Urethral Discharge as A Novel Manifestation of Urinary Tract Infection in Children ≤24 Months Old

Background: Children with urinary tract infections (UTIs) are prone to kidney scarring if they are not treated promptly; however, ambiguous symptoms before fever onset makes the early detection of UTIs difficult. Our study aimed to identify urethral discharge as an early manifestation in children with UTI. Methods: This study enrolled 678 children younger than 24 months with paired urinalysis and culture performed between 2015 and 2021; 544 children were diagnosed with UTIs. Clinical symptoms, urinalysis, and paired urine culture results were compared. Results: Urethral discharge was observed in 5.1% of children with UTI and yielded a specificity of 92.5% for diagnosing UTI. Children with urethral discharge had a less severe UTI course, furthermore, nine of them received antibiotics before fever occurred and seven of them were free of fever during UTI course. Urethral discharge was associated with alkalotic urine and Klebsiella pneumonia infection.Conclusions: Urethral discharge is an early symptom in children with UTI; it may present before fever onset and help ensure prompt antibiotic intervention.Trial registration: Not applicable.

Oral steroids for reducing kidney scarring in young children with febrile urinary tract infections: the contribution of Bayesian analysis to a randomized trial not reaching its intended sample size

Background This study aimed to evaluate the effect of oral dexamethasone in reducing kidney scars in infants with a first febrile urinary tract infection (UTI). Methods Children aged between 2 and 24 months with their first presumed UTI, at high risk for kidney scarring based on procalcitonin levels (≥1 ng/mL), were randomly assigned to receive dexamethasone in addition to routine care or routine care only. Kidney scars were identified by kidney scan at 6 months after initial UTI. Projections of enrollment and follow-up completion showed that the intended sample size could not be reached before funding and time to complete the study ran out. An amendment to the protocol was approved to conduct a Bayesian analysis. Results We randomized 48 children, of whom 42 had a UTI and 18 had outcome kidney scans (instead of 128 planned). Kidney scars were found in 0/7 and 2/11 patients in the treatment and control groups respectively. The probability that dexamethasone could prevent kidney scarring was 99% in the setting of an informative prior probability distribution (which fully incorporated in the final inference the information on treatment effect provided by previous studies) and 98% in the low-informative scenario (which discounted the prior literature information by 50%). The probabilities that dexamethasone could reduce kidney scar formation by up to 20% were 61% and 53% in the informative and low-informative scenario, respectively. Conclusions Dexamethasone is highly likely to reduce kidney scarring, with a more than 50% probability to reduce kidney scars by up to 20%. Trial registration number EudraCT number: 2013-000388-10; registered in 2013 (prospectively registered) Graphical Abstract

Urinary Tract Infections in Children

Urinary tract infections are one of the most common bacterial infections in children. It may cause severe complications in both acute and chronic periods. Escherichia coli is the most common microorganism that causes urinary tract infections in children. Recurrent urinary tract infection is a significant risk factor for kidney scarring. Early diagnosis and appropriate treatment of urinary tract infection, as well as determination of risk factors and prevention of recurrent urinary tract infections, should be the most critical goals in managing children with urinary tract infections.

Adjuvant corticosteroids for prevention of kidney scarring in children with acute pyelonephritis: a systematic review and meta-analysis

BackgroundAcute pyelonephritis in children may result in permanent kidney scarring that is primarily caused by inflammation during acute infection. Antibiotic therapy alone is not enough to significantly reduce kidney scarring, and adjuvant corticosteroid therapy has shown a significant reduction in inflammatory cytokines in urine prompting its evaluation in randomised controlled trials. A few clinical trials showed a trend towards a reduction in renal scarring but did not have an adequate sample size to show a significant effect. Therefore, we planned to synthesise the available evidence on the role of corticosteroids as adjuvant therapy in reducing kidney scarring.ObjectiveTo assess the efficacy and safety of adjuvant corticosteroid therapy for the prevention of kidney scarring in children with acute pyelonephritis.DesignSystematic review and meta-analysis.SettingCommunity-acquired febrile urinary tract infections.PatientsChildren (less than 18 years) with acute pyelonephritis.InterventionAdjuvant corticosteroid therapy (along with antibiotic treatment).Main outcome measuresPrimary: efficacy in preventing kidney scarring; secondary: serious adverse events associated with corticosteroid therapy.ResultsThree randomised trials (529 children) were included. Corticosteroids are effective in lowering the risk of kidney scarring as compared with placebo (risk ratio (RR): 0.57; 95% CI 0.36 to 0.90). No significant increase risk of bacteraemia (RR: 1.38; 95% CI 0.23 to 8.23) and hospitalisation (RR: 0.87; 95% CI 0.3 to 2.55) was observed in corticosteroid group.ConclusionModerate quality evidence suggests that short duration ‘adjuvant corticosteroid therapy’ along with routine antibiotic therapy in acute febrile urinary tract infection significantly reduces the risk of kidney scarring without any significant adverse effects.

Resistive Index (RI) in Febrile Urinary Tract Infection: New Predictive Value

Background and Objective: Urinary tract infection is the most common bacterial infection in the pediatric population.The upper urinary tract infection involves the kidney parenchyma and may cause scarring and permanent damage that will proceed to cause hypertension and decreased kidney function. Almost third of cases will relapse following the first infection in one year. There are different imaging techniques that can help to detect children at risk for future infections, kidney scarring or other systemic complications. The Ultrasonography of bladder and kidneys: is a relatively cheap, non-invasive and fast test that enables to find children with anatomical anomalies that can be corrected to avoid future infections or complications. Also, this test does not pose the risk of radiation exposure. Voiding cystourethrogram: is the test of choice to establish the presence of vesicoureteral reflux that is a major risk factor for future infections and scaring. This test has a radiation exposure risk, it is invasive and relatively complex to perform. DMSA scintigraphy test: may be performed to determine acute pyelonephritis or to investigate kidney scarring. This test has a greater radiation exposure risk. But it cannot distinguish between dysplasia of a kidney or scarring. With the development and improvement of the imaging capabilities of Doppler ultrasonography, we can measure the Resistive Index, which is a sonographic value to assess the kidney function. The normal value of the resistive index is 0.6 and the normal upper limit is 0.7. The increase in this value is related to kidney artery stenosis, extreme hypertension, infants, and intrinsic kidney disease. Importance: In this work, we want to measure if the Resistive Index can predict kidney scarring. Participants: We followed after 71 cases of kids from 0 to 11 years old that was admitted to our hospital Baruch Padeh Medical Center, Poriya, in the diagnosis of Urinary tract infection.71 children participated in the full evaluation. 56 children were under 2 years of age, 8 were aged 2 to 4 years, and 7 were over 5 years or older; 18 were males and 53 were females. Design: The diagnosis was made on the base of clinical presentation, laboratory blood analysis, urinary analysis, and urinary cultures. We measured the Resistive index in all of these patients. And they did the ordinary US of kidney parenchyma, the DMSA study and a cystography by the accepted protocols of our department. Settings: All patients underwent Doppler within 72 hours of hospitalization. Before our conclusions, we divided the patients in the study by their age. Main outcome: In the first group under 2 years old, we found a moderate correlation between the RI and DMSA study. And there was a strong correlation between RI and cystography .In the second group above 4 years, we found a strong correlation between RI both to DMSA and cystography. Results: In all the age groups we examined there is a strong correlation between RI and positive findings in cystography to find reflux.

Chronic Kidney Disease: The Complex History of the Organization of Long-Term Care and Bioethics. Why Now, More Than Ever, Action is Needed

Chronic kidney disease (CKD) has been redefined in the new millennium as any alteration of kidney morphology, function, blood, or urine composition lasting for at least 3 months. This broad definition also encompasses diseases or conditions that are associated with normal kidney function, such as a kidney scarring from an acute pyelonephritis episode or a single kidney, as a result of kidney donation. CKD is a relevant public health problem. According to the 2015 Global Burden of Disease Study, it was the 12th leading cause of death, leading to 1.1 million deaths, worldwide, each year. The role of CKD as a cause of death is evident where renal replacement therapy (RRT) is not available, however, its role in increasing death risk is not easily calculated. RRT consumes about 3–5% of the global healthcare budget where dialysis is available without restrictions. While the prevalence of CKD is increasing overall as lifespans extend, being linked to diabetes, hypertension, obesity, and atherosclerosis, CKD is at least partly preventable and its effects may be at least partly counterbalanced by early and appropriate care. We will welcome papers on all aspects of CKD, including organization, cost, and models of care. Papers from developing countries will be particularly welcomed.