Can Urinary Tract Infections Lead to End Stage Renal Disease?
ABSTRACT & COMMENTARY
Synopsis: Only three of 102 children with end stage renal disease (ESRD) seen over a 10-year period had a previous diagnosis of reflux nephropathy and only one of the three had recurrent urinary tract infections (UTIs). Thus, ESRD during childhood as a result of UTIs appears to be unusual. Recommendations for imaging evaluation of the urinary tract following a UTI should be reconsidered.
Source: Sreenarasinhaiah S, Hellerstein S. Urinary tract infections per se do not cause end-stage kidney disease. Ped Neph 1998;12:210-213.
One hundred and two consecutive children seen at the Children's Mercy Hospital in Kansas City who developed ESRD from 1986-1995 were reviewed. Congenital nephropathy/uropathy, including dysplasia, hypoplasia, posterior urethral valves, and neurogenic bladder, comprised one-third of the total, followed by focal glomerulosclerosis (11%) and hemolytic uremic syndrome (8%). Only three children were diagnosed as having reflux nephropathy. One of the three children had a history of a single, documented, afebrile UTI and one had recurrent UTIs. There were six children thought to have interstitial nephritis who developed ESRD between ages 6 months and 12.5 years. None of the six had a history of UTIs and therefore, probably did not have interstitial nephritis as a result of pyelonephritis. Sreenarasinhaiah and Hellerstein conclude that since UTIs are an infrequent cause of ESRD in an otherwise normal child, the approach to imaging evaluation of a child, at least one with afebrile UTIs, should be reviewed.
COMMENT BY THOMAS KENNEDY, MD, FAAP
This is a short report that is certain to stimulate some arguments. If you belong to a journal club, it's a great choice. Pediatric UTIs are always guaranteed to generate some controversy and this study won't disappoint. The title, a straightforward declarative statement, I suspect, was designed to catch attention and raise some eyebrows.
The significance of UTIs to pediatricians has always been two-fold: first, the desire to prevent the often significant acute morbidity of fever, toxicity, vomiting and, discomfort associated with parenchymal infections, and second, the serious concern abut the long-term sequelae and progression to chronic renal failure. The current study tries to erase the second of these concerns.
Not so fast. Just because none, or perhaps one, of 102 children in Kansas City who developed ESRD over a 10-year period did not appear to have uncomplicated UTIs as an etiology, it does not mean that several have not developed scarring and will progress to ESRD in their 30s or 40s. Sreenarasinhaiah and Hellerstein did not report on the renal function and/or blood pressure of children and adolescents with a history of URI or scarring. In fact, other studies have found the incidence of scarring to be up to 60% and the incidence of hypertension to be anywhere from 0-38%. The overall annual incidence in the United States is estimated to be approximately 3560 cases (approximately 0.5% of the total ESRD population attributed to chronic pyelonephritis). Again, the incidence is much higher in Great Britain. These and other wildly disparate data are enough to make your head spin.
Although the above apparently conflicting data is enough to raise controversy on its own, Sreenarasinhaiah and Hellerstein leap to a recommendation to reconsider the imaging evaluation of a child with one or more afebrile UTIs. This recommendation will be viewed either as a non-sequitur by the traditionalists or with enthusiasm by those of us who have always felt that renal imaging should not be routinely applied to any child with a documented UTI.
If the incidence of UTI and reflux as a cause of ESRD in the pediatric age group is, as Sreenarasinhaiah and Hellerstein found in their population, one in 102 (0.98%), then there are approximately 12 new cases of ESRD in children in the United States each year that are the result of UTI. Not many, but certainly not inconsequential. Go have fun discussing the article.
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