End-Stage Kidney Disease Following Reflux Nephropathy Since the 2011 AAP Guidelines

Area of Science:

• Pediatric Nephrology
• Diagnostic Imaging
• Clinical Practice Guidelines

Background:

• The 2011 American Academy of Pediatrics (AAP) guideline shifted imaging recommendations for pediatric febrile urinary tract infections (UTI).
• Voiding cysto-urethrogram (VCUG) was de-emphasized as a first-line study, with renal bladder ultrasound (RBUS) becoming the preferred initial imaging modality.
• The guideline aimed to reduce radiation exposure and discomfort for children while managing risks of high-grade vesico-ureteral reflux (VUR) or obstructive uropathy.

Purpose of the Study:

• To evaluate the impact of reduced voiding cysto-urethrogram (VCUG) utilization following the 2011 AAP guideline for febrile urinary tract infections (UTI) in children.
• To determine if the decreased use of VCUG has resulted in any adverse outcomes or harm to pediatric patients.
• To assess the current landscape of UTI imaging practices in children after the guideline's retirement in 2021.

Main Methods:

• Analysis of trends in voiding cysto-urethrogram (VCUG) utilization after the 2011 American Academy of Pediatrics (AAP) guideline for febrile urinary tract infections (UTI).
• Review of clinical outcomes and potential harms associated with the decreased use of VCUG in pediatric populations.
• Examination of current imaging practices in the post-guideline era, considering the guideline's retirement.

Main Results:

• The implementation of the 2011 AAP guideline led to a significant decrease in the use of voiding cysto-urethrogram (VCUG) for pediatric febrile urinary tract infections (UTI).
• Despite the reduction in VCUGs, available data does not indicate an increase in harm or missed diagnoses related to high-grade vesico-ureteral reflux (VUR) or obstructive uropathy.
• The proportion of children receiving VCUG remains low even after the guideline's retirement, suggesting a lasting shift in clinical practice.

Conclusions:

• The shift away from routine voiding cysto-urethrogram (VCUG) after febrile urinary tract infections (UTI) in children, as recommended by the 2011 AAP guideline, appears to be safe.
• The reduced utilization of VCUG has not demonstrably led to increased harm, supporting the guideline's approach of balancing diagnostic yield with procedural risks.
• Continued monitoring of imaging practices and patient outcomes in pediatric UTI is warranted, especially following the guideline's retirement.