In 1997, the American Urological Association (AUA) published the Guideline on the Management of Primary Vesicoureteral Reflux in Children [1]. Since that time there has been an expanding body of literature involving not only the evaluation and the management of vesicoureteral reflux (VUR) but also the role of screening in its management. For this reason, the AUA appointed a Panel of experts to update the 1997 document and elected to expand its scope to include guidelines for the screening of siblings of children with vesicoureteral reflux (VUR) and of neonates/ infants with prenatally diagnosed hydronephrosis. A literature search, review of the evidence, and data extraction from the relevant clinical studies and case series were performed. Extracted data underwent meta-analysis to determine the outcomes related to five topics: 1) management of children over one year of age with VUR; 2) evaluation and management of infants with VUR; 3) management of children with VUR and Bladder and Bowel Dysfunction (BBD); 4) screening of siblings and offspring of patients with VUR; and 5) screening of neonates and infants with prenatal hydronephrosis. This document summarizes the guideline statements derived from a meta-analysis. Additional chapters (1-5) provide a detailed summary of each of these topics. From the evidence and expert opinion, the Panel drafted guideline statements. According to AUA nomenclature, these statements are graded with respect to the degree of flexibility in application. A «standard» is the most rigid treatment policy. A «recommendation» has significantly less rigidity and an «option» the least. These terms are defined as follows:

In 1997, the American Urological Association (AUA) published the Guideline on the Management of Primary Vesicoureteral Reflux in Children. Since that time there has been an expanding body of literature involving not only the evaluation and the management of vesicoureteral reflux (VUR) but also the role of screening in its management. For this reason, the AUA appointed a Panel of experts to update the 1997 document and elected to expand its scope to include guidelines for the screening of siblings of children with vesicoureteral reflux (VUR) and of neonates/infants with prenatally diagnosed hydronephrosis. A literature search, review of the evidence, and data extraction from the relevant clinical studies and case series were performed. Extracted data underwent meta-analysis to determine the outcomes related to five topics: 1) management of children over one year of age with VUR; 2) evaluation and management of infants with VUR; 3) management of children with VUR and Bladder and Bowel Dysfunction (BBD); 4) screening of siblings and offspring of patients with VUR; and 5) screening of neonates and infants with prenatal hydronephrosis. This document summarizes the guideline statements derived from a meta-analysis. Additional chapters (1-5) provide a detailed summary of each of these topics.

MohamedBabikirAbdelraheem Carolyn L. Abitbol Philip Acott Piotr Adamczyk Ipek Akil Sema Akman Rosamund Modupe Akuse Samhar Ibrahim Al-Akash Khalid Al-Saran Nasser Al-Shanti Amira Al-Uzri Barbara Alexander Stephen Alexander Uri S. Alon Harika Alpay Bruce Alpert Abdullah A. Alsalloum Caupolicán Alvarado Antonio Amoroso Francisco Esparagoza Anacleto René Frydensbjerg Andersen Trine Borup Andersen Nigel G. Anderson Sharon Andreoli Bilal Aoun Billy S. Arant Mazen Arar Carlos Enrique Araya Gema Ariceta Pekka Arikoski Paul Ashley David Askenazi Farahnak Assadi Meredith A. Atkinson Massimo Attanasio Christoph Aufricht Ari Auron Chris Austin Tadej Avcin Diego H. Aviles Midori Awazu Rose Ayoob

鉴别儿童脱水最有价值的体征是:毛细血管重注时间延长,皮肤弹性和呼吸模式异常.但是,临床脱水的分级是根据多项体格检查结果综合进行评定的,这样会比仅靠体征评定的效果更好.

Purpose: The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to screening of siblings and offspring of index patients with vesicoureteral reflux and infants with prenatal hydronephrosis. From this evidence clinical practice guidelines are developed to manage the clinical scenarios insofar as the data permit.Materials and Methods: The Panel searched the MEDLINE database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children, clearly stating the number of children undergoing screening for vesicoureteral reflux. Vesicoureteral reflux should have been diagnosed with a cystogram and renal outcomes assessed by nuclear scintigraphy. The screening articles were extracted into data tables developed to evaluate epidemiological factors, patient and renal outcomes, and results of treatment. The reporting of meta-analysis of observational studies elaborated by the MOOSE group was followed. The extracted data were analyzed and formulated into evidence-based recommendations regarding the screening of siblings and offspring in index cases with vesicoureteral reflux and infants with prenatal hydronephrosis.Results: In screened populations the prevalence of vesicoureteral reflux is 27.4% in siblings and 35.7% in offspring. Prevalence decreases at a rate of 1 screened person every 3 months of age. The prevalence is the same in males and females. Bilateral reflux prevalence is similar to unilateral reflux. Grade I-II reflux is estimated to be present in 16.7% and grade III-V reflux in 9.8% of screened patients. The estimate for renal cortical abnormalities overall is 19.3%, with 27.8% having renal damage in cohorts of symptomatic and asymptomatic children combined. In asymptomatic siblings only the rate of renal damage is 14.4%. There are presently no randomized, controlled trials of treated vs untreated screened siblings with vesicoureteral reflux to evaluate health outcomes as spontaneous resolution, decreased rates of urinary infection, pyelonephritis or renal scarring.In screened populations with prenatal hydronephrosis the prevalence of vesicoureteral reflux is 16.2%. Reflux in the contralateral nondilated kidney accounted for a mean of 25.2% of detected cases for a mean prevalence of 4.1%. In patients with a normal postnatal renal ultrasound the prevalence of reflux is 17%. The prenatal anteroposterior renal pelvic diameter was not predictive of reflux prevalence. A diameter of 4 mm is associated with a 10% to 20% prevalence of vesicoureteral reflux. The prevalence of reflux is statistically significantly greater in females (23%) than males (16%) (p = 0.022). Reflux grade distribution is approximately a third each for grades I-II, III and IV-V. The estimate of renal damage in screened infants without infection is 21.8%. When stratified by reflux grade renal damage was estimated to be present in 6.2% grade I-III and 47.9% grade IV-V (p <0.0001). The risk of urinary tract infection in patients with and without prenatal hydronephrosis and vesicoureteral reflux could not be determined. The incidence of reported urinary tract infection in patients with reflux was 4.2%.Conclusions: The meta-analysis provided meaningful information regarding screening for vesicoureteral reflux. However, the lack of randomized clinical trials for screened patients to assess clinical health outcomes has made evidence-based guideline recommendations difficult. Consequently, screening guidelines are based on present practice, risk assessment, meta-analysis results and Panel consensus.

Purpose: The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to children with diagnosed reflux including those young or older than 1 year without evidence of bladder and bowel dysfunction and those older than 1 year with evidence of bladder and bowel dysfunction. From this evidence clinical practice guidelines were developed to manage the clinical scenarios insofar as the data permit.Materials and Methods: The Panel searched the MEDLINE database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children with vesicoureteral reflux and a defined care program that permitted identification of cohort specific clinical outcomes. The reporting of meta-analysis of observational studies elaborated by the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) group was followed. The extracted data were analyzed and formulated into evidence-based recommendations.Results: A total of 2,028 articles were reviewed and data were extracted from 131 articles. Data from 17,972 patients were included in this analysis. This systematic meta-analysis identified increasing frequency of urinary tract infection, increasing grade of vesicoureteral reflux and presence of bladder and bowel dysfunction as unique risk factors for renal cortical scarring. The efficacy of continuous antibiotic prophylaxis could not be established with current data. However, its purported lack of efficacy, as reported in selected prospective clinical trials, also is unproven owing to significant limitations in these studies. Reflux resolution and endoscopic surgical success rates are dependent upon bladder and bowel dysfunction. The Panel then structured guidelines for clinical vesicoureteral reflux management based on the goals of minimizing the risk of acute infection and renal injury, while minimizing the morbidity of testing and management. These guidelines are specific to children based on age as well as the presence of bladder and bowel dysfunction. Recommendations for long-term followup based on risk level are also included.Conclusions: Using a structured, formal meta-analytic technique with rigorous data selection, conditioning and quality assessment, we attempted to structure clinically relevant guidelines for managing vesicoureteral reflux in children. The lack of robust prospective randomized controlled trials limits the strength of these guidelines but they can serve to provide a framework for practice and set boundaries for safe and effective practice. As new data emerge, these guidelines will necessarily evolve.

The most useful individual signs for identifying dehydration in children are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. However, clinical dehydration scales based on a combination of physical examination findings are better predictors than individual signs. Oral rehydration therapy is the preferred treatment of mild to moderate dehydration caused by diarrhea in children. Appropriate oral rehydration therapy is as effective as intravenous fluid in managing fluid and electrolyte losses and has many advantages. Goals of oral rehydration therapy are restoration of circulating blood volume, restoration of interstitial fluid volume, and maintenance of rehydration. When rehydration is achieved, a normal age-appropriate diet should be initiated.

Katsushige Abe Asiri S. Abeyagunawardena Carolyn L. Abitbol Raymond D. Adelman Anil Agarwal Rekha Agrawal Enver Akalin Ali Akçay Barbara Alexander Stephen Alexander Uri S. Alon Seth Alpert Amira Al-Uzri Ofelia Alvarez Kerstin Amann Sandra Amaral Alessandro Amore Ali Anarat Jean-Luc André Sharon Andreoli Billy S. Arant Mazen Arar Klaus Arbeiter Marcello Arca Gianluigi Ardissino Gema Ariceta Osamu Arisaka Akira Ashida David Askenazi John R. Asplin John P. Atkinson Massimo Attanasio Filippo Aucella Christoph Aufricht Felicia Axelrod

PRESENT AFFILIATION Senior lecturer/researcher in paediatrics/paediatric neurology Institute of Neurological Science (ISN), National Research Council (CNR), Catania, Italy, July 2000– Adjunct Professor of paediatrics (MED/38), Faculty of Medicine, University of Catania, Italy, October 2004– Associate Professor of paediatrics (MED/38), Department of Paediatrics, University of Catania [Board certified, April 2006]

See related article, p 656.Defining a standard of care for the child with VUR has been elusive, not for lack of interest but lack of reliable evidence. VUR was first characterized 40 years ago as a congenital defect amenable to surgical correction. The assumption was that recurrent UTIs and further renal injury could be prevented if VUR were eliminated. Since 1965, more than 3000 articles have been published about the treatment of VUR in children, most of which introduced a surgical technique, reported individual experience with one technique, or compared outcomes of different techniques. Randomization of patients to prospective protocols or statistical analysis of data was not done; therefore, most children with persistent VUR underwent surgical treatment. The focus of treatment was the ureterovesical junction, not renal injury or patient morbidity. The cumulative value of the more than 2000 surgical publications can be reduced to knowing that competent pediatric surgeons can correct VUR successfully in 98% of children. When the American Urological Association established a Pediatric Vesicoureteral Reflux Clinical Guidelines Panel1Elder JS Peters CA Arant Jr, BS Ewalt DH Hawtrey CE Hurwitz RS et al.Pediatric vesicoureteral reflux guidelines panel summary report on the management of primary vesicoureteral reflux in children.J Urol. 1997; 157: 1846-1851Abstract Full Text Full Text PDF PubMed Scopus (531) Google Scholar to establish evidence-based guidelines for treatment of VUR, there were insufficient scientific data for a meta-analysis. Among 3207 papers reviewed, 168 were considered useful and only 3 prospective randomized controlled trials were identified.Little attention was given to medical management of VUR before 1980, with the exception of Smellie et al,2Smellie JM Prescod NP Shaw PJ Risdon RA Bryant TN Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults.Pediatr Nephrol. 1998; 12: 727-736Crossref PubMed Scopus (241) Google Scholar who by 1960 were treating patients conservatively, even those with severe VUR. This nonsurgical approach to treating VUR aimed at maintaining sterile urine. Treatment measures, all supervised by the same observer, included the use of continuous antibiotic prophylaxis; attention to appropriate bladder, bowel, and perineal hygiene habits; and education and consistent follow-up of the patient and parent. The clinical outcome in compliant patients seemed superior to the overall results of surgical treatment, especially in avoiding further renal injury. Similar good outcomes were not experienced by others when medical treatment of VUR was inconsistent or sporadic. The experience with medical management, in general and especially with dilating VUR, was recurrent UTI associated with new or progressive renal scarring and subsequent development of hypertension or chronic renal insufficiency.3Arant Jr, BS Vesicoureteric reflux and renal injury.Am J Kidney Dis. 1991; 17: 491-511Abstract Full Text PDF PubMed Scopus (167) Google Scholar There was reluctance to accept Smellie’s observations because no control or comparison treatment group was studied. Some might justifiably argue that remarkable results during 10 to 41 years of follow-up in 226 patients is evidence; however, the findings required validation.The first report of a prospective effort to compare medical and surgical treatments of VUR in children was conducted in 1987 by the Birmingham Reflux Study,4Birmingham Reflux Study Group Prospective trial of operative versus non-operative treatment of severe vesicoureteric reflux in children: five years’ observation.Br Med J. 1987; 295: 237-241Crossref PubMed Scopus (266) Google Scholar which observed no difference in outcome between groups at 5 years. A major limitation to that study was that medical management was approached more casually than recommended by Smellie. The International Reflux Study in Children initiated a prospective study in 1980 in which patients with dilating VUR (International grades III and IV), recruited from centers in Europe and North America, were allocated randomly to medical or surgical treatment. Medical treatment followed the protocol Smellie had used successfully. The most important finding of the study at 5 years was that there was no difference in outcome between children managed medically compared with those who underwent surgical correction, no difference in further UTI, or renal scarring.5Tamminen-Mobius T Bruner E Ebel KD Lebowitz R Olbing H Seppanen U et al.Cessation of vesicoureteral reflux for 5 years in infants and children allocated to medical treatment.J Urol. 1992; 148: 1662-1666PubMed Google Scholar These results created a surgical or medical option in the treatment of children with dilating VUR.It was disappointing, however, that VUR had persisted in half the patients who were treated medically. Data combined from 3 different studies by Elder et al1Elder JS Peters CA Arant Jr, BS Ewalt DH Hawtrey CE Hurwitz RS et al.Pediatric vesicoureteral reflux guidelines panel summary report on the management of primary vesicoureteral reflux in children.J Urol. 1997; 157: 1846-1851Abstract Full Text Full Text PDF PubMed Scopus (531) Google Scholar reported similar rates of reflux resolution for dilating VUR. Resolution of nondilating VUR was shown in 80% of young children by 5 years.6Arant Jr, BS Medical management of mild and moderate vesicoureteral reflux: followup studies of infants and young children. A preliminary report of the Southwest Pediatric Nephrology Study Group.J Urol. 1992; 148: 1683-1687PubMed Google Scholar When tradition, not science, holds that morbidity from UTI will increase, should patients with persistent VUR of any grade at 5 years be corrected surgically before the emergence of adolescence, sexual activity, or pregnancy? Several reports have described progressive deterioration of renal function during pregnancy in women who had bilateral renal scarring in childhood. However, the long-term observations in as many as 40 years in some patients treated conservatively by Smellie et al2Smellie JM Prescod NP Shaw PJ Risdon RA Bryant TN Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults.Pediatr Nephrol. 1998; 12: 727-736Crossref PubMed Scopus (241) Google Scholar strongly suggest that persistent VUR in women of childbearing age was not associated with progressive renal injury caused by recurrent bouts of acute pyelonephritis.It is unlikely that another prospective study will be done in the forseeable future to answer this question. The decision of most European centers in the IRSC to follow patients for another 5 years may obviate the need for such a study. The purpose of the continued effort by the IRSC in this report was to observe any further resolution of VUR after 5 years.4Birmingham Reflux Study Group Prospective trial of operative versus non-operative treatment of severe vesicoureteric reflux in children: five years’ observation.Br Med J. 1987; 295: 237-241Crossref PubMed Scopus (266) Google Scholar As reported by Smellie,2Smellie JM Prescod NP Shaw PJ Risdon RA Bryant TN Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults.Pediatr Nephrol. 1998; 12: 727-736Crossref PubMed Scopus (241) Google Scholar if most patients exhibited resolution of VUR or morbidity was low, then the pressure to correct the persistent VUR by surgical intervention was lessened; otherwise, the choice of long-term medical management of VUR was strengthened. The study found that between 5 and 10 years of follow-up, VUR improved further or was not present in a final VCUG in 77% of patients. Similarly, Wennerstrom et al8Wennerstrom M Hansson S Jodal U Stokland E Disappearance of vesico-ureteric reflux in children.Arch Pediatr Adolesc Med. 1998; 152: 879-883Crossref PubMed Scopus (82) Google Scholar reported that, at 10 years, 73% of dilating VUR in children had resolved.What has been the effect of scientific evidence on clinical decision making in children with VUR during the past 40 years? Reported data have been overlooked in favor of unfounded speculation or clinical tradition. For example, the first well-designed studies of VUR in children found no benefit of urethral dilatation or urethrotomy on the outcome of UTI or VUR.3Arant Jr, BS Vesicoureteric reflux and renal injury.Am J Kidney Dis. 1991; 17: 491-511Abstract Full Text PDF PubMed Scopus (167) Google Scholar, 9Kaplan GW Sammons TA King LR A blind comparison of dilatation, urethrotomy, and medication alone in the treatment of urinary tract infection in girls.J Urol. 1973; 109: 917-919PubMed Google Scholar Yet, there is someone in nearly every community who still subjects children to the risk and expense of surgeries 30 years after the studies were published in the pediatric and urologic literature. What are the data for delaying radiologic investigation of the urinary tract for 4 to 6 weeks after an acute UTI? This clinical tradition began with the speculation that acute inflammation at the ureterovesical junction would facilitate VUR and then disappear after the inflammation subsided. The immediate benefit was that fewer children with UTI may have been subjected to a surgical procedure if VUR was not identified. Although the intent was admirable, there was and still is no evidence to support this tradition; yet, most VCUGs in the United States are still scheduled 4 to 6 weeks after UTI. Many patients who are not taking antibiotic treatment will have another UTI before the study is performed. Reliable evidence suggests that there is no difference in the prevalence of VUR when VCUG is performed, either within a week of an infection or after 4 weeks.Can we now confidently recommend medical management for every child with VUR? There seems to be reliable evidence to support the practice, certainly for the first year, for any grade of VUR. When successful surgical correction is readily available, there will be concerns raised by parents, patients, and clinicians who question the rationale, inconvenience, and expense of continuous antibiotic therapy, urine cultures, and recurrent imaging studies during many years. However, the cost of a single hospitalization for surgical correction of VUR has been shown to exceed 5 years of medical treatment. A VCUG is needed only every 2 to 3 years unless the clinical course is complicated. When performed by experienced personnel, the procedure should not upset the patient or the parent unnecessarily; most anxiety stems from previous bad experience. Finally, should parents be allowed to choose a treatment for their child with VUR? Certainly they must participate in the decision, but choices should be made only after evidence, not opinion, is presented in an unbiased fashion. See related article, p 656. Defining a standard of care for the child with VUR has been elusive, not for lack of interest but lack of reliable evidence. VUR was first characterized 40 years ago as a congenital defect amenable to surgical correction. The assumption was that recurrent UTIs and further renal injury could be prevented if VUR were eliminated. Since 1965, more than 3000 articles have been published about the treatment of VUR in children, most of which introduced a surgical technique, reported individual experience with one technique, or compared outcomes of different techniques. Randomization of patients to prospective protocols or statistical analysis of data was not done; therefore, most children with persistent VUR underwent surgical treatment. The focus of treatment was the ureterovesical junction, not renal injury or patient morbidity. The cumulative value of the more than 2000 surgical publications can be reduced to knowing that competent pediatric surgeons can correct VUR successfully in 98% of children. When the American Urological Association established a Pediatric Vesicoureteral Reflux Clinical Guidelines Panel1Elder JS Peters CA Arant Jr, BS Ewalt DH Hawtrey CE Hurwitz RS et al.Pediatric vesicoureteral reflux guidelines panel summary report on the management of primary vesicoureteral reflux in children.J Urol. 1997; 157: 1846-1851Abstract Full Text Full Text PDF PubMed Scopus (531) Google Scholar to establish evidence-based guidelines for treatment of VUR, there were insufficient scientific data for a meta-analysis. Among 3207 papers reviewed, 168 were considered useful and only 3 prospective randomized controlled trials were identified. Little attention was given to medical management of VUR before 1980, with the exception of Smellie et al,2Smellie JM Prescod NP Shaw PJ Risdon RA Bryant TN Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults.Pediatr Nephrol. 1998; 12: 727-736Crossref PubMed Scopus (241) Google Scholar who by 1960 were treating patients conservatively, even those with severe VUR. This nonsurgical approach to treating VUR aimed at maintaining sterile urine. Treatment measures, all supervised by the same observer, included the use of continuous antibiotic prophylaxis; attention to appropriate bladder, bowel, and perineal hygiene habits; and education and consistent follow-up of the patient and parent. The clinical outcome in compliant patients seemed superior to the overall results of surgical treatment, especially in avoiding further renal injury. Similar good outcomes were not experienced by others when medical treatment of VUR was inconsistent or sporadic. The experience with medical management, in general and especially with dilating VUR, was recurrent UTI associated with new or progressive renal scarring and subsequent development of hypertension or chronic renal insufficiency.3Arant Jr, BS Vesicoureteric reflux and renal injury.Am J Kidney Dis. 1991; 17: 491-511Abstract Full Text PDF PubMed Scopus (167) Google Scholar There was reluctance to accept Smellie’s observations because no control or comparison treatment group was studied. Some might justifiably argue that remarkable results during 10 to 41 years of follow-up in 226 patients is evidence; however, the findings required validation. The first report of a prospective effort to compare medical and surgical treatments of VUR in children was conducted in 1987 by the Birmingham Reflux Study,4Birmingham Reflux Study Group Prospective trial of operative versus non-operative treatment of severe vesicoureteric reflux in children: five years’ observation.Br Med J. 1987; 295: 237-241Crossref PubMed Scopus (266) Google Scholar which observed no difference in outcome between groups at 5 years. A major limitation to that study was that medical management was approached more casually than recommended by Smellie. The International Reflux Study in Children initiated a prospective study in 1980 in which patients with dilating VUR (International grades III and IV), recruited from centers in Europe and North America, were allocated randomly to medical or surgical treatment. Medical treatment followed the protocol Smellie had used successfully. The most important finding of the study at 5 years was that there was no difference in outcome between children managed medically compared with those who underwent surgical correction, no difference in further UTI, or renal scarring.5Tamminen-Mobius T Bruner E Ebel KD Lebowitz R Olbing H Seppanen U et al.Cessation of vesicoureteral reflux for 5 years in infants and children allocated to medical treatment.J Urol. 1992; 148: 1662-1666PubMed Google Scholar These results created a surgical or medical option in the treatment of children with dilating VUR. It was disappointing, however, that VUR had persisted in half the patients who were treated medically. Data combined from 3 different studies by Elder et al1Elder JS Peters CA Arant Jr, BS Ewalt DH Hawtrey CE Hurwitz RS et al.Pediatric vesicoureteral reflux guidelines panel summary report on the management of primary vesicoureteral reflux in children.J Urol. 1997; 157: 1846-1851Abstract Full Text Full Text PDF PubMed Scopus (531) Google Scholar reported similar rates of reflux resolution for dilating VUR. Resolution of nondilating VUR was shown in 80% of young children by 5 years.6Arant Jr, BS Medical management of mild and moderate vesicoureteral reflux: followup studies of infants and young children. A preliminary report of the Southwest Pediatric Nephrology Study Group.J Urol. 1992; 148: 1683-1687PubMed Google Scholar When tradition, not science, holds that morbidity from UTI will increase, should patients with persistent VUR of any grade at 5 years be corrected surgically before the emergence of adolescence, sexual activity, or pregnancy? Several reports have described progressive deterioration of renal function during pregnancy in women who had bilateral renal scarring in childhood. However, the long-term observations in as many as 40 years in some patients treated conservatively by Smellie et al2Smellie JM Prescod NP Shaw PJ Risdon RA Bryant TN Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults.Pediatr Nephrol. 1998; 12: 727-736Crossref PubMed Scopus (241) Google Scholar strongly suggest that persistent VUR in women of childbearing age was not associated with progressive renal injury caused by recurrent bouts of acute pyelonephritis. It is unlikely that another prospective study will be done in the forseeable future to answer this question. The decision of most European centers in the IRSC to follow patients for another 5 years may obviate the need for such a study. The purpose of the continued effort by the IRSC in this report was to observe any further resolution of VUR after 5 years.4Birmingham Reflux Study Group Prospective trial of operative versus non-operative treatment of severe vesicoureteric reflux in children: five years’ observation.Br Med J. 1987; 295: 237-241Crossref PubMed Scopus (266) Google Scholar As reported by Smellie,2Smellie JM Prescod NP Shaw PJ Risdon RA Bryant TN Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults.Pediatr Nephrol. 1998; 12: 727-736Crossref PubMed Scopus (241) Google Scholar if most patients exhibited resolution of VUR or morbidity was low, then the pressure to correct the persistent VUR by surgical intervention was lessened; otherwise, the choice of long-term medical management of VUR was strengthened. The study found that between 5 and 10 years of follow-up, VUR improved further or was not present in a final VCUG in 77% of patients. Similarly, Wennerstrom et al8Wennerstrom M Hansson S Jodal U Stokland E Disappearance of vesico-ureteric reflux in children.Arch Pediatr Adolesc Med. 1998; 152: 879-883Crossref PubMed Scopus (82) Google Scholar reported that, at 10 years, 73% of dilating VUR in children had resolved. What has been the effect of scientific evidence on clinical decision making in children with VUR during the past 40 years? Reported data have been overlooked in favor of unfounded speculation or clinical tradition. For example, the first well-designed studies of VUR in children found no benefit of urethral dilatation or urethrotomy on the outcome of UTI or VUR.3Arant Jr, BS Vesicoureteric reflux and renal injury.Am J Kidney Dis. 1991; 17: 491-511Abstract Full Text PDF PubMed Scopus (167) Google Scholar, 9Kaplan GW Sammons TA King LR A blind comparison of dilatation, urethrotomy, and medication alone in the treatment of urinary tract infection in girls.J Urol. 1973; 109: 917-919PubMed Google Scholar Yet, there is someone in nearly every community who still subjects children to the risk and expense of surgeries 30 years after the studies were published in the pediatric and urologic literature. What are the data for delaying radiologic investigation of the urinary tract for 4 to 6 weeks after an acute UTI? This clinical tradition began with the speculation that acute inflammation at the ureterovesical junction would facilitate VUR and then disappear after the inflammation subsided. The immediate benefit was that fewer children with UTI may have been subjected to a surgical procedure if VUR was not identified. Although the intent was admirable, there was and still is no evidence to support this tradition; yet, most VCUGs in the United States are still scheduled 4 to 6 weeks after UTI. Many patients who are not taking antibiotic treatment will have another UTI before the study is performed. Reliable evidence suggests that there is no difference in the prevalence of VUR when VCUG is performed, either within a week of an infection or after 4 weeks. Can we now confidently recommend medical management for every child with VUR? There seems to be reliable evidence to support the practice, certainly for the first year, for any grade of VUR. When successful surgical correction is readily available, there will be concerns raised by parents, patients, and clinicians who question the rationale, inconvenience, and expense of continuous antibiotic therapy, urine cultures, and recurrent imaging studies during many years. However, the cost of a single hospitalization for surgical correction of VUR has been shown to exceed 5 years of medical treatment. A VCUG is needed only every 2 to 3 years unless the clinical course is complicated. When performed by experienced personnel, the procedure should not upset the patient or the parent unnecessarily; most anxiety stems from previous bad experience. Finally, should parents be allowed to choose a treatment for their child with VUR? Certainly they must participate in the decision, but choices should be made only after evidence, not opinion, is presented in an unbiased fashion. Outcome at 10 years of severe vesicoureteric reflux managed medically: Report of the International Reflux Study in ChildrenThe Journal of PediatricsVol. 139Issue 5PreviewObjective: 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. Full-Text PDF

Debate continues as to whether routine urinalysis for normal children is waranted. The American Academy of Pediatrics (AAP) recommends screening of urine at four developmental stages: infancy, early childhood, late childhood, and adolescence. 1 American Academy of PediatricsRecommendations for preventive pediatric health care. in: Policy Reference Guide: a comprehensive guide to AAP policy statement. American Academy of Pediatrics, Elk Grove Villlage, Illinois1993 Google Scholar To be valid a screening test should meet certain criteria, and dipstick urinalysis alone may not satisfy every concern for its widespread use. For instance, when a urinary abnormality is detected on a single specimen, the finding may not be specific for any particular disease, and treatment may not be established or even necessary. Morever, plans for further assessment made on the basis of one examination are usually misguided and, therefore, expensive. In addition, the cost of pursuing abnormal dipstick findings has been said to make urinalysis in symptom-free children poor value.

Purpose: The American Urological Association convened the Pediatric Vesicoureteral Reflux Guidelines Panel to analyze the literature regarding available methods for treating vesicoureteral reflux diagnosed following a urinary tract infection in children and to make practice policy recommendations based on the treatment outcomes data insofar as the data permit. Materials and Methods: The panel searched the MEDLINE data base for all articles from 1965 to 1994 on vesicoureteral reflux and systematically analyzed outcomes data for 7 treatment alternatives: 1) intermittent antibiotic therapy, 2) bladder training, 3) continuous antibiotic prophylaxis, 4) antibiotic prophylaxis and bladder training, 5) antibiotic prophylaxis, anticholinergics and bladder training, 6) open surgical repair and 7) endoscopic repair. Key outcomes identified were probability of reflux resolution, likelihood of developing pyelonephritis and scarring, and possibility of complications of medical and surgical treatment. Results: Available outcomes data on the various treatment alternatives were summarized in tabular form and graphically, and the relative probabilities of possible outcomes were compared for each alternative. Treatment recommendations were based on scientific evidence and expert opinion. The panel concluded that only a few recommendations can be derived purely from scientific evidence of a beneficial effect on health outcomes. Conclusions: For most children the panel recommended continuous antibiotic prophylaxis as initial treatment. Surgery was recommended for children with persistent reflux and other indications, as specified in the document. KEY Woms: vesico-ureteral reflux, kidney, ureter, bladder, outcome assessment (health care) Vesicoureteral reflux refers to the retrograde flow of urine from the bladder into the upper urinary tract. Reflux is a birth defect but it may also be acquired. Vesicoureteral reflux predisposes an individual to renal infection (pyelonephritis) by facilitating the transport of bacteria from the bladder to the upper urinary tract. The immunological and inflammatory reaction caused by a pyelonephritic infection may result in renal injury or scarring. Extensive renal scarring causes decreased renal function and it may result in renal insufficiency, end stage renal disease, renin mediated hypertension, decreased somatic growth and morbidity during pregnancy. The primary goal of treatment in children with reflux is preventing renal injury, symptomatic pyelonephritis and other complications of reflux. Medical therapy is based on the principle that reflux often resolves with time, and antibiotics maintain urine sterility and prevent infections while the patient awaits spontaneous resolution. The basis for surgical therapy is that, in select situations, ongoing vesicoureteral reflux has caused or has a significant potential for causing renal injury or other reflux related complications and ehtion of the reflux condition will minimize their likelihood. Although reflux is common in children with a urinary tract infection, there is disagree

PURPOSE:The American Urological Association convened the Pediatric Vesicoureteral Reflux Guidelines Panel to analyze the literature regarding available methods for treating vesicoureteral reflux diagnosed following a urinary tract infection in children and to make practice policy recommendations based on the treatment outcomes data insofar as the data permit.MATERIALS AND METHODS:The panel searched the MEDLINE data base for all articles from 1965 to 1994 on vesicoureteral reflux and systematically analyzed outcomes data for 7 treatment alternatives: 1) intermittent antibiotic therapy, 2) bladder training, 3) continuous antibiotic prophylaxis, 4) antibiotic prophylaxis and bladder training, 5) antibiotic prophylaxis, anticholinergics and bladder training, 6) open surgical repair and 7) endoscopic repair. Key outcomes identified were probability of reflux resolution, likelihood of developing pyelonephritis and scarring, and possibility of complications of medical and surgical treatment.RESULTS:Available outcomes data on the various treatment alternatives were summarized in tabular form and graphically, and the relative probabilities of possible outcomes were compared for each alternative. Treatment recommendations were based on scientific evidence and expert opinion. The panel concluded that only a few recommendations can be derived purely from scientific evidence of a beneficial effect on health outcomes.CONCLUSIONS:For most children the panel recommended continuous antibiotic prophylaxis as initial treatment. Surgery was recommended for children with persistent reflux and other indications, as specified in the document.

We reviewed the records of 132 children with persistent hypertension who were evaluated by our pediatric nephrology services between 1987 and 1991. Eighty-nine (67%) of these children were found to have renal or renovascular disease, 30 (23%) had primary hypertension and 13 (10%) had a non-renal cause for their hypertension. Glomerulonephritis (n = 37) and reflux nephropathy (n = 26) were the most frequent renal disorders identified. Renal artery thrombosis was the most common cause of hypertension in the neonatal period (in 6 of 12 neonates, 50%) whereas cystic kidney disease was the most common cause of hypertension in the 1st year of life (in 9 of 30 infants, 30%). The prevalence of primary hypertension increased with age; this diagnosis was made in 16 of 46 (35%) hypertensive patients between 12 and 18 years of age and, more surprisingly, in 8 of 27 (30%) children between 7 and 11 years of age. These data confirm that secondary hypertension is the most common cause of hypertension in children but suggest that primary hypertension is more prevalent than previously recognized in patients between 7 and 18 years of age.

No AccessJournal of Urology1 Nov 1992Commentary: Vesicoureteral Reflux—1992 Terry D. Allen, Billy S. Arant, and James A. Roberts Terry D. AllenTerry D. Allen More articles by this author , Billy S. ArantBilly S. Arant More articles by this author , and James A. RobertsJames A. Roberts More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)37022-2AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 1992 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byUral Z, Ulman I and Avanoglu A (2018) Bladder Dynamics and Vesicoureteral Reflux: Factors Associated With Idiopathic Lower Urinary Tract Dysfunction in ChildrenJournal of Urology, VOL. 179, NO. 4, (1564-1567), Online publication date: 1-Apr-2008.Yu T and Chen W (2018) Surgical Management of Grades III and IV Primary Vesicoureteral Reflux in Children With and Without Acute Pyelonephritis as Breakthrough Infections: A Comparative AnalysisJournal of Urology, VOL. 157, NO. 4, (1404-1406), Online publication date: 1-Apr-1997. Volume 148Issue 5 Part 2November 1992Page: 1758-1760 Advertisement Copyright & Permissions© 1992 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Terry D. Allen More articles by this author Billy S. Arant More articles by this author James A. Roberts More articles by this author Expand All Advertisement PDF downloadLoading ...

We examined 25 complete and partial nephrectomy specimens from 21 patients with advanced reflux nephropathy, all of which showed severe renal atrophy and loss of parenchyma. All specimens that included nonatrophic or partially atrophic renal tissue contained small medullary scars that involved only portions of the medullary pyramids. These sublobar medullary scars, which appeared linear and were typically discrete, extended from the inner medulla to the cortex. They obliterated collecting ducts, vasa recta and recurrent loops. The cortical portions of the scars contained remnants of nephrons and variable infiltrates of chronic inflammatory cells with lymphoid follicles. Seven of the specimens also contained acute disruptive ductal lesions with histopathological features characteristic of intrarenal reflux. We believe that the linear scars are the result of single duct medullary disruptions, mediated perhaps through obstruction of the several thousand nephrons subtended by each papillary duct and perhaps through localized disruption of the renal microvasculature. These sublobar scars accumulate as scarring progresses to end stage renal atrophy.

Factitious hematuria is a well-described cause of hematuria in adult patients but is rarely seen or considered in children.1-6 In this article, a 5-year-old girl with a history of gross hematuria with more than one pathologic explanation for recurrent hematuria is described. Because of persistent symptoms despite appropriate therapy, a factitious cause was considered. CASE REPORT The patient was the healthy product of the uncomplicated full-term pregnancy of an unmarried woman who reared the child in the home of her mother and sister. The diagnosis of urinary tract infection was made first at 2 years of age. In subsequent radiographic studies, two normal kidneys were identified, with complete duplication of the left collecting system and bilateral grade 2 vesicoureteric reflux.