Commentary to model for predicting high -grade vesicoureteral reflux in young children presenting with febrile urinary tract infection

      The authors employ three well known imaging and clinical risk factors associated with vesicoureteral reflux (recurrent UTI, non-E. coli pathogen, abnormal renal and bladder ultrasound) to create a scoring system for limiting the use of a VCUG in all children who present with a febrile UTI. It is no surprise that the presence of any one of these factors alone identifies an appreciable number of children with high grade (III–V) reflux. The authors, along with the American Academy of Pediatrics and the British National Institute for Clinical Excellence, have striven to reduce the use of the VCUG and are content with missing some with reflux and renal scarring. These efforts are not without controversy. The cohort in this study has particular characteristics that affect the generalizability of the conclusions. The majority was uncircumcised males and this may explain why only 92 of 324 children with febrile UTI's had reflux. Since most were infants under the age of toilet training, bowel and bladder dysfunction could not be evaluated. A small number of children underwent DMSA scanning, so the authors are incapable of legitimately assessing the severity or clinical significance of the reflux in the remainder, independent of grade. Notably, of the small number of low grade reflux children who did undergo DMSA evaluation, 30% had scars. This is the group the authors are suggesting should not undergo a VCUG at presentation, as they argue that the consequences of reflux were “minimal.” Finally, it may be unrealistic to assume that a child with reflux who was not fully evaluated initially would reliably return for evaluation after a second or third UTI. A number of children in this cohort do not live near a center and in any case, follow up in many circumstances is often not perfect. As demonstrated by the data in this report, the use of this scoring system to withhold VCUG imaging will result in missing children with reflux and renal damage.
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