Thread by @CatherineJ20

1/ Hi #NephTwitter #Renal #MedTwitter @ASPNeph radiology webinar this month was Vesicoureteral reflux #VUR and its management.

Let's get going with a poll!

What percentage of children with febrile UTI may end up having VUR?

2/ Answer: up to 30%
This may be an underestimate since many children don't get tested.

[PMID: 9743033] pubmed.ncbi.nlm.nih.gov/9743033/

3/ Risk factors for VUR:
⚡️Bowel and bladder dysfunction
⚡️Abnormal urinary tract anatomy
⚡️Younger children and infants
⚡️Girls affected >> boys
⚡️Family history: sibling with VUR ➡️ 25% recurrence risk
Read more 👇
PMID: pubmed.ncbi.nlm.nih.gov/33869117

4/ What tests aid Dx of VUR?
A. Renal ultrasound:
🔺Assess anatomy but not diagnostic for VUR
🔺Absence of hydronephrosis does NOT exclude VUR!!

5/Testing in VUR:
B. Voiding cystourethrogram [VCUG]:
🎯 for VUR.
💎 Timing: 👍 unless has active UTI pubmed.ncbi.nlm.nih.gov/9135273/
💎Prophylactic Abx: consider in 👶 and with abnormal renal imaging pubmed.ncbi.nlm.nih.gov/28855226/

6/ Webinar Pearls for VCUG:
🔹8 images for adequate study
- early filling, full bladder, R+ L obliques
🔹Cyclical voiding images are important
🔹Urethral 📷 with voiding after Foley removal to diagnose any obstruction

7/ 2 tests in place of VCUG:
1) Contrast enhanced voiding ultrasound [CeVUS]:
✅:
🔸No radiation
🔸Void in upright position
❌:
🔺Urethral catheterization
🔺May miss grade 1 VUR
👉: pubmed.ncbi.nlm.nih.gov/29181582/

8/ Another test in place of VCUG is:
2) Radionuclide cystogram (RNC):

Pros: Reduced radiation exposure
Cons: Less anatomic detail, not get precise grading

⚡️Used for follow-up evaluation of reflux rather than new diagnosis

9/ Functional nuclear imaging can be used in VUR; 2 tests are available

A. DMSA Scan
🔳Technetium-99m DMSA is a radioisotope injected IV
⚡️Size, shape and differential function
⚡️Detects renal scarring

10/ Another functional study :
B. MAG3:
🔺 👀 for UPJ or UVJ obstruction
🔺 Cannot detect VUR
🔺gives differential function

11/ Lets get into how to treat reflux! What is the role of antibiotic prophylaxis in VUR?

12/ Answer: A. Reduces UTI incidence …at the cost of antibiotic resistance.
Abx prophylaxis does not prevent scarring.
#RIVUR trial
nejm.org/doi/full/10.10…

13/ Non-surgical treatment of VUR includes
- Waitful watching for spontaneous resolution
- Address bowel and bladder dysfunction

14/ Surgical Rx of VUR includes
🔹Deflux: sub-ureteric transurethral injection of a copolymer
🔹Ureteral re-implantation [open or robotic]

Read more about surgical techniques in detail here! PMID: 16716788

15/ To wrap this tweetorial- what determines the prognosis for VUR?

16/ Answer: Degree of renal scarring
⚡️Scars ⬆️⬆️ risk of hypertension and CKD
⚡️ Long term follow up is key!!
⚡️ Monitor for HTN, renal function and proteinuria

17/ For a case-based clinical discussion on vesicoureteric reflux with a radiologist and an expert, login to @ASPNeph website, June 2022 webinar #Membereducation

18/ Special thanks to #ASPNFOAM group for helping me write my first tweetorial! @drM_sudha @nefron1310 @Swasthithinks

@drM_sudha @nefron1310 @SwastiThinks