Selçuk YÜKSEL, Tülay BECERİR, Burçin SEYHAN

İdrar yolu enfeksiyonu geçiren çocuk hastalarda klinik ve laboratuvar kanıtların böbrek hasarı ile ilişkisinin değerlendirilmesi

Amaç: İdrar yolu enfeksiyonu (İYE) çocukluk çağının önemli enfeksiyon hastalıklarından birisidir. Bazı çocuklarda renal skar gelişimine neden olarak uzun dönemde ciddi komplikasyonlara neden olmaktadır. Bu çalışmada akut piyelonefrit kliniği ile başvuran çocuk hastalarda renal hasar gelişimindeki risk faktörlerinin belirlenmesi amaçlanmıştır.Gereç ve yöntem: Çalışmamızda Pamukkale Üniversitesi Tıp Fakültesi çocuk nefroloji polikliniğine başvuran idrar yolu enfeksiyonu tanısı ile takipli hastaların dosyaları retrospektif olarak değerlendirildi. Akut piyelonefrit tanısı idrar kültürü ve klinik bulgular ile kanıtlanmış ve Dimerkaptosuksinik asit renal sintigrafisi (DMSA) çekilmiş 197 hasta çalışmaya dahil edildi. Hastaların başvuru sırasında saptanan ve anamnezden elde edilen klinik (ateş, tekrarlayan İYE, işeme disfonksiyonu vb.), laboratuar (C-reaktif protein (CRP) ve eritrosit sedimentasyon hızı (ESH), beyaz küre sayısı (BK), polimorfonükleer lökosit sayısı (PNL), ortalama platalet hacmi (MPV), trombosit sayısı, serum üre ve kreatinin düzeyleri) ve görüntüleme (üriner sistem ultrasonografi (USG), voiding sistoüretrografi (VSUG) ve DMSA sintigrafisi) bulguları incelendi. Bulgular: Kız hastaların sayısı (n:153) erkek hastaların sayısından (n:44) anlamlı olarak daha yüksek saptandı (p<0,001). Hastaların tedavi öncesi ateş düzeyinin 38ºC ve üzerinde olması, klinik bulguların iki gün ve daha fazla süredir devam ediyor olması, tekrarlayan İYE varlığı, BK, PNL, ESH ve CRP yüksekliğinin renal hasarlanmayı artırdığı tespit edildi (p<0,001). USG ve VSUG’ nin renal hasarlanmayı gösterme açısından düşük sensitiviteye sahip olduğu görüldü.Sonuç: Hastaların başvuru sırasında tespit edilen klinik ve laboratuar verileri ile renal hasarlanma oranı belirlenmesi bu hastalarda uygun takip ve tedavi ile morbidite ve mortalite oranının azaltılmasını sağlayabilir.

Anahtar Kelimeler:

idrar yolu enfeksiyonu, çocuk, risk faktörleri, renal skar, ateş

The evaluation of the relationship of clinical and laboratory evidence with renal damage in the pediatric patients that had urinary tract infections

Purpose: Urinary tract infection (UTI) is one of the important infectious diseases of childhood age. It causes serious late-term complications by leading to development of renal scarring in some pediatric patients. In the present study, it was aimed to determine the risk factors in development of renal damage in the pediatric patients that admitted with clinical of acute pyelonephritis.Materials and methods: In our study, the medical files of the patients were admitted to the pediatric nephrology polyclinic of Pamukkale University Medical Faculty and followed-up with the diagnosis of urinary tract infection were retrospectively evaluated. The study included 197 patients diagnosed with acute pyelonephritis (confirmed by urine culture and clinical evidence) and undergoing dimercaptosuccinic acid (DMSA) scintigraphic imaging. The clinical evidence (fever, recurrent UTI, voiding dysfunction etc.), laboratory evidence (C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, polymorphonuclear leukocyte (PNL) count, mean platelet volume (MPV), platelet count, serum urea and creatinine levels) and imaging evidence(urinary tract system ultrasonography (USG), voiding cystourethrography (VCUG) and DMSA scintigraphy) of the patients detected at admission and obtained by anamnesis were evaluated. Results: The number of the female patients (n=153) was found significantly higher than number of the male patients (n=44) (p<0.001). It was detected that pretreatment fever of 38ºC and over, persisting clinical evidence for 2 days or longer, the presence of recurrent UTI and high levels of WBC, PNL, ESR and CRP significantly increased renal damage in the patients (p<0.001). It was determined that USG and VCUG have low sensitivity regarding prediction of renal damage.Conclusion: Determination of renal damage rate by clinical and laboratory data detected at patient admission may contribute to a reduction in morbidity and mortality rates by applying an appropriate follow-up and treatment modality.

Keywords:

Urinary tract infection, child, risk factors, renal scar, fever,

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1. Tullus K, Shaikh N. Urinary tract infections in children. Lancet 2020;395:1659-1668. https://doi.org/10.1016/S0140-6736(20)30676-0.
2. Millner R, Becknell B. Urinary Tract Infections. Pediatr Clin North Am 2019;66:1-13. https://doi.org/10.1016/j.pcl.2018.08.002
3. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med. 2002;8;113. https://doi.org/10.1016/s0002-9343(02)01054-9 4. Moorthy I, Easty M, McHung K, Ridout D, Biassoni D, Gordon I. The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection. Arch Dis Child 2005;90:733-736. https://doi.org/10.1136/adc.2004.057604
5. Yüksel S, Yüksel G, Çakar N. Urinary tract infection in children. Turkiye Klinikleri J Pediatr 2002; 11: 41-49.
6. Sinha MD, Gibson P, Kane T, Lewis MA. Accuracy of ultrasonic detection of renal scarring in different centres using DMSA as the gold standart. Nephrol Dial Transplant 2007;22:2213-2216. https://doi.org/10.1093/ndt/gfm155
7. Benador D, Benador N, Slosman DO. Are younger children at highest risk of renal sequelae after pyelonephritis? Lancet 1997;349:17-19. https://doi.org/10.1016/s0022-3476(94)70248-9
8. Jakobsson B, Berg U, Svensson L. Renal scarring after acute pyelonephritis. Arch Dis Child 1994;70:111-115 https://doi.org/10.1136/adc.70.2.111
9. Yüksel S, Çakar N, Çakmak FN, et al. Risk factors of renal damage in children with acut pyelonephritis. Turkiye Klinikleri J Pediatr 2007;16:158-164.
10. Pecile P, Miorin E, Romanello C, et al. Age-Related Renal Paranchymal Lesions in children with First Febrile Urinary Tract Infections. Pediatrics 2009;124:23-29. https://doi.org/10.1542/peds.2008-1192
11. Hiraoka M, Hashimoto G, Tsuchida S, Tsukahara H, Ohshima Y, Mayumi M. Early treatment of urinary infection prevents renal damage on cortical scintigraphy. Pediatr Nephrol 2003;18:115-118. https://doi.org/10.1007/s00467-002-1023-y
12. Doganis D, Siafas K, Mavrikou M, et al. Does Early Treatment of Urinary Tract Infection Prevent Renal Damage? Pediatrics 2007;120:922-928. https://doi.org/10.1542/peds.2006-2417
13. Hewitt IK, Zucchetta P, Rigon L, et al. Early Treatment of Acute Pyelonephritis in Children Fails to Reduce Renal Scarring: Data from the Italian Renal Infection Study Trials. Pediatrics 2008;122:486-490 https://doi.org/10.1542/peds.2007-2894
14. Smellie JM, Poulton A, Prescod NP. Retrospective study of children with renal scarring associated with reflux and urinary infection. BMY 1994;308:1193-1196.
15. Chang SL, Shortliffe LD. Pediatric urinary tract infections. Pediatr Clin North Am 2006;53:379-400. https://doi.org/10.1136/bmj.308.6938.1193
16. Garin EH, Olovarria F, Araya C, Broussain M, Barrea C, Young L. Diagnostic significance of clinical and laboratory findings to localize site of urinary infection. Pediatr Nephrol 2007;22:1002-1006. https://doi.org/10.1136/bmj.308.6938.1193
17. Lai SW, Ng KC: Retrospective analysis of inflammatory parameters in acute pyelonephritis. Scand J Urol Nephrol 2003;37:250–252. https://doi.org/10.1080/00365590310008145
18. Soylu A, Kasap B, Demir K, Türkmen M, Kavukçu S: Predictive value of clinical and laboratory variables for vesicoureteral reflux in children. Pediatr Nephrol 2007;22:844– 848. https://doi.org/10.1007/s00467-006-0418-6 19. Oostenbrink R, Van der Heijden AJ, Moons KG, Moll HA: Prediction of vesico-ureteric reflux in childhood urinary tract infection: a multivariate approach. Acta Paediatr 2000;89:806–810.
20. Kosmeri C, Kalaitzidis R, Siomou E. An update on renal scarring after urinary tract infection in children: what are the risk factors? J Pediatr Urol 2019;15:598-603. https://doi.org/10.1016/j.jpurol.2019.09.010 21. Spencer JR, Schaeffer AJ. Paediatric urinary tract infection. Urol Clin North Am 1986;13: 661– 672. https://doi.org/10.1016/j.jpurol.2019.09.010
22. Gleeson FV, Gordon I. Imaging in urinary tract infection. Arch Dis Child 1991;66:1282–1283.
23. Kaack MB, Dowling KJ, Patterson GM, Roberts JA Immunology of pyelonephritis VIII. E. coli causes granulocytic aggregation and renal ischemia. J Urol 1986;136:1117–1122. https://doi.org/10.1136/adc.66.11.1282
24. Roberts JA Mechanisms of renal damage in chronic pyelonephritis (reflux nephropathy). Curr Top Pathol 1995;88:265–287. https://doi.org/10.1007/978-3-642-79517-6_9
25. Snodgrass WT, Shah A, Yang M, et al. Prevalence and risk factors for renal scars in children with febrile UTI and/or VUR: a cross-sectional observational study of 565 consecutive patients. J Pediatr Urol 2013;9:856-863. https://doi.org/10.1016/j.jpurol.2012.11.019
26. Ferreiro C, Piepsz A, Nogarède C, Tondeur M, Hainaut M, Levy J. Late renal sequelae in intravenously treated complicated urinary tract infection. Eur J Pediatr 2013;172:1243–1248. https://doi.org/10.1007/s00431-013-2024-5 27. Keren R, Shaikh N, Pohl H, et al. Risk factors for recurrent urinary tract infection and renal scarring. Pediatrics 2015;136:e13–e21. https://doi.org/10.1542/peds.2015-0409
28. Jakobsson B, Berg U, Svensson L. Renal scarring after acute pyelonephritis. Arch Dis Child 1994;70: 111-115. https://doi.org/10.1136/adc.70.2.111
29. Chiristian MT, McColl JH, MacKenzie JR, Beattie TJ. Risk assesment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography. Arch Dis Child 2000 82:376-380. https://doi.org/10.1136/adc.82.5.376 30. Moorthy I, Wheat D, Gordon I. Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standart. Pediatr Nephrol 2004;19:153-156. https://doi.org/10.1007/s00467-003-1363-2
31. Moorthy I, Easty M, McHugh K, Ridout D, Biassoni D, Gordon I. The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection. Arch Dis Child 2005;90:733-736. https://doi.org/10.1136/adc.2004.057604