Screening of newborn babies for familial ureteric reflux

Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

The prevalence of familial vesicoureteric reflux in infants with normal antenatal scans

AIM

To determine the prevalence of familial vesicoureteric reflux (VUR) by studying the outcomes of screening in a contemporary cohort of newborns with normal antenatal kidney scans.

METHODS

A review of screening outcomes in newborns with a first degree relative with VUR, normal antenatal scans and no prior urine infections between 2014-2019 at three maternity units in the North East of England was conducted. Imaging consisted of micturating cystourethrogram (MCUG) in all and renal tract ultrasound scan (RUS) routinely in two units and by clinician preference in one unit.

RESULTS

At a median age of 59 days, 265 infants underwent MCUG. High-grade VUR (Grades 3-5) was detected in 13 (4.9%) and low-grade VUR (Grades 1-2) in 24 (9.1%). In the 152 infants who had a RUS, abnormalities were detected in 21 (13.8%). An abnormal postnatal RUS has a low positive predictive value (14.3%) for high-grade VUR, but a normal RUS has a high negative predictive value (95.4%).

CONCLUSION

Compared to historical cohorts from two decades ago, the yield from familial VUR screening is low and unjustifiable in the setting of normal antenatal anomaly scans.

Genetic basis of human congenital anomalies of the kidney and urinary tract

The clinical spectrum of congenital anomalies of the kidney and urinary tract (CAKUT) encompasses a common birth defect in humans that has significant impact on long-term patient survival. Overall, data indicate that approximately 20% of patients may have a genetic disorder that is usually not detected based on standard clinical evaluation, implicating many different mutational mechanisms and pathogenic pathways. In particular, 10% to 15% of CAKUT patients harbor an unsuspected genomic disorder that increases risk of neurocognitive impairment and whose early recognition can impact clinical care. The emergence of high-throughput genomic technologies is expected to provide insight into the common and rare genetic determinants of diseases and offer opportunities for early diagnosis with genetic testing.

Estimation of the relationship between the polymorphisms of selected genes: ACE, AGTR1, TGFβ1 and GNB3 with the occurrence of primary vesicoureteral reflux

PURPOSE

Etiopathogenesis of VUR is composite and not fully understood. Many data indicate the importance of genetic predisposition. The aim of this study was to establish the relationship of selected polymorphisms: 14094 polymorphism of the ACE, polymorphism rs1800469 of TGFβ-1, rs5443 gene polymorphism of the GNB3 and receptor gene polymorphism rs5186 type 1 AGTR1 with the occurrence of the primary vesicoureteral reflux.

MATERIAL

The study included 190 children: 90 with the primary VUR confirmed with the voiding cystourethrogram and excluded secondary VUR and a control group of 100 children without a history of the diseases of the genitourinary tract.

METHODS

The study was planned in the scheme: "tested case versus control." Genomic DNA was isolated from the leukocytes of peripheral blood samples. The results were statistically analyzed in the Statistica 10 using χ ² test and analysis of the variance Anova.

RESULTS

Any of the four studied polymorphisms showed no difference in the distribution of genotypes between patients with primary vesicoureteral reflux and the control group. In patients with VUR and TT genotype polymorphism rs5443 GNB3 gene, the glomerular filtration rate was significantly higher than in patients with genotype CC or CT.

CONCLUSIONS

(1) No relationship was found between the studied polymorphisms (14094 ACE gene, rs1800469 gene TGFβ1, GNB3 gene rs5443, rs5186 AGTR1 gene) and the occurrence of primary vesicoureteral reflux. (2) TT genotype polymorphism rs5443 GNB3 gene may be a protective factor for the improved renal function in patients with primary vesicoureteral reflux in patients with genotype CC or CT.

Genetics of Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder to the upper urinary tract. It is the most common congenital urological anomaly affecting 1-2% of children and 30-40% of patients with urinary tract infections. VUR is a major risk factor for pyelonephritic scarring and chronic renal failure in children. It is the result of a shortened intravesical ureter with an enlarged or malpositioned ureteric orifice. An ectopic embryonal ureteric budding development is implicated in the pathogenesis of VUR, which is a complex genetic developmental disorder. Many genes are involved in the ureteric budding formation and subsequently in the urinary tract and kidney development. Previous studies demonstrate an heterogeneous genetic pattern of VUR. In fact no single major locus or gene for primary VUR has been identified. It is likely that different forms of VUR with different genetic determinantes are present. Moreover genetic studies of syndromes with associated VUR have revealed several possible candidate genes involved in the pathogenesis of VUR and related urinary tract malformations. Mutations in genes essential for urinary tract morphogenesis are linked to numerous congenital syndromes, and in most of those VUR is a feature. The Authors provide an overview of the developmental processes leading to the VUR. The different genes and signaling pathways controlling the embryonal urinary tract development are analyzed. A better understanding of VUR genetic bases could improve the management of this condition in children.

Distributed expertise: qualitative study of a British network of multidisciplinary teams supporting parents of children with chronic kidney disease

BACKGROUND

Long-term childhood conditions are often managed by hospital-based multidisciplinary teams (MDTs) of professionals with discipline specific expertise of a condition, in partnership with parents. However, little evidence exists on professional-parent interactions in this context. An exploration of professionals' accounts of the way they individually and collectively teach parents to manage their child's clinical care at home is, therefore, important for meeting parents' needs, informing policy and educating novice professionals. Using chronic kidney disease as an exemplar this paper reports on one aspect of a study of interactions between professionals and parents in a network of 12 children's kidney units in Britain.

METHODS

We conducted semi-structured, qualitative interviews with a convenience sample of 112 professionals (clinical-psychologists, dietitians, doctors, nurses, pharmacists, play-workers, therapists and social workers), exploring accounts of their parent-educative activity. We analysed data using framework and the concept of distributed expertise.

RESULTS

Four themes emerged that related to the way expertise was distributed within and across teams: (i) recognizing each other's' expertise, (ii) sharing expertise within the MDT, (iii) language interpretation, and (iv) acting as brokers. Two different professional identifications were also seen to co-exist within MDTs, with participants using the term 'we' both as the intra-professional 'we' (relating to the professional identity) when describing expertise within a disciplinary group (for example: 'As dietitians we aim to give tailored advice to optimize children's growth'), and the inter-professional 'we' (a 'team-identification'), when discussing expertise within the team (for example: 'We work as a team and make sure we're all happy with every aspect of their training before they go home').

CONCLUSIONS

This study highlights the dual identifications implicit in 'being professional' in this context (to the team and to one's profession) as well as the unique role that each member of a team contributes to children's care. Our methodology and results have the potential to be transferred to teams managing other conditions.

Does prompt treatment of urinary tract infection in preschool children prevent renal scarring: mixed retrospective and prospective audits

OBJECTIVE

To test whether active management of urinary tract infections (UTI) in young children by general practitioners can reduce kidney scarring rates.

DESIGN

A comparison of two audits in Newcastle, of children aged <8 years, presenting with UTIs ; a retrospective audit of conventional management during 1992-1995 (1990s) versus a prospective audit of direct access management during 2004-2011 (2000s).

MAIN OUTCOME MEASURES

Kidney scarring rates, and their relationship with time-to-treat.

RESULTS

Children with a first UTI in the 2000s compared to those in the 1990s, were referred younger, were half as likely to have a renal scar (girls OR 0.47, 95% CI 0.29 to 0.76; boys 0.35, 0.16 to 0.81), and were about 12 times more likely to have vesicoureteric reflux without scarring (girls 11.9, 4.3 to 33.5; boys 14.4, 4.3 to 47.6). In the 2000s, general practitioners treated about half the children at first consultation. Children who were treated within 3 days of their symptoms starting were one-third as likely to scar as those whose symptoms lasted longer (0.33, 0.12 to 0.72).

INTERPRETATION

Most kidney defects seen in children after UTIs, are acquired scars, and in Newcastle, active management in primary care has halved this rate.

Multidisciplinary teams, and parents, negotiating common ground in shared-care of children with long-term conditions: a mixed methods study

BACKGROUND

Limited negotiation around care decisions is believed to undermine collaborative working between parents of children with long-term conditions and professionals, but there is little evidence of how they actually negotiate their respective roles. Using chronic kidney disease as an exemplar this paper reports on a multi-method study of social interaction between multidisciplinary teams and parents as they shared clinical care.

METHODS

Phases 1 and 2: a telephone survey mapping multidisciplinary teams' parent-educative activities, and qualitative interviews with 112 professionals (Clinical-psychologists, Dietitians, Doctors, Nurses, Play-specialists, Pharmacists, Therapists and Social-workers) exploring their accounts of parent-teaching in the 12 British children's kidney units. Phase 3: six ethnographic case studies in two units involving observations of professional/parent interactions during shared-care, and individual interviews. We used an analytical framework based on concepts drawn from Communities of Practice and Activity Theory.

RESULTS

Professionals spoke of the challenge of explaining to each other how they are aware of parents' understanding of clinical knowledge, and described three patterns of parent-educative activity that were common across MDTs: Engaging parents in shared practice; Knowledge exchange and role negotiation, and Promoting common ground. Over time, professionals had developed a shared repertoire of tools to support their negotiations with parents that helped them accomplish common ground during the practice of shared-care. We observed mutual engagement between professionals and parents where a common understanding of the joint enterprise of clinical caring was negotiated.

CONCLUSIONS

For professionals, making implicit knowledge explicit is important as it can provide them with a language through which to articulate more clearly to each other what is the basis of their intuition-based hunches about parents' support needs, and may help them to negotiate with parents and accelerate parents' learning about shared caring. Our methodology and results are potentially transferrable to shared management of other conditions.

A new genome scan for primary nonsyndromic vesicoureteric reflux emphasizes high genetic heterogeneity and shows linkage and association with various genes already implicated in urinary tract development

Primary vesicoureteric reflux (VUR), the retrograde flow of urine from the bladder toward the kidneys, results from a developmental anomaly of the vesicoureteric valve mechanism, and is often associated with other urinary tract anomalies. It is the most common urological problem in children, with an estimated prevalence of 1–2%, and is a major cause of hypertension in childhood and of renal failure in childhood or adult life. We present the results of a genetic linkage and association scan using 900,000 markers. Our linkage results show a large number of suggestive linkage peaks, with different results in two groups of families, suggesting that VUR is even more genetically heterogeneous than previously imagined. The only marker achieving P < 0.02 for linkage in both groups of families is 270 kb from EMX2. In three sibships, we found recessive linkage to KHDRBS3, previously reported in a Somali family. In another family we discovered sex-reversal associated with VUR, implicating PRKX, for which there was weak support for dominant linkage in the overall data set. Several other candidate genes are suggested by our linkage or association results, and four of our linkage peaks are within copy-number variants recently found to be associated with renal hypodysplasia. Undoubtedly there are many genes related to VUR. Our study gives support to some loci suggested by earlier studies as well as suggesting new ones, and provides numerous indications for further investigations.

Lower urinary tract development and disease

Congenital anomalies of the lower urinary tract (CALUT) are a family of birth defects of the ureter, the bladder, and the urethra. CALUT includes ureteral anomaliesc such as congenital abnormalities of the ureteropelvic junction (UPJ) and ureterovesical junction (UVJ), and birth defects of the bladder and the urethra such as bladder-exstrophy-epispadias complex (BEEC), prune belly syndrome (PBS), and posterior urethral valves (PUVs). CALUT is one of the most common birth defects and is often associated with antenatal hydronephrosis, vesicoureteral reflux (VUR), urinary tract obstruction, urinary tract infections (UTI), chronic kidney disease, and renal failure in children. Here, we discuss the current genetic and molecular knowledge about lower urinary tract development and genetic basis of CALUT in both human and mouse models. We provide an overview of the developmental processes leading to the formation of the ureter, the bladder, and the urethra, and different genes and signaling pathways controlling these developmental processes. Human genetic disorders that affect the ureter, the bladder and the urethra and associated gene mutations are also presented. As we are entering the postgenomic era of personalized medicine, information in this article may provide useful interpretation for the genetic and genomic test results collected from patients with lower urinary tract birth defects. With evidence-based interpretations, clinicians may provide more effective personalized therapies to patients and genetic counseling for their families.

The Online Parent Information and Support project, meeting parents' information and support needs for home-based management of childhood chronic kidney disease: research protocol

AIM

This article is a report of a protocol for studying the development and evaluation of an online parent information and support package for home-based care of children with chronic kidney disease stages 3-5. The study is funded by a National Institute of Health Research, Research for Patient Benefit Grant awarded (December 2010). Approval to undetake the study was obtained from the Department of Health National Research Ethics Service (June 2011).

BACKGROUND

Children with chronic kidney disease require skilled, home-based care by parents, supported by professionals. Parents have identified a need for continuously available online resources to supplement professional support, and structured resources tailored to parents' needs are highlighted by policy makers as key to optimizing care; yet, online resource provision is patchy with little evidence base.

METHODS

Using mixed methods, we will (i) conduct parent/child/young person/professional/patient and parent volunteer focus groups to explore views on existing resources, (ii) collaboratively define gaps in provision, identify desirable components, develop/test resources and conduct a feasibility randomized controlled trial, and (iii) of usual professional support versus usual support supplemented by the package. Eighty parents of children with chronic kidney disease will be randomized. Primary outcomes will assess parents' self-efficacy and views of resources, using standardized measures at entry and 24 weeks, and semi-structured interviews at 24 weeks. We will finalize trial components for a later definitive trial.

DISCUSSION

By working collaboratively, we will derive a detailed insight into parents' information and support needs and experiences of using the package, and should see improved parental self-efficacy.

Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months

OBJECTIVE

To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections (UTIs) in febrile infants and young children.

METHODS

Analysis of the medical literature published since the last version of the guideline was supplemented by analysis of data provided by authors of recent publications. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed and graded.

RESULTS

Diagnosis is made on the basis of the presence of both pyuria and at least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen of urine. After 7 to 14 days of antimicrobial treatment, close clinical follow-up monitoring should be maintained to permit prompt diagnosis and treatment of recurrent infections. Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities. Data from the most recent 6 studies do not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants without vesicoureteral reflux (VUR) or with grade I to IV VUR. Therefore, a voiding cystourethrography (VCUG) is not recommended routinely after the first UTI; VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complex clinical circumstances. VCUG should also be performed if there is a recurrence of a febrile UTI. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of care; variations may be appropriate. Recommendations about antimicrobial prophylaxis and implications for performance of VCUG are based on currently available evidence. As with all American Academy of Pediatrics clinical guidelines, the recommendations will be reviewed routinely and incorporate new evidence, such as data from the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study.

CONCLUSIONS

Changes in this revision include criteria for the diagnosis of UTI and recommendations for imaging.

Primary, nonsyndromic vesicoureteric reflux and nephropathy in sibling pairs: a United Kingdom cohort for a DNA bank

BACKGROUND AND OBJECTIVES

Primary vesicoureteric reflux (VUR) can coexist with reflux nephropathy (RN) and impaired renal function. VUR appears to be an inherited condition and is reported in approximately one third of siblings of index cases. The objective was to establish a DNA collection and clinical database from U.K. families containing affected sibling pairs for future VUR genetics studies. The cohort's clinical characteristics have been described.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Most patients were identified from tertiary pediatric nephrology centers; each family had an index case with cystography-proven primary, nonsyndromic VUR. Affected siblings had radiologically proven VUR and/or radiographically proven RN.

RESULTS

One hundred eighty-nine index cases identified families with an additional 218 affected siblings. More than 90% were <20 years at the study's end. Blood was collected and leukocyte DNA extracted from all 407 patients and from 189 mothers and 183 fathers. Clinical presentation was established in 122; 92 had urinary tract infections and 16 had abnormal antenatal renal scans. RN was radiologically proven in 223 patients. Four patients had been transplanted; none were on dialysis. In 174 others aged >1 year, estimated GFR (eGFR) was calculated. Five had eGFR 15 to 59 and 48 had eGFR 60 to 89 ml/min per 1.73 m(2). Values were lower in bilateral RN patients than in those with either unilateral or absent RN.

CONCLUSIONS

The large DNA collection from families with VUR and associated RN constitutes a resource for researchers exploring the most likely complex, genetic components predisposing to VUR and RN.

Can prompt treatment of childhood UTI prevent kidney scarring?

The aim of the study reported here was to determine whether kidney scarring after urinary tract infections (UTI) in children can be prevented and to identify the risk factors for developing scars. We identified children in the Northern health region of the UK who had been seen to develop scars, identified as new defects on dimercapto-succinic acid (DMSA) scanning. Risk factors were sought by reviewing case-notes and interviews with parents. Twenty girls were identified whose new scarring was strongly associated with having both vesicoureteric reflux (VUR) and a UTI (p = 0.0001); 19/23 (83%) of kidneys exposed to both of these factors developed scars. Children were much more likely to be febrile (94 vs. 30%, p < 0.0001) or unwell (82 vs. 10%, p < 0.0001) during their earlier UTIs when they were of median age 2.8 years (range 0.3-5.0 years) and did not scar, compared to their later UTIs at age 7.3 years (1.2-12.5 years), when they did scar. However, most patients were treated within 1 day of their symptoms for their early UTIs, compared to a wait >or=7 days for later UTIs (p = 0.001). Being febrile or unwell during a UTI does not predict the development of scars, but prompt treatment appears to prevent scarring in children with VUR.

Mutations in the ROBO2 and SLIT2 genes are rare causes of familial vesico-ureteral reflux

Familial clustering of vesico-ureteral reflux (VUR) suggests that genetic factors play an important role in the pathogenesis of this condition. The SLIT2 protein and its receptor, ROBO2, have key functions in the formation of the ureteric bud. Two recent studies have found that ROBO2 gene missense mutations are associated with VUR. In the study reported here, we investigated the genetic contribution of the SLIT2 and ROBO2 genes in non-syndromic familial VUR by mutation screening of 54 unrelated patients with primary VUR. Direct sequencing of all 26 exons and the exon-intron boundaries revealed six ROBO2 gene variants, two of which were new. Direct sequencing of all 37 exons and the exon-intron boundaries identified 20 SLIT2 gene variants, two of which were new. One variant, c.4253C > T, which was found in two families, leads to an amino acid substitution in a relatively well-conserved amino acid, p.Ala1418Val, which was predicted to cause an altered secondary structure but to have little impact on the three-dimensional structure. This missense variant did not segregate with VUR in these two families and was not found in 96 control subjects. We conclude that gene variants in ROBO2 and SLIT2 are rare causes of VUR in humans. Our results provide further evidence for the genetic heterogeneity of this disorder.

A recessive gene for primary vesicoureteral reflux maps to chromosome 12p11-q13

Primary vesicoureteral reflux (pVUR) is one of the most common causes of pediatric kidney failure. Linkage scans suggest that pVUR is genetically heterogeneous with two loci on chromosomes 1p13 and 2q37 under autosomal dominant inheritance. Absence of pVUR in parents of affected individuals raises the possibility of a recessive contribution to pVUR. We performed a genome-wide linkage scan in 12 large families segregating pVUR, comprising 72 affected individuals. To avoid potential misspecification of the trait locus, we performed a parametric linkage analysis using both dominant and recessive models. Analysis under the dominant model yielded no signals across the entire genome. In contrast, we identified a unique linkage peak under the recessive model on chromosome 12p11-q13 (D12S1048), which we confirmed by fine mapping. This interval achieved a peak heterogeneity LOD score of 3.6 with 60% of families linked. This heterogeneity LOD score improved to 4.5 with exclusion of two high-density pedigrees that failed to link across the entire genome. The linkage signal on chromosome 12p11-q13 originated from pedigrees of varying ethnicity, suggesting that recessive inheritance of a high frequency risk allele occurs in pVUR kindreds from many different populations. In conclusion, this study identifies a major new locus for pVUR and suggests that in addition to genetic heterogeneity, recessive contributions should be considered in all pVUR genome scans.

An exploration of mothers' and fathers' views of their identities in chronic-kidney-disease management: parents as students?

AIM

To explore parents' views of their identities as they learn to manage their child's chronic kidney disease.

BACKGROUND

Parents are expected to participate in management and usually learn necessary skills from the multidisciplinary team. Research highlights the importance of professionals defining parents' management roles in chronic disease; but little is known about parents' views on their own identities as the complex and dynamic process of teaching and learning unfolds around their child's condition. According to positioning theory, identity development is a dynamic and fluid process that occurs during interaction, with each person positioning themselves while simultaneously positioning the other person, yet this concept has not been considered in relation to parents' contributions to disease management.

DESIGN

A longitudinal, grounded theory study conducted in a UK Children's Kidney Unit.

METHOD

This paper focuses on one aspect of a larger study exploring family learning in disease management. Six mothers and two fathers of six children with a recently diagnosed chronic kidney disease participated in a total of 21 semi-structured interviews during the 18 months after referral to the unit. Interviews included discussion about the parts they played in relation to professionals during the management process. Findings were interpreted within a framework of positioning theory.

RESULTS

Parents participated in teaching/learning/assessment that was both planned (involving allocated clinical lessons and tasks) and spontaneous (in response to current situations), to facilitate their participation. They positioned multidisciplinary team members as teachers as well as professionals, simultaneously positioning themselves as students as well as parents.

CONCLUSION

Parents' clinical duties and obligations are not an automatic part of parenting but become part of the broader process of sharing disease management, this can lead to them assuming the additional identity of a 'student'.

RELEVANCE TO CLINICAL PRACTICE

Involving parents in ongoing discussions about their positions in management may help promote their active and informed participation.

Vesicoureteric reflux is not a benign condition

Renal parenchymal defects may be congenital, usually associated with dilated vesicoureteric reflux (VUR), or they may appear in previously normal kidneys and be caused by reflux nephropathy due to VUR combined with urinary tract infection (UTI). A piglet model defined that the 70% of children with VUR and vulnerable pyramids would scar rapidly with their first UTI. Because most defects are present at first imaging after a UTI, and from the lack of benefit from apparently reasonable clinical interventions, many now believe that most defects are congenital, their association with VUR being a shared dysplasia rather than causal. Consequently, guidelines now argue for less assiduous management. These conclusions ignore adult human transplant evidence, adult pig studies, and clinical anecdotes, which indicate that scars may develop in infant kidneys quicker than urine culture can confirm the diagnosis, and that reflux nephropathy has no age limit. Its rarity over 4 years suggests that most vulnerable children develop scars before then, despite all medical efforts. I argue that preventing such scarring will require better diagnosis of infant UTI, quicker treatment, reliable imaging of scars and VUR, and subsequent protection until VUR resolves. To make a difference, we need more assiduous management, not less, and cannot afford to consider VUR to be a benign condition.

Childhood chronic-kidney-disease: a longitudinal-qualitative study of families learning to share management early in the trajectory

OBJECTIVE

To explore the ways families learn to share management during the early stages of childhood chronic-kidney-disease.

METHODS

This longitudinal, descriptive study based on the tenets of grounded theory, aimed to derive meaning about family-professional interactions during shared management. Data were obtained from six newly referred families, four renal nurses, four paediatric nephrologists and one dietician through: 36 semi-structured interviews, 21 case-note reviews and four child/parent learning diaries.

RESULTS

Three learning stages were identified: dependent (families' understanding was superficial, they lacked underlying knowledge and were totally reliant on professional guidance); co-dependent (families engaged competently in management but still required extensive guidance); independent (families communicated effectively with staff and competently adjusted management within professionally defined parameters). Five families actively shared management from early in the trajectory and progressed to independent learning when, by mutual agreement, professional input to management gradually decreased. The remaining family adopted a passive approach to management, did not progress to independent learning and remained reliant on professional input.

CONCLUSIONS

Families in this study demonstrated three learning stages in becoming competent at management. Future research is needed to investigate the ways professionals promote family competence early in the trajectory and the factors that can facilitate or hinder families' progression to independent learning.

Vesicoureteral reflux

Vesicoureteral reflux (VUR), the retrograde flow of urine from the bladder toward the kidney, is common in young children. About 30% of children with urinary tract infections will be diagnosed with VUR after a voiding cystourethrogram. For most, VUR will resolve spontaneously; 20% to 30% will have further infections, but few will experience long-term renal sequelae. Developmentally, VUR arises from disruption of complex signaling pathways and cellular differentiation. These mechanisms are probably genetically programmed but may be influenced by environmental exposures. Phenotypic expression of VUR is variable, ranging from asymptomatic forms to severe renal parenchymal disease and end-stage disease. VUR is often familial but is genetically heterogeneous with variability in mode of inheritance and in which gene, or the number of genes, that are involved. Numerous genetic studies that explore associations with VUR are available. The relative utility of these for understanding the genetics of VUR is often limited because of small sample size, poor methodology, and a diverse spectrum of patients. Much, if not all, of the renal parenchymal damage associated with end-stage disease is likely to be congenital, which limits the opportunity for intervention to familial cases where risk prediction may be available. Management of children with VUR remains controversial because there is no strong supportive evidence that prophylactic antibiotics or surgical intervention improve outcomes. Furthermore, well-designed genetic epidemiological studies focusing on the severe end of the VUR phenotype may help define the causal pathway and identify modifiable or disease predictive factors.

ROBO2 gene variants are associated with familial vesicoureteral reflux

The SLIT2 receptor ROBO2 plays a key role in the formation of the ureteric bud, and its inactivation in mice leads to supernumerary ureteric bud development, lack of ureter remodeling, and improper insertion of the ureters into the bladder. Recently, two heterozygous ROBO2 missense mutations were identified in two families with primary vesicoureteral reflux occurring in combination with congenital anomalies of the kidney and urinary tract (VUR/CAKUT). This study investigated a possible causal role of ROBO2 gene variants in 95 unrelated patients with primary VUR (n = 78) or VUR/CAKUT. Eighty-two percent of all patients had a family history of genitourinary anomalies. Twenty-four ROBO2 gene variants were identified by direct sequencing of all 26 exons and the exon-intron boundaries. Of these, four led to amino acid substitutions: Gly328Ser, Asn515Ile, Asp766Gly, and Arg797Gln. When the families were examined, the missense variants co-segregated with VUR (three families) or VUR/CAKUT (one family). These variants were not found in 190 control subjects, and the affected amino acids have been conserved through evolution. In conclusion, a relatively high frequency of ROBO2 variants (5.1%) was found in familial cases; however, functional studies and validation in other cohorts are warranted.

A genome search for primary vesicoureteral reflux shows further evidence for genetic heterogeneity

Vesicoureteral reflux (VUR) is the most common disease of the urinary tract in children. In order to identify gene(s) involved in this complex disorder, we performed a genome-wide search in a selected sample of 31 patients with primary VUR from eight families originating from southern Italy. Sixteen additional families with 41 patients were included in a second stage. Nonparametric, affected-only linkage analysis identified four genomic areas on chromosomes 1, 3, and 4 (p < 0.05); the best result corresponded to the D3S3681-D3S1569 interval on chromosome 3 (nonparametric linkage score, NPL = 2.75, p = 0.008). This region was then saturated with 26 additional markers, tested in the complete group of 72 patients from 24 families (NPL = 2.01, p = 0.01). We identified a genomic area on 3q22.2-23, where 26 patients from six multiplex families shared overlapping haplotypes. However, we did not find evidence for a common ancestral haplotype. The region on chromosome 1 was delimited to 1p36.2-34.3 (D1S228-D1S255, max. NPL = 1.70, p = 0.03), after additional fine typing. Furthermore, on chromosome 22q11.22-12.3, patients from a single family showed excess allele sharing (NPL = 3.35, p = 0.015). Only the chromosome 3q region has been previously reported in the single genome-wide screening available for primary VUR. Our results suggest the presence of several novel loci for primary VUR, giving further evidence for the genetic heterogeneity of this disorder.

Mild pyelectasis diagnosed by prenatal ultrasound is not a predictor of urinary tract morbidity in childhood

OBJECTIVES

To determine whether children with prenatally diagnosed mild pyelectasis have more urinary tract morbidity during childhood than children without this finding.

METHODS

Case-control study in children with pyelectasis (anteroposterior diameter of the fetal renal pelvis of 5-10 mm). A validated questionnaire was sent to the parents of 208 cases and 416 matched controls.

RESULTS

The questionnaire was returned by 146 cases and 250 controls. There was a male predominance in the case group (p = < 0.0001). There was no difference in voiding habits or in prevalence of urinary tract infections (UTI). The prevalence of UTI was high: 11.6% in cases and 10.0% in controls. The only difference was a higher prevalence of constipation in the case group (p = 0.003). Postnatally, 41 children had an ultrasound examination and 16 were referred to a paediatrician or urologist: 3 had persisting pyelectasis, 3 had a recurrent UTI and 1 required surgery (a pyeloplasty). Four of the controls were referred to a paediatrician or urologist: 3 had recurrent UTI and 1 had urinary incontinence.

CONCLUSION

Children with a mild fetal pyelectasis do not have more urinary tract morbidity during childhood than children without this finding. Therefore, there seems to be no need for additional investigation after birth.

Infections and vesicoureteral reflux

Vesicoureteral reflux (VUR) is a common condition in children. It may cause and maintain urinary tract infections, eventually leading to progressive renal damage and end-stage renal disease. Ideally, VUR should be detected and treated before renal scarring occurs. Although fetal hydronephrosis on antenatal ultrasound may be the first indicator, the role of further diagnostic investigations in these newborns is still controversial. Because VUR is an inherited condition, offspring of women with a family history of VUR and urinary tract infection should be screened closely for early detection of VUR. Once diagnosed, however, the optimal management of VUR (i.e. medical or surgical treatment) remains controversial. Evidence-based treatment recommendations, like the American Urological Association guidelines, may aid physicians in their therapeutic decision making, but cannot replace personal experience or surgical skill.

Vesicoureteral reflux

Vesicoureteral reflux, the abnormal flow of urine from the bladder into the ureter, is one of the most common congenital anomalies found in children. The association of vesicoureteral reflux with urinary tract infections and renal scarring has important clinical implications. New insights into pathogenesis and new surgical techniques are changing the approach to the management of this disorder.

Cyclic contrast-enhanced harmonic voiding urosonography for the evaluation of reflux. Can we keep the cost of the examination low?

The purpose of this study was to evaluate whether a second cycle of contrast-enhanced voiding urosonography (VUS) with no added contrast medium (CM) can increase the detection rate of vesicoureteral reflux (VUR). One hundred twelve consecutive children with a mean age of 2.9 years with 224 kidney-ureter units (KUU) underwent two cycles of contrast-enhanced harmonic VUS. The first cycle of VUS was performed with 3.5-12.5 ml of suspension 300 mg/ml SH U 508 A and was followed immediately by a second cycle with only saline without adding CM. VUR was detected in 57 KUU from 44 children (39%) at the first cycle of VUS. Eight of the remaining 68 non-refluxing children (12%) demonstrated VUR at the second cycle (P=0.045). Most cases of missed reflux at the first cycle were grade II (75%). However, in two KUU from two children missed reflux was grade III. In one child reflux (grade II) was missed on the second cycle. Comparing the second cycle of VUS with the first cycle, concordant findings regarding the presence or absence as well as the grade of reflux were found in 94% of KUU. A second cycle of contrast-enhanced harmonic VUS with no added CM discloses significantly more cases of VUR at no additional cost for the examination.

Familial Vesicoureteral Reflux: Testing Replication of Linkage in Seven New Multigenerational Kindreds

Vesicoureteral reflux (VUR) (OMIM %193000), a common cause of childhood renal failure, is strongly influenced by hereditary factors. Familial VUR most closely conforms to autosomal-dominant inheritance, but because of variable penetrance and expressivity, large multigenerational pedigrees tractable to linkage analysis have been difficult to ascertain. A single genome-wide study of familial VUR has demonstrated linkage to chromosome 1p13, with 78% locus heterogeneity. Previous studies in humans have also suggested loci on chromosomes 6p21, 10q26, and 19q13, whereas mutations in ROBO2 were recently reported in some patients with VUR. Replication of these studies was attempted in seven previously undescribed families from Italy and the United States. Simulation studies, assuming 50% locus heterogeneity, showed that these kindreds had 85% power to replicate linkage and 53% power to achieve genome-wide significance at candidate intervals. Thirty-five markers on chromosomes 1p13, 3p12, 6p21, 10q26, and 19q13 were genotyped and analysis of linkage under a variety of models was performed. Parametric analysis excluded linkage to all candidate loci under genetic homogeneity; moreover, the data did not support statistically significant linkage under models of locus heterogeneity. Similarly, nonparametric, allele-sharing analysis did not reveal any evidence of linkage at any of the loci tested. Thus, despite sufficient power, linkage of familial VUR to previously reported candidate intervals could not be replicated. These data demonstrate substantial genetic heterogeneity of VUR and suggest that mapping strategies relying on a large number of kindreds or single "loaded" pedigrees will be most effective to achieve replication or detection of linkage.

[Neonatal pelvic ectasia: long-term outcome and association with ureterovesical anomalies]

OBJECTIVE

To analyze the outcome of neonatal pelvic ectasia (PE) and the association between this entity and vesicoureteral reflux and/or other urinary tract abnormalities.

PATIENTS AND METHODS

We performed a retrospective study of 255 children (205 boys, 50 girls) with an ultrasonographic diagnosis of PE in the first month of life. The initial ultrasonographic examination was indicated by urinary tract infection in 30 neonates, abnormalities in the prenatal ultrasonographic examination in 150 and by other reasons in 75. Pelvic ectasia was classified in four stages according to anteroposterior pelvic diameter: I < 1 cm, II 1-1.5 cm, III 1.6-2 cm, and IV > 2 cm.

RESULTS

Pelvic ectasia was bilateral in 153 children (60 %) and unilateral in 102 (left side in 81.4 % and right side in 18.6 %). Stage I was found in 75.49 %, stage II in 20.34 %, stage III in 3.9 % and stage IV in 0.24 %. The mean follow-up was 32.6 +/- 25.2 months. At the end of the first year, the results of renal ultrasound were normal in 70.2 % of left-sided PE and in 55.9 % of right-sided PE, but 46 patients (18 %) showed worsening of PE between the first and second ultrasound scans. Voiding cystourethrography was performed in 79.6 % of the children and some abnormalities were found in 50 (24.6 %): urethral dilatations in two patients and vesicoureteral reflux in 48. No correlation was found between vesicoureteral reflux and the degree of ectasia (74 % had an anteroposterior diameter of < or = 1 cm). Urinary tract infection was present in 24.3 % of the children and 13 required surgery (eight pyeloplasties, four urethral reimplantations and two resections of type III urethral valves).

CONCLUSIONS

Neonatal PE was more prevalent in boys (4:1) and was more frequently located on the left side in both sexes. Associated vesicourethral reflux was found in 23.64 % with no correlation between the degree of dilation and the presence or degree of reflux. Consequently, cystourethrography should be performed in any child with pelvic ectasia, regardless of stage, side or sex.

Low contrast dose voiding urosonography in children with phase inversion imaging

Voiding urosonography (VUS) using a microbubble contrast agent has been introduced as an alternative technique in the diagnosis of vesicoureteral reflux (VUR). This study was undertaken to assess if phase inversion ultrasound (PIUS), a recent microbubble specific imaging technique, has advantages over fundamental in VUS and if it allows a reduction of contrast agent dose. Forty-three children with suspected VUR (aged 3 days-12 years, average of 3.9 years) with 92 kidney-ureter units (KUU) were included. Everyone obtained a baseline US scan that was followed by VUS using Levovist as the contrast agent. Constant switching between fundamental and PIUS performed the enhanced part for comparison. Every child underwent VCUG immediately afterwards. Contrast enhancement was stronger and longer lasting on PIUS than on fundamental US in all 43 cases. Reflux was detected in a total of 21 KUU, out of 92 KUU (23%). PIUS revealed VUR in 18; fundamental in 14 KUU and VCUG depicted 16 cases of reflux (p> or =0.29). The mean volume of Levovist dose administered to the bladder was 7.4+/-3.4% of the bladder volume. VUS using PI mode provided considerably stronger and longer enhancement and slightly improved the detection of VUR. It allowed a reduction of contrast dose and cost by approximately 35% over current dose recommendations for fundamental US.

Renal parenchymal damage in sibling vesicoureteric reflux

AIM

To compare the incidence of renal damage in siblings of patients with vesicoureteric reflux (VUR) who presented with a documented history of urinary tract infection (UTI) with asymptomatic siblings who were diagnosed with reflux during a screening programme for hereditary VUR.

METHODS

Medical and radiological records of the VUR patients (1990-2000) were examined for age, gender, mode of presentation, reflux grade and renal damage.

RESULTS

VUR was noted in 226 siblings (352 ureters) in 107 families. Of the 119 siblings of index patients, 64 were investigated for a documented UTI and 55 with no history of UTI were detected during screening for sibling reflux. Dimercaptosuccinic acid scan revealed reflux nephropathy in 25 (26%) of the 97 renal refluxing units (RRU) of siblings who presented with a UTI and in 6 (7%) of the 89 RRU of asymptomatic siblings who underwent screening voiding cystourethrography (p=0.0006). Mild renal damage was present in 20 (21%) RRU of siblings with UTI and in 2 (2%) RRU of the screened siblings (p < 0.001). Moderate to severe renal damage was present in 5 (5%) RRU of siblings with UTI and in 4 (4%) RRU of the screened siblings (p > 0.05).

CONCLUSION

This study demonstrated that the incidence of mild renal scarring was much higher in siblings who presented with UTI than in asymptomatic siblings. However, the incidence of moderate and severe renal scarring among asymptomatic siblings was comparable to that in siblings with VUR and UTI.

Familial vesicoureteral reflux

PURPOSE

Vesicoureteral reflux is known to occur in families. We summarized worldwide data on the incidence and nature of vesicoureteral reflux in siblings of children with vesicoureteral reflux.

MATERIALS AND METHODS

We searched MEDLINE using the words siblings vesicoureteral reflux, familial vesicoureteral reflux, offspring vesicoureteral reflux and vesicoureteral reflux screening. All articles that we identified that were published from 1972 to 2002 were analyzed for the incidence of renal damage in siblings of patients with vesicoureteral reflux.

RESULTS

Siblings of patients with vesicoureteral reflux have a much higher incidence of reflux than the normal population. There is a direct relationship of patient age to the incidence and severity of reflux. Most investigators advocate screening asymptomatic siblings of patients with vesicoureteral reflux.

CONCLUSIONS

The incidence of sibling reflux is significant. When vesicoureteral reflux is discovered in symptomatic siblings, it is usually high grade and associated with a high incidence of reflux nephropathy. Randomized controlled studies are needed to compare renal damage in patients with reflux detected through screening to renal damage in those diagnosed after urinary tract infection to establish how much renal damage may be prevented by screening in asymptomatic siblings.

Future expectations--what paediatric nephrologists and urologists await from paediatric uroradiology

Cooperation between paediatric nephrology/urology and paediatric radiology is essential for timely and correct diagnosis and therapy of kidney and urinary tract disorders. We need the direct contact between doctors before or after investigations, interdisciplinary discussions, and rapid access to the images. This should lead to optimal settings for investigations, a reduction of radiation burden and the number of investigations, and further improvement in the management of patients. Modern sonography including colour Doppler sonography, amplitude-coded Doppler sonography, and eventually 3D-ultrasound is and will be the method of choice as the basic, non-invasive investigation. These investigations should become the routine in all institutions. Refinement and standardisation of already established investigations are needed. Recently introduced investigations, like MRI, will have to show their impact on future diagnostic imaging. Future introduction of new non-invasive methods is welcome, e.g. to correctly diagnose vesicoureteral reflux without catheterisation/puncture of the bladder.

Mothers' evolving relationships with doctors and nurses during the chronic childhood illness trajectory

AIMS

In this paper the evolution of mothers' relationships with doctors and nurses during the chronic childhood illness trajectory is explored and discussed and the implications for child health care are considered. The discussion reports one aspect of a qualitative study that sought to determine whether time of diagnosis influenced mothers' coping across the illness trajectory.

BACKGROUND

The quality of relationships between mothers, who are usually the primary carers, and nursing and medical staff is central to the experience of coping with chronic childhood illness. Mothers need to develop expertise in a wide range of technical skills and knowledge of complex health care issues, while also coming to terms with the uncertainty of a condition with an unpredictable trajectory. Attempts to understand the significance of relationships between those living with chronic illness and staff have highlighted a number of factors that may influence the degree to which they are viewed as satisfactory. The way staff communicate with families has been identified as one of the mediating processes through which the quality of such is determined.

DESIGN

Mothers of 15 children diagnosed presymptomatically and 14 children diagnosed postsymptomatically with the chronic illness Vesicoureteric Reflux (VUR) were interviewed to assess and compare coping strategies across the trajectory. Mothers' written consent was obtained and interviews were tape-recorded, transcribed and analysed using the 'Framework Technique'.

FINDINGS AND CONCLUSION

The need to develop and sustain trusting relationships with staff was reported as a continual source of stress for mothers. The formation of satisfactory alliances, based on mutual respect and good communication early in the trajectory, in particular during the prediagnostic phase, was found to be instrumental in coping and competence development during the later chronic phase of the trajectory. Further research is needed to map prospectively the evolution of relationships between mothers and staff across the trajectory.

No evidence for AT2R gene derangement in human urinary tract anomalies

BACKGROUND

It has been recently found that mice, especially males, with a disrupted angiotensin type 2 receptor (AT2R) gene, which is located on the X-chromosome, often have a range of congenital anomalies of the kidney and urinary tract (CAKUT), including renal hypoplasia, and that Caucasian male patients with ureteropelvic junction stenosis (UPJ) and multicystic dysplastic kidneys frequently have A-G transition in intron 1 of the AT2R gene. We have previously found that renal hypoplasia is remarkably predominant in Japanese boys.

METHODS

We investigated sex ratios for the frequency of each CAKUT. The frequency of the A-G transition between the controls and 66 Japanese boys with CAKUT were compared. There was renal hypoplasia in 16, UPJ in 17, vesicoureteral in 20, and other anomalies in 13. We also investigated whether any mutations in AT2R genes were detectable in patients with renal hypoplasia.

RESULTS

In contrast to mice with a disruption of the AT2R gene, the male-to-female ratios in human patients proved to be considerably variable: 16 for renal hypoplasia, 2.1 for UPJ, 0.8 for vesicoureteral, and 1.2 for others. The frequency of the A-G transition was not different between the control population and the patients with CAKUT [31 of 102 (30%) vs. 23 of 66 (35%), respectively]. A sequencing study disclosed no mutations in nine boys with renal hypoplasia.

CONCLUSIONS

These findings indicate that the AT2R gene may not play a major role in the development of renal hypoplasia and other CAKUT in humans, at least in the Japanese population.

Antenatal renal pelvic measurements: what do they mean?

OBJECTIVE

To analyse data on cases with urological abnormalities recorded over a 15-year period (1984-98) by the Northern Region Congenital Abnormality Survey (NorCAS), with special reference to fetal renal pelvic measurements.

MATERIALS AND METHODS

Data on all urological cases recorded in the NorCAS database and in notification documents forwarded from hospitals in the Northern Region were extracted and incorporated in a separate unattributable database for analysis. Specific fields for filing recorded fetal renal pelvic measurements with their corresponding gestational ages were inserted; it was ensured as far as possible that these measurements were made in the anteroposterior plane.

RESULTS

The total number of cases analysed was 2737; a measurement of the fetal renal pelvis was recorded in 813, and more than once in 468, giving 1301 measurement episodes with the corresponding gestational ages, pregnancy and postnatal outcome. The male/female (M/F) ratio was significantly higher in those cases which had a fetal renal pelvic measurement recorded than in those which had not. This was because there was a 12/1 M/F ratio in measured cases of vesico-ureteric reflux (VUR). Few cases of VUR had a fetal renal pelvic measurement recorded. The difference in the fetal renal pelvic measurements between those cases which were normal postnatally and those which had a structural abnormality, an obstructive lesion or VUR became significant at 7 mm and at 18 weeks of gestational age. Over the whole period the proportion of cases in which micturating cysto-urethrography was technically possible and might have contributed to the diagnosis was 28.5%; the highest was 44.1% in 1998.

CONCLUSIONS

Antenatal renal dilatation occurs infrequently in the presence of VUR and when it does, the fetus will probably be male. Antenatal ultrasonography is unlikely to contribute to detecting VUR in females, the gender in whom early diagnosis is particularly desirable. Other means of suspecting VUR antenatally, e.g. the family history or genetic coding, may be more valuable. A measurement of the fetal renal pelvis of > or = 7 mm at a gestational age of 18 weeks should prompt subsequent careful ultrasonography during the pregnancy and early postnatal investigation of the urinary tract. The diagnosis of VUR should not be excluded because the fetal renal pelvis is only minimally dilated if the fetus is female.

Contrast-enhanced gray-scale and color Doppler voiding urosonography versus voiding cystourethrography in the diagnosis and grading of vesicoureteral reflux

PURPOSE

The purpose of this study was to compare contrast-enhanced gray-scale voiding urosonography (CE-VUS) and contrast-enhanced color Doppler voiding urosonography (CE-CDVUS) with voiding cystourethrography (VCUG) to verify whether the use of color Doppler imaging improves the diagnosis and grading of vesicoureteral reflux (VUR).

METHODS

In 74 patients, CE-VUS and CE-CDVUS were compared with VCUG, which was used as the gold standard. SHU 508 A (Levovist) was used as the echo-enhancing contrast agent. VUR was diagnosed if hyperechoic dots or color signals were visualized in the ureter on sonograms. VUR grading was based on morphologic and dynamic findings on CE-VUS and morphologic and color findings on CE-CDVUS. VCUG was performed conventionally, and grading by VCUG was in accordance with the international system of radiographic VUR grading. Patients who voided during 1 examination only (either CE-VUS and CE-CDVUS or VCUG) were excluded from the study. Agreement between the results of CE-VUS and VCUG and between those of CE-CDVUS and VCUG in diagnosing VUR was calculated by kappa statistics. CE-VUS and CE-CDVUS were compared for diagnostic accuracy by the McNemar test.

RESULTS

The agreement between CE-VUS and VCUG in predicting VUR was 90% (kappa score, 0.77; p < 0.001). The agreement between CE-CDVUS and VCUG was 96% (kappa score, 0.91; p < 0.001). CE-CDVUS showed a significantly higher diagnostic accuracy than did CE-VUS (96% versus 90% of cases correctly classified; McNemar chi2 = 4; p < 0.05). This was mainly related to the lower number of false-negative results for grade I and grade II VUR when CE-CDVUS was used.

CONCLUSIONS

The use of color Doppler imaging significantly improves the accuracy of contrast voiding urosonography in the detection and grading of VUR.

Mothers' coping in chronic childhood illness: the effect of presymptomatic diagnosis of vesicoureteric reflux

AIMS OF THE STUDY WERE TO: Assess coping strategies of mothers who have a child with vesicoureteric reflex (VUR), determine mothers' understanding of VUR before and after diagnosis, assess mothers' perceived needs for support when coping with their child's VUR and compare the above aims between two groups of mothers of children with VUR.

BACKGROUND

Vesicoureteric reflex (VUR) is a chronic, congenital, asymptomatic condition which when combined with urinary tract infection (UTI) can result in reflux nephropathy (RN), contributing to 20% of kidney transplants. Unfortunately, VUR is not usually diagnosed until after proven UTI, by which time RN has often developed. However, recent research, the familial ureteric reflux study (FURS) identified for the first time VUR in a cohort of new-borns investigated because of family history. Early detection and prompt treatment of UTI in the presence of VUR may significantly reduce the development of RN but this requires extreme vigilance by mothers, who are usually the primary carers.

DESIGN

As mothers' experiences and perceptions were the focus, a qualitative design using semistructured, in-depth interviews was used. After obtaining ethical approval, mothers of 15 children with VUR diagnosed presymptomatically (i.e. after participation in the FUR study) and mothers of 14 children with VUR diagnosed post symptomatically were selected using a theoretical sampling matrix. All mothers gave informed consent and interviews were taped, transcribed and analysed using the 'Framework' technique.

FINDINGS

Findings for both groups fall into three discrete phases: the prediagnostic, diagnostic and postdiagnostic. Analysis showed that mothers in the post symptomatic diagnosis group experienced most problems in coping, particularly because of difficulty in engaging medical intervention in the prediagnostic phase. Generally, mothers in the presymptomatic group coped well apart from those who themselves had VUR and/or RN who expressed guilt about their child inheriting the condition and consequently difficulty in coping.

CONCLUSION

Early diagnosis of VUR improved mothers' coping. However, both groups identified a major need for improved information provision and support to assist coping with the sustained uncertainty of the condition.

Pregnancy outcome in women with reflux nephropathy and the inheritance of vesico-ureteric reflux

In women with reflux nephropathy, we investigated whether pre-existing hypertension and impaired renal function influence the rates of preeclampsia, renal function deterioration and preterm birth. The infants were investigated for vesico-ureteric reflux (VUR). A prospective audit of 54 pregnancies in 46 women with reflux nephropathy was performed. Preeclampsia complicated 24% of pregnancies and was increased in women with pre-existing hypertension (42%) compared with normotensive women (14%), (RR 3.0 (95% CI 1.1-7.8)). Nine (18%) women experienced deterioration in renal function during pregnancy Women with mild or moderate renal impairment were at increased risk of renal function deterioration (RR 12.7 (95% CI 1.6-98.5); RR 19.8 (95% CI 2.6-155)), respectively A third of infants were delivered preterm. The risk of preterm birth was increased if the mother had pre-existing hypertension (p = 0.01) or moderate renal impairment (p = 0.002). Seventeen (43%) of the 40 infants who underwent micturating cystourethrography had VUR, consistent with autosomal dominant inheritance with reduced penetrance. In reflux nephropathy, pre-existing hypertension was associated with an increased risk of preeclampsia and pre-existing renal impairment with deterioration in renal function. Infants of women with reflux nephropathy should be screened for VUR.

A molecular and genetic view of human renal and urinary tract malformations

Malformations of the kidney and lower urinary tract are common causes of chronic renal failure in infants and young children, but little is known about the molecular pathogenesis of these disorders. In animal experiments, the main causes of malformation are mutations, chemical and pharmaceutical teratogens, obstruction of fetal urinary flow, and alterations of maternal nutrition. The focus of this review is to consider how mutations and other alterations of gene expression during development cause human urinary tract malformations. Some of these disorders are associated with congenital anomalies in multiple organ systems, and two such syndromes are considered in detail: first, the renal-coloboma syndrome, in which mutations of the PAX2 transcription factor cause partial failure of urinary tract growth; second, Kallmann's syndrome, in which mutations of a cell-signaling molecule are associated with the absence of the urinary tract. In patients seen by nephrologists and urologists, however, most urinary tract malformations occur in isolation, and in some of these individuals, a genetic pathogenesis is strongly suggested by a positive family history and genetic linkage studies. One common example is primary vesicoureteric reflux. Furthermore, sporadic malformations have been shown to be associated with polymorphisms of genes expressed during construction of the urinary tract. In the long term, an understanding of the genetic aspects of human urinary tract malformations will help to unravel the pathogenesis of these disorders and may facilitate the design of genetic screening tests with a view to early diagnosis.

Screening for fetal urological abnormalities: how effective?

OBJECTIVE

To analyse urological cases registered with the Northern Congenital Abnormality Survey (NorCAS) and thus assess antenatal diagnostic sensitivity, measure regional interhospital variation and determine whether antenatal ultrasonography has contributed to the prevention of urinary tract disease in childhood.

METHODS

All notification documents forwarded to NorCAS from its inception in 1984 until 31 December 1996 were inspected and those relating to urological abnormalities were abstracted. Information about postnatal progress was often missing. Twenty-three hospitals delivering maternity services were identified and randomly allocated a code letter a-w. Data were analysed in two periods, 1984-90 and 1991-96. To quantify hospital performance an 'expected number' for each hospital was calculated from the overall incidence per 1000 births and the number of births in each hospital.

RESULTS

There was a clear improvement in antenatal diagnostic sensitivity for the major urological abnormalities in the second period, but there was considerable variation among hospitals in the number of cases notified; this applied particularly to antenatal renal dilatation. Two hospitals notified significantly more cases in this category than all the others. The difference in notification rates among hospitals was caused by diagnoses such as vesico-ureteric reflux (VUR), pelvi-ureteric junction obstruction and megaureter, which often produce antenatal renal dilatation. Hospitals which notified more of these cases performed more micturating cystograms and identified more children with VUR. Measurements of the fetal renal pelvis were regularly made by only seven hospitals; one of these had difficulties with postnatal follow-up. There was evidence that moderate degrees of antenatal renal dilatation (4-10 mm) were associated with VUR; 8.5% of the children in whom VUR was diagnosed had fetal renal dilatation of this order.

CONCLUSION

Antenatal renal dilatation and its significance are either not being recognized or not appreciated in some hospitals. The high incidence of VUR in cases with moderate antenatal renal dilatation indicates that children with this condition may be escaping diagnosis.

Vesicoureteral reflux in male and female neonates as detected by voiding ultrasonography

BACKGROUND

Vesicoureteral reflux (VUR) is assumed to be congenital, and its early diagnosis is desired in order to prevent acquired renal damage. However, the incidence of VUR in neonates remains to be revealed.

METHODS

Two thousand newborn babies (1048 boys and 952 girls) underwent voiding ultrasonography (an ultrasound examination of urinary tract during provoked voiding). Those who showed transient renal pelvic dilation during voiding, who had small kidneys, or who subsequently developed urinary infection underwent voiding cystourethrography.

RESULTS

Transient renal pelvic dilation was observed in 16 babies (0.8%), including one boy with small kidneys. Among the rest of the babies, one boy had a small kidney, and nine babies subsequently developed urinary infection. Voiding cystourethrography revealed VUR in 24 ureters of 16 children (11 boys and 5 girls). Dimercaptosuccinate renoscintigraphy confirmed small kidneys, with generally reduced tracer uptake in a total of three boys, all having VUR. Voiding ultrasonography detected transient renal pelvic dilation in 17 (71%) of the 24 kidneys with VUR and, strikingly, 16 of the 17 (94%) kidneys with high-grade VUR (grade III or more).

CONCLUSION

This study effectively detected VUR in 0.8% of the neonates (mostly of high grades and predominantly in males) and voiding ultrasonography showed a decided usefulness for the detection of VUR. The male preponderance of VUR in neonates was considered to be due to the occurrence of congenitally small kidneys, with reflux found exclusively in males and easier ultrasound detection of VUR in male neonates because the majority of diagnoses are reported to be high grades of VUR.