Urinary Tract Infection Report Writing – Statistics Assignment Help

Assignment Task

Task

Title: Urinary Tract Infection as a predictor for progression of renal scar in patients with primary vesicoureteric reflux: A prospective observational study.

Abstract: 

Primary vesicoureteric reflux is the retrograde flow of urine from the bladder into the ureters and is a common cause of chronic renal failure in children. The refluxing urine has a deleterious effect on the developing kidneys which are detected as scars of radionuclide imaging.

Aim : 

To determine whether urinary tract infection associated with primary vesicoureteric reflux causes the occurrence of new renal scars or progression of existing renal scars.

Materials and Methods All patients were diagnosed to have primary VUR on voiding cystourethrogram and were advised to take continuous antibiotic prophylaxis upon diagnosis. A baseline dimercaptosuccinic acid scan was done to document the presence of renal scars. Patients were followed up prospectively for a period of 3 to 5 years. Occurrence and number of breakthrough UTIs were recorded. A Follow-up DMSA scan was done to document and progression in the grade of scarring of the rental units.

Introduction: 

Vesicoureteric reflux (VUR) includes the abnormality of retrograde flow of urine from the bladder to the ureters and is the fourth commonest cause of end-stage renal disease in children. [1]. The refluxing infected urine causes loss of nephrons due to pyelonephritis and subsequent reflux nephropathy. Primary VUR is caused by abnormal insertion of the ureter into the bladder, which obviates the flap valve mechanism at the vesicoureteric junction. This resolves with age as bladder growth and remodeling occurs. Hence, treatment aims at maintaining the urine sterile which prevents pyelonephritis till the child grows, failing which other invasive methods are carried out.

The assumption that “sterile reflux” (reflux without infection) is benign has been challenged by several authors. The ongoing renal scarring may be a consequence of the hydrodynamic so-called “water hammer” effect of the retrograde flow of sterile urine. [6] Urinary tract infection (UTI) without VUR demonstrated to have renal scarring. [7] Renal scarring also depends upon age and genetic predisposition. Younger children develop renal scars even after a single episode of UTI. [7] Asymptomatic siblings of VUR patients have a different predilection for renal scarring [9]. Children with antenatally detected hydronephrosis have been found to have renal scars on early postnatal evaluations. The parenchymal damage is more severe in patients with high-grade reflux suggesting the effect of reflux.

The majority of studies justify the use of uroprophylaxis in children with VUR. Queries on the incidence of renal damage and its progression in the absence of UTI are still unanswered. The present study aims to determine the occurrence and progression of scars on DMSA scans in patients with primary VUR with and without UTI.

Materials and Methods:

The study was approved by the institutional ethics committee and registered with the Clinical Trial Registry of India. All patients attending the pediatric nephrology clinic (NUC) of a tertiary care teaching hospital with a diagnosis of primary VUR were included in the study. Consent for participation in the study was obtained from the guardians. All patients included in the study were followed for three years from the date of enrollment. Patients lost to follow-up and with incomplete data were excluded from the study.

Retrospective data was collected from the database maintained in the NUC register. The clinical variables collected from the retrospective database were; age at diagnosis, gender, history of UTI, number of UTI episodes, grade of VUR at diagnosis, and grade of renal scar at presentation. Prospectively patients were followed to look for any change in the scarring, and number of UTI episodes.

Inclusion of patients with a diagnosis of primary VUR was considered in the absence of associated neuromuscular or obstructive phenomenon to the lower urinary tract. Patients were diagnosed based on standard voiding cystourethrography (VCUG). Grading of reflux was done from grade 1 through grade 5 as per the International Reflux Study Committee. [9]. All patients diagnosed to have VUR were continued with chemoprophylaxis and were followed up in the NUC. Upon diagnosis to have VUR, patients underwent a Dimercaptosuccinuic Acid nuclear scan (DMSA) (after an infection-free period of 6 weeks) to document the baseline status of the renal function. Renal units were evaluated for the presence of scars [71] and the scars were graded according to Goldraich et al [72]. RUU with scar grade 5 at presentation was also excluded from the study.

Patients were advised to attend the NUC every 3 months and routine urinalysis was performed on all patients. Any patient developing a symptom of UTI (fever, lower urinary symptoms, poor feeding, abdominal pain, gastrointestinal symptoms, etc.) was also advised to attend the NUC apart from the routine 3 monthly visits. Urine was collected by a midstream void in older children and by a plastic bag attached to the perineum in nontoilet trained patients. The following criteria were used for the diagnosis of UTI.

A. More than 5 WBC per high power field in a centrifuged specimen

And

B. Presence of more than 105 colony-forming units on culture.

All patients underwent DMSA scanning and grading of scars biennially. [9,72]. Patients developing Uti were advised for a DMSA scan after 6 weeks of control of UTIs. Patients were advised for reimplantation if there was any deterioration of scar status. For patients having a long follow-up and more than two DMSA scans during the follow-up, the first scan and the last scan were taken into consideration for the progression of scars. The exposure variables were defined as age, sex, antenatal diagnosis, grade of VUR at diagnosis, and presence of UTI (Single or multiple). The outcome was defined as the appearance of a new scar or progress in the grade of the scar. A comparison was performed for each renoureteric unit (RUU).

All data were entered into a Microsoft Excel spreadsheet. The summary measure of quantitative data was expressed as mean ± SD or median ± interquartile range depending upon distribution. The qualitative data were summarized using percentages and proportions. A comparison was done using the chi-square or Fisher exact test. Correlation analysis was done for exposure to UTIs and the progression of scars. A predictive value for the number of UTIs to the progression of the scar was determined if any. A P-value less than 0.05 was considered significant.

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