BERKELEY, CA (UroToday Inc.) - Vesicoureteral reflux is diagnosed in 20% to 40% of children with a first febrile urinary tract infection. Voiding cystourethrography is recommended for the evaluation of febrile urinary tract infection in children. However, for 60% to 80% of the children, the voiding cystourethrography is usually normal. Moreover, it is traumatizing, painful, and expensive coupled with repeated radiation exposure in long term follow up. Leroy et al analyzed the relationship between procalcitonin and vesicoureteral reflux. Procalcitonin has been shown to be associated with severe pyelonephritis and renal scars, which are may correlate to vesicoureteral reflux.

They performed a retrospective hospital-based cohort study included all children who were 1 month to 4 years of age and had a first febrile urinary tract infection. 136 patients were found and 25% had vesicoureteral reflux. The median procalcitonin concentration was significantly higher in children with reflux than in those without (1.2 vs 0.6 ng/mL). High procalcitonin ( 0.5 ng/mL) was associated with reflux (odds ratio [OR]: 4.6; 95% confidence interval [CI]: 1.6-16.2). After logistic-regression adjustment for all potential confounders, the association remained significant (OR: 4.9; 95% CI: 1.7-14.0). The relationship was stronger for high-grade ( 3) reflux (OR: 8.7; 95% CI: 1.2-382) than low-grade reflux (OR: 3.6; 95% CI: 1.1-15.3). High procalcitonin sensitivities were 85% (95% CI: 70-94) and 92% (95% CI: 65-99) for all-grade and high-grade reflux, respectively, with 44% specificity (95% CI: 35-54).

The group concluded that a high procalcitonin is a strong and independent predictor of vesicoureteral reflux and could be used to identify low-risk patients to avoid unnecessary voiding cystourethrography. One must take into consideration that urinary tract infections in children are multifactorial in nature. Reflux may play a role, but other factors such as virulence of the bacteria and immunity in the bladder must also be taken into consideration. Although procalcitonin appears promising, a prospective randomized trial to correlate the reflux, infections, and renal scarring must be undertaken. It seems that dysplasia most likely correlates with those children who do poorly with reflux, which are the minority of the group. We must first be able to distinguish renal scarring from dysplasia and see if treatment makes a clinical difference. Without a biopsy specimen, that is difficult and hopefully imaging modalities such as MRI may play a role in the future.

Pediatrics, 115(6): 706-709, June 2005