Diagnostic Accuracy of Prenatal Ultrasound for Predicting Renal Bladder Ultrasound Abnormalities after First Urinary Tract Infection in Children: A Systematic Review and Meta-analysis
Kathryn Trandem, MD PhD, Evans Whitaker, MD MLIS, Hillary Copp, MD MS.
University of California School of Medicine, San Francisco, San Francisco, CA, USA.
INTRODUCTION: The American Academy of Pediatrics guidelines recommend a renal bladder ultrasound after a first febrile urinary tract infection in children 2-24 months of age. However, a systematic review or quality assessment of the literature has not been published to support this recommendation. We sought to assess the diagnostic accuracy of prenatal ultrasound compared to the post-urinary tract infection ultrasound for detection of urinary tract abnormality. We hypothesize that the diagnostic accuracy of the prenatal ultrasound is high and therefore, a post-urinary tract infection ultrasound would provide limited further diagnostic information. METHODS: English-language articles were identified by searching Medline, Embase, and the Cochrane Library. We included studies of subjects younger than 18 years with first febrile urinary tract infection who had both prenatal and post-urinary tract infection ultrasound. Data on anatomical abnormalities determined by prenatal and post-urinary tract infection ultrasound were extracted by 2 independent reviewers, from which prenatal ultrasound performance characteristics (true-positives, false-positives, false-negatives, and true-negatives) were derived. Meta-analysis of 10 studies (4438 patients) was performed by using a random effects meta-analysis to control for heterogeneity; composite estimates of negative predictive value were calculated. All analyses were performed in Stata v.15.1 (College Station, TX). RESULTS: The negative predictive values of the 10 individual studies ranged from 61% to 98%. Combining these results, an abnormal post-urinary tract infection ultrasound in a child with a previously normal prenatal ultrasound (negative predictive value) was 84% (95% CI 77-91%). Using a more stringent definition for abnormal post-urinary tract infection ultrasound (criteria that would likely prompt further studies or change the clinical management), the negative predictive value increased to 95% (95% CI 93-97%). All except 2/10 studies only included patients if they had a normal prenatal ultrasound, which restricted analysis to the calculation of negative predictive value. Significant heterogeneity limited the precision of the negative predictive value, which was attributable to variability in the timing of the prenatal and post-urinary tract infection ultrasound, the definition of urinary tract infection, and the delineation of abnormal post-urinary tract infection ultrasound. CONCLUSIONS: Based on poor quality data regarding the diagnostic accuracy of prenatal ultrasound, current American Academy of Pediatrics guidelines do not recommend utilization of prenatal ultrasound results and instead uniformly call for a post-urinary tract infection ultrasound to guide management decisions in children with first febrile urinary tract infection. The performance characteristics of prenatal ultrasound must be better delineated with additional investigation that includes attention to timing of both prenatal and post-urinary tract infection ultrasound along with the application of clinically meaningful definitions of abnormal post-urinary tract infection ultrasound. With this knowledge we may be better able to apply the results of prenatal ultrasound- a test that is already widely broadly performed- to guide clinical management and potentially reduce a significant healthcare expense with the more selective use of the post-urinary tract infection ultrasound.
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