Childhood Kidney Diseases

Korean Society of Pediatric Nephrology (대한소아신장학회)
권호 표지
DOI QR코드

DOI QR Code

A Case with Abrupt Progression of Renal Scarring or Abrupt Deterioration of Renal Function Associated with Vesicoureteral Reflux

고등급의 방광요관역류가 있는 환아에서 급격히 진행된 신반흔

  • Kim, Moon-Kyu (Department of Pediatrics, CHA Bundang Medical Center, CHA University) ;
  • Park, Sung-Eun (Department of Pediatrics, CHA Bundang Medical Center, CHA University) ;
  • Lee, Jun-Ho (Department of Pediatrics, CHA Bundang Medical Center, CHA University)
  • 김문규 (차의과학대학교 분당차병원 소아청소년과) ;
  • 박성은 (차의과학대학교 분당차병원 소아청소년과) ;
  • 이준호 (차의과학대학교 분당차병원 소아청소년과)
  • Received : 2011.07.29
  • Accepted : 2011.09.01
  • Published : 2011.10.31
Download PDF
⟨ Previous Next ⟩

Abstract

Abrupt progression of renal scarring associated with vesicoureteral reflux (VUR) is rare in males over 2 years old of age. We report a 5 year old boy with sustained unilateral high grade VUR who experienced abrupt progression of renal scarring; he had a relative renal radionuclide uptake of 38% at 2 years of age that dropped to 8% after three years. Per his parent's wishes, he took prophylactic antibiotics for 25 months after his first febrile urinary tract infection (UTI) at 4 months old without surgical management. One episode of recurrent breakthrough infection occurred at the age of 2 years. This observation reminds us that a recommending surgical management for sustained high grade VUR associated with renal scarring might be needed. Close follow up of DMSA for renal scanning, and long term follow up of patients after the first febrile UTI are important.

영아때 방광요관역류 환아로 진단된 남아중 2세가 넘어 후천적으로 신반흔이 급격히 악화되는 경우는 드물다. 본 증례는 생후 4개월 때 첫 열성 요로감염으로 입원하여, 왼쪽 5등급 방광요관역류로 진단되었고, 부모가 수술을 원치 않아 2년간 예방적 항생제 요법만 시행받았다. 생후 29개월 때 열성 요로감염이 한 차례 재발하였고, 이후 3년간 추적관찰되지 않았다. 이 후, 5세 때 본원을 방문하여 신장초음파, DMSA 신스캔, 배뇨성 방광요도조영술을 재시행받았다. 추적 DMSA 신스캔에서 왼쪽 신상대섭취율이 생후 2세경 38%였으나, 8%까지 떨어졌으며, 왼쪽 방광요관역류는 4등급으로 남아있었다. 현재 방광요관역류의 수술적 요법이 신기능의 예후와 관련이 없다고 알려져 있으나, 이런 증례를 볼 때, 아직은 신반흔을 동반한 고등급의 방광요관역류 환자들에게 수술적 요법을 권유하는 것이 임상의들에겐 타당하다고 볼 수 있으며, 어떤 치료요법이 선택되어지든 상관없이 첫 요로감염 이후 환자를 장기적인 추적 관찰하는 것이 중요하다고 사려된다.

Keywords

References

  1. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics 1999;103:843-52.
  2. Hodson CJ. The effects of disturbance of flow on the kidney. J Infect Dis 1969;120:54-60. https://doi.org/10.1093/infdis/120.1.54
  3. Ransley PG, Risdon RA. The renal papillae, intrarenal reflux and chronic pyelonephritis. In: Hodson CJ, Kincaid-Smith P (eds). Reflux Nephropathy. New York : Masson Publishing, 1979:126-33.
  4. Goonassekera CD, Gordon I, Dillon MJ. 15-year follow-up of reflux nephropathy by imaging. Clin Nephrol 1998;50:224-31.
  5. Swerkersson S, Jodal U, Sixt R, Stokland E, Hansson S. Relationship among vesicoureteral reflux, urinary tract infection and renal damage in children. J Urol 2007;178:647-51. https://doi.org/10.1016/j.juro.2007.04.004
  6. Saadeh SA, Mattoo TK. Managing urinary tract infections. Pediatr Nephrol DOI 10. 1007/s00467-011-1801-5, 2011
  7. Montini G, Zucchetta P, Tomasi L, Talenti E, Rigamonti W, Picco G, et al. Value of imaging studies after a first febrile urinary tract infection in young children: data from Italian renal infection study 1. Pediatrics 2009;123:e239-46. https://doi.org/10.1542/peds.2008-1003
  8. Wennerstrom M, Hansson S, Jodal U, Stokland E. Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr 2000;136:30-4. https://doi.org/10.1016/S0022-3476(00)90045-3
  9. Jakobsson B, Berg U, Swensson L. Renal scarring after acute pyelonephritis. Arch Dis Child 1994;70:111-5. https://doi.org/10.1136/adc.70.2.111
  10. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics 2010;126:1084-91. https://doi.org/10.1542/peds.2010-0685
  11. Martinell J, Hansson S, Claesson I, Jacobsson B, Lidin-Janson G, Jodal U. Detection of urographic scars in girls with pyelonephritis followed for 13-38 years. Pediatr Nephrol 2000;14:1006-10. https://doi.org/10.1007/s004670050063
  12. Olbing H, Smellie JM, Jodal U, Lax H. New renal scars in children with severe VUR: a 10-year study of randomized treatment. Pediatr Nephrol 2003;1128-31.
  13. Cendron M. Reflux nephropathy. J Pediatr Urol 2008;4:414-21. https://doi.org/10.1016/j.jpurol.2008.04.009
  14. Haszon I, Friedman AL, Papp F, Bereczki C, Baji S, Bodroqi T, et al. ACE gene polymorphism and renal scarring in primary vesicoureteric reflux. Pediatr Nephrol 2002;17:1027-31. https://doi.org/10.1007/s00467-002-0968-1
  15. Ransley PG, Risdon RA, Godley ML. High pressure sterile reflux and renal scarring: an experimental study in the pig and minipig. In: Hodson CJ, Heptinstall RH, Winberg J (eds) Contributions to nephrology, vol 39, Karger, Basel, 1984:164-8.
  16. Ransley PG, Risdon RA. Reflux and renal scarring. Br J Radiol [Suppl] 1978;14:1-35.