Steroids May Alleviate Acute Pyelonephritis in Children

From Medscape Medical News Laurie Barclay, MD August 22, 2011 — Adjunctive treatment with oral methylprednisolone may lower the occurrence and/or severity of renal scarring in children hospitalized for acute pyelonephritis, according to the results of a randomized controlled trial reported online in the August 15 issue of Pediatrics. "Renal scarring after acute pyelonephritis is associated with long-term sequelae," write Ya-Yun Huang, MD, from the Department of Pediatrics, National Cheng Kung University Medical College and Hospital in Tainan, Taiwan, and colleagues. "Preventing scarring after acute pyelonephritis depends not only on early diagnosis and rapid treatment to eradicate the bacteria but also ameliorating the destructive inflammatory response." The goal of the study was to examine whether glucocorticoids could prevent formation of renal scars after a first episode of acute pyelonephritis in pediatric patients younger than 16 years at high risk for renal scar formation. Inclusion criteria were an inflammatory volume of at least 4.6 mL on technetium-99m–labeled dimercaptosuccinic acid scan (DMSA) or abnormal renal ultrasonography findings. A total of 84 participants were enrolled and were randomly selected to receive either antibiotics plus methylprednisolone sodium phosphate (1.6 mg/kg/day; n = 19) or antibiotics plus placebo (n = 65) every 6 hours for 3 days. The main study endpoint was renal scarring seen on DMSA performed 6 months after treatment. At baseline, both groups had similar patient characteristics, acute inflammatory parameters, and DMSA findings. At 6 months after treatment, 33.3% of children who received methylprednisolone had renal scarring on DMSA, as did 60.0% of those who received placebo (P < .05), with median cortical defect volumes of 0.0 mL (range, 0 - 4.5 mL) and 1.5 mL (range, 0 - 14.8 mL), respectively (P < .01). Compared with the placebo group, patients in the methylprednisolone group also had faster defervescence after treatment. "Adjunctive oral [methylprednisolone] therapy reduced the occurrence and/or severity of renal scarring after acute pyelonephritis in these hospitalized children who had a high risk of renal scar formation," the study authors write. Limitations of this study include setting in a single tertiary referral center with a pioneer and small-scale design, small numbers of patients in some of the subgroup analyses, and inconsistency of the method used to identify patients at high risk for renal scarring. "Nevertheless, the results are promising, and additional studies with larger populations should be designed to validate these effects and determine the optimum dosage of [glucocorticoids] and the age of patients most likely to benefit from them," the study authors conclude. "Adjunctive oral [methylprednisolone] with adequate antibiotics merits further consideration as a potential treatment regimen to alleviate permanent tissue injury in admitted children with serious [acute pyelonephritis]." The National Cheng Kung University Hospital (Tainan) and the National Science Council (Taipei, Taiwan) supported this study. The study authors have disclosed no relevant financial relationships. Pediatrics. Published online August 15, 2011.