BK virus is a polyoma virus which has been associated with impaired graft function in kidney transplant recipients. After primary infection, the virus becomes latent in the renal/urinary epithelium. In immunocompetent hosts, there are usually no pathological sequelae. An 11-year-old female on chronic immunosuppression for a severe auto-immune/inflammatory condition was referred to Paediatric Nephrology due to a persistently elevated serum creatinine. Extensive investigation yielded BK viruria and viraemia. Kidney biopsy showed multifocal lymphocytic tubulitis, with cytonuclear changes. Immunohistochemical staining for SV40 was positive, and a diagnosis of native kidney BK virus nephropathy was made. We present the first non-malignancy/transplant-associated paediatric case of BK virus nephropathy in a native kidney. In an era of increasing use of immunosuppressive medicines for a variety of indications, clinicians should include BK virus infection in their differential diagnosis for nephropathy in patients on chronic, high-dose immunosuppression.

BACKGROUND AND HYPOTHESIS:Podocytopathy associated with likely pathogenic/pathogenic variants of Transient receptor potential cation channel subfamily C member 6 (TRPC6) (TRPC6-AP) has been recognized for about 20 years. As a result of its rarity however, the spectrum of clinical phenotypes and genotype-phenotype correlation of TRPC6-AP remains poorly understood. Here, we characterized clinical, histological and genetic correlates of familial and sporadic patients with TRPC6-AP. METHODS:In this multicentre observational study, an online questionnaire followed by a systematic literature review was performed to create a cohort with comprehensive data on genetic and clinical outcomes [age of onset, clinical presentation, treatment response, kidney biopsy findings and progression to kidney failure (KF)]. Logistic regression, Cox proportional hazards model and Kaplan-Meier analyses investigated the associations between genetic variants and disease progression. RESULTS:Among 87 families (96 familial and 45 sporadic cases), 31 distinct missense TRPC6 variants (including 2 novel) were identified, with c.2683C>T p.(Arg895Cys) and c.523C>T p.(Arg175Trp) the commonest variants. Proteinuric kidney disease/nephrotic syndrome was the most common clinical presentation (83.7%), while focal segmental glomerulosclerosis was the most common histological finding (89.4%). By 33 (interquartile range 17-40) years, 48.9% (69/141) of patients had progressed to KF. Sporadic TRPC6-AP demonstrated an earlier progression to KF than familial cases (P = .001) and were more likely to present with nephrotic syndrome [odds ratio 4.34 (1.85-10.15); P = .001]. Gain-of-function TRPC6 variants were more frequent in familial than sporadic TRPC6-AP (70.8% vs 44.4%; P = .004). Compared with patients with other TRPC6 variants, patients with TRPC6 p.R175W and p.R895C variants progressed to KF earlier [median kidney survival of 21 years, hazard ratio 2.985 (95% confidence interval 1.40-5.79); and 38 years, hazard ratio 1.65 (95% confidence interval 1.01-2.81), respectively, log-rank P = .005]. CONCLUSION:Our study shows unique clinical and genetic correlations of TRPC6-AP, which may enable personalized care and promising novel therapies.

Objectives Congenital adrenal hyperplasia (CAH) is an uncommon genetic disorder which affects cortisol production in the adrenal glands. It is usually treated with glucocorticoids. We present a case of non-classical CAH caused by the partial deficiency of 11 beta-hydroxylase (11 beta OH) which was treated with aldosterone antagonist (eplerenone) monotherapy.Case Presentation An adolescent male was diagnosed with 11 beta-hydroxylase deficiency (11 beta OHD) at 13 years of age when he presented with hypertension, fatigue and headaches. He was initially treated with glucocorticoids, but requested an alternative therapy. Eplerenone was commenced at 25 mg with subsequent dose increases to 100 mg daily. His hypertension was controlled on this regimen, achieving a 24 h average blood pressure of 124/81 mmHg.Conclusions CAH caused by 11 beta OHD is a known cause of hypertension. It is usually managed with glucocorticoids, and antihypertensives are added if blood pressure remains uncontrolled. In this case, glucocorticoid therapy was not tolerated and treatment with aldosterone antagonist monotherapy was effective in controlling his hypertension.

Background: EBV DNA monitoring is currently the main strategy to identify renal transplant recipients potentially at risk of EBV complications. EBV miRNA expression is markedly altered in different disease presentations associated with EBV. We performed a longitudinal assessment of the impact of rituximab on circulating EBV miRNA in 3 paediatric kidney transplant recipients. Methods: Forty-two miRNAs encoded within 2 EBV open reading frames (BART and BHRF) were examined over a 28-month period using miRNA qPCR custom panels. EBV DNA was measured using qPCR and lymphocyte subsets were measured by flow cytometry. Results: Patients were 3 years post kidney transplant and received cycles of rituximab infusions. Treatment with rituximab caused an immediate depletion of the circulating B cells and reduced the expression of the miRNAs and EBV DNA levels. About 4 months post treatment, as the circulating B cells repopulated, EBV miRNAs levels increased. A total of 29 plasma samples were studied and between 4 and 34 EBV miRNAs were detected. A significant correlation was observed between the numbers of EBV miRNAs expressed and the EBV DNA level (r = 0.63, p = 0.001). Conclusion: We provide an in-depth longitudinal assessment of the impact of rituximab on specific circulating EBV miRNA expression in three paediatric kidney transplant recipients. Rituximab treatment resulted in the reduction of EBV miRNA expression and EBV DNA viral loads. Larger studies are required to determine whether EBV miRNA levels could be useful biomarkers to predict transplant recipients at risk of developing post-transplant lymphoproliferative disease.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides are rare disorders in childhood with a variable clinical presentation. Given ANCA vasculitides' rarity, data informing clinical practice and treatment are mainly based on adult data. The purpose of this study was to characterize clinical characteristics of ANCA-associated glomerulonephritis (AAGN) in childhood to determine factors associated with adverse renal outcome and the requirement for kidney replacement therapy (KRT) across a global study population. This was a retrospective cross-sectional international survey distributed through professional pediatric nephrology organizations from December 2019 to March 2020 intended to create a registry of children with AAGN to understand clinical practices. Through an online form, pediatric nephrologists entered demographic and clinical information on all children with AAGN in their center in de-identified fashion. All centers were required to obtain their own institutional ethics or governance approval. Inclusion criteria were patients under 20 years at presentation who were diagnosed with AAGN in 2000-2019 and had kidney involvement. Data elements that were collected included baseline demographic data, clinical features at presentation, treatment received (maintenance and induction), and data on 3 clinical outcomes: requirement for KRT, serum creatinine concentration (Scr), and death. Specifically, nephrologists were asked to report the peak Scr and any requirement for KRT in the first 3 months after presentation during the induction treatment period. Nephrologists were also asked to report on the need for KRT and vital status at last known follow-up. Further methodological details are in Item S1. Based on responses received from 114 different clinicians, 337 children from 41 different countries were included in the final analysis. Median duration between initial presentation and last known follow-up was 26 (IQR, 11-57) months. Table S1 details baseline characteristics of included children. Table S2 shows the organ involvement at presentation across different clinical phenotypes. Table 1 shows the most frequent induction and maintenance treatments used in the entire cohort. A total of 113 children (34%) received plasma exchange at induction. Sixteen deaths were reported in this cohort (5% mortality), with a mean age at death of 13.7 ±5.7 years.Table 1Main Combinations of Induction and Maintenance Treatment in Entire AAGN CohortMain Treatment CombinationsValueInductionSteroids,aIntravenous or oral. cyclophosphamide100 (30%)Steroids,aIntravenous or oral. cyclophosphamide, PE (± IVIG)56 (17%)Steroids,aIntravenous or oral. rituximab25 (7%)SteroidsaIntravenous or oral.22 (7%)Steroids,aIntravenous or oral. cyclophosphamide, rituximab, PE (± IVIG)21 (6%)Steroids,aIntravenous or oral. mycophenolate mofetil13 (4%)Other combinations96 (28%)None4 (1%)MaintenanceMycophenolate mofetil and steroids100 (31%)Azathioprine and steroids49 (15%)Cyclophosphamide and steroids25 (8%)Steroids20 (6%)Steroids and rituximab19 (6%)Azathioprine17 (5%)Mycophenolate mofetil8 (2%)Rituximab8 (2%)Other combinations62 (19%)None15 (5%)Induction therapy information was available from all 337 patients, maintenance treatment data from 327 patients. "Other combinations" refers to multiple different combinations used less commonly. Abbreviations: IVIG, intravenous immunoglobulin; PE, plasma exchange.a Intravenous or oral. Open table in a new tab Induction therapy information was available from all 337 patients, maintenance treatment data from 327 patients. "Other combinations" refers to multiple different combinations used less commonly. Abbreviations: IVIG, intravenous immunoglobulin; PE, plasma exchange. Table 2 characterizes the clinical factors and treatment according to KRT requirements at initial presentation and at last known follow-up. We found a high prevalence of adverse renal outcomes, with 40% of children requiring KRT at last known follow-up, slightly higher than previously published data.1Calatroni M. Consonni F. Allinovi M. et al.Prognostic factors and long-term outcome with ANCA-associated kidney vasculitis in childhood.Clin J Am Soc Nephrol. 2021; 16: 1043-1051https://doi.org/10.2215/CJN.19181220Crossref PubMed Scopus (8) Google Scholar, 2Özçelik G. Sönmez H.E. Şahin S. et al.Clinical and histopathological prognostic factors affecting the renal outcomes in childhood ANCA-associated vasculitis.Pediatr Nephrol. 2019; 34: 847-854https://doi.org/10.1007/s00467-018-4162-5Crossref PubMed Scopus (8) Google Scholar, 3Morishita K.A. Moorthy L.N. Lubieniecka J.M. et al.Early outcomes in children with antineutrophil cytoplasmic antibody-associated vasculitis.Arthritis Rheumatol. 2017; 69: 1470-1479https://doi.org/10.1002/art.40112Crossref PubMed Scopus (39) Google Scholar, 4Sacri A.-S. Chambaraud T. Ranchin B. et al.Clinical characteristics and outcomes of childhood-onset ANCA-associated vasculitis: a French nationwide study.Nephrol Dial Transplant. 2015; 30: i104-i112https://doi.org/10.1093/ndt/gfv011Crossref PubMed Scopus (70) Google Scholar Children who did (vs did not) require KRT at last known follow-up had a higher peak Scr during the first 3 months after their initial presentation. There was a higher proportion of girls and a higher proportion of myeloperoxidase-ANCA positivity in children who required KRT at last known follow-up, compared to those who did not require KRT. We note that children who required KRT at last known follow-up were more likely to have received plasma exchange as induction treatment, but this may simply be because children with more severe kidney involvement at presentation were more likely to be treated with plasma exchange. We note that mycophenolate mofetil was used more commonly as maintenance treatment for children compared to azathioprine, which differs from suggestions in the adult literature.5Hiemstra T.F. Walsh M. Mahr A. et al.Mycophenolate mofetil vs azathioprine for remission maintenance in antineutrophil cytoplasmic antibody-associated vasculitis: a randomized controlled trial.JAMA. 2010; 304: 2381-2388https://doi.org/10.1001/jama.2010.1658Crossref PubMed Scopus (468) Google ScholarTable 2Clinical Variables and the Requirement for KRT During the First 3 Months After Initial Presentation and Last Known Follow-up in 326 Children With AAGNRequired KRT at Initial PresentationRequired KRT at Last Known Follow-upYesNoYesNoNo. of patients119207132194Female sex75%69%78%68%Age at presentation, y12.1 ± 4.412.5 ± 5.411.9 ± 4.612.7 ± 5.3MPO-ANCA71%64%77%60%High-income GDP61%66%58%68%Peak Scr during initial presentation, μmol/L736 ± 345173 ± 121616 ± 333218 ± 115Organ involvement at presentation Respiratory tract50%42%50%41% Ear, nose, and throat12%17%10%19% Skin13%32%17%30% Musculoskeletal9%24%18%19% Neurological16%8%18%6% Eye5%10%7%9%Induction treatment IV steroids95%80%92%81% Rituximab29%27%25%29% IV cyclophosphamide55%57%64%56% Plasma exchange57%19%44%26%Maintenance treatment Azathioprine22%27%24%27% Mycophenolate mofetil46%45%43%47% Rituximab17%17%14%19%Continuous variables given as mean ± SD. Follow-up on the need for KRT was not available on 11 children; therefore data on 326 children are presented in this table. Conversion factor for Scr μmol/L to mg/dL, ×0.0113. Abbreviations: GDP, gross domestic product; IV, intravenous; MPO, myeloperoxidase. Open table in a new tab Continuous variables given as mean ± SD. Follow-up on the need for KRT was not available on 11 children; therefore data on 326 children are presented in this table. Conversion factor for Scr μmol/L to mg/dL, ×0.0113. Abbreviations: GDP, gross domestic product; IV, intravenous; MPO, myeloperoxidase. This study is unique, as it was conducted across 41 countries, giving a broad cross-sectional assessment of demographics and baseline characteristics of children affected by AAGN. Potential limitations of this study include an over-representation of children with severe renal outcomes, given the collection of data through a survey of pediatric nephrologists; but this is also a strength, as this study focuses on the subgroup of children with ANCA vasculitis who have kidney involvement. Data were only available at disease presentation and latest follow-up, which limits our ability to comment on kidney function over time. In addition, we did not collect data on histology, meaning that the diagnosis of AAGN was clinical rather than histological and we had limited ability to relate histology to clinical outcomes. We also do not have data on proteinuria at presentation, which is a further limitation. In conclusion, this large international cohort of children with AAGN demonstrates the high risk of chronic kidney disease and requirement for KRT in this population. Designed the study, collected and collated data, conducted and reviewed analyses: MM, TW, NP, FS, MV, KT; devised the statistical analysis plan, conducted statistical analyses: DK, RK, LS; reviewed patients for inclusion, collected data: MA, IA, AA, JB, RB, BB, ZB, OB, EY-hC, DC, SD, ED, MD-D, LAE, LE, VF, HF, JF-D, AG, VG, MLG, MHansen, MHattori, XH, NH, DI, HGK, VK, IK, AL, SM, AMaxted, AMoczulska, RM, TN, MP, CP, IP, CS-K, SS, RSchild, MS, RSinha, APS, MStack, MSzczepanska, AT, JT, VU, CZ, JZ. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual's own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, are appropriately investigated and resolved, including with documentation in the literature if appropriate. This study has been supported by the European Rare Kidney Disease Network (ERKNet). ERKNet is co-funded by the European Union within the framework of the Third Health Programme "ERN-2016 - Framework Partnership Agreement 2017-2021." The funders had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication. The authors declare that they have no relevant financial interests. We are grateful to the European Society of Paediatric Nephrology (ESPN) and the International Paediatric Nephrology Association (IPNA) for their support in administering this study. We are grateful to all colleagues and pediatric nephrology centers contributing cases to this study. Aspects of this work were presented in abstract form at the 53rd ESPN Annual Meeting held in Amsterdam, The Netherlands, in September 2021. Received February 11, 2022. Evaluated by 2 external peer reviewers, with direct editorial input from a Statistics/Methods Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form May 18, 2022. Download .pdf (.29 MB) Help with pdf files Supplementary File (PDF)Item S1; Tables S1, S2.

Abstract Inwardly rectifying potassium channels (Kir) allow potassium (K+) to easily move into cells. They are implicated in several diverse physiological processes throughout the body. KCNJ16 associated tubulopathy and deafness affects a subset of Kir transport channels. This disease was first described in 2021, amongst a cohort of 9 patients in total. Sudden cardiac arrest has been described as a presenting symptom of tubulopathy previously. We report the case of an infant who presented with sudden cardiac arrest (SCA) aged 7 months secondary to severe hypokalaemia. Singleton exome analysis identified apparent homozygous missense variants in KCNJ16 (c.409C>G; p.R137G). To our knowledge, this is the first description of sudden cardiac arrest at presentation in this form of tubulopathy.

BACKGROUND:Adolescence is a time of significant change for patients, guardians and clinicians. The paediatrician must ensure patients develop the necessary skills and knowledge required to transition and to function as an independent entity, with autonomy over their own care. The transfer from paediatric to adult care carries an increased risk of graft-related complications attributable to a multitude of reasons, particularly non-adherence to immunosuppressive medicines and poor attendance at scheduled appointments. This systematic review was conducted to ascertain the transitional care models available to clinicians caring for kidney transplant recipients and to compare the approach in each respective case. METHODS:A systematic review was performed, in a methodology outlined by the PRISMA guidelines. OVID MEDLINE and EMBASE databases were searched for studies that outlined valid, replicable models pertaining to transitional care of paediatric kidney transplant recipients between 1946 and Quarter 3 of 2021. The reference lists of selected articles were also perused for further eligible studies and experts in the field were consulted for further eligible articles. Two investigators assessed all studies for eligibility and independently performed data extraction. Any discrepancies were settled by consensus. RESULTS:A total of 1121 abstracts were identified, which was reduced to 1029 upon removal of duplicates. A total of 51 articles were deemed appropriate for full-text review and critical appraisal. A total of 12 articles that described models for transition pertaining to kidney transplant patients were included in qualitative synthesis. Every paper utilized a different transition model. All but one model included a physician and nurse at minimum in the transition process. The involvement of adult nephrologists, medical social work, psychology and psychiatry was variable. The mean age for the initiation of transition was 13.4 years (range: 10-17.5 years). The mean age at transfer to adult services was 18.3 years (range: 16-20.5 years). CONCLUSIONS:Despite the well-established need for good transitional care for paediatric solid-organ transplant recipients, models tailored specifically for kidney transplant recipients are lacking. Further research and validation studies are required to ascertain the best method of providing effective transitional care to these patients. Transitional care should become a standardized process for adolescents and young adults with kidney transplants.

Therapeutic plasma exchange (TPE) is utilised in the management of a limited number of paediatric renal conditions. Despite its widespread acceptance and advancements in the practice of apheresis, there remains a paucity of data pertaining to paediatrics. We present a large retrospective review of our cohort of paediatric patients undergoing TPE for renal indications, outlining their outcomes and complications. A retrospective chart review was conducted for all patients (under 16 years) undergoing TPE for renal conditions between January 2002 and June 2019 in Ireland. Demographic and clinical data were extracted, with patients anonymised and stratified according to their pathology. A total of 58 patients were identified. A total of 1137 exchanges were performed using heparin sodium anticoagulation. The median age was 35.5 months (IQR 18–110 months). The leading indication was neurological involvement in Shiga toxin–producing Escherichia coli haemolytic uraemic syndrome (STEC-HUS) (n = 29). Complications (minor or major) occurred in 65.5

Acute kidney injury (AKI) is a common problem in the neonatal intensive care unit (NICU). Neonates born at <1,000 g (extremely low birth weight, ELBW) are at an increased risk of secondary associated comorbidities such as intrauterine growth restriction, prematurity, volume restriction, ischaemic injury, among others. Studies estimate up to 50% ELBW infants experience at least one episode of AKI during their NICU stay. Although no curative treatment for AKI currently exists, recognition is vital to reduce potential ongoing injury and mitigate long-term consequences of AKI. However, the definition of AKI is imperfect in this population and presents clinical challenges to correct identification, thus contributing to under recognition and reporting. Additionally, the absence of guidelines for the management of AKI in ELBW infants has led to variations in practice. This review summarizes AKI in the ELBW infant and includes suggestions such as close observation of daily fluid balance, review of medications to reduce nephrotoxic exposure, management of electrolytes, maximizing nutrition, and the use of diuretics and/or dialysis when appropriate.

Cerebral Palsy (CP) describes a heterogenous group of non-progressive disorders of posture or movement, causing activity limitation, due to a lesion in the developing brain. CP is an umbrella term for a heterogenous condition and is, therefore, descriptive rather than a diagnosis. Each case requires detailed consideration of etiology. Our understanding of the underlying cause of CP has developed significantly, with areas such as inflammation, epigenetics and genetic susceptibility to subsequent insults providing new insights. Alongside this, there has been increasing recognition of the multi-organ dysfunction (MOD) associated with CP, in particular in children with higher levels of motor impairment. Therefore, CP should not be seen as an unchanging disorder caused by a solitary insult but rather, as a condition which evolves over time. Assessment of multi-organ function may help to prevent complications in later childhood or adulthood. It may also contribute to an improved understanding of the etiology and thus may have an implication in prevention, interventional methods and therapies. MOD in CP has not yet been quantified and a scoring system may prove useful in allowing advanced clinical planning and follow-up of children with CP. Additionally, several biomarkers hold promise in assisting with long-term monitoring. Clinicians should be aware of the multi-system complications that are associated with CP and which may present significant diagnostic challenges given that many children with CP communicate non-verbally. A step-wise, logical, multi-system approach is required to ensure that the best care is provided to these children. This review summarizes multi-organ dysfunction in children with CP whilst highlighting emerging research and gaps in our knowledge. We identify some potential organ-specific biomarkers which may prove useful in developing guidelines for follow-up and management of these children throughout their lifespan.

Background CAKUT are the most common cause of end-stage renal failure in children (Pediatr Nephrol. 24, 2009, 1719). Many children with CAKUT have poor urinary drainage which can compromise post-transplant outcome. Identifying safe ways to manage anatomical abnormalities and provide effective urinary drainage is key to transplant success. Much debate exists regarding optimum urinary diversion techniques. The definitive formation of a continent urinary diversion is always preferable but may not always be possible. We explore the role of ureterostomy formation at transplantation in a complex pediatric group. Methods We report six pediatric patients who had ureterostomy formation at the time of transplantation at the National Paediatric Transplant Centre in Dublin, Ireland. We compared renal function and burden of urinary tract infection to a group with alternative urinary diversion procedures and a group with normal bladders over a 5-year period. Results There was no demonstrable difference in estimated glomerular filtration rate between the groups at 5-year follow-up. The overall burden of UTI was low and similar in frequency between the three groups. Conclusions Ureterostomy formation is a safe and effective option for temporary urinary diversion in children with complex abdominal anatomy facilitating transplantation; it is, however, important to consider the implications and risk of ureterostomy for definitive surgery after transplantation.

Our objective was to establish the rate of neurological involvement in Shiga toxin-producing Escherichia coli–hemolytic uremic syndrome (STEC-HUS) and describe the clinical presentation, management and outcome. A retrospective chart review of children aged ≤ 16 years with STEC-HUS in Children’s Health Ireland from 2005 to 2018 was conducted. Laboratory confirmation of STEC infection was required for inclusion. Neurological involvement was defined as encephalopathy, focal neurological deficit, and/or seizure activity. Data on clinical presentation, management, and outcome were collected. We identified 240 children with HUS; 202 had confirmed STEC infection. Neurological involvement occurred in 22 (11%). The most common presentation was seizures (73%). In the neurological group, 19 (86%) were treated with plasma exchange and/or eculizumab. Of the 21 surviving children with neurological involvement, 19 (91%) achieved a complete neurological recovery. A higher proportion of children in the neurological group had renal sequelae (27% vs. 12%, P = .031). One patient died from multi-organ failure. Conclusion: We have identified the rate of neurological involvement in a large cohort of children with STEC-HUS as 11%. Neurological involvement in STEC-HUS is associated with good long-term outcome (complete neurological recovery in 91%) and a low case-fatality rate (4.5%) in our cohort.

To assess clinical characteristics and indication for imaging of the patients who have had indirect MAG3 cystography (IRC) performed in CHI at Crumlin and Temple Street, and whether it changed patient management. In this retrospective audit we identified all children who had IRC performed in Temple Street and Crumlin in the last 4 years by searching the radiology systems. Data collected included age of patient at time of scan, indication for scan, results of scan, whether a conventional micturating cystourethrogram (MCUG) had previously/subsequently been performed, and what changes were made to management. N=36 patients were identified (3 male). Mean age at scanning was 9 years 5 months. The most common indication was recurrent UTI (33/36), with additional renal scarring in 14/33 of these. 12 patients had had a previous MCUG, and 11 of these demonstrated reflux. 5 patients had previously had a STING procedure and one had ongoing reflux on IRC and was referred for surgery. 8 patients had reflux demonstrated on IRC. 4 of these went on to have surgical intervention based on their IRC – 1 had a ureteric reimplantation, and 3 had STING procedures. 3 patients had a standard MCUG following a negative IRC due to high suspicion of reflux. One of these displayed grade 1 reflux, one displayed grade 2 bilateral reflux, and one was normal. The patient with grade 2 bilateral reflux also had renal scarring and went on to have a STING procedure performed. IRC is a safe, non-invasive alternative to MCUG in older children with suspicion of reflux. Demonstration of reflux on IRC can be helpful in decision making regarding further intervention for patients with recurrent UTIs, particularly with renal scarring. For the majority of patients a negative result can reassuring, without the patient having an invasive procedure.