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PEDIATRIC
UROLOGY
doi: 10.1590/S1677-55382011000200030
Risk
factors for progression to end-stage renal disease in children with posterior
urethral valves
Ansari MS, Gulia A, Srivastava A, Kapoor R
Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate
Institute of Medical Sciences, Lucknow, India
J Pediatr Urol. 2010; 6: 261-4
- Objective:
To identify the variables which affect long-term renal outcome in children
with posterior urethral valves (PUV).
Materials and Methods: Retrospective analysis of 260 children with PUV
who underwent ablation of valves in 1992-2008 at our tertiary care center.
The following risk factors for progression to end-stage renal disease
(ESRD) were analyzed: nadir serum creatinine greater than 1.0mg/dL,
bilateral grade 3 or higher VUR at diagnosis, recurrent febrile UTIs,
and severe bladder dysfunction. Patients were divided into two groups:
those who developed ESRD (group 1) and those who did not (group 2).
Results: Forty (17.62%) patients had nadir serum creatinine > 1mg/dL.
At time of initial presentation, high-grade VUR was seen in 63.1% and
33.5% of groups 1 and 2, respectively (P = 0.002). Overall, 77 (34%)
of the boys developed breakthrough urinary tract infections: 37.03%
and 33.5% in groups 1 and 2, respectively (P = 1). Fifty-nine (26%)
patients were found to have severe bladder dysfunction: 77.8% and 19%
in groups 1 and 2, respectively (P < 0.0001). Twenty-seven (11.89%)
patients progressed to ESRD, at mean age of 11.21 years (5-16). On univariate
analysis, the risk-predicting variables were: nadir serum creatinine
value greater than 1mg/dL (P < 0.0001), bilateral high-grade VUR
(P = 0.002) and severe bladder dysfunction (P < 0.0001). On multivariate
logistic regression analysis, nadir serum creatinine greater than 1mg/dL
(OR 23.79; CI 8.20-69.05) and severe bladder dysfunction (OR 5.67; CI
1.90-16.93) were found to be independent risk factors predictive of
ultimate progression to ESRD.
Conclusions: Nadir serum creatinine and bladder dysfunction are the
main factors affecting long-term renal outcome in cases of PUV. Early
identification and treatment of bladder dysfunction may thus be beneficial.
- Editorial
Comment
This paper looked at a large series of children with posterior urethral
valves in order to identify risk factors for end-stage renal disease.
Patients were followed for a mean of 7.2 years. A total of 227 patients
were eligible for inclusion in the review. The authors looked at age
at presentation, nadir serum creatinine, presence of high-grade reflux,
recurrent febrile urinary tract infections, and severe bladder dysfunction
as variables. 30% of patients developed chronic kidney disease and 12%
progressed to end-stage renal disease. On univariate analysis nadir
creatinine greater than 1 mg/dL, bilateral high-grade reflux, and severe
bladder dysfunction were found to be risk factors. On multivariate analysis;
however, only nadir serum creatinine greater than 1 mg/dL and severe
bladder dysfunction were predictive of progression to end-stage renal
disease.
The strength of this study is the large number of patients at a single
institution. Certainly longer follow-up would likely reveal a greater
number of patients who progress to end-stage renal disease. Their findings
are in line with another large series recently published which also
demonstrated bladder dysfunction and nadir creatinine to be the only
independent risk factors for end-stage renal disease using multivariate
analysis (1). While nadir serum creatinine is not a modifiable risk
factor, bladder dysfunction can certainly be managed aggressively in
these at risk patients. This paper helps to reemphasize the importance
of screening for bladder dysfunction early on. It remains to be seen
whether or not early and aggressive management of bladder dysfunction
can have an impact on outcomes.
Reference
- DeFoor
W, Clark C, Jackson E, Reddy P, Minevich E, Sheldon C: Risk factors
for end stage renal disease in children with posterior urethral valves.
J Urol. 2008; 180 (4 Suppl): 1705-8; discussion 1708.
Dr.
M. Chad Wallis
Division of Pediatric Urology
University of Utah
Salt Lake City, Utah, USA
E-mail: chad.wallis@hsc.utah.edu
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