VUR Flashcards
1
Q
Initial EVALUATION of child with VUR
A
General medical evaluation in all patients:
- Measurement of height, weight, and blood pressure, and serum creatinine if bilateral renal abnormalities are found.
- Urinalysis for proteinuria and bacteriuria; if urinalysis indicates infection, a urine culture and sensitivity is recommended.
- A baseline serum creatinine may be obtained to establish an estimate of glomerular filtration rate.
Imaging procedures:
- Renal ultrasound to assess the upper urinary tract is recommended.
- DMSA (technetium-99m-labeled dimercaptosuccinic acid) renal imaging can be obtained to assess the kidney for scarring and function.
Assessment of voiding patterns:
• Symptoms indicative of bladder/bowel dysfunction (BBD) should be sought including: urinary frequency and urgency, prolonged voiding intervals, daytime wetting, perineal/penile pain, holding maneuvers (posturing to prevent wetting), and constipation/encopresis.
Family and patient education:
- Discussion should include rationale for treating VUR, potential consequences of untreated VUR, equivalency of certain treatment approaches, assessment of likely adherence with the care plan.
- Determination of parental concerns and accommodation of parental preferences when treatment choices offer a similar risk-benefit balance.
2
Q
Initial MANAGEMENT of child with VUR
A
The goals of management are to 1) prevent recurring febrile urinary tract infection (UTI) 2) prevent renal injury; and 3) minimize morbidity of treatment and follow-up.
- The child with VUR <1 year of age:
- CAP is recommended for children <1 year of age with VUR and a history of a febrile UTI.
- In the absence of a history of febrile UTI, CAP is recommended for the child 1 year of age with VUR grades lll-V identified through screening.
- In the absence of a history of febrile UTI, the child <1 year of age with VUR grades l-ll who is identified through screening may be offered CAP.
- Circumcision of the male infant with VUR may be considered based on an increased risk of UTI in boys who are not circumcised.
- Parents need to be made aware of this association to permit informed decision-making.
- The child with UTI and VUR >1 year of age (Table 1):
- If clinical evidence of BBD is present, treatment is indicated, preferably before any surgical intervention for VUR is undertaken.
- Treatment options include behavioral therapy, biofeedback (for children >5 years of age), anticholinergic medications, alpha blockers, and treatment of constipation.
- CAP is recommended for the child with BBD and VUR due to the increased risk of UTI while BBD is present and being treated.
- CAP may be considered for the child >1 year of age with a history of UTI and VUR in the absence of BBD.
- Observational management without CAP, with prompt initiation of antibiotic therapy for UTI, may be considered for the child >1 year of age with VUR in the absence of BBD, recurrent febrile UTIs, or renal cortical abnormalities.
- Surgical intervention for VUR including both open and endoscopic methods, may be used.
3
Q
Followup management of child with VUR
A
General follow-up in all patients:
- General evaluation, including monitoring of blood pressure, height, and weight is recommended annually.
- Urinalysis for proteinuria and bacteriuria is indicated annually, including a urine culture and sensitivity if the urinalysis is suggestive of infection.
- Imaging – ultrasonography and cystography:
- Ultrasonography is recommended every 12 months to monitor renal growth and any parenchymal scarring.
- Voiding cystography (radionuclide cystogram or low-dose fluoroscopy, when available) is recommended between 12 and 24 months.
- Longer intervals between follow-up studies are suggested in patients who may have lower rates of spontaneous resolution (i.e. those with VUR grades lll-V, BBD, and older age).
- If an observational approach without CAP is being used, follow-up cystography is an option.
- Follow-up cystography may be performed after 1 year of age in patients with VUR grades l-ll; these patients have high rates of spontaneous resolution and boys also have a low risk of recurrent UTI.
- A single normal voiding cystogram may serve to establish resolution.
- The clinical significance of grade I VUR, and the need for ongoing evaluation is undefined.
- Imaging – DMSA:
- Recommended when renal ultrasound is abnormal, when there is a greater concern for scarring (i.e. breakthrough UTI [BT-UTI]; grade lll-V VUR), or if serum creatinine is elevated.
- May be considered for follow-up of children with VUR to detect new renal scarring, especially after a febrile UTI.
4
Q
Intervention for the child with breakthrough UTI
A
- If symptomatic BT-UTI occurs, a change in therapy is recommended.
- The clinical scenario will guide the choice of treatment alternatives; this includes VUR grade, degree of renal scarring, if any, and evidence of abnormal voiding patterns (BBD) that might contribute to UTI, as well as parental preferences.
- Patients receiving CAP with a febrile BT-UTI should be considered for open surgical ureteral reimplantation or endoscopic injection of bulking agents for intervention with curative intent.
- In patients receiving CAP with a single febrile BT-UTI and no evidence of pre-existing or new renal cortical abnormalities, changing to an alternative antibiotic agent is an option prior to intervention with curative intent.
- In patients not receiving CAP who develop a febrile UTI, initiation of CAP is recommended.
- In patients not receiving CAP who develop a non-febrile UTI, CAP is an option; not all cases of pyelonephritis are associated with fever.
5
Q
Surgical treatment of VUR
A
- Surgical treatment of VUR, including both open and endoscopic methods, is an option.
- Following open surgical or endoscopic procedures for VUR, a renal ultrasound should be obtained to assess for obstruction.
- Postoperative voiding cystography following endoscopic injection of bulking agents is recommended.
- Postoperative cystography may be performed following open ureteral reimplantation.
6
Q
Management following resolution of VUR
A
- Either spontaneously or by surgical intervention, monitoring of blood pressure, height, and weight, and urinalysis for protein and UTI is recommended annually through adolescence.
- If both kidneys are normal by ultrasound or DMSA scanning, such follow-up is an option
- With the occurrence of a febrile UTI following resolution or surgical treatment of VUR, evaluation for BBD or recurrent VUR is recommended.
- Discussion is recommended of the long-term concerns of hypertension (particularly during pregnancy), renal functional loss, recurrent UTI, and familial VUR in the child’s siblings and offspring with the family and child at an appropriate age.
7
Q
Screening for VUR in siblings
A
The incidence of VUR in siblings of children with VUR is 27% overall and decreases with age. The incidence of VUR in offspring of a parent with reflux is 37%.
For siblings of children with VUR:
- A voiding cystourethrogram (VCUG) or radionuclide cystogram is recommended on evidence of renal cortical abnormalities or renal size asymmetry on ultrasound or a history of UTI in the sibling who has not been tested.
- Given that the value of identifying and treating VUR is unproven:
- Ultrasound screening of the kidneys may be performed to identify significant renal scarring and to focus attention on the presence and potential further risk of VUR.
- Screening offspring of patients with VUR can be considered as similar to screening of siblings
8
Q
Neonates with prenatal hydronephrosis
A
The incidence of VUR in children who have had hydronephrosis detected prenatally is 16% overall. The likelihood of VUR is not predicted by the severity of the hydronephrosis either prenatally or postnatally.
- VCUG is recommended for children with high-grade (Society for Fetal Urology [SFU] grade 3 and 4) hydronephrosis, hydroureter or an abnormal bladder on ultrasound (late-term prenatal or postnatal), or who develop a UTI on observation.
- Screening for VUR in children with a history of prenatally detected hydronephrosis with low grade hydronephrosis (SFU grade 1 or 2) is an option.
- An observational approach without screening for VUR, with prompt treatment of any UTI, may be taken for children with prenatally detected hydronephrosis (SFU grade 1 or 2).
