Sofia Sjöström

Predictive Factors for Resolution of Congenital High Grade Vesicoureteral Reflux in Infants: Results of Univariate and Multivariate Analyses

PURPOSE We studied variables with impact on cessation of congenital high grade vesicoureteral reflux in univariate analyses and provide a multivariate model for prediction of reflux resolution. MATERIALS AND METHODS A total of 80 male and 35 female infants (median age 2.7 months) were included in this prospective observational study. Of the cases 71% were diagnosed after urinary tract infection and 26% after prenatal ultrasound. Reflux was bilateral in 70% of the patients and maximum grade was III in 16%, IV in 45% and V in 39%. The study protocol included repeat videocystometries, renal scintigrams, chromium edetic acid clearances and free voiding observations. Median followup was 36 months. RESULTS Overall spontaneous reflux resolution, including cases downgraded to grade I to II, was 38%. Variables significantly negatively correlated to resolution were breakthrough febrile urinary tract infection, bladder dysfunction, higher grade of reflux at inclusion, renal abnormality, subnormal renal function, increased bladder capacity, residual urine and passive occurrence of reflux. Multivariate Cox proportional hazard model with stepwise selection identified 3 independent predictors--renal abnormality (hazard ratio 0.45, 95% CI 0.31-0.64, p <0.0001), bladder dysfunction (hazard ratio 0.43, 95% CI 0.29-0.64, p <0.0001) and breakthrough urinary tract infection (hazard ratio 0.38, 95% CI 0.18-0.78, p = 0.009). Performance of the model was evaluated by the receiver operating characteristic curve, with a calculated area under the curve of 83%. CONCLUSIONS Overall resolution rate in congenital high grade vesicoureteral reflux is high during the first years of life. By multivariate analyses renal abnormality, bladder dysfunction and breakthrough febrile urinary tract infection were identified as strong independent negative predictive factors for reflux resolution.

Longitudinal Development of Renal Damage and Renal Function in Infants With High Grade Vesicoureteral Reflux

PURPOSE We sought to study renal abnormality and renal function through time in infants with high grade vesicoureteral reflux. MATERIALS AND METHODS This prospective observational study included 115 infants (80 boys and 35 girls) younger than 1 year with grade III to V vesicoureteral reflux. The diagnosis was made after prenatal ultrasound in 26% of the patients and after urinary tract infection in 71%. Patients were followed by renal scintigraphy, 51chromium edetic acid clearance and video cystometry. Median followup was 62 months. RESULTS Renal abnormality, which was found in 90% of the children at followup, was generalized in 71% and focal in 29%. The abnormality was bilateral in 28% of the affected patients. Total glomerular filtration rate was less than 80% of expected in 30% of the patients. Single kidney function was less than 40% of expected total glomerular filtration rate in 71% of the patients. Renal status (parenchymal abnormality and function) remained unchanged through time in 84 of 108 available cases (78%), improved in 5 (5%) and deteriorated in 19 (18%). Predictive factors for deterioration were recurrent febrile urinary tract infection, bilateral abnormality and reduced total glomerular filtration rate. Deteriorated renal status was more common in cases diagnosed prenatally than in those detected after urinary tract infection. CONCLUSIONS Among these infants with high grade vesicoureteral reflux renal abnormality was frequent and was associated with subnormal filtration of one of the kidneys. Decreased total glomerular filtration rate was seen in about a third of the patients. Overall deterioration of renal status was seen in only a fifth of the patients. Infection control seems to be an important factor to minimize the risk.

Is the mode of occurrence of vesicoureteral reflux correlated to bladder function and spontaneous resolution

PURPOSE To investigate whether mode of occurrence of vesicoureteral reflux (VUR), during micturition (M), during filling without increase in pressure (passive, P) or in response to an overactive contraction (OA), can be explained by differences in bladder function. Also, to study if the mode of occurrence of VUR can predict spontaneous resolution. MATERIALS AND METHODS There were 93 infants (68 boys and 25 girls) with VUR (grade III-V) included. Videocystometry was performed at median ages 5, 22 and 32 months registering grade and mode of reflux and bladder function characteristics. RESULTS Mode of occurrence of reflux changed with age. During infancy P, OA and M reflux comprised almost equal parts. At follow up, P reflux had increased and both OA and M reflux had decreased. This was partly due to a significantly higher probability of spontaneous resolution for M than P reflux, at 40 months (42 vs 18%). P and M reflux were significantly correlated to bladder function characteristics. P reflux was seen in children with high bladder capacity and occurred early in filling. Other predictors were higher age within the respective group and female sex. M reflux was correlated to lack of residual urine, low bladder capacity and absence of overactivity. Other indicators were male sex and low-grade reflux. CONCLUSIONS P and M reflux correlate to different bladder patterns: P with high bladder capacity and M with low bladder capacity and without signs of bladder dysfunction. M seems to be benign with a higher resolution rate.

Increased joint pain after massive weight loss: is there an association with joint hypermobility?

BACKGROUND Obesity is associated with an increased risk of pain in weight-bearing joints. Although pain often decreases after obesity surgery, this is the reverse for some patients. Hypermobility is described as an excessive range of motion in joints and has been suggested to be a possible cause of joint pain. It is not known whether there is an association between increased joint pain after weight loss and hypermobility. OBJECTIVES The objective of this study was to investigate whether there is an association between hypermobility and increased joint pain after massive weight loss. SETTING University hospital, Sweden. METHODS A survey including a screening questionnaire about hypermobility and questions about joint pain was sent to 149 people who had previously undergone bariatric surgery. Ninety-three people (72 women and 21 men) completed the questionnaire. RESULTS Nineteen of the respondents fulfilled the criteria for hypermobility. There were no significant differences between the groups with and without hypermobility regarding pain in weight-bearing joints before or after surgery. There was a significant difference between the groups with increased or novel pain in the ankles, shoulders, hands, and feet (P<.05) after the weight loss. Furthermore, the patients with hypermobility had increased or novel pain in a significantly higher number of weight-bearing joints, other joints, and joints in total (P< .05). CONCLUSION Even with a small sample size, a tendency can be seen for people with hypermobility to experience increased joint pain after weight loss compared with those without hypermobility.

Radiological bladder characteristics in VCU for young children with high-grade VUR

OBJECTIVES It has been suggested that infants with dilating vesicoureteral reflux (VUR) often have lower urinary tract (LUT) dysfunction. Signs such as high voiding pressure levels, low bladder capacity and dyscoordination at voiding have previously been thought to be indicative of dysfunction. However, these findings have also been recognised in healthy infants and are, thus, not specific to dysfunction in this age group. The urodynamic findings of interest for LUT dysfunction in children with high-grade VUR have been shown to be high bladder capacity with incomplete emptying, and often with overactivity during filling. Because the bladders in children with VUR are often only investigated with voiding cystourethrography (VCUG) and not urodynamics, the question has arisen as to whether some of the urodynamic findings indicating dysfunction can be recognised as radiological signs. The aim of the present study was to evaluate whether cystometric signs of LUT dysfunction in infants with high-grade VUR could be recognised in VCUG. MATERIALS AND METHODS One hundred and fifteen infants (80 boys) with Grades III-V VUR were included and investigated repeatedly with videocystometry (VCM) at a median age 6, 21 and 39 months. The sign looked for in the VCUG was bladder size (large, normal or small), according to the chosen levels in the bony pelvis. To validate the chosen levels for the different bladder sizes, bladder capacity data from a longitudinal study in healthy children were used. In addition, abnormalities in bladder wall/form and filling of the posterior urethra without voiding, as signs of bladder overactivity and detrusor-sphincter dyscoordination, were evaluated. RESULTS Bladder size was estimated on VCUG as large, normal or small, according to pelvic landmarks. Large bladder size was mainly seen at the second and third evaluations (64% and 46%), whereas small capacity was mainly seen during the first year (33%). Corresponding cystometric capacities (ml) showed a significant difference between the groups of small, normal and large bladder size. The cystometric capacities of large and small bladder size were also compared with bladder capacity in healthy controls, where large had significantly higher bladder capacity versus age (P = 0.0001) and small had significantly lower (P = 0.011) bladder capacity versus age than in the healthy controls. Bladder shape/wall pathology was mainly seen during the first year (42%), combined with small capacity, and correlated to overactive contractions during filling. Moreover, filling of the posterior urethra without voiding, indicating detrusor/sphincter dyscoordination at voiding, was quite common during the first year (33%), and then successively decreased. CONCLUSIONS The clinical implication from this study of small children with high-grade VUR was that a large bladder on VCUG was synonymous with a high-capacity bladder. According to earlier studies, this is a sign of LUT dysfunction in this age group and should therefore be an indicator for additional studies of bladder function. Overactive contractions could also be recognised in VCUG, but only at the infant evaluation, which should also be regarded as an indicator of LUT dysfunction. All other bladder VCUG signs mainly seen during early infancy were signs of immature bladder function and not a result of VUR dysfunction.

Predictive factors for spontaneous resolution of congenital High-Grade infantile Vesicouretral Reflux

Abstract Purpose The aim was to identify prognostic factors for spontaneous resolution of congenital high-grade vesicoureteral reflux (VUR). Material and Methods 115 infants (85 boys and 35 girls) were included at median age 2.7 months. 74% were diagnosed after urinary tract infection (UTI) and 26% after prenatal ultrasound. VUR was bilateral in 70% and of maximum grade III in 15%, grade IV in 45% and grade V in 40%. All have been followed with repeated video-VUCG, renal scintigrams (MAG-3 and DMSA) and 51Cr-EDTA-Clearances. Median follow-up time was 36 months. Results The overall spontaneous resolution rate (to grade II or less) was 39%. Significantly lower resolution was found in univariate Cox analysis, illustrated in Kaplan Meier survival curves, in those with renal damage, breakthrough UTI, bladder dysfunction, high bladder capacity, impaired renal function (lowered GFR), and reflux occurring without increase in pressure early during filling. Voiding reflux was connected to a high rate of spontaneous resolution. The resolution rate was also directly related to grade of VUR. There was no significant difference in resolution rate between boys and girls, pre or postnatal diagnosis, uni or bilateral VUR at start. Conclusions The overall resolution rate in congenital high-grade vesicoureteral reflux was high during the first years of life. A number of factors have been identified as important in the prediction of the long-time outcome of VUR in this study. Of these factors renal damage, bladder dysfunction and recurrent UTI have been shown to be the strongest independent predictors in a stepwise multivariate Cox analysis.