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Re: Prediction of Vesicoureteral reflux: Sibilla or more?

Dear Editor,

The study of Leroy et al. [1] about the predictive value of some simple clinical parameters on the presence of VUR in children with previous pyelonephritis seems to disclaimed the data previously described by Oostenbrink [2]. Nowadays all the protocols foresee the execution of a micturating cystourethrography (MCUG) in children after a pyelonephritis. Some years ago we performed a prospective study that showed how it is possible to reduce significantly the number of cystourethrography in these children [3]. We have shown that in children (0-4 years of age) without VUR elevated fever is preceded by one or more symptoms, such us low fever, anorexia, irritability or drowsiness, diarrhea, foul-smelling urine. At least one of the symptoms mentioned above, was present in the clinical history of 114 out of 218 children with fever >38.5 °C; of these children, only 16 later revealed VUR; on the other side, 85 of the 104 children without symptoms preceding elevated fever, revealed VUR (p<000.1). If MCGU had been performed only in children without any other symptom before fever onset (104 out of 218 febrile children), VUR would have been detected in 85 out of 101 (84.1%), with 16 patients missing diagnosis (most of these undiagnosed VURs were low grade). The reduction in MCGUs performed would have been considerable (114 instead of 218). Greater sensitivity could be also obtained by performing MCGU in all children < 4 months (only 9 undiagnosed VUR). Prediction of VUR after a first febrile urinary tract infection in children is possible: so our strategy seems to improve the cost-benefit relationship in children with UTI by significantly reducing the need for invasive and expensive radiological procedures [4].

References:

[1] S. Leroy, E. Marc, C. Adamsbaum, D. Gendrel, G. Breart, M. Chalumeau. Prediction of vesicoureteral reflux after a first febrile urinary tract infection in children: validation of a clinical decision rule. Arch Dis Child 2006; 91: 241-244

[2] J.H. Baumer. Can we predict vesicoureteric reflux? Arch Dis Child 2006; 91:210-211

[3] M. Pennesi, MD and Christine M. Salvatore, MD, Leopoldo Peratoner, MD. Different Clinical Presentations of Pyelonephritis in Children With and Without Vescico ureteral and Reflux: An Italian Multicenter Study. Pediatrics 1998; 102: 1493-1494