRADE 1-3 AND CHILDREN
<1YR OF AGE OF ANY GRADE
GRADE 4 WITH NO SCARRING

SURGICAL MANAGEMENT

NON COMPLIANCE
RECURRENT UTI
GRADE 4 WITH SCARRING
GRADE 5
UNRESOLVED VUR BY ADOLESCENTS

TEFLON INJECTION HAS BEEN


ABANDONED BECAUSE OF
CONCERNE ABOUT EMBOLIZATION OF
PARTICLES
COLLAGEN NOT WELL
RECOMMENDED BECAUSE OF HIGH
RATE OF RECURRENCES

INFANT AND YOUNG CHILDREN SHOULD


RECEIVED PROOHYLAXIS TILL THE AGE
OF 5-6 YR AS LONG AS VUR IS PRESENT
CHILDREN Dx AFTER THE AGE OF 5YR
GIVEN PROPHYLAXIS FOR 1YR
FOR THOSE WITH NEW SCAR
FORMATION PROPHYLAXIS IS GIVEN
FOR LONGER PERIOD

OUTCOME
GRADE 1-2:..85% RESOLVED
GRADE 3-425-30% RESOLVED

STUDIES TO COMPARE MEDICAL AND


SURGICAL MANAGEMENT FOR GRADE
4-5 FAILED TO SHOW ANY
STATISTICALDIFFERENCE AND
CONCLUDED THAT THE DEGREE OF
PARENCHYMAL REDUCTION AND
FUNCTIONAL IMPAIRMENT AT THE
START WERE THE MAIN FACTORS TO
DETERMINE THE OUTCOME

..DIAGNOSIScontinue
ANTENATAL SCREENING
WORKUP FOR UTI

Antenatal hydronephrosis

Abnormalities detected antenatally:


1.Abnormalities in the size of the kidneys
2.Abnormalities in the texture of the kidneys
3.The presence of visible cysts
4.The presence of hydronephrosis

Causes of abnormally large sized


kidneys
1.
2.
3.
4.
5.
6.

hydronephrosis
Polycystic kidney disease
Multicystic dysplastic kidney
Congenital nephrotic syndrome
Renal tumour
Compensatory hypertrophy

Conditions that can be detected antenatally

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

PUJ obstruction
VUJ obstruction
VUR
Bladder outlet obstruction
Megaureter
Douplex system
Renal agenesis
Renal dysplasia
ADPKD
ARPKD
Congenital N/S

Antenatal hydronephrosis
(ANH)
Definition:
renal pelvis diameter >5mm
Mild
5-9mm
Moderate 10-15
Severe
>15mm

Society of Fetal Urology Grading System for


Antenatally Detected Hydronephrosis
Grade
I
II

III

IV

Renal pelvis
Parenchymal thickness
Mild splitting (dilatation)
Normal
Moderate splitting
complex confined
within renal border
Normal
Marked splitting
pelvis dilated outside
renal border
calyces dilated
Normal
Further pelvicalyceal dilatation Thin

The Bristol group published prospective


data
18766 pregnant women
100 (0.59%)cases with antenatal
hydronephrosis
46% were bilateral
36% had normal postnatal ultrasound
28% of antenatal hydronephrosis will need
surgery

Postnatal investigations
Antibiotic prophylaxis
us@1&6wk
Normal

hydronephrosis

Stop ab.

MCUG

repeat us@1yr

vur no vur

DMSA MAG3

Indication for urgent MCUG


1. Bilateral hydronephrosis + distended
bladder
2. Unilateral hydronephrosis + solitary
kidney

CONCLUSION
Children after a first UTI should be
investigated
infant with antenatal hydronephrosis
warrant intensive investigation
The goal of treatment of UTI is prevention
of renal injury and symptoms associated
with UTI
Surgery can cures VUR however Reflux
resolves with time