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Research Article| Volume 17, ISSUE 2, P208.e1-208.e5, April 2021

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The additive impact of the distal ureteral diameter ratio in predicting early breakthrough urinary tract infections in children with vesicoureteral reflux

Published:January 11, 2021DOI:https://doi.org/10.1016/j.jpurol.2021.01.003

      Summary

      Introduction

      Many factors influence patient and provider decisions to surgically correct vesicoureteral reflux (VUR), including risk of breakthrough febrile urinary tract infections and likelihood of spontaneous resolution. Ureteral diameter ratio has been shown in several studies to be more predictive than reflux grade with regard to breakthrough urinary tract infection (UTI). We developed and investigated the accuracy of a computational model for predicating febrile breakthrough urinary tract infection within 13 months of starting prophylactic antibiotics in children with VUR.

      Objective

      The aim of this study was to validate a model for evaluating the impact of distal ureteral diameter ratio (UDR) in predicting early breakthrough urinary tract infections in children with VUR.

      Study design

      Following a retrospective review, we recorded patient demographics, presenting symptoms, VUR grade, laterality, VUR during filling or voiding, initial bladder volume at the onset of VUR, ureteral duplication, voiding dysfunction, distal ureteral diameter ratio, and number of UTIs prior to VUR diagnosis. NeUROn++, a set of C++ programs, was used to model each data set using logistic regression and neural networks with different architectures.

      Results

      After exclusions, 136 children (93 girls and 43 boys) diagnosed with primary VUR had detailed VCUG and UDR data available. Fourteen children (10.3%) experienced breakthrough febrile UTI events within 13 months of VUR diagnosis. There was a significant association with UDR and breakthrough UTI (p = 0.008). Various computational prediction models for the outcome of breakthrough UTI were developed and evaluated. The computational model that fit best was a model using all variables with an ROC of 0.802.

      Discussion and conclusions

      Clinicians and parents often opt for intervention based on likelihood of spontaneous resolution of VUR as well as clinical course, thereby placing an emphasis on the ability to predict likelihood of breakthrough UTI infections. Our statistical analysis and prediction models further confirm UDR as an important variable predictive of breakthrough UTIs within the first 13 months of beginning prophylactic antibiotics. Furthermore, we developed a neural network model incorporating UDR and grade with an ability to yield the greatest accuracy of any breakthrough UTI predictive calculator to date at 80%.

      Keywords

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      References

        • Stull T.L.
        • LiPuma J.J.
        Epidemiology and natural history of urinary tract infections in children.
        Med Clin. 1991; 75: 287-297
        • Hoberman A.
        • Chao H.P.
        • Keller D.M.
        • Hickey R.
        • Davis H.W.
        • Ellis D.
        Prevalence of urinary tract infection in febrile infants.
        J Pediatr. 1993; 123: 17-23
        • Skoog S.J.
        • Peters C.A.
        • Arant Jr., B.S.
        • Copp H.L.
        • Elder J.S.
        • Hudson R.G.
        • et al.
        Pediatric vesicoureteral reflux guidelines panel summary report: clinical practice guidelines for screening siblings of children with vesicoureteral reflux and neonates/infants with prenatal hydronephrosis.
        J Urol. 2010; 184: 1145-1151
        • Lin K.Y.
        • Chiu N.T.
        • Chen M.J.
        • Lai C.H.
        • Huang J.J.
        • Wang Y.T.
        • et al.
        Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection.
        Pediatr Nephrol. 2003; 18: 362-365
        • Cooper C.S.
        Individualizing management of vesicoureteral reflux.
        Nephro-Urol Mon. 2012; 4: 530-534
        • Arlen A.M.
        • Alexander S.E.
        • Wald M.
        • Cooper C.S.
        Computer model predicting breakthrough febrile urinary tract infection in children with primary vesicoureteral reflux.
        J Pediatr Urol. 2016; 12 (288.e1-.e5)
        • MacNeily A.E.
        Pediatric urinary tract infections: current controversies.
        Can J Urol. 2001; 8: 18-23
        • Greenfield S.P.
        • Chesney R.W.
        • Carpenter M.
        • Moxey-Mims M.
        • Nyberg L.
        • Hoberman A.
        • et al.
        Vesicoureteral reflux: the RIVUR study and the way forward.
        J Urol. 2008; 179: 405-407
        • Swanton A.R.
        • Arlen A.M.
        • Alexander S.E.
        • Kieran K.
        • Storm D.W.
        • Cooper C.S.
        Inter-rater reliability of distal ureteral diameter ratio compared to grade of VUR.
        J Pediatr Urol. 2017; 13 (207.e1-.e5)
        • Cooper C.S.
        • Alexander S.E.
        • Kieran K.
        • Storm D.W.
        Utility of the distal ureteral diameter on VCUG for grading VUR.
        J Pediatr Urol. 2015; 11 (183.e1-6)
        • Arlen A.M.
        • Kirsch A.J.
        • Leong T.
        • Cooper C.S.
        Validation of the ureteral diameter ratio for predicting early spontaneous resolution of primary vesicoureteral reflux.
        J Pediatr Urol. 2017; 13 (383.e1-.e6)
        • Payza A.D.
        • Hoşgör M.
        • Serdaroğlu E.
        • Sencan A.
        Can distal ureteral diameter measurement predict primary vesicoureteral reflux clinical outcome and success of endoscopic injection?.
        J Pediatr Urol. 2019; 15 (515.e1-.e8)
        • Lebowitz R.L.
        • Olbing H.
        • Parkkulainen K.V.
        • Smellie J.M.
        • Tamminen-Möbius T.E.
        International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children.
        Pediatr Radiol. 1985; 15: 105-109
        • Carpenter M.A.
        • Hoberman A.
        • Mattoo T.K.
        • Mathews R.
        • Keren R.
        • Chesney R.W.
        • et al.
        The RIVUR trial: profile and baseline clinical associations of children with vesicoureteral reflux.
        Pediatrics. 2013; 132: e34-45
        • Cooper C.S.
        • Birusingh K.K.
        • Austin J.C.
        • Knudson M.J.
        • Brophy P.D.
        Distal ureteral diameter measurement objectively predicts vesicoureteral reflux outcome.
        J Pediatr Urol. 2013; 9: 99-103
        • Arlen A.M.
        • Leong T.
        • Guidos P.J.
        • Alexander S.E.
        • Cooper C.S.
        Distal ureteral diameter ratio is predictive of breakthrough febrile urinary tract infection.
        J Urol. 2017; 198: 1418-1423
        • Arlen A.M.
        • Leong T.
        • Wu C.Q.
        • Traore E.J.
        • Cooper C.S.
        • Kirsch A.J.
        Predicting breakthrough urinary tract infection: comparative analysis of vesicoureteral reflux index, grade and ureteral diameter ratio.
        J Urol. 2020; 204: 572-577
      1. Antimicrobial prophylaxis for children with vesicoureteral reflux.
        N Engl J Med. 2014; 370: 2367-2376
        • Stein R.
        • Dogan H.S.
        • Hoebeke P.
        • Kočvara R.
        • Nijman R.J.
        • Radmayr C.
        • et al.
        Urinary tract infections in children: EAU/ESPU guidelines.
        Eur Urol. 2015; 67: 546-558
        • Roberts K.B.
        Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.
        Pediatrics. 2011; 128: 595-610