Angioplasty for renovascular hypertension in children: 20-year experience.

OBJECTIVE: Our aim was to evaluate the clinical outcomes, safety, and efficacy of percutaneous transluminal angioplasty for renovascular hypertension in children. METHODS: A retrospective review of data for all children with renovascular hypertension who underwent percutaneous transluminal angioplasty at a single center between 1984 and 2003 was performed. Patients with renal transplants and inflammatory multisystem diseases were excluded. RESULTS: Thirty-three children, 1.9 to 17.9 years of age (median: 10.3 years), underwent renal angioplasty and/or stenting. Underlying syndromes were present in 10. On angiograms, 16 had bilateral renal artery stenosis, 15 intrarenal disease, 8 aortic stenosis, and 7 cerebrovascular disease. Forty-eight percutaneous transluminal angioplasty procedures were performed, including 15 stenting procedures. There was a high rate of restenosis after stenting (7 of 19 cases, compared with 2 of 27 cases after balloon dilation). Outcomes were cured (ie, blood pressure normal without treatment) for 9 patients, improved blood pressure with same or reduced treatment for 7, blood pressure maintained in >95th percentile because of cerebrovascular disease for 2, no change in blood pressure despite technical success for 10, and technical failure for 5. Blood pressure control improved in 11 of 13 children who had main renal artery disease alone and in 6 of 20 with associated intrarenal disease or stenoses in other vascular beds. There was 1 procedure-related death and 5 minor complications. CONCLUSIONS: Angioplasty produced clinically worthwhile improvement for approximately 50% of patients. High incidence rates of extrarenal involvement and intrarenal disease and a high restenosis rate after stenting accounted for poor blood pressure control in the rest.

Primary vesicoureteric reflux as a predictor of renal damage in children hospitalized with urinary tract infection: a systematic review and meta-analysis.

Renal parenchymal disease after urinary tract infection (UTI) has been associated with the development of hypertension and renal functional impairment. A systematic literature review and meta-analysis was performed to determine how effectively the finding of primary vesicoureteric reflux (VUR) on micturating cystography (MCU) in children hospitalized with UTI predicted renal parenchymal disease on (99m)Technetium-dimercaptosuccinic acid ((99m)Tc-DMSA) scintigraphy. Medline, Embase, and PubMed were use to find reports with original data for children hospitalized with bacteriologically-proven UTI who had undergone both MCU and (99m)Tc-DMSA scintigraphy, and which also reported both positive and negative results of these tests. A meta-analysis of likelihood ratios positive and negative for MCU was then performed, including tests for heterogeneity. Twelve valid studies were found, seven with data for 537 children, with a positive (99m)Tc-DMSA scan prevalence of 59% overall, and seven studies with data for 1062 kidneys, with a positive (99m)Tc-DMSA scan prevalence of 36%. The likelihood ratio positive for MCU was 1.96 (95% CI, 1.51 to 2.54) for children, and 2.34 (1.53 to 3.57) for kidneys. The likelihood ratio negative was 0.71 (0.58 to 0.85) for children and 0.72 (0.61 to 0.86) for kidneys. There was evidence of heterogeneity. The meta-analysis showed that a positive MCU increases the risk of renal damage in hospitalized UTI patients by about 20%, whereas a negative MCU increases the chance of no renal involvement by just 8%. VUR is hence a weak predictor of renal damage in pediatric patients hospitalized with UTI. Physicians should be aware of the limitations of using MCU-detected primary VUR as an effective screening test for renal damage in this population. Furthermore, the pathogenesis of renal damage in such patients is probably complex because it is often detected without demonstrable VUR.