DeLair Sean M, Eandi Jonathan, White Marina J, Nguyen Thuan, Stone Anthony R, Kurzrock Eric A
University of California, Davis School of Medicine, Sacramento, CA 95817, USA.
J Spinal Cord Med. 2007;30 Suppl 1(Suppl 1):S30-4. doi: 10.1080/10790268.2007.11753966.
BACKGROUND/OBJECTIVE: Because hydronephrosis and reflux are reversible, we believe cortical loss represents true renal deterioration in children with spinal dysraphism. Our goal was to better define risk factors for cortical loss.
After institutional review board approval, we reviewed the medical records of 272 children with spinal dysraphism. The following factors were evaluated: age, sex, renal and bladder imaging, urodynamic parameters, medications, catheterization program, continence, infections, and surgical history. Renal cortical loss was defined by scarring or a differential function greater than 15% using a nuclear scan. Univariate and multivariate logistic regression models were fitted to test the associations of specific variables with cortical loss.
Renal cortical loss was found in 41% of children with high-grade reflux vs. 2% of children without reflux. Univariate analysis showed only high-grade reflux and female sex to be independent risk factors. Controlling for age and sex, reflux and initiation of catheterization after 1 year of age are significant risk factors. High bladder pressure and hydronephrosis in the absence of reflux were not associated with cortical loss. Multivariate analysis showed that girls with reflux have a 55-fold increased risk of cortical loss.
By limiting the definition of renal deterioration to cortical loss, we identified relevant risk factors: reflux, female sex, and delayed initiation of clean intermittent catheterization. We have also discounted other suspected risk factors: hydronephrosis and elevated bladder pressure. Rather than continuing our focus on hydronephrosis and urodynamics, we believe more research and management debate should be afforded to females with reflux.
背景/目的：由于肾积水和反流是可逆的，我们认为皮质丢失代表了脊柱裂患儿真正的肾脏恶化。我们的目标是更好地确定皮质丢失的风险因素。
经机构审查委员会批准后，我们查阅了272例脊柱裂患儿的病历。评估了以下因素：年龄、性别、肾脏和膀胱影像学检查、尿动力学参数、药物治疗、导尿计划、控尿情况、感染及手术史。使用核素扫描，通过瘢痕形成或功能差异大于15%来定义肾皮质丢失。采用单因素和多因素逻辑回归模型来检验特定变量与皮质丢失之间的关联。
41%的重度反流患儿出现肾皮质丢失，而无反流患儿中这一比例为2%。单因素分析显示只有重度反流和女性是独立的风险因素。在控制年龄和性别后，反流以及1岁后开始导尿是显著的风险因素。无反流情况下的高膀胱压力和肾积水与皮质丢失无关。多因素分析显示，有反流的女孩发生皮质丢失的风险增加55倍。
通过将肾脏恶化的定义限定为皮质丢失，我们确定了相关风险因素：反流、女性以及清洁间歇性导尿开始延迟。我们也排除了其他一些可疑的风险因素：肾积水和膀胱压力升高。我们认为，与其继续关注肾积水和尿动力学，对于有反流的女性应开展更多的研究和管理方面的讨论。
