Estimation of renal function in children and adolescents with spinal dysraphism.

PURPOSE: In children with spinal dysraphism such as myelomeningocele the relation between muscle mass and body composition varies considerably. Therefore, it is difficult to evaluate the relevance of renal function assessments done with serum creatinine. Since serum cystatin C has been suggested to be independent of body size and composition, this evaluation was compared to chromium(51) edetic acid clearance. MATERIALS AND METHODS: Simultaneous measurements of cystatin C and chromium(51) edetic acid clearance were performed prospectively in 65 patients 2 to 19 years old with spinal dysraphism. RESULTS: Cystatin C values were within the normal range in all patients, while chromium(51) edetic acid clearance was reduced in 10. A significant relation was seen. CONCLUSIONS: Using chromium(51) edetic acid clearance as a gold standard, children with spinal dysraphism and slightly to moderately reduced renal function may remain undiagnosed if cystatin C is used for evaluation.

Complications of clean intermittent catheterization in young females with myelomeningocele: 10 to 19 years of followup.

PURPOSE: We evaluated the rate of complications associated with catheterization and the risk of urethral lesions in girls with myelomeningocele treated with clean intermittent catheterization for a minimum of 10 years. MATERIALS AND METHODS: We examined the medical records of 31 females with myelomeningocele followed from the start of clean intermittent catheterization until age 11 to 20 years. Catheterization had been performed for a median of 15 years (range 10 to 19). Altogether, catheterization was used for a total of 459 patient-years. Noncoated polyvinyl chloride catheters were used in all cases. Anticholinergic treatment was given during 176 of the patient-years. RESULTS: Complications of catheterization were recorded in 13 patients on 20 occasions. Macroscopic hematuria was seen in 4 individuals. In 2 patients the hematuria was caused by urethral polyps that were cured by resection. Difficulties with catheterization occurred in 12 patients. The problems were solved by temporary use of lubrication or by other minor changes in management. There were no difficulties recorded after puberty. The risk of difficulties at catheterization doubled with the use of a Ch8 to Ch10 catheter compared to a Ch12 or larger catheter, and doubled during assisted clean intermittent catheterization compared to clean intermittent self-catheterization. CONCLUSIONS: There were remarkably few problems associated with clean intermittent catheterization in these females with myelomeningocele, despite long treatment periods and use of noncoated polyvinyl chloride catheters. Clean intermittent self-catheterization and large size catheters were associated with few complications.

Complications of clean intermittent catheterization in boys and young males with neurogenic bladder dysfunction.

PURPOSE: We evaluate the risk for urethral lesions and epididymitis in boys with neurogenic bladder dysfunction treated by clean intermittent catheterization (CIC) for a minimum of 10 years. MATERIALS AND METHODS: The medical records of 28 males with neurogenic bladder dysfunction followed from the start of CIC until the age of 15 to 20 years were reviewed. RESULTS: CIC had been performed for a median of 16 years (range 10 to 21). Overall CIC was used for 438 years (265 before and 173 after puberty). During 76% of the years a noncoated polyvinyl chloride catheter with lubrication was used and in 24% of years a hydrophilic coated polyvinyl chloride catheter was used. The catheter size was 12C or greater in 43% of the cases. Independence from self-catheterization occurred during 37% of the CIC years. Of the patients 19 experienced at least 1 episode of difficulty inserting the catheter and/or had macroscopic hematuria on a total of 42 occasions. Major urethral lesions were seen on cystoscopy in 7 patients on 9 occasions (5 false passages, 1 superficial recess, 2 meatal stenoses, 1 urethral stricture). Major urethral lesions were not associated with puberty and did not occur during self-catheterization or with use of catheters 12C or greater. Epididymitis was seen in only a 12 year-old boy. CONCLUSIONS: The overall rate of complications was low. The incidence of major urethral lesions did not increase during puberty. Self-catheterization and 12C catheter or greater seemed to be protective against major lesions.

Protective effect of breastfeeding against urinary tract infection.

AIM: To assess the possible protective effect of exclusive breastfeeding against first-time febrile urinary tract infection (UTI) in children. METHODS: Two children's hospitals and local child health centres in the Göteborg area, Sweden, participated in a prospective case-control study. In total, 200 consecutive cases (89M, 111F), aged 0-6y, presenting with first-time febrile UTI were enrolled. The mean +/- SD age was 0.98 +/- 1.15 y. As control subjects, 336 children (147M, 189F) were recruited from the child health centre of the case, matched for age and gender and included consecutively for each case during the first days after diagnosis. The duration of exclusive breastfeeding was obtained from the case and controls by a standardized procedure. RESULTS: Ongoing exclusive breastfeeding gave a significantly lower risk of infection. A longer duration of breastfeeding gave a lower risk of infection after weaning, indicating a long-term mechanism. The protective role of breastfeeding was strongest directly after birth, then decreased until 7 mo of age, after which age no effect was demonstrated. CONCLUSION: A protective role of breastfeeding against UTI was demonstrated. The study provides statistical support to the view that breast milk is a part of the natural defence against UTI.

Antibiotic treatment for five days is effective in children with acute cystitis.

UNLABELLED: Short courses of antibiotics are often recommended to treat children with acute cystitis despite lack of firm evidence to support such management. The aim of this study therefore was to analyse the short-term outcome of such treatment. The retrospective analysis included 300 children (252F, 48M) fulfilling the criteria of first-time acute cystitis and managed according to a protocol recommending 5 d treatment. In 214 (71%) the treatment was given according to the protocol and in the others for 7 or 10 d. Nitrofurantoin was used in 150 (50%) and trimethoprim without or with sulfonamide in 129 (43%). The short-term results were excellent with 96% of the children being free from symptoms at the first follow-up visit after a median of 6 d. Only 2 girls had persisting bacteriuria and thus the frequency of bacteriological treatment failure was 1%. Recurrence within 30 d occurred in 4 girls (2%). CONCLUSION: A 5 d treatment with antibiotics is adequate in children with acute cystitis. Routine follow-up visits after a first acute cystitis may not be necessary, providing that the bacteria causing the infection are sensitive to the prescribed antibiotic and that there is no history of defective bladder or bowel emptying.

Outcome at 10 years of severe vesicoureteric reflux managed medically: Report of the International Reflux Study in Children.

OBJECTIVE: To study the progress of vesicoureteric reflux (VUR) grade III or IV in children followed up prospectively over 10 years. STUDY DESIGN: One hundred forty-nine children (33 boys and 116 girls) with VUR were recruited for the International Reflux Study in Children and were treated with a medical regimen and monitored by means of serial cystograms. VUR disappearance was based on negative findings on 2 consecutive cystograms. RESULTS: At 5 years, VUR with dilatation was seen in 72 (48%) children and VUR without dilatation, in 55 (37%); 22 (15%) children had no reflux. At 10 years, VUR with dilatation was seen in 34 (23%) children and VUR without dilatation, in 37 (25%); 78 (52%) children had no reflux. Grade IV VUR persisted in 8 children. Absence of VUR was significantly associated with grade III versus grade IV VUR (P = .007), unilateral versus bilateral reflux (P = .0002), and age > or = 5 years at entry versus age < 5 years (P = .001). Neither sex nor renal scarring at entry individually affected resolution of VUR. Among 43 (29%) children with intermittent VUR, only 6 had reflux with dilatation at 10 years. CONCLUSION: Continuing reduction in the severity of VUR in children receiving careful medical treatment was observed over 10 years. On the basis of negative findings on 2 consecutive cystograms, VUR was absent in half of the children.

Association between urinary tract infection, renal damage and birth size.

UNLABELLED: The aim of this study was to investigate whether birth size is associated with permanent renal damage in children with urinary tract infection (UTI). A cohort of 1221 children under 16 y of age was diagnosed with their first symptomatic UTI between 1970 and 1979. Of these, 74 had urographic renal scarring in childhood and 57 were re-examined as adults. The birth files of 48 of these patients (35F, 13M) were available, and birthweight and birthlength in relation to gestational age were analysed and compared with a Swedish reference population. Children who had renal damage without vesicoureteric reflux were significantly smaller at birth (median weight, -0.76 SDS) compared with both children who had renal damage and reflux (median weight, -0.01 SDS) and the reference population. CONCLUSION: The demonstration of low birthweight among children with UTI and renal damage but no reflux suggests that low birthweight may be a risk factor for the development of renal damage.

Renal concentrating capacity test using desmopressin at bedtime.

A crossover trial was undertaken to evaluate the bedtime administration of desmopressin (Minirin) as a renal concentrating capacity test (RCCT). Medication was given intranasally as a single 20-microgram dose to 58 children ranging from 3 to 15 years of age with suspected or known renal impairment. The night-time test was shown to be a simple and effective means of assessing renal concentrating capacity. Comparison with the standard daytime test resulted in a 60 mosmol/kg higher mean osmolality in the night-time test. The results were reproducible, with a 95% confidence interval of -26 to 43 mosmol/kg. The procedure was easy to perform, with 51 of 52 patients (or their parents) preferring the night-time regimen compared with the daytime test. Night-time desmopressin therefore offers the potential of a user-friendly RCCT in patients with suspected impairment of renal tubular function.

Detection of urographic scars in girls with pyelonephritis followed for 13-38 years.

We report the detection and progression of renal scars in girls prospectively followed from their first recognized urinary tract infection. There were 107 infection-prone subjects with a median age of 7.1 years at the first and 21.7 years at the last urography. Of 51 females who ultimately had lesions, 38 had established scars at the first urography. In 18 subjects, new scars were found in previously undamaged kidneys, 5 already with unilateral scarring. There had been a normal urography after the 5th birthday in 8 of those with later scarring. Worsening of scarring was seen in 10 of the 38 subjects with established scars. The renal damage was in most cases slight or moderate. By stepwise logistic regression analysis, grade of reflux and number of pyelonephritic attacks correlated with scarring, and number of pyelonephritic attacks with new scars and worsening of the lesions. In summary, of the females who ultimately had renal lesions, one-third developed new scars. In most of those with established scars at the first urography, the focal character of lesions suggests that most were also acquired. Since reflux and number of pyelonephritic attacks were identified as risk factors, prevention of renal deterioration should be possible.

Ambulatory blood pressure 16-26 years after the first urinary tract infection in childhood.

OBJECTIVE: To evaluate blood pressure in a population-based cohort with urographic renal scarring after childhood urinary tract infection. DESIGN: Follow-up investigation 16-26 years after the first recognized urinary tract infection. SETTING: University out-patient clinic for children with urinary infections serving the local area. PATIENTS: From the original cohort of 1221 consecutive children with first urinary tract infection diagnosed during 1970-1979, 57 of 68 with non-obstructive renal scarring participated as well as 51 matched subjects without scarring. MAIN OUTCOME MEASURE: 24 h ambulatory blood pressure. RESULTS: Acceptable blood pressure monitorings were obtained from 53 individuals with and 47 without scarring. There were no significant differences between the two groups even when only patients with the most extensive scarring (individual kidney clearance < 30 ml/min per 1.73 m2) or patients with bilateral scarring were compared with the non-scarring group. Mean systolic or diastolic blood pressure above +2 SD were found in 5/53 (9%) and 3/47 (6%) in the scarring and non-scarring group, respectively. Plasma renin activity, angiotensin II and aldosterone concentrations were not significantly different, but atrial natriuretic protein was significantly higher in the scarring group (P = 0.004). CONCLUSION: This study demonstrates a low risk of hypertension two decades after childhood urinary tract infection. It should be stressed that the patients with renal scarring were under close supervision throughout childhood. Those with scarring had higher concentrations of atrial natriuretic protein which might indicate a counter-regulation mechanism.

Renal function 16 to 26 years after the first urinary tract infection in childhood.

OBJECTIVE: To evaluate renal function in a population-based cohort with urographic renal scarring after childhood urinary tract infection (UTI). DESIGN: Follow-up investigation 16 to 26 years after the first recognized UTI. SETTING: Outpatient university clinic for children with UTI serving the local area. PATIENTS: From the original cohort of 1221 consecutive children with first UTI diagnosed during 1970 to 1979, 57 (41 females and 16 males; mean age, 24.5 years) of 68 with nonobstructive renal scarring participated as well as 51 (38 females and 13 males; mean age, 24.9 years) matched subjects without scarring. MAIN OUTCOME MEASURE: Glomerular filtration rate (GFR) measured by chromium 51-EDTA clearance, expressed as milliliters per minute per 1.73 square meters. RESULTS: Median GFR was 99 in both those with and without renal scarring. In patients with unilateral scarring, the total GFR remained unchanged over the years whereas the individual GFR of the scarred kidneys declined significantly from 46 to 39. In 7 patients with bilateral scarring, the GFR declined from 94 to 84 (P = .14); compared with those with unilateral scarring, the GFR was significantly lower at follow-up (P = .007). Median urinary albumin-creatinine ratio was 1.2 and 0.6 mg/mmol in those with scarring and those without, respectively (P = .30). CONCLUSIONS: The GFR 2 decades after the first recognized UTI in childhood was well preserved. However, a significant reduction of individual renal GFR in the unilaterally scarred kidneys indicates that further follow-up is required. Although there were few patients with bilateral scarring, a more serious prognosis can be expected among them.

Primary and acquired renal scarring in boys and girls with urinary tract infection.

OBJECTIVES: To determine when pyelonephritic renal scarring was detected in children with urinary tract infection (UTI) and characterize those with primary and acquired scarring, respectively. STUDY DESIGN: A population-based cohort of 1221 children (989 girls and 232 boys) with first recognized symptomatic UTI, aged 0 to 15 years, were diagnosed and followed up prospectively at a single children's hospital; 652 had febrile UTI. Seven hundred fifty-three were evaluated by urography. Renal scarring was classified as primary or acquired, the latter without signs of scarring at the first investigation. To evaluate the frequency of recurrent UTI in those with acquired scarring, a comparison with group-matched children without scarring was performed. RESULTS: A total of 74 children without obstruction had renal scarring (acquired in 40). Primary scarring was found in 18 of 21 (86%) of the boys and 16 of 53 (30%) of the girls (P <.001). The majority of boys with scarring had dilated reflux (67%) in contrast to girls (23%). Recurrent UTI was rare in boys, whereas girls with acquired scarring had significantly more febrile recurrences than girls without scarring. CONCLUSIONS: Most boys had primary, probably congenital, reflux-associated renal damage, whereas most girls had acquired scarring related to recurrences of febrile UTI.

Medical or surgical management for children with vesico-ureteric reflux?

A critical survey of the literature on treatment of children with vesico-ureteric reflux was carried out in order to create a basis for the new Swedish management policy. There are few studies that meet modern standards of scientific methodology and provide adequate patient numbers. The only large investigations that randomized patients to operative or non-operative treatment were the Birmingham Reflux Study and the International Reflux Study in Children. In these studies, long-term outcome of renal status and renal function, as well as the number of recurrent infections, were independent of treatment modality. Although pyelonephritic recurrences were less common in the surgically managed group, this did not influence appearance of renal damage. There is no evidence to indicate clear superiority of either medical or surgical management. Further studies are needed to address such questions as the optimal duration of antibacterial prophylaxis and the effect of a dilating reflux that persists into adulthood.

Guidelines for management of children with urinary tract infection and vesico-ureteric reflux. Recommendations from a Swedish state-of-the-art conference. Swedish Medical Research Council.

There are considerable variations in the management of children with urinary tract infection and reflux. These new guidelines were written after critical review of the literature, but are also based on clinical experience, since there are issues that have not been otherwise adequately studied. The aim is to limit renal damage and future complications, with minimal discomfort to the child, and to avoid unnecessary costs. The recommendations include increased attention to bladder dysfunction, shortening of the time of antibacterial prophylaxis and focus on renal development and function rather than on reflux.

Urodynamic pattern in asymptomatic infants: siblings of children with vesicoureteral reflux.

PURPOSE: We studied the urodynamic pattern in asymptomatic infants who are siblings of children with vesicoureteral reflux. MATERIALS AND METHODS: Cystometry and perineal electromyography were performed with voiding cystourethrography in 16 male and 21 female infant siblings screened for reflux at age 0.2 to 7.3 months (median 1.1). RESULTS: Vesicoureteral reflux was present in 25% of the male and 10% of the female infants. In those without vesicoureteral reflux unstable bladder contractions were noted in 8% of the male and 16% of the female subjects. In these infants median maximum voiding detrusor pressure was 127 (range 84 to 211) and 72 cm. water (range 42 to 240), respectively, and median bladder capacity was 20 ml. (range 10 to 49 and 10 to 120, respectively). Maximum voiding detrusor pressure was significantly higher in male than in female infants (p <0.01). Perineal electromyography was interpretable in 13 of the 16 male and 16 of the 21 female infants overall. All but 1 female subject had increased activity during voiding, which was also present intermittently in all subjects. CONCLUSIONS: Our study of asymptomatic siblings of children with vesicoureteral reflux has provided results that may be used as reference data for normal urodynamics in early infancy. Instability was rare. Bladder capacity was lower than expected with a predicted capacity at birth of approximately 20 ml. Maximum voiding pressure was high, especially in male subjects. The urodynamic voiding pattern suggests physiological dyscoordination, probably due to immature detrusor-sphincter function.

Disappearance of vesicoureteral reflux in children.

OBJECTIVE: To describe the disappearance of reflux in children with vesicoureteral reflux, in whom there are presently no population-based long-term studies. DESIGN: An unselected cohort of children with reflux detected after their first known symptomatic urinary tract infection was followed up prospectively for up to 15 years. SETTING: A single children's hospital in a distinct geographical area at which most children with symptomatic urinary tract infection were treated. PATIENTS: Two hundred thirty children--173 girls and 57 boys--with unilateral (n=130) and bilateral (n=100) reflux. Dilated reflux (grades III-V) was found in 54 patients (23.5%). The frequency of reflux was 34% in girls and 31% in boys who were examined after urinary tract infection. MAIN OUTCOME MEASURE: Disappearance of reflux. RESULTS: The probability of spontaneous disappearance of reflux was estimated using Kaplan-Meier survival curves based on 164 children who underwent multiple voiding cystourethrographies. There was a marked tendency for disappearance of reflux, with 73% of children with dilated reflux having no or only grade I reflux after 10 years. Shorter persistence of reflux was found in children with undilated reflux at the initial investigation and in boys compared with girls. However, age at first investigation was not related to the rate of disappearance, and there was no difference between children with bilateral compared with unilateral reflux. CONCLUSIONS: This study of an unselected group of children with urinary tract infection shows a favorable long-term outcome concerning disappearance of reflux. In children with dilated reflux, this tendency was more pronounced than previously reported.

Evaluation of DMSA scintigraphy and urography in assessing both acute and permanent renal damage in children.

PURPOSE: To evaluate dimercaptosuccinic acid (DMSA) scintigraphy and urography in the detection of renal involvement in children with urinary tract infection (UTI) in order to identify patients with a high risk of developing renal damage. MATERIAL AND METHODS: A total of 157 children (median age 0.4 years, range 5 days to 5.8 years) with first-time symptomatic UTI were examined scintigraphy (with an assessment of renal area involvement) and urography at the time of UTI and 1 year later. All evaluations were made blindly. RESULTS: Of the total 314 kidneys, 80 (25%) were abnormal at initial scintigraphy. Of these 80 kidneys, 44 (55%) had normalized at follow-up. Of the 234 initially normal kidneys, 29 (12%) were abnormal at follow-up. One year after UTI, abnormalities were seen in 59 children at scintigraphy and in 18 children at urography. Renal area involvement was larger and split function abnormalities more common in kidneys that were abnormal at both scintigraphy and urography than in kidneys with only scintigraphic abnormalities. CONCLUSION: Quantitation of renal area involvement and split renal function at early scintigraphy would seem to be useful in identifying patients at risk of developing renal damage. Urography at 1 year after infection identified mainly those with the most severe scintigraphic abnormalities. The clinical importance of scintigraphic abnormalities that are not confirmed by urography is not known.

Urodynamic pattern in infants with urinary tract infection.

PURPOSE: We studied the urodynamic pattern in infants with urinary tract infection and evaluated the influence of the infection. MATERIALS AND METHODS: Cystometry was combined with voiding cystourethrography (video cystometry) in 90 male and 68 female infants admitted to the hospital with first time urinary tract infection. Evaluation was performed 1 to 30 days (mean 11) and 32 to 78 days (mean 46) after diagnosis in 93 and 65 infants, respectively. RESULTS: Bladder instability was found in two-thirds of male and female infants. Compared to older children male infants had high voiding detrusor pressure and low bladder capacity (hypercontractility). Female infants also had increased voiding pressure levels but they were significantly lower than those in male infants. The voiding detrusor pressure was even higher in both sexes when evaluation was delayed after the infection. CONCLUSIONS: Infants with urinary tract infection have bladder instability and hypercontractility compared to older children. Bladder hypercontractility was less pronounced early after infection, suggesting that the infectious agents inhibit detrusor muscle contractility. Whether hypercontractility is a normal urodynamic pattern in infancy or represents bladder dysfunction can only be addressed by urodynamic studies of healthy infants.