Heather J Lambert

New renal scarring in children who at age 3 and 4 years had had normal scans with dimercaptosuccinic acid : follow up study

Abstract Objective: To determine up to what age children remain at risk of developing a new renal scar from a urinary tract infection. Design: Follow up study. Families of children who had normal ultrasound scans and scanning with dimercaptosuccinic acid (DMSA) after referral with a urinary tract infection when aged 3 (209) or 4 (220) were invited to bring the children for repeat scans 2-11 years later. A history of infections since the original scan was obtained for children not having a repeat scan. Setting: Teaching hospital. Subjects: Children from three health districts in whom a normal scan had been obtained at age 3-4 years in 1985-1992 because of a urinary tract infection. Main outcome measure: Frequency of new renal scars in each age group. Results: In each group, about 97% of children either had repeat scanning (over 80%) or were confidently believed by their general practitioner or parent not to have had another urinary infection. The rate of further infections since the original scan was similar in the 3 and 4 year old groups (48/176 (27%) and 55/179 (31%)). Few children in either group known to have had further urinary infections did not have repeat scanning (3/209 (1.4%) and 4/220 (1.8%)). In the 3 year old group, 2.4% (5/209) had one or more new kidney scars at repeat scanning (one sided 95% confidence interval up to 5.0%), whereas none of the 4 year olds did (one sided 95% confidence interval up to 1.4%). The children who developed scars were all aged under 3.4 years when scanned originally. Conclusions: Children with a urinary tract infection but unscarred kidneys after the third birthday have about a 1 in 40 risk of developing a scar subsequently, but after the fourth birthday the risk is either very low or zero. Thus the need for urinary surveillance is much reduced in a large number of children. Key messages Urinary tract infections can cause renal scars in young children that may lead to hypertension or renal failure, often years later Scars can be detected immediately on scanning with dimercaptosuccinic acid (DMSA) but may not be apparent for years if only intravenous urography is used Previous studies based on intravenous urography have suggested that new scars may develop in children up to the age of 10 years This study, which used DMSA scanning, shows that there is little or no risk of new renal scars developing in children aged 4 and older

Oral health in children with renal disease

Abstract Thirty-eight children (aged 2–16 years) attending a regional kidney unit had a full clinical and radiological dental examination. Twenty had previously undergone a renal transplant, 11 had chronic renal failure and 7 had other renal diseases. Periodontal disease was uncommon The presence of gingival hyperplasia (gum overgrowth), as recorded in 22 of the children, did not show any relationship with the use of immunosuppressant therapy. However, gingival overgrowth was so excessive in 2 patients that surgical removal was required. The prevalence of dental caries was low. Enamel defects were common, and of an unusual pattern, with a much higher prevalence of diffuse opacities and enamel hypoplasia than in the normal child population, 83% and 22%, respectively. This increased prevalence is probably due to disordered calcium and phosphate metabolism. The prevalence of these defects may reflect an early onset of renal disease, since there were a number of very young children in the programme. Dental and medical care should be closely integrated for children with renal disease to avoid the undesirable dental sequelae of, in particular, gingival overgrowth, carcinoma and enamel hypoplasia.

Fathers’ contributions to the management of their child’s long-term medical condition: a narrative review of the literature

Context  Fathers’ contributions to the management of long‐term childhood medical conditions are under‐represented in the literature; therefore, the full extent of their involvement is poorly understood by practitioners and researchers, so strategies for promoting their involvement have not yet been fully considered.

Whole-Genome Linkage and Association Scan in Primary, Nonsyndromic Vesicoureteric Reflux

Primary vesicoureteric reflux accounts for approximately 10% of kidney failure requiring dialysis or transplantation, and sibling studies suggest a large genetic component. Here, we report a whole-genome linkage and association scan in primary, nonsyndromic vesicoureteric reflux and reflux nephropathy. We used linkage and family-based association approaches to analyze 320 white families (661 affected individuals, generally from families with two affected siblings) from two populations (United Kingdom and Slovenian). We found modest evidence of linkage but no clear overlap with previous studies. We tested for but did not detect association with six candidate genes (AGTR2, HNF1B, PAX2, RET, ROBO2, and UPK3A). Family-based analysis detected associations with one single-nucleotide polymorphism (SNP) in the UK families, with three SNPs in the Slovenian families, and with three SNPs in the combined families. A case-control analysis detected associations with three additional SNPs. The results of this study, which is the largest to date investigating the genetics of reflux, suggest that major loci may not exist for this common renal tract malformation within European populations.

Redefining Urinary Tract Infections by Bacterial Colony Counts

OBJECTIVES: To determine the best urinary bacterial concentration to diagnose urine infections. METHODS: We studied a quantitative culture of paired urine samples from children that were promptly tested together after serial dilution. The initial diagnosis of urinary tract infection made from the result of the first urine culture and subsequently modified according to the second sample result, and then the ratio of their colony counts was considered. A total of 203 children (aged 2.0 weeks to 17.7 years) were screened for urine infection in a hospital setting. RESULTS: The 36 children who had a urinary tract infection, defined as having the same uropathogen in both urine samples at concentrations within 25-fold of each other, had a mean colony count of 1.7 × 107 colony-forming units/mL. Among the 167 children who did not have a urinary tract infection, 12 (7.2%) would have had a false-positive diagnosis made on the first sample, which was revealed because the second sample result was different (n = 7) or had a ≥25-fold different colony count (n = 5). Raising the threshold from 105 to 106 colony-forming units/mL reduces the false-positive rate 4.8%. If 2 samples are cultured, the false-positive rates fall to 3.6% and 0.6%, respectively. All 9 children (5.4% of those without a urinary tract infection) who had a mixed culture with ≥105 colony-forming units/mL of a uropathogen (heavy mixed growth) in the first sample had a urine infection excluded by the second sample result. CONCLUSION: The minimum urinary bacterial concentration that is used to diagnose a urine infection should be increased from ≥105 to ≥106 colony-forming units/mL, because that would reduce the false-positive rate from 7.2% to 4.8% if 1 sample was cultured and from 3.6% to 0.6% if 2 samples were cultured. Urine samples with heavy mixed growths should be considered contaminated.

A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial

Abstract Objectives To determine whether a nurse led education and direct access service improves the care of children with urinary tract infections. Design Prospective cluster randomised trial. Setting General practitioners in the catchment area of a UK paediatric nephrology department. Participants 88 general practices (346 general practitioners, 107 000 children). Main outcome measures Rate and quality of diagnosis of urinary tract infection, use of prophylactic antibiotics, convenience for families, and the number of infants with vesicoureteric reflux in whom renal scarring may have been prevented. Results The study practices diagnosed twice as many urinary tract infections as the control practices (6.42 v 3.45/1000 children/year; ratio 1.86, 95% confidence interval 1.42 to 2.44); nearly four times more in infants (age < 1 year) and six times more in children without specific symptoms. Diagnoses were made more robustly by study practices than by control practices; 99% v 89% of referred patients had their urine cultured and 79% v 60% had bacteriologically proved urinary tract infections (P < 0.001 for both). Overall, 294 of 312 (94%) children aged under 4 years were prescribed antibiotic prophylaxis by study doctors compared with 61 of 147 (41%) by control doctors (P < 0.001). Study families visited hospital half as much as the control families. Twice as many renal scars were identified in patients attending the study practices. Twelve study infants but no control infants had reflux without scarring. Conclusion A nurse led intervention improved the management of urinary tract infections in children, was valued by doctors and parents, and may have prevented some renal scarring.

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.

Involving fathers in research

Scientific Inquiry provides a forum to facilitate the ongoing process of questioning and evaluating practice, presents informed practice based on available data, and innovates new practices through research and experimental learning.

Central–peripheral temperature difference, blood pressure, and arginine vasopressin in preterm neonates undergoing volume expansion

AIM To examine the effect of intravascular volume expansion for the treatment of hypovolaemia in sick preterm neonates. METHODS An intravenous infusion of 20 ml per kg of 4.5 % albumin was given to 14 preterm neonates. The effects on systolic blood pressure, central peripheral temperature difference (c-pT), and plasma arginine vasopressin concentration (pAVP) were measured. RESULTS Thirteen babies showed a rise in systolic blood pressure. The six babies with the highest initial values of pAVP and c-pT showed a fall in both of these after infusion. The babies with lower initial pAVP (below 4 pmol/l) showed either a rise (two) or no change (six) after albumin infusion. There was a significant correlation between c-pT and log pAVP before (r2=0.61; p<0.05) and after infusion (r2=0.45; p<0.05). CONCLUSIONS Plasma AVP concentration is related to c-pT in unwell preterm newborns. This study suggests that clinical assessment of hypovolaemia in preterm newborns is poor and could be improved by using c-pT.

Do systemic symptoms predict the risk of kidney scarring after urinary tract infection

Background and aims: In the NICE guideline on childhood urinary tract infection (UTI), it is assumed that the presence or severity of systemic symptoms, especially fever, predicts for renal scarring, and different management is recommended accordingly. We aimed to test this hypothesis by retrospective case note analysis. Design and subjects: Notes of children aged under 5 years referred with a first UTI who were assessed for scarring were reviewed. Main outcome criteria: Ability to predict for single or multiple scarring from age, sex, fever, vomiting or anorexia or malaise, or need for hospitalisation, within the age bands used by NICE. Results: There were 51 (65% girls) scarred and 140 (69% girls) unscarred children. Fever, systemic symptoms and hospitalisation were all commoner among younger children (<6 months vs 6 months–3 years vs >3 years; fever 0.67 vs 0.38 vs 0.38; systemic symptoms 0.78 vs 0.62 vs 0.43; hospitalisation 0.67 vs 0.29 vs 0.19; p<0.001 for all). Having vomiting, anorexia or malaise at presentation correlated weakly with single or multiple renal scarring (R2 = 0.03; p = 0.02), but sex, age, fever or hospitalisation did not (p>0.5 for all). Sensitivity and specificity data, and plots of proportionate reduction of uncertainty showed that none of these variables was useful for predicting any scarring in children aged <3 years and that they were only weakly predictive in older children. Conclusions: Clinical signs at presentation in childhood UTI cannot be used to predict for mild or multiple scarring, and should not be used to guide management. NICE’s recommendation to do so is not justified.