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Do systemic symptoms predict the risk of kidney scarring after urinary tract infection?
M G Coulthard1, H J Lambert, M J Keir
1Department of Paediatric Nephrology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle, UK. malcolm.coulthard@nuth.nhs.uk
Insights
Clinical symptoms like fever in childhood urinary tract infections (UTI) do not reliably predict kidney scarring. Current guidelines recommending management based on these signs are not supported by evidence.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Clinical Epidemiology
Background:
- The National Institute for Health and Care Excellence (NICE) guideline for childhood urinary tract infection (UTI) assumes systemic symptoms, particularly fever, predict renal scarring.
- Management strategies for childhood UTI are currently based on this assumption.
Purpose of the Study:
- To evaluate the hypothesis that clinical signs at presentation can predict renal scarring in children with UTI.
- To assess the predictive value of fever, systemic symptoms, and hospitalization for renal scarring.
Main Methods:
- Retrospective analysis of case notes from children under 5 years old with a first UTI who were assessed for scarring.
- Examined the ability to predict scarring based on age, sex, fever, vomiting, anorexia, malaise, and hospitalization, using age bands defined by NICE.
Main Results:
- Fever, systemic symptoms, and hospitalization were more common in younger children.
- Vomiting, anorexia, or malaise weakly correlated with scarring (R² = 0.03, p = 0.02).
- Sex, age, fever, or hospitalization did not significantly predict scarring (p > 0.5). Predictive value was poor for children under 3 years and only weak for older children.
Conclusions:
- Clinical signs at the presentation of childhood UTI are insufficient to predict renal scarring.
- Current NICE recommendations to guide management based on these clinical signs are not evidence-based and should be reconsidered.
Background And Aims:
In the NICE guideline on childhood urinary tract infection (UTI), it is assumed that the presence or severity of systemic symptoms, especially fever, predicts for renal scarring, and different management is recommended accordingly. We aimed to test this hypothesis by retrospective case note analysis.
Design And Subjects:
Notes of children aged under 5 years referred with a first UTI who were assessed for scarring were reviewed.
Main Outcome Criteria:
Ability to predict for single or multiple scarring from age, sex, fever, vomiting or anorexia or malaise, or need for hospitalisation, within the age bands used by NICE.
Results:
There were 51 (65% girls) scarred and 140 (69% girls) unscarred children. Fever, systemic symptoms and hospitalisation were all commoner among younger children (<6 months vs 6 months-3 years vs >3 years; fever 0.67 vs 0.38 vs 0.38; systemic symptoms 0.78 vs 0.62 vs 0.43; hospitalisation 0.67 vs 0.29 vs 0.19; p<0.001 for all). Having vomiting, anorexia or malaise at presentation correlated weakly with single or multiple renal scarring (R(2) = 0.03; p = 0.02), but sex, age, fever or hospitalisation did not (p>0.5 for all). Sensitivity and specificity data, and plots of proportionate reduction of uncertainty showed that none of these variables was useful for predicting any scarring in children aged <3 years and that they were only weakly predictive in older children.
Conclusions:
Clinical signs at presentation in childhood UTI cannot be used to predict for mild or multiple scarring, and should not be used to guide management. NICE's recommendation to do so is not justified.
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