AUA Says When to Screen Families for Vesicoureteral Reflux

From Reuters Health Information
David Douglas

August 6, 2010 — Siblings and offspring of patients with vesicoureteral reflux (VUR), and infants with prenatal hydronephrosis, also have high prevalences of VUR – but it's not clear how much they'll gain from having the condition diagnosed, the American Urological Association says.

On July 21st in the Journal of Urology, the Association issued updated guidelines to help physicians decide who to screen, and when.

But due to a lack of randomized clinical trials, the Association's update panel found it difficult to make evidence-based recommendations. When necessary, the panel members based the guidelines on current practice, risk assessment, meta-analysis results and consensus.

Led by Dr. Steven J. Skoog of the Oregon Health & Sciences University in Portland, the panel issued seven "summary guidelines," with two labeled "recommendations" (the first two, below) and the others labeled "options."

•In siblings of children with VUR, a voiding cystourethrogram (VCUG) or radionuclide cystogram is recommended if ultrasound shows renal corticoid abnormalities or renal size asymmetry, or if the sibling has a history of urinary tract infections (UTI).
•VCUG is recommended for infants with high-grade hydronephrosis (Society for Fetal Urology grades 3-4), hydroureter or abnormal bladder, or UTI.
•Given the unclear benefit of finding and treating VUR, siblings of children with VUR can be observed without screening, as long as any acute UTI is promptly followed by evaluation for VUR.
•Older siblings who are toilet trained may be screened, although the value of detecting VUR is unclear.
•Siblings of children with VUR can have renal ultrasound studies 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.
•Children with prenatal hydronephrosis (SFU grades 1-2) can be observed without screening as long as any UTI is promptly treated, given the unproven value of identifying and treating VUR. VCUG in these patients is optional.
In developing these guidelines, the panel analyzed pooled data from 22 sibling screening studies involving more than 3200 children, as well as 43 studies of more than 6500 infants with prenatal hydronephrosis.

Overall in the meta-analysis, the prevalence of VUR was 27.4% in siblings and 35.7% in offspring. The prevalence decreased as the age of the screened cohort increased, and the annual resolution rate of 4% "can aid in assessing the need for screening based on patient age," the authors note.

Infants with prenatal hydronephrosis had a 16.2% prevalence of VUR.

Overall, the panel concludes that despite absence of clear-cut benefit, "identification of VUR may increase the awareness of parents and health providers to the potentially increased risk of pyelonephritis and renal scarring."

J Urol. 2010;184:1145-1151.

Reuters Health Information 2010. © 2010 Reuters Ltd.