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Are younger children at highest risk of renal sequelae after pyelonephritis?
D Benador1, N Benador, D Slosman
1Department of Paediatrics, Cantonal University Hospital, Geneva, Switzerland.
Insights
The risk of renal scars after pyelonephritis does not decrease with age in children. All children, regardless of age, benefit from measures preventing kidney damage following urinary tract infections.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Radiology
Background:
- Conventional belief suggests infants face the highest risk of renal sequelae after pyelonephritis, with risk decreasing in older children.
- This assumption has influenced age-based treatment strategies for pyelonephritis.
- A prospective study was conducted to re-evaluate renal lesion occurrence across different pediatric age groups.
Purpose of the Study:
- To investigate the occurrence and progression of renal lesions in children aged 0-16 years following pyelonephritis.
- To challenge the traditional view of age-related risk for renal sequelae post-pyelonephritis.
- To inform optimal management strategies for pediatric urinary tract infections.
Main Methods:
- Prospective enrollment of 201 children (0-16 years) with probable pyelonephritis and positive urine culture.
- Acute phase assessment using technetium-99m-dimercaptosuccinic acid (DMSA) scintigraphy and ultrasonography.
- Voiding cystourethrography and repeat DMSA scintigraphy (after 2+ months) to assess renal scars and vesicoureteric reflux.
Main Results:
- Renal lesions were detected in 55% of infants (<1 year), 79% of children (1-5 years), and 69% (>5 years) during the acute phase.
- Repeat scintigraphy revealed renal scars in 40% of infants, 86% of children (1-5 years), and 64% of children (>5 years).
- Vesicoureteric reflux was present in 36% of patients with renal scars; high scar rates were observed across all age groups, even in first-time infections.
Conclusions:
- The study findings contradict the notion that pyelonephritis risk for renal scarring diminishes with age.
- All pediatric patients, irrespective of age, are susceptible to renal scarring after pyelonephritis.
- Preventive measures against renal sequelae are crucial for all children diagnosed with pyelonephritis.
Background:
The general belief about the relation between risk of renal sequelae after pyelonephritis and age is that infants are at highest risk and children older than 5 years at lower risk. This assumption has led to differences in treatment based on age. The aim of this prospective study was to investigate the occurrence of renal lesions in children aged 0-16 years.
Methods:
Between May, 1994, and January, 1996, all children aged 0-16 years who were admitted to our department with a diagnosis of probable pyelonephritis and a positive urine culture were included in this prospective study. All patients received antibiotics for 7-21 days. During the acute phase of urinary-tract infection, scintigraphy with technetium-99m-dimercaptosuccinic acid (DMSA) and ultrasonography were done. Voiding cystourethrography was undertaken at least 6 weeks after the end of antibiotic treatment. When scintigraphy showed renal parenchymal lesions, repeat scintigraphy was done after at least 2 months to assess the progression of renal lesions. For the analysis, children were grouped by age according to presumed risk of renal sequelae after pyelonephritis: high risk (< 1 year), moderate risk (1-5 years), low risk (> 5 years).
Findings:
201 patients were enrolled in the study (119 < 1 year, 47 aged 1-5 years, 35 > 5 years). During the acute phase of urinary-tract infection, renal lesions were found in 66 (55%) infants under 1 year, in 37 (79%) children aged 1-5 years, and in 24 (69%) children older than 5 years. Of these 127 children, 108 underwent repeat scintigraphy after an average of 3 months (50 < 1 year, 36 aged 1-5 years, 22 > 5 years). Overall, renal scars were found on repeat scintigraphy in 20 (40%) infants under 1 year, in 31 (86%) children aged 1-5 years, and in 14 (64%) children older than 5 years. 38 (36%) of these 65 patients had vesicoureteric reflux. Among 88 children who had a first documented urinary-tract infection and underwent repeat scintigraphy, renal scars were found in 20 (43%) under 1 year, in 26 (84%) aged 1-5 years, and in eight (80%) older than 5 years.
Interpretation:
This study did not confirm the conventional view that the risk of renal scars after pyelonephritis diminishes with age. We believe that all children, irrespective of age, will benefit from any measure that prevents the development of renal sequelae.