1/📢Hello #medtwitter
This month's (Aug) @ASPNeph Radiology webinar was all about vesicoureteral reflux (VUR)
Here are some clinical pearls!
What's new!?
#Medtweetorial #nephtwitter #ASPNeph #vesicoureteralreflux #vur
VUR - Against the flow!
2/ Let's get started with a poll!
Which one of these is true about VUR?
3/ Ans - All the above
PMID: 32022517
Let's quickly define vesicoureteral reflux
Retrograde flow of urine from the bladder into the upper urinary tract due to dysfunctional vesicoureteric junction (VUJ)
4/ Some interesting history facts :
🔹Galen & da Vinci: UVJ is a mediator of unidirectional flow of urine from kidneys to bladder
🔹Hutch(1952): Relationship between VUR & chronic pyelonephritis in paraplegic pts
🔹Hodson(1959): UTI & renal scarring ➡️ high likelihood of VUR
5/ What are the causes of Vesicoureteral reflux?
🔸Primary VUR
- Lack of VUJ maturation
- Most common
🔸Secondary VUR
- Organic obstruction or neurologic dysfunction
6/ VUR can be induced by multiple birth defects affecting urinary tract development:
🔸Ureteric budding
🔸Ureter differentiation & elongation, peristalsis
🔸UVJ formation
🔸Bladder & urethra development
🧬genes implicated:
RET
PAX2
ROBO2
KAL1
HOXA13
NIPBL
PMID: 28612055
7/ VUR
🔸Usually asymptomatic
🔸often presents with nonspecific signs & symptoms like failure to thrive, fever when UTI, lethargy, abdominal pain, voiding symptoms etc, especially with high grade VUR
8/ What are the Clinical consequences of VUR?
It was previously thought that VUR ➡️ Recurrent UTIs ➡️Renal scarring ➡️CKD
⚡️Now it is increasingly recognized that children are born with dysplastic kidneys to begin with, which is associated with reflux-VUR, recurrent UTIs and CKD
9/ Poll
Which of these is the definitive method of diagnosing VUR and defining its severity?
10/ Ans - VCUG/MCUG
Let's look at how to proceed with imaging in a child with febrile UTI
Renal Bladder Ultrasound-RBUS
Initial imaging choice for fUTI & as a follow up scan to monitor disease progression
Detects hydronephrosis & dilated ureter
Normal USG doesn't rule out VUR
11A/ VCUG/MCUG Voiding/Micturating cystourethrogram
Indications
♦️<6m
Fever ≥ 39°C & atypical UTI
Renal anomaly on RBUS
♦️6m-3y
Recurrent UTIs
Male infants with prenatally diagnosed b/l hydronephrosis
♦️>3y
Usually not indicated unless there is strong suspicion or Hypertension
11B/ VCUG findings and grading
⚡️Findings: Retrograde reflux of the contrast into the ureters during micturition is diagnostic of VUR.
⚡️Grading: Divided in to 5 grades based on the severity of VUR on VCUG
12/ DMSA Renal Scan
🔹Nuclear imaging method using radioactive DMSA (dimercapto succinic acid)
🔹Assess cortical tissue, renal function and scarring
🔹Indicated for treatment monitoring and as a follow up scan to look for worsening renal function
13/ MAG3 Renal Scintigraphy (radionuclear cystourethrography)
🔸Nuclear medicine scan using MAG3 (mercaptoacetyltriglycine)
🔸Detects UVJ and UPJ obstruction
🔸Measures differential renal function
PMID: 25126000
14/ Treatment options💊🏥
Over the last few years Individualized, risk-based approach to the management of VUR with an overall shift to more conservative management has been noticed
PMID: 33869117
15/ Here is a table summarizing @AmerAcadPeds and NICE guidelines for the diagnosis and management of UTI in children👇
📍 emjreviews.com/microbiology-i…
16/ Treatment - EAU guidelines
The European Association of Urology guidelines prominently state that “there is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment”
PMID: 28243965
17/ Let’s look at #RIVUR study
2-year, multisite, RCT
607 children with VUR
Did antibiotic prophylaxis prevent recurrent UTIs (primary) & scarring in kidneys (secondary)❓
Conclusion: Prophylaxis prevented recurrent UTI but not scarring
nejm.org/doi/full/10.10…
VA by @drM_sudha
18A/ @AmerMedicalAssn & @AmerAcadPeds recommendations :
AMA - Recommends annual evaluation of BP, height, weight, urine analysis, and RBUS until the abnormality resolved or is no longer clinically significant
18B/ AAP - All infants with fUTIs undergo renal & bladder ultrasonography. VCUG is indicated if RBUS reveals hydronephrosis, scarring, high-grade VUR, obstructive uropathy & in some atypical/complex clinical situations. Not recommended routinely after a first fUTI
PMID:20650499
19/ Prognosis:
Cystic dysplasia and VUR can lead to -
🔸Recurrent UTIs
🔸Scarring in the kidneys
🔸Hypertension
🔸CKD and eventually ESKD
PMID: 28612054
20/ That's all folks!
For a case-based clinical discussion with radiology expert login to @ASPNeph website, August webinar. Answer questions to get #MOC2credits #Membereducation #ASPNFOAMgroup
21/ Special thanks to @SwastiThinks @drM_sudha @priti899 for your help in publishing my first tweetorial!
Until next time....
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