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The Utility of Renal Sonographic Measurements as Predictors of Early Vesicoureteral Reflux (VUR) Outcomes
Ryan Albright, MPH1, M. Bridget Zimmerman, PhD2, Christopher S. Cooper, MD3.
1University of Iowa Carver College of Medicine, Iowa City, IA, USA, 2University of Iowa Department of Biostatistics, Iowa City, IA, USA, 3University of Iowa Department of Urology, Iowa City, IA, USA.
BackgroundIncreasing degrees of abnormal ureteral bud embryogenesis may result in increasing grades of VUR and renal dysgenesis and decreased VUR resolution. Renal ultrasound (US) measurements may therefore be predictive of early resolution in children with VUR. Our hypothesis is that increased renal parenchymal thickness (ParT) or medullary pyramidal thickness (PT) are associated with decreased VUR grades and increased spontaneous resolution.
MethodsRecords and imaging of 202 children ≤ 2 years of age (median age [IQR] 0.37 [0.12–1.41] years) with primary VUR and renal US within 6 months of initial voiding cystourethrogram and ≥ 2 years of follow-up were reviewed. Measurements included renal length, PT, and ParT which were compared using linear mixed models adjusted for age and sex. Logistic regression models assessed predictors of spontaneous resolution, including renal length, PT, and ParT in addition to age, sex, grade, laterality, and UTI history.
Results Within 2 years, 78 (39%) achieved spontaneous resolution, 73 (36%) underwent operative intervention, and 51 (25%) had persistent reflux. Higher grades of VUR correlated with lower mean PT and ParT (p < 0.0001). Lower grades were strongly associated with spontaneous resolution (p = 0.002 at 1 year; p < 0.0001 at 2 years). Resolution was associated with greater PT (p < 0.001), greater ParT (p = 0.004 at 1 year; p = 0.019 at 2 years), and smaller renal lengths (p < 0.001 at 1 year; p = 0.015 at 2 years). PT was the strongest independent predictor of spontaneous resolution after VUR grade (AUC 0.70 at 1 year; 0.711 at 2 years). Combining PT with renal length improved predictive accuracy (AUC 0.73), and combining PT with VUR grade and renal length achieved the highest predictive accuracy (AUC up to 0.79 at 2 years).
ConclusionsIncreased PT and ParT and decreased renal length were independent predictors of spontaneous VUR resolution. PT provided the strongest predictive value and enhanced discrimination when added to models with grade, age, gender, laterality, and presenting symptoms. The addition of these more objective sonographic measurements in multivariate models may permit more reliable predictions of early clinical outcomes and individualized patient management.
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