Swanton A R, Arlen A M, Alexander S E, Kieran K, Storm D W, Cooper C S
Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
J Pediatr Urol. 2017 Apr;13(2):207.e1-207.e5. doi: 10.1016/j.jpurol.2016.10.021. Epub 2016 Dec 1.
Management of vesicoureteral reflux (VUR) remains controversial, and reflux grade constitutes an important prognostic factor. Recent work has suggested that distal ureteral diameter ratio (UDR) is a predictive factor relative to clinical outcome independent of grade. Previous studies have noted significant inter-rater variability with grading of VUR. The present study compared inter-rater reliability of reflux grade and UDR in children with primary VUR.
Four pediatric urologists independently reviewed, in a blinded fashion, voiding cystourethrograms. For each renal unit, grade was assigned according to the standardized international scale. The UDR was calculated by dividing the largest ureteral diameter within the false pelvis by the distance between L1-L3 vertebral bodies. Correlation within each rater was determined using Pearson's correlation coefficient. Reliability of VUR grade and UDR were calculated using two-way ANOVA model inter-rater agreement.
Four independent raters reliably measured VUR grade (ICC = 0.87, 95% CI = 0.78-0.93) and UDR (ICC = 0.95, 95% CI = 0.92-0.97). While UDR and grade were equally reliable measures, UDR had a tighter confidence interval. For each rater, grade and UDR were well correlated (r = 0.73-0.84; P < 0.0001). For higher-grade reflux, grade was more variable than UDR (Summary Figure). Using empirical thresholds, the increased variability of grade compared with UDR may lead to significant differences in clinical decision-making among physicians (P = 0.022).
Known discordance with grading reflux emphasizes the need for a more objective VUR measurement, as clinicians and parents often opt for clinical intervention based on both clinical course and the likelihood of spontaneous resolution. While ICC for UDR and grade were not significantly different, the confidence intervals for grade were wider due to greater variability among grade measurements. This suggests that using UDR measurements may lead to more accurate characterization of VUR and ultimately more consistent clinical decision-making across providers.
Ureteral diameter ratio has good inter-rater reliability among pediatric urologists, with less clinically relevant variability than VUR grade. Ureteral diameter ratio is a more objective and reliable measure than grade, and may be more useful in clinical decision-making.
膀胱输尿管反流（VUR）的管理仍存在争议，反流分级是一个重要的预后因素。最近的研究表明，输尿管远端直径比（UDR）是一个独立于分级的与临床结局相关的预测因素。以往研究指出，VUR分级的评估者间存在显著差异。本研究比较了原发性VUR患儿反流分级和UDR的评估者间可靠性。
4名儿科泌尿科医生以盲法独立审查排尿性膀胱尿道造影。对于每个肾单位，根据标准化国际量表进行分级。UDR通过将假骨盆内输尿管最大直径除以L1-L3椎体之间的距离来计算。使用Pearson相关系数确定每个评估者内部的相关性。使用双向方差分析模型评估者间一致性来计算VUR分级和UDR的可靠性。
4名独立评估者能够可靠地测量VUR分级（组内相关系数[ICC]=0.87，95%置信区间[CI]=0.78-0.93）和UDR（ICC=0.95，95%CI=0.92-0.97）。虽然UDR和分级是同样可靠的测量指标，但UDR的置信区间更窄。对于每个评估者，分级和UDR具有良好的相关性（r=0.73-0.84；P<0.0001）。对于更高分级的反流，分级比UDR的变异性更大（总结图）。使用经验阈值，与UDR相比，分级变异性增加可能导致医生之间临床决策的显著差异（P=0.022）。
已知反流分级存在不一致性，这强调了需要一种更客观的VUR测量方法，因为临床医生和家长通常会根据临床病程和自发缓解的可能性选择临床干预。虽然UDR和分级的ICC没有显著差异，但由于分级测量的变异性更大，分级的置信区间更宽。这表明使用UDR测量可能会导致对VUR更准确的特征描述，并最终使各医疗服务提供者之间的临床决策更加一致。
输尿管直径比在儿科泌尿科医生中具有良好的评估者间可靠性，与VUR分级相比，临床相关变异性更小。输尿管直径比是比分级更客观、更可靠的测量指标，可能在临床决策中更有用。
