Mohanan Nochiparambil, Colhoun Eric, Puri Prem
National Children's Hospital, Dublin, Ireland.
J Urol. 2008 Oct;180(4 Suppl):1635-8; discussion 1638. doi: 10.1016/j.juro.2008.03.094. Epub 2008 Aug 16.
The association of vesicoureteral reflux, urinary tract infection and renal scarring is well recognized. We evaluated the incidence of renal parenchymal scarring in a large series of infants with primary high grade vesicoureteral reflux.
The medical records of 549 consecutive infants with primary high grade vesicoureteral reflux between 1985 and 2006 were reviewed. A total of 473 infants (86.1%) presented with febrile urinary tract infections, 63 (11.5%) were screened for sibling vesicoureteral reflux and 13 (2.4%) were investigated because of prenatally diagnosed hydronephrosis. Age at diagnosis was defined as patient age at the first voiding cystourethrogram. Renal parenchymal scarring was evaluated by dimercapto-succinic acid scan and classified into 3 groups, including mild--focal defects with between 40% and 45% relative uptake of renal radionuclide, moderate--relative uptake between 20% and 40%, and severe--a shrunken kidney with relative uptake less than 20%.
Of the 549 infants 292 (53%) were boys and 257 (47%) were girls with a median age of 6 months (range 2 to 12). Reflux was unilateral in 160 and bilateral in 389 (938 ureters). Reflux grade was II to V in 19, 372, 458 and 89 ureters, respectively. All patients with grade II reflux had high grade reflux on the contralateral side. Renal parenchymal scarring was present in 122 of the 458 infants (27%) evaluated with dimercapto-succinic scan. The incidence of renal parenchymal scarring was only 9% in infants without a history of urinary tract infection and 29% in those who presented with a urinary tract infection (p <0.01). Moderate to severe renal parenchymal scarring was present in 55 infants, of whom 73% were male and 27% were female.
The data show that moderate to severe renal scarring is associated with grade IV and V reflux, and male sex. The incidence of renal scarring is significantly lower in infants in whom high grade vesicoureteral reflux is detected by screening before the development of urinary tract infection. Early detection may prevent urinary tract infection related renal parenchymal scarring.
膀胱输尿管反流、尿路感染和肾瘢痕形成之间的关联已得到充分认识。我们评估了一大系列原发性重度膀胱输尿管反流婴儿的肾实质瘢痕形成发生率。
回顾了1985年至2006年间549例连续性原发性重度膀胱输尿管反流婴儿的病历。共有473例婴儿（86.1%）出现发热性尿路感染，63例（11.5%）因同胞膀胱输尿管反流接受筛查，13例（2.4%）因产前诊断的肾积水接受检查。诊断时的年龄定义为首次排尿膀胱尿道造影时的患者年龄。通过二巯基丁二酸扫描评估肾实质瘢痕形成，并分为3组，包括轻度——肾放射性核素相对摄取率在40%至45%之间的局灶性缺损，中度——相对摄取率在20%至40%之间，重度——肾萎缩且相对摄取率低于20%。
549例婴儿中，292例（53%）为男孩，257例（47%）为女孩，中位年龄为6个月（范围2至12个月）。反流为单侧的有160例，双侧的有389例（938条输尿管）。反流分级为II级至V级的输尿管分别有19条、372条、458条和89条。所有II级反流患者对侧均有重度反流。在458例接受二巯基丁二酸扫描评估的婴儿中，122例（27%）存在肾实质瘢痕形成。无尿路感染病史的婴儿中肾实质瘢痕形成的发生率仅为9%，而有尿路感染的婴儿中为29%（p<0.01）。55例婴儿存在中度至重度肾实质瘢痕形成，其中73%为男性，27%为女性。
数据表明，中度至重度肾瘢痕形成与IV级和V级反流以及男性性别有关。在尿路感染发生前通过筛查发现重度膀胱输尿管反流的婴儿中，肾瘢痕形成的发生率显著较低。早期发现可能预防与尿路感染相关的肾实质瘢痕形成。
