Çocukluk Çağı Tekrarlayan İdrar Yolu Enfeksiyonlarının Klinik Özellikleri Ve Görüntüleme Yöntemleri ile Değerlendirilmesi

Year 2024, Volume: 7 Issue: 2, 233 - 238, 30.06.2024

Meriban Karadoğan , Müferet Ergüven , Nurdan Yildiz

Abstract

Giriş ve Amaç: Çocukluk çağının oldukça yaygın enfeksiyonlarından olan üriner sistem enfeksiyonları, akut ve uzun dönemde komplikasyonlara neden olabilmektedirler. Bu retrospektif çalışmada, tekrarlayan idrar yolu enfeksiyonu (İYE) tanısı alan hastaların, klinik özellikleri ve renal skar gelişimi için risk faktörlerinin belirlenmesi amaçlanmıştır.
Yöntem: Temmuz 1987-Aralık 2008 tarihleri arasında Göztepe Eğitim ve Araştırma Hastanesi Çocuk Nefroloji Polikliniği’ne başvuran 791 hastanın başvuru yaşı, şikayeti, cinsiyeti ve görüntüleme yöntemleri kaydedildi. Çalışma verileri değerlendirilirken tanımlayıcı istatistiksel metodlar ve ki-kare test kullanıldı.
Bulgular: Hastaların %77 (n=609)’i kız, %23 (n=182)’i erkek; yaş ortalaması 5,27±3,74 idi. En sık şikayetler ateş (%42,2), karın ağrısı (%27,3), idrar kaçırma (%18,6) idi. USG ile 220 hastada üriner sistemde patoloji tespit edildi. Voiding sistoüreterografi ile 293 hastada (%37) vezikoüreteral reflü (VUR), dimerkapto-süksinik asit sintigrafi ile 165 hastada (%20,9) skar, 28 hastada (%3,5) hipoaktivite saptandı. Erkek çocuklarda VUR oranı (%46,2; n=84), kız çocuklardan (%34,3; n=209) yüksek bulundu (p<0.01). VUR görülen çocuklarda skar görülme oranı (%34,8; n=102), görülmeyenlerden (%12,7; n=63) ve febril İYE geçiren hastalarda skar oranı (%30, n=101), afebril İYE geçirenlerden (%14, n=64) yüksek bulundu (p<0,01). Üriner sistemi anatomik ve fonksiyonel olarak normal olan olguların %11,1’inde skar mevcuttu. USG’ nin VUR tespitinde duyarlılığın %33,10; özgüllüğün %81,73; skar tespitinde duyarlılığın %37,5, özgüllüğün %96,8 olarak bulundu.
Sonuç: Üriner sistem enfeksiyonları ciddi komplikasyonlara yol açabilmesi nedeni ile önemini hala korumaktadır. Her yaş grubunda tekrarlayan enfeksiyonda ilk görüntüleme yöntemleri USG ve Tc-DMSA olmalıdır. USG, VUR ve skar saptamada etkin değildir. USG’de pelvik dilatasyon ve/veya DMSA’da skar saptanan hastalarda yüksek dereceli reflü olasılığı artmış olduğundan VCUG mutlaka yapılmalıdır.

Keywords

çocuk, idrar yolu enfeksiyonları, skar, vezikoüreteral reflü

Ethical Statement

Araştırmaya başlamadan önce SB. Göztepe Eitim ve Araştırma Hastanesi Etik Kurulu’ndan 10 Mart 2009 tarihinde ve 55/F nolu karar ile yazılı izin alınmıştır.

References

• Emre S, Üriner Sistem Enfeksiyonları. Neyzi O, Ertuğrul T (Ed). Pediyatri (3.Baskı) İstanbul; Nobel Tıp Kitabevi 2002; p. 1491-1495.
• Elder, J.S. Urinary tract infections. In: Behrman, R.E., Vaughan, V.C., Jensen, H.B., (Ed), Nelson Textbook of Paediatrics, W.B.,Saunders, Philadelphia, 2004;1785-1790.
• Hanson S, Jodal U. Urinary Tract Infection. In: Avner ED, Harmon WE, Niaudet P. Pediatric Nephrology (5th ed.) Philadelphia, Lippincott Williams, 2004: 1007-1025.
• Bek, K, Akman, S, Bilge I, et al. Chronic kidney disease in children in Turkey. Pediatric nephrology 24 (2009): 797-806. doi:10.1007/s00467-008-1080-y
• Dönmez O. Çocuklarda İdrar Yolu Enfeksiyonları. Uludağ Üniversitesi Tıp Fakültesi Çocuk Sağlığı ve Hastalıkları ABD. Güncel Pediatri 2003;1:50-58.
• Sharifian M, Karimi A, Tabatabaei SR, et al. Microbial Sensitivity Pattern in Urinary Tract Infections in Children: A Single Center of 1, 177. Urine Cultures Jpn J. Infect. Dis. 2006;59:380- 382. doi: 10.7883/yoken.JJID.2006.380
• Pylkkanen J, Vilska J, Koskimies O. The value of level diagnosis of childhood urinary tract infection in predicting renal injury. Acta Paediatrica Scand 1981;70:879-883. doi: 10.1111/j.1651-2227.1981.tb06244.x
• Berg UB, Johansson SB. Age as a determinant of renal functional damage in urinary tract infection. Arch Dis Childhood 1983;58:963-969. doi: 10.1136/adc.58.12.963
• McKerrow W, Davidson-Lamb N, P.F Jones. Urinary tract infection in children. BMJ 1984;289:299-303. doi: 10.1136/bmj.289.6440.299
• Hansson S, Martinell J, Stokland E, Jodal U. The natural history of bacteriuria in childhood. İnfect dis clin North am 1987;1:713-729. doi: 10.1016/s0891-5520(05)70370-6
• Benador D, Benador N, Slosman D, Mermillod B, E Girardin E. Are younger children at higher risk of renal sequelae after pyelonephritis? Lancet. 1997;349;17-19. doi: 10.1016/s0140-6736(96)06126-0
• Qureshi AM.. Clinical presentation of urinary tract infection among children. J Ayub Med Coll Abbottabad. 2005;17:79-81.
• Elzouki AY, Mir NA, Jeswal OP. Symptomatic urinary tract infection in pediatric patients-a developmental aspect. Int J Pediatr Nephrol. 1985;6:267-70:1116-9.
• Rushton HG. Urinary tract infections in children: Epidemiology, evaluation and management. Pediatric Clinics of North America. 1997;44:1133-69. doi: 10.1016/s0031-3955(05)70551-4
• Hoberman A, Charron M, Hickey RW, et al. Imaging studies after a first febrile urinary tract infection in young children. New England Journal of Medicine. 2003;16;348(3):195-202. doi: 10.1056/NEJMoa021698
• Alon US, Ganapathy S. Should renal ultrasonography be done routinely in children with first urinary tract infection? Clinical pediatrics. 1999;38:21-5. doi:10.1177/ 000992289903800103
• Gelfand, M. J., Koch, B. L., Cordero, G. G., Salmanzadeh, A., Gartside, P. S. Vesicoureteral reflux: subpopulations of patients defined by clinical variables. Pediatric radiology, 2000;30:121-4. doi: 10.1007/s002470050028
• O Honkinen, O Ruuskanen, H Rikalainen, E O Mäkinen, I Välimäki. Ultrasonography as a screening procedure in children with urinary tract infections. The Pediatric Infectious Disease Journal, 1986; 5:633-635. doi: 10.1097/00006454-198611000-00006
• Stokland E, Hellstrom M, Hansson S, Jodal O, Oden A., Jacobsson, B. Reliability of ultrasonography in the identification of reflux nephropathy in children. Br Med J. 1994;309:235-239. doi: 10.1136/bmj.309.6949.235
• Dacher JN, Hitzel A, Avni FE, Vera P. Imaging strategies in pediatric urinary tract infection. European radiology, 2005;15:1283-8. doi: 10.1007/s00330-005-2702-4
• Alon U, Berant M, Pery M Intravenous pyelography in children with urinary tract infection and vesicoureteral reflux. Pediatrics. 1989; 83:332-336.
• Tsai JD, Huang FY, Tsai TC. Asymptomatic vesicoureteral reflux detected by neonatal ultrasonographic screening. Pediatr Nephrology, 1998;12: 206-209. doi: 10.1007/s004670050438
• Davey MS, Zerin JM, Reilly C, Ambrosius, W. T. Mild renal pelvic dilatation is not predictive of vesicoureteral reflux in children. Pediatr Radiology, 1999;27:908-11. doi: 10.1007/s002470050268
• Blane CE, Dipietro MA, Zerin JM, Sedman AB, Bloom DA. Renal sonography is not a reliable screening examination for vesicoureteral reflux. The Journal of Urology, 1993;150:752-755. doi: 10.1016/s0022-5347(17)35605-7
• Hiraoka M, Hori C, Sudo M, Kasuga K. Ultrasonic indicators of ureteric reflux in the newborn. Lancet, 1994;343:519-20. doi: 10.1016/s0140-6736(94)91466-4
• Baker R, Barbaris HT. Comparative results of urologic evaluation of children with initial and recurrent urinary tract infection. The Journal of Urology, 1976;116:503–505. doı: 10.1016/s0022-5347(17)58880-1
• Ginsberg CM, McCracken GH. Urinary tract infections in young infants. Pediatrics. 1982;69:409-412.
• Farnsworth, R. H., Rossleigh, M. A., Leighton, D. M., Bass, S. J., Rosenberg, A. R. The detection of reflux nephropathy in infants by 99 m technetium dimercaptosuccinic acid studies. The Journal of Urology, 1991;145:542-546. doı: 10.1016/s0022-5347(17)38391-x
• McKerrow W, Davidson-Lamb N, Jones PF. Urinary tract infection in children. Br Med J (Clin Res Educ). 1984; 289:299-303. doı: 10.1136/bmj.289.6440.299
• Lee JH, Son CH, Lee MS, Park YS. Vesicoureteral reflux increases the risk of renal scars: a study of unilateral reflux. Pediatr Nephrology. 2006;21:1281-4. doı: 10.1007/s00467-006-0147-x
• Polito, C., Rambaldi, P. F., Signoriello, G., Mansi, L., La Manna, A. Permanent renal parenchymal defects after febrile UTI are closely associated with vesicoureteric reflux. Pediatric Nephrology. 2006;21:521-6. doı: 10.1007/ s00467-006-0036-3
• Majd M, Rushton H.G. Renal cortical scintigraphy in the diagnosis of acute pyelonephritis. In Seminars in nuclear medicine 1992;22:98–111. doı: 10.1016/s0001- 2998(05)80085-6
• Rushton HG. The evaluation of acute pyelonephritis and renal scarring with technetium 99m-dimercaptosuccinic acid renal scintigraphy: Evolving concepts and future directions. Pediatric Nephrology. 1997;11:108–120. doı: 10.1007/s004670050243
• Jakobsson B, Berg U, Svensson L. Renal scarring after acute pyelonephritis. Archives of disease in childhood, 1994;70:111–115. doı: 10.1007/BF00858145
• Wu CY, Chiu PC, Hsieh KS, et al. Childhood UTI: A clinical analysis of 597 cases. Acta Paediatrics Taiwan. 2004;45:313-4. Doi: 10.1016/j.pedneo.2012.08.003
• Goldman M, Lahat E, Straus S. et al. Imaging after UTI in neonatal period. Pediatrics. 2000;105:1232-35. doı: 10.1542/peds.105.6.1232
• Peru H, Bakkaloglu S. A, Soylemezoglu O, Buyan, N, Hasanoglu, E. The relationship between urinary tract infections and vesicoureteral reflux in Turkish children International urology and nephrology, 2008. doı: 10.1007/s11255-008-9420-1
• Ransley PG, Risdon RA. Renal papillary morphology and intrarenal reflux in the young pig. Urological research. 1975;3:105-9. doı: 10.1007/BF00256030
• Smellie JM, Normand ICS. Bacteriuria, reflux and renal scarring. Archives of Disease in Childhood, 501975;50:581. doı: 10.1136/adc.50.8.581
• Filly, R., Friedland, G. W., Govan, D. E., Fair, W. R Development and progression of clubbing and scarring in children with recurrrent urinary tract infections. Radiology. 1974;113: 45. doı: 10.1148/113.1.145
• Hoberman A, Charron M, Hickey RW, et al. Imaging studies after a first febrile urinary tract infection in young children. New England Journal of Medicine. 3482003; 348:195-202. doı: 10.1056/NEJMoa021698
• Gordon I. Vesicoureteral reflux, urinary tract infection and renal damage in children. Lancet. 1995;346:489–490.
• Jakobsson B, Jacobson SG, Hjalmas K. Vesicoureteral reflux and other risk factors for renal damage: identification of high and low-risk children. Acta Paediatr. 1999;431:31–39. doı: 10.1111/j.1651-2227.1999.tb01316.x
• Najib KH, Fallahzadeh E, Fallahzadeh MH, Erjaee A. Renal Scar Formation in Children with Recurrent Urinary Tract Infections. Iranian Red Crescent Medical Journal 2009;11:93
• Moorthy I, Wheat D, Gordon I. Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard Pediatric Nephrology. 2004; 19:153–156. doı: 10.1007/s00467-003-1363-2
• Temiz Y, Tarcan T, Önol FF, Alpay H, Sımsek F. The efficacy of Tc99m dimercaptosuccinic acid (Tc-DMSA) scintigraphy and ultrasonography in detecting renal scars in children with primary vesicoureteral reflux (VUR) International Urology and Nephrology. 2006;38:149–152. doı: 10.1007/s11255-005-3829-6
• Tseng MH, Lin WJ, Lo WT et al. Does a normal DMSA obviate the performance of voiding cystourethrography in evaluation of young children after their first urinary tract infection? The Journal of pediatrics. 2007;150:96–99. doı: 10.1016/j.jpeds.2006.09.028
• Hansson S, Dhamey M, Sigstro¨m O et al. Dimercapto-succinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. The Journal of Urology. 2004;172:1071–1074. doı: 10.1097/01.ju.0000135337.71154.60
• Arant BS Jr. Vesicoureteric reflux and renal injury. American journal of kidney diseases, 1991 17:491–511. doı: 10.1016/s0272-6386(12)80490-2
• Rushton, H. G., Majd, M., Jantausch, B., Wiedermann, B. L., Belman, A. B. Renal scarring following reflux and nonreflux pyelonephritis in children: evaluation with 99mtechnetium dimercaptosuccinic acid scintigraphy. The Journal of Urology. 1992;147:1327–32. doı:10.1016/s0022-5347 (17)37555-9
• Huang FY, Tsai TC. Resolution of vesicoureteral reflux during medical management in children. Pediatr Nephrol. 1995;9:715-7. doı: 10.1007/BF00868720
• Kang I, Park CH, Kim CI. Does the renal scarring affect the spontaneous resolution and breakthrough infection in children with vesicoureteral reflux (VUR)? EAU Annual Congress - Stockholm 2009.
• Duckett JW, Walker RD, Weiss R. Surgical results: International reflux study in children – United States branch. The Journal of Urology, 1992;148:1674–1675. doı: 10.1016/s0022-5347(17)36999-9
• Olbing I, Claesson I, Ebel KD et al. Renal scars and parenchymal thinning in children with vesicoureteral reflux: a 5-year report of the International Reflux Study in Children (European branch). TheJournal of Urology. 1992;148:1653–1656. doı: 10.1016/s0022-5347(17)36995-1
• Venhola M, Huttunen NP, Uhari M. Meta-analysis of vesicoureteral reflux and urinary tract infection in children. Scandinavian journal of urology and nephrology, 2006;40:98-102. doi: 10.1097/INF.0000000000003628
• Wheeler D, Vimalachandra D, Roy L et al. Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomized controlled trials. Archives of Disease in Childhood. 2003;88:688–694. doı: 10.1136/adc.88.8.688