pediatric vesicoureteral reflex (vur) by carolina veronese

Pediatric Vesicoureteral Reflux (VUR)

Diagnosis, Assessment, and Follow up

Carolina Veronese, HMS III

2012

Carolina Veronese, 2012 Gillian Lieberman, MD

June 2012


Agenda

- Introduction

- Anatomy

- Pathogenesis

- Epidemiology

- Case Presentation

- Menu of Radiologic Tests - Diagnostic Criteria - Complications - Follow up - Recommendations


VUR - It is the retrograde passage of urine from the

bladder into the upper urinary tract.

- It is the most common urologic finding in children.

- Found in 1% of newborns and 30-45% of young children with UTI.

- VUR predisposes patients to recurrent pyelonephritis therefore it is a risk factor for renal scarring.

- It is also a marker for abnormal renal development.


Renal Anatomy

University of Maryland Medical Center http://www.umm.edu/imagepages/1101.htm

University of Minnesota Masonic Cancer Center http://www.cancer.umn.edu/cancerinfo/NCI/CDR435963.html


VUR: Pathogenesis

- Primary VUR: most common form caused by a congenital defect that results in a decreased length of intravesical ureter leading to an abnormal valvular mechanism.

- Secondary VUR: in this type, the length of intravesical ureter is normal and results in a normal valvular mechanism which is overwhelmed by abnormally high pressure within the bladder associated with bladder outlet obstruction.

Pediatric Nephrology, Avner, ED, Harmon, WE,

Niaudet, P (Eds), Lippincott 2004. p.1028.


VUR: Epidemiology

• White children: Black children = 3:1

• Girls: Boys = 2:1

• Children < 2 years of age are more likely to have VUR than older children.

• Prevalence: sibling with VUR = 27.4%; parent with VUR = 35.7%

• Found in 1% of newborns and 30-45% of young children with UTI.


Our Patient Presentation

4 month old healthy baby girl born to healthy mother at 41 weeks gestation who presents to the pediatrician with 40C fever, lethargy and poor feeding. Symptoms began early AM and have worsened in the course of two hours.

- PE: patient is lethargic, fever of 41.2C. Remaining of the physical exam is unremarkable.

- What tests would you like to order?


Our Patient: Work Up

• Urine dipstick test is positive for nitrites and leukocytes.

• Clinical suspicion was for a UTI

• What do we do next?


The American College of Radiology (ACR) has developed appropriateness criteria to help physicians decide the best imaging studies for different patient presentations.

http://www.acr.org/Quality-Safety/Appropriateness-Criteria


ACR criteria: fever < 38.5C

American College of Radiology http://www.acr.org/Quality-Safety/Appropriateness-Criteria


ACR criteria: fever > 38.5C

American College of Radiology http://www.acr.org/Quality-Safety/Appropriateness-Criteria


Menu of Radiologic Tests

• Ultrasound

• Voiding cystourethrogram (VCUG)

• Radionuclide cystogram (RNC)

• Dimercapto succinic acid scan (DMSA)


Our Patient: Renal Ultrasound

Radiologist report: intermittent dilation of the right renal collecting system, prominent extrarenal pelvis and moderate intrarenal calyceal dilation (green

star). No right hydroureter, left hydronephrosis or hydroureter. Bladder is normal.

Images courtesy of Children’s Hospital Boston

Transverse Right Kidney Transverse Right Kidney


VCUG

• Voiding cystourethrogram

• Fluoroscopy study that involves:

– Catheterization of the bladder

– Bladder is filled with cystograffin (contrast).

– X-rays are taken to determine if contrast enters the ureters +/- the kidneys

– VUR is diagnosed if contrast is seen in the ureters +/- kidneys.


VCUG of our patient


Bladder filled with contrast

VCUG showing the catheter inside the bladder


Our Patient: Reflux on VCUG Images courtesy of Children’s Hospital Boston

VCUG image showing the bladder filled with contrast and contrast inside a dilated right ureter (black arrow).

VCUG image showing the bladder filled with contrast and contrast inside an anatomically

normal left ureter (black arrow).


VCUG showing bilateral reflux

Results:

Bilateral vesicoureteral reflux, right grade 3 to 4 (star), and left grade 3 (circle).

Severity Classification:

• Mild — Grades I and II

• Moderate — Grade III

• Severe — Grades IV and V



VUR: Grading System

Brady Urological Institute – Johns Hopkins Hospital http://urology.jhu.edu/pediatric/diseases/reflux.php


Prenatal Diagnostic Criteria of VUR

Ultrasound Image Gallery http://www.ultrasound-images.com/fetal-urogenital.htm#Fetal_hydronephrosis

• The criteria to diagnose hydronephrosis in utero according to the American Urological Association is: – Second trimester US: renal

pelvic diameter (RPD) > 4mm or;

– Third trimester US: RPD > 7mm

• Repeat US postnatal. • If hydronephrosis or

hydroureter present -> VCUG

• If US is normal -> repeat US in 3 months


Postnatal Diagnostic Criteria of VUR

• Infants who usually present with febrile UTI have higher risk of abnormalities of GU tract (VUR and obstructive uropathy)

• Diagnostic tools: US and VCUG or Radionuclide cystogram


Radionuclide Cystogram

• Nuclear Medicine study • Catheterization of the

bladder • Bladder is filled saline

mixed with Technetium-99

• Gamma ray camera takes pictures while the bladder is being filled and during voiding process.

• Less radiation than a VCUG.

Medscape http://emedicine.medscape.com/article/414836-overview#a23

RNC showing contrast inside the bladder, right ureter, and right kidney, on a patient with VUR.


Treatment of VUR

Options available:

- Prophylactic antibiotics and re-test in a couple of years for spontaneous resolution.

- Surgical reimplatantion of the ureters

- Endoscopic injections of dextranomer and hyaluronic acid gel.

Deflux http://www.deflux.com/country/global/

Reflux persistence for 1 to 5 years following presentation

Elder, JS, Peters, CA, Arant, BS Jr, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children. J Urol 1997; 157:1846. Copyright © 1997 American Urological Association.


VUR: Complications

• Renal Scarring – Initial rationale was that renal parenchyma scarring was

caused the reflux of infected urine, but not sterile urine.

– Current view questions whether VUR and its severity lead to renal parenchyma scarring or whether VUR serves only as a marker for congenital renal maldevelopment (renal hypoplasia, dysplasia, or both).

– Prospective studies comparing prophylactic antibiotics vs. antibiotics and surgery showed decreased febrile illness in the latter group but no reduction of renal scarring over five years¹.


DMSA: Assessing Renal Scarring

• DMSA (dimercapto succinic acid) Scan is a nuclear medicine study

• IV injection of contrast

• Takes 2 hours for the contrast to be absorbed by the kidneys.

• Child has to remain still for the duration of the test (1 hour). Sedation is indicated for those who cannot comply.


Companion Patient 1: Renal scarring on DMSA scan

Dimercaptosuccinic acid (DMSA) scan showing areas of photopenia (green stars) at the right kidney consistent with scarring in this patient with vesicoureteral reflux. Image: Medscape. http://emedicine.medscape.com/article/414836-overview#a23


Our Patient: Follow Up

• Patient was started on prophylactic antibiotics but continued to have multiple febrile UTIs over a period of 6 months.

• Patient underwent bilateral ureteral re-implantation at the age of 10 months.

• Patient was found to have a duplex right renal

collecting system and ureter.

Children’s Hospital of Philadelphia http://www.chop.edu/healthinfo/duplex-kidney.html


Our Patient: Cystoscopic Images pre-surgery

In Purple: Right vesicoureteral junction

with 2 orifices

In Orange: Left vesicoureteral junction

with 1 orifice


VUR: Long-term follow up

• Patients with VUR should receive long-term follow up after surgical or spontaneous resolution to assess and prevent renal scarring and sequelae.

• AUA guidelines recommends annual assessment of growth (height & weight), blood pressure, and urinalysis to detect proteinuria or bacteria, through adolescence.


Our patient: Post surgical RNC

• 3 months post-surgery, patient underwent radionuclide cystogram to evaluate the results of the surgery. RN showed no reflux.



Our Patient: 1 year post-op US

• Repeat US to evaluate kidneys showed duplex right renal collecting system, without hydroureteronephrosis, normal left kidney and ureter, and normal bladder.

Image courtesy of Children’s Hospital Boston


Our Patient: 1 year post-op check up

• Patient is 22 months old

• Weight in the 20% as opposed to 5% pre-surgery

• Height in the 40% as opposed to 15% pre-surgery

• Patient had one UTI a month post-surgery but has remained infection free ever since.

• Blood pressure is normal and no signs of proteinuria or any renal problems.


Conclusion

• The current treatment is still based on the long-held view that VUR + UTIs can lead to renal scarring, hypertension, and chronic renal disease.

• Current management is designed to try to prevent pyelonephritis and renal scarring, assess the probability for possible spontaneous resolution, and address patient/family preferences.

• The benefits of the current treatments available is unclear as renal outcome data of patients treated vs. those who only received surveillance is lacking.

• Patients with VUR should be screened for voiding dysfunction.


Conclusion cont.

• Current recommendation: – Grades I and II: medically managed with prophylactic

antibiotics. Surgical correction is not indicated. Patients should receive mandatory urine cultures whenever UTI is suspected or with any unexplained febrile illnesses.

– Grades III to V: surgical correction is recommended due to greatest risk of recurrent UTIs, renal scarring, and HTN.

– It is important to remember that family preference should play a major role in the final therapeutic decision.


Thank you!

Special thanks to: Diana Rodriguez Pamela Deaver

From Boston Children’s Hospital


References • ¹Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomized controlled trials.

Wheeler D, Vimalachandra D, Hodson EM, Roy LP, Smith G, Craig JC. Arch Dis Child. 2003;88(8):688.)

• AUA Guideline: Management and screening of primary VUR in children. http://www.auanet.org/content/clinical-practice-guidelines/clinical-guidelines.cfm?sub=vur2010 June 15, 2012

• Management of vesicoureteral reflux. McLorey, G & Herrin, JT. Uptodate . http://www.uptodate.com/contents/management-of-vesicoureteral-reflux?source=preview&anchor=H2&selectedTitle=2~86#H16. June 15, 2012

• Presentation, diagnosis, and clinical course of vesicoureteral reflux. McLorey, G & Herrin, JT. Uptodate http://www.uptodate.com/contents/presentation-diagnosis-and-clinical-course-of-vesicoureteral-reflux?source=search_result&search=VUR&selectedTitle=1%7E86 June 15, 2012

• Vesicoureteral reflux imaging. McCarthy KF, Lin EC. Medscape http://emedicine.medscape.com/article/414836-overview#a01 June 15, 2012

pediatric vesicoureteral reflex (vur) by carolina veronese

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