Guidelines Department, American Urological Association, 1000 Corporate Blvd., Linthicum, Maryland 21090, USA.
J Urol. 2010 Sep;184(3):1145-51. doi: 10.1016/j.juro.2010.05.066. Epub 2010 Jul 21.
The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to screening of siblings and offspring of index patients with vesicoureteral reflux and infants with prenatal hydronephrosis. From this evidence clinical practice guidelines are developed to manage the clinical scenarios insofar as the data permit.
The Panel searched the MEDLINE(R) database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children, clearly stating the number of children undergoing screening for vesicoureteral reflux. Vesicoureteral reflux should have been diagnosed with a cystogram and renal outcomes assessed by nuclear scintigraphy. The screening articles were extracted into data tables developed to evaluate epidemiological factors, patient and renal outcomes, and results of treatment. The reporting of meta-analysis of observational studies elaborated by the MOOSE group was followed. The extracted data were analyzed and formulated into evidence-based recommendations regarding the screening of siblings and offspring in index cases with vesicoureteral reflux and infants with prenatal hydronephrosis.
In screened populations the prevalence of vesicoureteral reflux is 27.4% in siblings and 35.7% in offspring. Prevalence decreases at a rate of 1 screened person every 3 months of age. The prevalence is the same in males and females. Bilateral reflux prevalence is similar to unilateral reflux. Grade I-II reflux is estimated to be present in 16.7% and grade III-V reflux in 9.8% of screened patients. The estimate for renal cortical abnormalities overall is 19.3%, with 27.8% having renal damage in cohorts of symptomatic and asymptomatic children combined. In asymptomatic siblings only the rate of renal damage is 14.4%. There are presently no randomized, controlled trials of treated vs untreated screened siblings with vesicoureteral reflux to evaluate health outcomes as spontaneous resolution, decreased rates of urinary infection, pyelonephritis or renal scarring. In screened populations with prenatal hydronephrosis the prevalence of vesicoureteral reflux is 16.2%. Reflux in the contralateral nondilated kidney accounted for a mean of 25.2% of detected cases for a mean prevalence of 4.1%. In patients with a normal postnatal renal ultrasound the prevalence of reflux is 17%. The prenatal anteroposterior renal pelvic diameter was not predictive of reflux prevalence. A diameter of 4 mm is associated with a 10% to 20% prevalence of vesicoureteral reflux. The prevalence of reflux is statistically significantly greater in females (23%) than males (16%) (p=0.022). Reflux grade distribution is approximately a third each for grades I-II, III and IV-V. The estimate of renal damage in screened infants without infection is 21.8%. When stratified by reflux grade renal damage was estimated to be present in 6.2% grade I-III and 47.9% grade IV-V (p <0.0001). The risk of urinary tract infection in patients with and without prenatal hydronephrosis and vesicoureteral reflux could not be determined. The incidence of reported urinary tract infection in patients with reflux was 4.2%.
The meta-analysis provided meaningful information regarding screening for vesicoureteral reflux. However, the lack of randomized clinical trials for screened patients to assess clinical health outcomes has made evidence-based guideline recommendations difficult. Consequently, screening guidelines are based on present practice, risk assessment, meta-analysis results and Panel consensus.
美国泌尿外科学会于 2005 年 7 月成立了膀胱输尿管反流指南更新委员会，以更新儿童原发性膀胱输尿管反流管理指南。专家组将任务分为 5 个主题，涉及特定的膀胱输尿管反流管理问题，这些问题对应于 3 种不同索引患者的管理和 2 种不同索引患者的筛查。本报告总结了现有关于膀胱输尿管反流索引患者的兄弟姐妹和后代以及产前肾积水婴儿筛查的证据。根据这些证据，制定了临床实践指南，以便在数据允许的情况下管理临床情况。
专家组从 1994 年至 2008 年在 MEDLINE（R）数据库中搜索了所有与 5 个选定指南主题相关的文章。审查了数据库，并将每个摘要分为特定的主题领域。排除病例报告、基础科学、二次反流、综述文章和不相关的文章。应接受的提取文章应评估了一组儿童，明确说明接受膀胱输尿管反流筛查的儿童人数。膀胱输尿管反流应通过膀胱造影诊断，并通过核闪烁扫描评估肾脏结局。将膀胱输尿管反流指数病例和产前肾积水婴儿的筛查文章提取到数据表中，以评估流行病学因素、患者和肾脏结局以及治疗结果。遵循 MOOSE 小组对观察性研究荟萃分析的报告。分析提取的数据，并制定关于膀胱输尿管反流指数病例和产前肾积水婴儿的兄弟姐妹筛查的循证建议。
在筛查人群中，膀胱输尿管反流的患病率为兄弟姐妹的 27.4%，子女的 35.7%。患病率以每 3 个月 1 人的速度下降。患病率在男性和女性中相同。双侧反流的患病率与单侧反流相似。估计 I-II 级反流的患病率为 16.7%，III-V 级反流的患病率为 9.8%。总体上皮质肾异常的估计值为 19.3%，在有症状和无症状儿童的队列中，有 27.8%的儿童有肾损伤。在无症状的兄弟姐妹中，只有肾损伤的比率为 14.4%。目前，没有随机对照试验评估接受和未接受治疗的膀胱输尿管反流筛查兄弟姐妹的健康结果，例如自发缓解、尿路感染、肾盂肾炎或肾瘢痕形成的发生率降低。在产前肾积水的筛查人群中，膀胱输尿管反流的患病率为 16.2%。对侧未扩张肾脏的反流占检测病例的平均 25.2%，平均患病率为 4.1%。在接受正常产后肾脏超声检查的患者中，反流的患病率为 17%。产前前后肾盂直径不能预测反流的患病率。直径为 4 毫米与 10%至 20%的膀胱输尿管反流患病率相关。反流的患病率在女性（23%）显著高于男性（16%）（p=0.022）。反流分级分布大约为 I-II 级、III 级和 IV-V 级各占三分之一。在无感染的筛查婴儿中，估计肾损伤的患病率为 21.8%。按反流分级分层，6.2%的 I-III 级和 47.9%的 IV-V 级（p <0.0001）存在肾损伤。在有或没有产前肾积水和膀胱输尿管反流的患者中，尿路感染的风险无法确定。有反流的患者报告的尿路感染发生率为 4.2%。
荟萃分析提供了有关膀胱输尿管反流筛查的有意义信息。然而，由于缺乏评估筛查患者临床健康结果的随机临床试验，因此难以制定循证指南建议。因此，筛查指南基于现有实践、风险评估、荟萃分析结果和专家组共识。
