Publication: 2010-2021 Yılları Arasında Ondokuz Mayıs Üniversitesi Çocuk Nefroloji Bölümünde Vezikoüreteral Reflü Nedeniğle Takip Edilen 0-18 Yaş Arasında Hastaların Değerlendirilmesi
Abstract
Amaç: Vezikoüretral reflü (VUR) idrarın mesaneden üst üriner sisteme geri kaçışıdır. Altta yatan nedene göre birincil ve ikincil olmak üzere iki gruba ayrılır. VUR'un klinik önemi, VUR'lu hastada enfekte idrarın bakterileri mesaneden böbreğe taşıyarak hastaları akut piyelonefrite yatkın hale getirdiği, bunun da böbrek skarlaşması, hipertansiyon ve kronik böbrek hastalığına yol açabileceği varsayımına dayanmaktadır. Ancak, VUR tanılı hastalarda böbrekte skarlaşmaya etki eden faktörler giderek daha fazla sorgulanmaktadır. Sonuç olarak, VUR'un klinik etkisi ve tedavisi tartışmalıdır. Bu çalışmadaki amacımız 01.01.2010 – 31.12.2021 tarihleri arasında Ondokuz Mayıs üniversitesi Çocuk Nefroloji bölümünde primer VUR tanısı ile izlenmiş hastaların klinik, laboratuvar, görüntüleme bulguları ile, takip ve tedavi sonuçlarının ortaya konması ve prognoza etki eden faktörlerin saptanmasıdır. Materyal ve Metod: Çalışmada 01.01.2010 – 31.12.2021 tarihleri arasında VUR tanısı ile izlenen 263 hastanın dosyaları geriye dönük olarak incelendi. Çalışmaya 0-18 yaş arası çocuk nefroloji kliniğine başvuran, üriner sistem ultrasonografisi, işeme sistoüretrografisi (VCUG) ve renal kortikal böbrek sintigrafisi (Tc-99m DMSA) yapılmış olan, VCUG'da VUR saptanan primer VUR tanılı hastalar alındı. Bulgular: Çalışmada incelenen 263 hastadan %40,7'si erkek, %59,3'ü kız idi. Hastaların başvuru yaşı ortalaması 3,80 ± 3,80 yıl (ortanca 3,08 yıl), ortalama izlem süresi 3,99 ± 3,23 yıl (ortanca 3,12 yıl) saptandı. Hasta grubumuzda yüksek dereceli reflü tanısı olanlar (150 hasta, %57,03) ağırlıkta idi. Kız hastalarda daha çok düşük-orta dereceli reflü saptanırken (86 hasta, %55,1), erkek hastalarda daha çok yüksek dereceli reflü (80 hasta, %74,8) saptandı. Kliniğimize en sık başvuru nedeni %79,1 ile üriner sistem enfeksiyonu geçirilmesi, ikinci en sık başvuru nedeni ise %17,5 ile antenatal hidronefroz (HN) idi. VUR tanılı hastaların tanı anındaki üriner sistem ultrasonografileri tarandığında yaklaşık yarısında (125 hasta, % 47,5) HN saptandı. Düşük orta dereceli reflüsü olan hastaların %34,5'inde HN varken, yüksek dereceli reflü olan hastaların %57,3'ünde HN saptandı. Yüksek dereceli reflüsü olan hastalarda HN anlamlı derecede yüksekti (p<0,05). Böbrek fonksiyonlarının değerlendirilmesinde glomerüler filtrasyon hızı (GFH) kullanıldı. Erkek hastalarda ve renal skarı olan hastalarda GFH daha düşük saptandı (p<0.05). Renal skarı olan hastalar ile olmayan hastalar karşılaştırıldığında cinsiyet, reflü derecesi açısından istatiksel anlamlı fark tespit edilmedi. Fakat proflaktik antibiyotik kullanmayan hastalarda renal skarlaşma daha fazla idi (p<0.05). Kısaca çalışmamızda reflü derecesi artışı ile GFH azalması ve renal skarlaşma arasında fark tespit edilmedi. Tekrarlayan idrar yolu enfeksiyonu (TİYE) beklendiği şekilde kız çocuklarda erkeklerden anlamlı derecede fazlaydı (p<0.05). Renal skarı olan hastalarda proteinüri ve hipertansiyon vardı fakat skar olmayan hastalar ile karşılaştırıldığında istatiksel anlamlı fark tespit edilmedi. Tedavi açısından ise hastaların %42,6'sı konservatif izlenirken, %57,4'üne endoskopik ve/veya açık cerrahi uygulandığı, kız hastaların erkek hastalara göre (p=0.032), TİYE olanların olmayanlara göre (p<0.05), renal skarı olanların olmayanlara göre (p<0.05) daha fazla oranda opere edildiği saptandı. Sonuç: Primer VUR tekrarlayan idrar yolu enfeksiyonlarına, renal parankimal skara, hipertansiyona, proteinüriye ve glomerüler filtrasyon hızında azalma ile birlikte kronik böbrek hastalığına sebep olur. Çalışmamıza göre GFH renal skarı olan çocuklarda anlamlı derecede düşüktür. Literatürden farklı olarak reflü derecesi artışı ile GFH azalması ve renal skarlaşma arasında ilişki saptanmamıştır. Son yıllarda çok tartışmalı bir konu olan proflaktik antibiyotik kullanımı da incelenmiş olup çalışmamızda renal skarı azalttığı gösterilmiştir. Çalışma grubumuzun daha çok yüksek dereceli reflü hastalarından oluştuğu düşünüldüğünde, özellikle yüksek dereceli reflü hastalarında proflaktik antibiyotik kullanımı uzun dönemde böbrek fonksiyonları için faydalı olabilir. Ayrıca çalışmamızdaki hastaların yaklaşık yarısında ultrasonografide HN saptanmamış olması nedeni ile, VUR tanılı hastalarda renal ultrasonografinin normal olabileceği akılda tutulmalıdır. Anahtar kelimeler: Vezikoüreteral reflü, Renal skar, İdrar yolu enfeksiyonu.
Objective: Vesicourethral reflux (VUR) is the escape of urine from the bladder back to the upper urinary tract. According to the underlying cause, it is divided into two groups as primary and secondary. The clinical significance of VUR is based on the assumption that infected urine in patients with VUR carries bacteria from the bladder to the kidney, predisposing patients to acute pyelonephritis, which can lead to kidney scarring, hypertension, and chronic kidney disease. However, the factors affecting kidney scarring in patients with VUR are increasingly questioned. In conclusion, the clinical effect and treatment of VUR is controversial. Our aim in this study is to reveal the clinical, laboratory, imaging findings, follow-up and treatment results of patients who were followed up with the diagnosis of primary VUR in the Department of Pediatric Nephrology of Ondokuz Mayıs University between 01.01.2010 and 31.12.2021 and to determine the factors affecting the prognosis Material and method: In the study, the files of 263 patients who were followed up with the diagnosis of VUR between 01.01.2010 and 31.12.2021 were retrospectively examined. The study included patients with primary VUR who were admitted to a pediatric nephrology clinic between the ages of 0-18 years, who underwent urinary system ultrasonography, voiding cystourethrography (VCUG) and renal cortical kidney scintigraphy (Tc-99m DMSA), and who had VUR detected in VCUG Results: Of the 263 patients examined in the study, 40.7% were male and 59.3% were female. The mean age of admission was 3.80 ± 3.80 years (median 3.08 years), and the mean follow-up period was 3.99 ± 3.23 years (median 3.12 years). In our patient group, those with a diagnosis of high-grade reflux (150 patients, 57.03%) were predominant. While low-to-moderate reflux was detected more in female patients (86 patients, 55.1%), higher grade reflux was detected in male patients (80 patients, 74.8%). The most common reason for admission to our clinic was urinary tract infection with 79.1% and antenatal hydronephrosis (HN) with 17.5% of the patients. While HN was detected in 34.5% of patients with low moderate reflux, HN was detected in 57.3% of patients with high-grade reflux. HN was significantly higher in patients with high-grade reflux (p<0.05). Glomerular filtration rate (GFR) was used to evaluate renal function. In male patients and patients with renal scarring, GFR was lower (p<0.05). When patients with renal scarring and patients without it were compared, there was no statistically significant difference in terms of gender and reflux degree. However, renal scarring was higher in patients who did not use prophylactic antibiotics (p<0.05). In short, in our study, there was no difference between increased reflux degree and decrease in GFR and renal scarring. Recurrent urinary tract infection (UTI) was significantly higher in girls than in boys as expected (p<0.05). Some patients with renal scarring had proteinuria and hypertension, but there was no statistically significant difference compared to patients without scarring. In terms of treatment, while 42.6% of the patients were followed conservatively, endoscopic and/or open surgery was performed in 57.4% of the patients, and female patients were operated more frequently than male patients (p=0,032). At the same time, it was observed that the patients with recurrent infections and with renal scars were operated at a higher rate (p<0,05 and p<0.05). Discussion and conclusion: Primary VUR causes recurrent urinary tract infections, renal parenchymal scar, hypertension, proteinuria and chronic kidney disease with decreased glomerular filtration rate. According to our study, GFR is significantly lower in children with renal scarring. Contrary to the literature, there is no relationship between increased reflux degree and decrease in GFR and renal scarring. In recent years, the use of prophylactic antibiotics, which is a very controversial issue, has also been examined and it has been shown to reduce renal scarring in our study. Considering that our study group consisted mostly of high-grade reflux patients, the use of prophylactic antibiotics may be beneficial for kidney function in the long term, especially in high-grade reflux patients. In addition, HN was not detected in ultrasonography in approximately half of the patients in our study, teherefore it should be kept in mind that renal ultrasonography may be normal in patients with VUR. Keywords: vesicoureteral reflux; renal scar, urinary tract infection
Objective: Vesicourethral reflux (VUR) is the escape of urine from the bladder back to the upper urinary tract. According to the underlying cause, it is divided into two groups as primary and secondary. The clinical significance of VUR is based on the assumption that infected urine in patients with VUR carries bacteria from the bladder to the kidney, predisposing patients to acute pyelonephritis, which can lead to kidney scarring, hypertension, and chronic kidney disease. However, the factors affecting kidney scarring in patients with VUR are increasingly questioned. In conclusion, the clinical effect and treatment of VUR is controversial. Our aim in this study is to reveal the clinical, laboratory, imaging findings, follow-up and treatment results of patients who were followed up with the diagnosis of primary VUR in the Department of Pediatric Nephrology of Ondokuz Mayıs University between 01.01.2010 and 31.12.2021 and to determine the factors affecting the prognosis Material and method: In the study, the files of 263 patients who were followed up with the diagnosis of VUR between 01.01.2010 and 31.12.2021 were retrospectively examined. The study included patients with primary VUR who were admitted to a pediatric nephrology clinic between the ages of 0-18 years, who underwent urinary system ultrasonography, voiding cystourethrography (VCUG) and renal cortical kidney scintigraphy (Tc-99m DMSA), and who had VUR detected in VCUG Results: Of the 263 patients examined in the study, 40.7% were male and 59.3% were female. The mean age of admission was 3.80 ± 3.80 years (median 3.08 years), and the mean follow-up period was 3.99 ± 3.23 years (median 3.12 years). In our patient group, those with a diagnosis of high-grade reflux (150 patients, 57.03%) were predominant. While low-to-moderate reflux was detected more in female patients (86 patients, 55.1%), higher grade reflux was detected in male patients (80 patients, 74.8%). The most common reason for admission to our clinic was urinary tract infection with 79.1% and antenatal hydronephrosis (HN) with 17.5% of the patients. While HN was detected in 34.5% of patients with low moderate reflux, HN was detected in 57.3% of patients with high-grade reflux. HN was significantly higher in patients with high-grade reflux (p<0.05). Glomerular filtration rate (GFR) was used to evaluate renal function. In male patients and patients with renal scarring, GFR was lower (p<0.05). When patients with renal scarring and patients without it were compared, there was no statistically significant difference in terms of gender and reflux degree. However, renal scarring was higher in patients who did not use prophylactic antibiotics (p<0.05). In short, in our study, there was no difference between increased reflux degree and decrease in GFR and renal scarring. Recurrent urinary tract infection (UTI) was significantly higher in girls than in boys as expected (p<0.05). Some patients with renal scarring had proteinuria and hypertension, but there was no statistically significant difference compared to patients without scarring. In terms of treatment, while 42.6% of the patients were followed conservatively, endoscopic and/or open surgery was performed in 57.4% of the patients, and female patients were operated more frequently than male patients (p=0,032). At the same time, it was observed that the patients with recurrent infections and with renal scars were operated at a higher rate (p<0,05 and p<0.05). Discussion and conclusion: Primary VUR causes recurrent urinary tract infections, renal parenchymal scar, hypertension, proteinuria and chronic kidney disease with decreased glomerular filtration rate. According to our study, GFR is significantly lower in children with renal scarring. Contrary to the literature, there is no relationship between increased reflux degree and decrease in GFR and renal scarring. In recent years, the use of prophylactic antibiotics, which is a very controversial issue, has also been examined and it has been shown to reduce renal scarring in our study. Considering that our study group consisted mostly of high-grade reflux patients, the use of prophylactic antibiotics may be beneficial for kidney function in the long term, especially in high-grade reflux patients. In addition, HN was not detected in ultrasonography in approximately half of the patients in our study, teherefore it should be kept in mind that renal ultrasonography may be normal in patients with VUR. Keywords: vesicoureteral reflux; renal scar, urinary tract infection
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