Audit of Micturating Cystourethrograms performed over 1 year in a Children's Hospital

Transcription

1 Audit of Micturating Cystourethrograms performed over 1 year in a Children's Hospital Poster No.: C-1773 Congress: ECR 2012 Type: Scientific Exhibit Authors: K. Lyons, J. Sorensen, E. L. Twomey, V. Donoghue, M Riordan, S. Ryan ; Dublin/IE, Dublin 1/IE Keywords: Infection, Congenital, Diagnostic procedure, Cystography / Uretrography, Audit and standards, Ultrasound, Fluoroscopy, Urinary Tract / Bladder, Paediatric, Kidney DOI: /ecr2012/C-1773 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Purpose There has been significant controversy recently regarding the investigation and management of urinary tract infections (UTIs) in children [1]. The protocol in our institution up to now has been that all UTIs in children under the age of 12 months have been investigated with a renal ultrasound, followed by a micturating cystourethrogram (MCUG) to evaluate for the presence of vesicoureteric reflux (VUR). Younger children are more prone to VUR because of the relative shortness of the submucosal ureters [2]. The severity of VUR is graded between I-V Table 1 on page 4 [3]. Table 1: Lebowitz et al. (1985) International System of Radiographic Grading of Vesicoureteric Reflux. Pediatr Radiol. 15(2):105-9 References: Radiology, Beaumont Hospital - Dublin/IE The prevalence of VUR in children investigated for a first UTI is approximately 20-40% [1]. Overall, children with VUR are more likely to get UTIs, and are at an increased risk of developing renal damage. The majority of Grade I-II VUR resolves spontaneously. Grade III-V is considered more clinically significant and is less likely to spontaneously resolve [4]. Most studies do indicate an association between renal parenchymal defects and grade of VUR [5]. Traditionally, all children with VUR have been given antibiotic prophylaxis, with the aim to keep them free from infections until the VUR resolved or until the risk of developing new renal parenchymal defects diminished. Page 2 of 18

3 Recent studies have questioned this approach. During the past decade, with the advent of prenatal diagnosis of kidney malformations, it has become clear that a significant proportion of the kidney damage seen in relation to VUR is congenital and part of the same malformation as the VUR [6]. Studies have not shown that antibiotic prophylaxis decreases scarring in children with all grades of VUR, although a recent RCT did find that girls aged months with Grade III-IV reflux were significantly less likely to develop new renal damage in a previously unscarred area when on antibiotic prophylaxis [7,8]. The diagnosis of VUR by MCUG requires catheterisation which is unpleasant for children and their parents, carries iatrogenic risks and exposes the child to radiation. It has been postulated that significant (> Grade III-V) reflux will likely be detected on ultrasound. NICE guidelines were published in 2007 regarding diagnosis of paediatric UTIs. [9] Subsequently, Irish guidelines were proposed this year recommending only performing a MCUG on children <6 months with atypical/ recurrent UTIs/ abnormal ultrasound. We decided to audit the results of all MCUGs performed over a yearlong period and to correlate them with ultrasound findings prior to institution of these guidelines. Page 3 of 18

4 Images for this section: Table 1: Lebowitz et al. (1985) International System of Radiographic Grading of Vesicoureteric Reflux. Pediatr Radiol. 15(2):105-9 Radiology, Beaumont Hospital - Dublin/IE Page 4 of 18

5 Methods and Materials An audit of all MCUGs (n=123) performed between 1 September 2010 and 1 September 2011 was conducted. Correlation was made with ultrasound imaging. 106/123 studies were performed for the investigation of UTIs. Catheterization failed in 1/106 cases, and ultrasound was not available in 1/106 cases so 104 studies were reviewed. Fig. 1: Inclusion and exclusion criteria References: Radiology, Beaumont Hospital - Dublin/IE A virtual change in protocol was applied applying the proposed new guidelines and a virtual re-audit was conducted. The findings were compared. Page 5 of 18

6 Images for this section: Fig. 1: Inclusion and exclusion criteria Radiology, Beaumont Hospital - Dublin/IE Page 6 of 18

7 Results The median age at UTI was 18 weeks (range 0-381). 67(64%) patients were boys. 16 (15%) of children were aged over 12 months. 66 (63%) MCUGs were normal and 39 studies were abnormal (37%). 38 studies (36%) demonstrated VUR. 20/69 (29%) babies aged less than 6 months old and 9/19 (46%) aged between 6 months and one year had reflux on MCUG. Fig. 2: MCUG Results References: Radiology, Beaumont Hospital - Dublin/IE The sensitivity and specificity of ultrasound in the detection of VUR were 21% and 74% respectively. The majority of babies aged less than 12 months with VUR had normal ultrasounds and did not have any atypical features to their UTIs. Page 7 of 18

8 Fig. 3: MCUGs positive for VUR References: Radiology, Beaumont Hospital - Dublin/IE Only 29% of babies aged less than 6 months with more severe (Grade III-V) VUR had abnormal ultrasounds/ atypical features. Page 8 of 18

9 Fig. 4: MCUGs positive for Grade III-V Reflux References: Radiology, Beaumont Hospital - Dublin/IE Applying the current protocol to children aged less than one year, 88 MCUGs were done to detect 29 refluxers, of which 10 cases were Grade III-V. If the proposed new protocol were used and only those under 6 months with an abnormal ultrasound/ atypical features/ recurrent infection had an MCUG then 19 MCUGs would be done but only 5/29 refluxers would be identified. Only 2/10 cases of Grade III-V reflux would be detected. Page 9 of 18

10 Fig. 5: Virtual Re-audit: Applying the proposed new guidelines References: Radiology, Beaumont Hospital - Dublin/IE If only infants aged less than 6 months had MCUGs, then 69 MCUGs would be done but only 20/29 reflux cases would be identified (7/10 Grade III-V). If all babies aged less than 12 months with an abnormal ultrasound/ atypical features/ recurrent infection had an MCUG, then 29 MCUGs would be done but only 10/29 of the refluxers would be identified (4/10 Grade III-V). Below are two examples of babies that had normal renal ultrasounds with significant VUR on MCUG. Page 10 of 18

11 Fig. 6: Renal ultrasound and MCUG of an 18 week old boy with his first UTI. The ultrasound was normal, as shown, and the MCUG demonstrated Grade V VUR with parenchymal staining. References: Radiology, Beaumont Hospital - Dublin/IE Fig. 7: A 13 week old boy who presented with his first UTI had a normal renal ultrasound (as depicted) and Grade IV VUR on MCUG. References: Radiology, Beaumont Hospital - Dublin/IE Page 11 of 18

12 Images for this section: Fig. 2: MCUG Results Radiology, Beaumont Hospital - Dublin/IE Page 12 of 18

13 Fig. 3: MCUGs positive for VUR Radiology, Beaumont Hospital - Dublin/IE Page 13 of 18

14 Fig. 4: MCUGs positive for Grade III-V Reflux Radiology, Beaumont Hospital - Dublin/IE Fig. 5: Virtual Re-audit: Applying the proposed new guidelines Radiology, Beaumont Hospital - Dublin/IE Page 14 of 18

15 Fig. 6: Renal ultrasound and MCUG of an 18 week old boy with his first UTI. The ultrasound was normal, as shown, and the MCUG demonstrated Grade V VUR with parenchymal staining. Radiology, Beaumont Hospital - Dublin/IE Fig. 7: A 13 week old boy who presented with his first UTI had a normal renal ultrasound (as depicted) and Grade IV VUR on MCUG. Radiology, Beaumont Hospital - Dublin/IE Page 15 of 18

16 Conclusion The incidence of VUR in our population is in keeping with other studies. Ultrasound is a poor predictor of the presence of VUR in babies aged less than 12months, regardless of grade. Implementation of the new guidelines would potentially result in 3 cases of Grade IV-V VUR and 3 cases of Grade III VUR being missed in babies aged less than age of 12 months. Available data suggests that early identification and referral to Pediatric Nephrology services is beneficial in these cases. There is strong evidence to suggest that antibiotic prophylaxis decreases the incidence of renal scarring in Grade III-V VUR. Based on these findings, we do not support the reduction in age for MCUG to <6 months and suggest that ultrasound findings are not used as part of the indication for MCUG. As a consequence of this study, the protocol is being revised to include more clinical indications for MCUG on the basis of a child's risk rather than on ultrasound findings. Page 16 of 18

17 References Mathews et al. (2009) Controversies in the management of vesicoureteral reflux: The rationale for the RIVUR study. J Pediatr Urol. 5(5): Hansson et al. Urinary tract infections in children below two years of age: A quality assurance project in Sweden. Acta Paediatrica 1999;88(3): Lebowitz et al. (1985) International System of Radiographic Grading of Vesicoureteric Reflux. Pediatr Radiol. 15(2): Smellie et al. Medical versus surgical treatment in children with severe bilateral vesicoureteric reflux and bilateral nephropathy: A randomised trial. Lancet 2001;357(9265): Jacobson et al. Long-term prognosis of post-infectious renal scarring in relation to radiological findings in childhood - a 27-year follow-up. Pediatric Nephrology 1992;6(1): Ylinen et al. Risk of renal scarring in vesicoureteral reflux detected either antenatally or during the neonatal period. Urology 2003;61(6): Gordon et al. Primary vesicoureteric reflux as a predictor of renal damage in children hospitalized with urinary tract infection: A systematic review and meta-analysis. Journal of the American Society of Nephrology 2003;14(3): Brandstrom et al. (2010) The Swedish Reflux Trial in Children: IV Renal Damage. J Urol. 184(1): National Institute for Health and Clinical Excellence. Urinary Tract Infection in Children, London: NICE 2007 ( Page 17 of 18

18 Personal Information Karen Lyons, MB, BCh, BAO, BMedSc Department of Paediatric Radiology, Children's University Hospital, Temple Street, Dublin 1, Ireland. Page 18 of 18