The Swedish infant high-grade reflux trial: UTI and renal damage
The Swedish infant high-grade reflux trial: UTI and renal damage
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DOI：
10.1016/j.jpurol.2016.12.023
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发表时间：
2017-04-01
影响因子：
2
通讯作者：
Brandstrom, Per
中科院分区：
文献类型：
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作者：
Nordenstrom, Josefin;Sjostrom, Sofia;Brandstrom, Per
儿童高度膀胱输尿管反流（VUR）与反复尿路感染（UTI）和肾损害有关。尽管在生命的最初几年持续进行抗生素预防（CAP），但突破性UTI是一个值得关注的问题，并引起早期干预。我们调查是否早期内镜治疗（ET）的VUR 4-5级可以降低UTI复发和肾scarring.Materials and MethodsThis前瞻性，随机，对照，多中心，1年的随访试验包括77名婴儿，< 8个月的年龄与VUR 4-5级（表）随机CAP（n=39）或ET（预防，直到决议）（n=38）的风险。在研究开始时和1年后进行排尿性膀胱尿道造影、超声、肾动脉造影和自由排尿观察。在67例（87%）儿童中观察到脑实质缺陷，其中39例（34例男孩，5例女孩）表现为全身性。在后续行动中，肾功能恶化（新的疤痕或进展，旧的受损面积）和症状UTIs reported.ResultsThere有27个复发性发热UTIs在6（16%）儿童在ET组和10（26%）在CAP组（P=0.43），在8（36%）女孩和8（15%）男孩（P = 0.039）。ET组22例（59%）和CAP组8例（21%）观察到成功的VUR结局（VUR 0-2）（p = 0.0014）。仅在随访时持续扩张性反流患者中观察到多次复发（p = 0.019）。在8名儿童（9个肾脏）中观察到肾造影恶化，治疗组（p = 0.48）或性别（p = 0.17）之间无差异。肾功能恶化与1年时的高膀胱容量（BC）和大残尿量（PVR）相关（p=0.0092和p=0.041）。8例肾功能恶化的儿童中有6例复发性UTI（p=0.0032）。随访时，在持续性VUR 3-5的儿童中观察到9个肾单位中有7个恶化。单变量logistic回归分析发现女性和高PVR是UTI复发的阳性预测因子（p=0.039和0.034），高PVR倾向于预测肾功能恶化（p = 0.053）。随访时VUR分级与UTI复发和肾功能恶化相关。ConclusionThis study did not show any difference between ET and CAP in reducing the risk of UTI recurrence or renal deficiency. ET组VUR缓解率较高，随访时VUR分级与UTI复发和肾脏恶化相关。
IntroductionHigh-grade vesicoureteral reflux (VUR) in children is associated with recurrent urinary tract infection (UTI) and renal damage. Breakthrough UTI despite continuous antibiotic prophylaxis (CAP) during the first years of life is a matter of concern and evokes early intervention. We investigated whether early endoscopic treatment (ET) of VUR grade 4-5 can reduce the risk of UTI recurrence and renal scarring.Materials and methodsThis prospective, randomized, controlled, multicentre, 1-year follow-up trial comprised 77 infants, < 8 months of age with VUR grade 4-5 (Table) randomized to CAP (n=39) or ET (with prophylaxis until resolution) (n=38). Voiding cystourethrogram, ultrasound, renal scintigraphy, and free voiding observation were performed at study entry and after 1 year. Parenchymal defects were seen in 67 (87%) children at entry, 39 (34 boys, 5 girls) of them characterized as generalized. At follow-up, renal deterioration (new scars or progress in old damaged area) and symptomatic UTIs were reported.ResultsThere were 27 recurrent febrile UTIs in 6 (16%) children in the ET group and in 10 (26%) in the CAP group (p=0.43), in eight (36%) girls and eight (15%) boys (p = 0.039). Successful VUR outcome (VUR 0-2) was seen in 22 (59%) in the ET and eight (21%) in the CAP group (p = 0.0014). Multiple recurrences were only seen in patients with persistent dilating reflux at follow-up (p = 0.019). Deterioration on scintigraphy was seen in eight children (9 kidneys) with no difference between treatment groups (p = 0.48) or sex (p = 0.17). Renal deterioration was associated with high bladder capacity (BC) and large residual volume (PVR) at 1 year (p=0.0092 and p=0.041). Six of the eight children with renal deterioration had a recurrent UTI (p=0.0032). Seven of nine renal units with deterioration were seen in children with persistent VUR 3-5 at follow-up. Univariable logistic regression identified female sex and high PVR as positive predictors for recurrent UTI (p=0.039 and 0.034) and high PVR tended to predict renal deterioration (p = 0.053).DiscussionNo differences between the treatment groups regarding recurrent UTI and renal deterioration could be found. Increased PVR and female sex were positive predictors for UTI recurrences. VUR grade at follow-up was correlated to UTI recurrence and renal deterioration.ConclusionThis study did not show any difference between ET and CAP in reducing the risk of UTI recurrence or renal deterioration. The rate of VUR resolution was higher in the ET group and VUR grade at follow-up correlated with both UTI recurrence and renal deterioration.