Friday, October 21, 2011

Kids' Urinary Infections Usually Not a Kidney Risk

From Reuters Health Information By Amy Norton NEW YORK (Reuters Health) Oct 12 - Most children with recurrent urinary tract infections (UTIs) are not at increased risk of chronic kidney disease later in life, a new meta-analysis suggests. "If there is no structural abnormalities in the kidney ultrasound after the first UTI, the parents should not be worried at all" about the risk of chronic kidney disease, said lead researcher Dr. Jarmo Salo of the University of Oulu in Finland. Recurrent UTIs in young children have been seen as a possible risk factor for chronic kidney disease later in life, especially in cases with vesicoureteral reflux (VUR). But the idea that repeat UTIs and VUR are risk factors for chronic kidney disease is not universally accepted -- nor is the practice of testing children for VUR when they have a urinary tract infection. For the new study, reported October 10th in Pediatrics, researchers pooled data from 10 studies, with 1,576 patients, that either looked at the history of childhood UTIs in people with chronic kidney disease, or that followed children with UTIs to monitor their renal function. They also reviewed the records of all 366 patients who were treated for chronic kidney disease at their hospital over one year. The 10 studies showed no evidence that childhood UTIs -- even along with VUR -- were the main cause of chronic kidney disease, according to the researchers. And of the kidney disease patients who did have a history of childhood UTIs, all also had structural abnormalities in their kidneys. Similarly, of the 366 patients at their center, the researchers found that only three had repeat childhood UTIs that might have contributed to their chronic kidney disease -- and all had structural abnormalities in the kidneys that would be detectable on ultrasound. Dr. Salo told Reuters Health in an email that doctors in Finland no longer "actively" look for VUR because there's evidence that it is a "normal phenomenon," and that treating it does not prevent long-term kidney damage. "We suggest that the (x-ray) imaging studies are not necessary if the child has structurally normal kidneys in ultrasound," Dr. Salo said. But a pediatric urologist not involved in the study cautioned against making a "sweeping" recommendation against VUR testing. "The good news for parents is yes, the chances of your child developing kidney disease will be very low," said Dr. Hiep T. Nguyen of Children's Hospital Boston. However, he told Reuters Health, repeat UTIs in young children (generally younger than 5) are not the same as those in older kids or adults. And some of those children are at increased risk for kidney damage -- particularly if they have more-severe, high-grade VUR. What's more, Dr. Nguyen said, there is evidence that finding and treating high-grade VUR with low-dose antibiotics and period testing to see whether reflux has resolved may prevent kidney damage. Nguyen said that a young child with a UTI should have an ultrasound "at a minimum" to look for structural abnormalities in the kidneys.Dr. Salo agreed. But the area of controversy is in testing for VUR. Essentially, Dr. Nguyen said, pediatricians are increasingly moving away from recommending VUR testing for children with urinary tract infections. Pediatricians, he noted, see a lot of children with UTIs, and most of those kids will have no long-term kidney disease as a result. But urology specialists see the people with chronic kidney disease, and they are apt to see the value in testing for VUR so that kids with reflux can be treated. "We are looking from two different viewpoints," Dr. Nguyen said. VUR has a strong genetic component, and researchers are working on gene tests -- where a child will just have to "spit in a cup," Dr. Nguyen said -- that could help pinpoint the kids with UTIs who would be the best candidates for VUR testing. For now, the decision to do VUR testing is basically case-by-case. Dr. John Gearhart, director of pediatric urology at Johns Hopkins Children's Center in Baltimore, said the current findings "should reassure mothers and fathers." But he agreed that there are cases where testing for VUR is appropriate: if there's a family history of the condition, for example, or if a young child has more than one urinary infection that includes fever. Testing for VUR does involve radiation, albeit as low a dose as possible, Dr. Gearhart noted in an interview. So limiting the number of children who have it is important. There can also be side effects from the low-dose antibiotics given to children with VUR -- such as stomach upset, diarrhea and yeast infections. There is an ongoing North American clinical trial looking at whether giving antibiotics to young children with mild to moderate VUR prevents kidney scarring, which could eventually lead to chronic kidney disease. That, according to Dr. Gearhart, should give more insights into whether it is helpful to give all children with VUR preventive antibiotics. SOURCE: Pediatrics 2011.

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