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Risk factors for kidney scarring and vesicoureteral reflux in 421 children after their first acute pyelonephritis, and appraisal of international guidelines

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Abstract

Background

Acute pyelonephritis (AP) is a common bacterial infection in childhood. Follow-up guidelines on these children are controversial. This study aimed to identify risk factors for kidney scarring and vesicoureteral reflux (VUR). Furthermore, international follow-up guidelines were used for simulation to evaluate sensitivity and specificity.

Methods

Urinary culture-confirmed first-time AP patients (aged 0–14 years) were enrolled (n = 421) from review of patient charts. All underwent kidney ultrasound (US) and a technetium-99m-dimercaptosuccinic acid (DMSA) scan or technetium-99m-mercaptoacetyltriglycine scinti-renography (MAG3) at 4–6 months of follow-up. The international guidelines used for simulation were from the National Institute of Health UK (NICE), the American Association of Paediatrics (AAP) and the Swedish Paediatric Society (SPS).

Results

17.8% presented with an abnormal DMSA/MAG3 at follow-up, 7.1% were diagnosed with VUR grades III–V and 4.7% were admitted for surgery. Non-Escherichia coli infections, abnormal kidney US, elevated creatinine and delayed response to treatment (>48 h) were risk factors for abnormal DMSA findings and VUR grades III–V. NICE and SPS guidelines showed best sensitivity in diagnosing VUR grades III–V (75%) compared with AAP (56%).

Conclusions

Risk factors are helpful in identifying the children in need of further investigations and minimizing invasive work-up for the rest. International guidelines on follow-up detect a varying number of children with kidney damage and/or significant VUR. Future work must focus on identifying more specific risk factors, better imaging, or specific biomarkers, to enhance sensitivity and specificity in detecting the children at high risk for developing recurrent infections and/or nephropathy.

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Data Availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

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Funding

The project received a grant from the Health Research Foundation of Central Denmark Region.

Author information

Authors and Affiliations

  1. Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark

    Anders Breinbjerg, Cecilie Siggaard Jørgensen, Konstantinos Kamperis & Søren Rittig

  2. Department of Clinical Medicine, Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus University, Aarhus, Denmark

    Jørgen Frøkiær

  3. Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK

    Kjell Tullus

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  1. Anders Breinbjerg
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  2. Cecilie Siggaard Jørgensen
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  3. Jørgen Frøkiær
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  5. Konstantinos Kamperis
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Contributions

All authors made substantial contributions to the work. Anders Breinbjerg conceived the project, collected data, performed the analysis and wrote the paper. Cecilie S. Jørgensen collected data and helped revise the manuscript. Kjell Tullus contributed to data analysis and revised the manuscript. Jørgen Frøkiær helped design the study and revised the manuscript. Konstantinos Kamperis and Søren Rittig helped on design, concept and analysis, and revised the manuscript.

Corresponding author

Correspondence to Anders Breinbjerg.

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Ethics approval

The study was conducted with approval from the Danish Patient Safety Authority (number 3-3013-2075/1), and the Danish Data Protection Agency (number 2012-58-006) under the Central Region of Denmark. The study was conducted in accordance with the declaration of Helsinki.

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The authors declare that there are no conflicts of interest.

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Breinbjerg, A., Jørgensen, C.S., Frøkiær, J. et al. Risk factors for kidney scarring and vesicoureteral reflux in 421 children after their first acute pyelonephritis, and appraisal of international guidelines. Pediatr Nephrol 36, 2777–2787 (2021). https://doi.org/10.1007/s00467-021-05042-7

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