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.

This study describes blood pressure and renal function, as well as indices of renal disease, in females with and without renal scarring followed from their first urinary tract infection (UTI) in childhood. Of the 111 patients with a median follow-up time of 15 years, 54 had renal scarring (reflux nephropathy) on urography, which was severe in 19 and moderate in 35. The glomerular filtration rate was lower in patients with severe renal scarring and correlated with renal area on urography. However, the filtration rate was decreased below the lower reference limit in only 7 patients, with a lowest value of 70 ml/min per 1.73 m2. The diastolic blood pressure was higher in women with severe scarring. Hypertension of at least 140/90 mmHg was diagnosed in 3 of 54 (5.5%) females with renal scarring, 2 before and 1 at the follow-up examination. The excretion of albumin in urine was low and not correlated to filtration rate. Tubular enzymes in urine were similar in all groups. Thus the renal function was well preserved and the incidence of hypertension low. Within this range of renal function, the level of albumin in urine did not predict the degree of renal scarring.

This study describes the pattern of urinary tract infections (UTI) in 87 females prospectively followed for a median of 23 years from their first recognized symptomatic infection in childhood. At 16 years of age they were selected for follow-up into adulthood because of renal scarring (reflux nephropathy) in 45 and recurrent UTI in 42. The attack rate (number of urinary tract infections per individual per observation year) was highest during the 1st year of life (1.9), with a gradual decrease to the lowest rate (0.2) at age 11–15 years. A moderately increased attack rate (0.4), was seen in the late teens, extending through to the mid twenties. The proportion of infections having a pyelonephritic character decreased with age and number of infection episodes, but not in females with severe renal scarring. Pyelonephritic infections were correlated with vesicoureteric reflux, and renal scarring to low age at the index infection, total number of pyelonephritic episodes and reflux. Females with renal scarring continued to have a high proportion of pyelonephritic recurrences after 10 years of age, implying that they risk progressive renal disease and should be closely followed into adulthood.

The renal findings on intravenous urography (IVU) are reported in 306 children (73 boys, 233 girls) from eight European centres entered into an international study comparing medical and surgical management of children with urinary tract infection and severe vesico-ureteric reflux followed for 5 years. One hundred and fifty-five children were randomly allocated to medical and 151 to surgical treatment. Protocol and investigative techniques were standardised and randomisation, data collection and analysis were performed centrally in Essen, Germany. At entry 149 (49%) has established renal scarring (79 medical, 70 surgical). Children with normal kidneys (105), areas of thinned parenchyma (52) and grade of reflux were also evenly distributed. IVU was repeated at 6, 18 and 54 months and serial urine culture,99mtechnetium-dimercaptosuccinic acid scans and plasma creatinine estimations were performed. Two hundred and seventy-two children (89%) completed this follow-up. In 174 children (57%), (90 medical, 84 surgical) there was renal growth without morphological change. New renal scars developed in 19 children treated medically and 20 surgically; 12 (5 medical, 7 surgical) developed in previously normal kidneys. Six followed post-operative obstruction. No significant difference in outcome was found between medical or surgical management in terms of the development of new renal lesions or the progression of established renal scars.

Twenty-seven infants who survived intensive care during early infancy in the pioneering period of neonatal intensive care (1956-1965) were investigated after 8-17 years. The selection criterion was maintenance of a tracheotomy for more than 15 days during the first 12 months of life. A variety of clinical, physiological, radiological and psychiatric sequelae was found. Respiratory symptoms were the dominating problem during the post-tracheotomy period. The long-term follow-up revealed that these symptoms had a strong tendency to subside. At the time of the follow-up, as many as 20 children (74%) did not experience any functional impairment.

Early detection and treatment of nephropathy in childhood urinary tract infection is important for the planning of treatment and supervision. In patients without abnormalities of calyces or defects of kidney outline standardized measurements of the thickness of the parenchyma at three sites on each kidney are more informative in establishing early affection of the kidney than other measurable parameters available. The majority of patients who will develop focal renal scarring can be identified early after their first symptomatic infection from measurement of the appropriate dimensions of the parenchyma.

Serum levels of antibodies to lipid A were determined with an enzyme-linked immunosorbent assay in 26 girls with their first known symptomatic urinary tract infection (UTI) and in 15 girls with asymptomatic bacteriuria (ABU). Also included were six female patients with recurrence of acute upper UTI, five of whom had renal changes after the infections; 28 female patients with renal scarring but not symptomatic UTI at the time of investigation; and uninfected individuals. IgG and IgM antibodies to lipid A were found in approximately 50% of the uninfected children older than two years of age. Girls with acute cystitis, acute pyelonephritis, or ABU showed significantly elevated levels of IgG antibodies to lipid A as compared with children with no history of UTI. High levels of IgG antibodies to lipid A may be indicative of severe renal infection and development or progression of renal parenchymal reduction. The diagnostic value of determining levels of antibodies to lipid A is discussed.

Compensatory renal growth was estimated from repeated urograms over 8 to 15 years in 26 children with urinary tract infection and unilateral renal scarring. These children were derived from an unselected series of 596 patients followed from their first symptomatic urinary tract infection. Renal size was assessed from the renal area, length, and parenchymal thickness. The renal area proved to be a good measure of the compensatory growth of the unscarred kidney as well as of the loss of substance of the scarred kidney. In this series of children, who had been closely supervised from the time of their first infection, unilateral renal scarring was well compensated for by hypertrophy of the contralateral kidney. Thus, the total renal parenchymal area 8 to 15 years after the first investigation was 98 to 99% of the expected normal area. Interestingly, a conspicuous growth spurt was observed at puberty in some of the scarred kidneys, sometimes a decade after the original damage. Prognosis was not influenced by sex, age at onset, or complications such as vesicoureteric reflux and frequent febrile recurrences. Reflux with dilatation was compatible with compensatory renal growth. We conclude that acute febrile pyelonephritis in childhood carries a good prognosis with regard to preservation of renal parenchyma and level of GFR, if diagnosis and treatment are prompt and long-term supervision is provided.

The normal range of variation of the parenchymal thickness in well defined parts of the kidney was determined in children (0 to 15 years). The values were correlated with the distance between the superior surface of L1 and the inferior surface of L3. The ratio between the parenchymal thickness on the right side and the left side was also determined. The results are compiled in two nomograms.

Von den Patienten mit der Sammeldiagnose Harnwegsinfektion (HWI) entwickeln nur wenige progrediente Nierenparenchymschäden. Bisher haben wir keine einfache und sichere Möglichkeit, diese Risikopatienten früh ausfindig zu machen, um bei ihnen eine Nierenschädigung zu verhüten. Trotz zahlreicher Studien über die HWI ist das gesicherte Wissen über den Krankheitsablauf ungenügend und die Bedeutung von Unterschieden im klinischen Bild nur unzureichend geklärt.

A 3-year follow-up of 116 schoolgirls with asymptomatic bacteriuria, treated or untreated is reported. It is concluded that bacteria isolated from girls with asymptomatic bacteriuria do not commonly cause symptomatic pyelonephritis and that the risk of developing renal damage as a result of asymptomatic bacteriuria in a schoolgirl with a roentgenographically normal urinary tract seems to be small. It is also suggested that for the majority of these patients therapy is not necessary.

The urinary tracts of 116 schoolgirls with asymptomatic bacteriuria detected at screening were investigated by excretory urography and micturition cystourethrography. Three years later the studies were repeated in 11 patients with scarred kidneys, 11 patients with unscarred kidneys plus reflux, and 14 untreated patients with radiologically normal urinary tracts. Exceptionally small scarred kidneys showed little growth. Unscarred kidneys with vesico-ureteral reflux exhibited normal growth, as did unscarred kidneys in untreated patients. The risk of kidney damage developing as a result of asymptomatic bacteriuria in a schoolgirl with a radiologically normal urinary tract seems to be small.