Farrugia Marie-Klaire, Montini Giovanni
Chelsea & Westminster and Imperial College Hospitals (West London Children's Alliance), London, UK; Imperial College London, UK.
Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy.
J Pediatr Urol. 2025 Feb;21(1):115-122. doi: 10.1016/j.jpurol.2024.09.016. Epub 2024 Sep 26.
Vesicoureteric reflux (VUR) diagnosed following investigation of prenatally-detected urinary tract dilatation (UTD), often remains asymptomatic and yet raises much parental and medical anxiety and management conundrums. Previous studies suggest that "prenatal" VUR appears to have a different natural history to that of VUR diagnosed following investigation of recurrent febrile urinary tract infections (UTIs). The concept is not new: reports from Great Ormond Street (1997) and the Society for Fetal Urology registry (1999) highlighted the characteristics of VUR patients diagnosed following investigation of prenatal hydronephrosis, who were noted to be predominantly male with high-grade VUR and established renal uptake defects on DMSA. To date, studies on VUR management and outcome have included both prenatally-diagnosed and symptomatic patients, confounding the results. Studies focussing specifically on the asymptomatic cohort are few, and generally only include patients on prophylaxis. Hence the true natural history of the condition is not known. A systematic review of 18 articles including 829 asymptomatic infants, of whom 473 (69.4 %) were males and 48.7 % had high grade (IV-V) VUR, revealed that 15.4 % of infants developed at least one breakthrough UTI despite initiation of CAP from birth. The limited data available showed no conclusive benefit of CAP, primarily due to lack of a strong comparator cohort. The recent PREDICT trial is the only randomised controlled trial to date, specifically on asymptomatic patients, assigned to prophylaxis or no treatment. Febrile UTI's mostly occurred in the first 6 months, in 21 % of the prophylaxis group vs 35 % of the no treatment group. Although the trial showed a small significant benefit of prophylaxis, this came at the expense of non-E Coli and resistant UTI's in the prophylaxis group. Importantly, there was no difference between the groups in the incidence of new scars at 2-year follow up. The authors concluded that prophylaxis might only be of benefit in girls, for the first year only. This thought-provoking study challenged current practice and led to this narrative review, aimed at a critical appraisal of the literature on this topic.
在对产前检测出的尿路扩张（UTD）进行检查后诊断出的膀胱输尿管反流（VUR），通常没有症状，但却引起了家长和医生的诸多焦虑以及管理难题。先前的研究表明，“产前”VUR的自然病史似乎与在对复发性发热性尿路感染（UTIs）进行检查后诊断出的VUR不同。这个概念并不新鲜：大奥蒙德街医院（1997年）和胎儿泌尿学会登记处（1999年）的报告强调了在对产前肾积水进行检查后诊断出的VUR患者的特征，这些患者主要为男性，患有高级别VUR，并且在二巯基丁二酸（DMSA）检查中有明确的肾脏摄取缺陷。迄今为止，关于VUR管理和结果的研究包括了产前诊断和有症状的患者，这使得结果混淆不清。专门针对无症状队列的研究很少，并且通常只包括接受预防治疗的患者。因此，这种疾病的真正自然病史尚不清楚。一项对18篇文章的系统综述，包括829名无症状婴儿，其中473名（69.4%）为男性，48.7%患有高级别（IV - V级）VUR，结果显示，尽管从出生就开始进行抗生素预防（CAP），仍有15.4%的婴儿发生了至少一次突破性尿路感染。现有的有限数据显示CAP没有确凿的益处，主要是由于缺乏一个强有力的对照队列。最近的PREDICT试验是迄今为止唯一一项专门针对无症状患者的随机对照试验，将患者分为接受预防治疗或不治疗两组。发热性尿路感染大多发生在头6个月，预防治疗组为21%，不治疗组为35%。尽管该试验显示预防治疗有微小但显著的益处，但这是以预防治疗组中非大肠杆菌和耐药性尿路感染的增加为代价的。重要的是，在2年随访时，两组新瘢痕的发生率没有差异。作者得出结论，预防治疗可能仅对女孩有益，且仅在第一年有益。这项发人深省的研究对当前的做法提出了挑战，并引发了本叙述性综述，旨在对该主题的文献进行批判性评估。
