Clinical and Experimental Pediatrics

대한소아청소년과학회 (The Korean Pediatric Society)
권호 표지

일측성 방광 요관 역류 환아에서 신반흔의 발생

The Occurrence of Renal Scarring in Children with Unilateral Vesicoureteral Reflux

  • 이태호 (부산 왈레스기념 침례병원 소아과) ;
  • 손미란 (부산 왈레스기념 침례병원 소아과) ;
  • 변순옥 (부산 왈레스기념 침례병원 소아과) ;
  • 문정웅 (부산 왈레스기념 침례병원 소아과)
  • Lee, Tae Ho (Department of Pediatrics, Wallace Memorial Baptist Hospital) ;
  • Son, Mi Ran (Department of Pediatrics, Wallace Memorial Baptist Hospital) ;
  • Byun, Soon Ok (Department of Pediatrics, Wallace Memorial Baptist Hospital) ;
  • Moon, Jung Woong (Department of Pediatrics, Wallace Memorial Baptist Hospital)
  • 투고 : 2005.04.18
  • 심사 : 2005.06.23
  • 발행 : 2005.09.15
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

목 적 : 소아에서 급성 신우신염 후에 신반흔이 형성될 수 있고, 형성된 신반흔은 고혈압, 신부전을 야기 시킬 수 있다. 이러한 신반흔을 일으킬 수 있는 요인으로 대표적인 것이 방광 요관 역류의 존재였다. 그러나 계속적으로 신반흔과 방광 요관 역류가 상관이 없다는 연구 결과가 있어 이에 대한 다른 관찰이 필요하였다. 본 연구는 요로 감염 후 일측성 방광 요관 역류를 보이는 환아를 모아서 신반흔의 발생에 대하여 살펴보았다. 방 법 : 1996년 1월에서 2004년 12월까지 부산 왈레스기념 침례병원 소아과에 요로 감염으로 입원한 환아 중 VCUG를 시행하여 일측성 방광 요관 역류를 보인 35명의 환아를 대상으로 하였다. 입원초기에 ESR, CRP, 신장초음파 검사를 시행하였고 요로 배양검사 음성 후 VCUG 검사를 하였다. 4-6개월 후 DMSA 스캔을 시행하였고 신반흔 발생 유무와 나이, 성별, 발열 기간, ESR, CRP, 방광 요관 역류의 유무, 방광 요관 역류 정도에 대하여 조사하였다. 결 과 : 1) 방광 요관 역류를 보이는 35신단위에서 신반흔 발생률은 29%로 방광 요관 역류가 없는 35신단위의 3%에 비해 유의하게 높았다(P<0.05). 2) 방광 요관 역류가 있으면서 신반흔을 보인 10신단위의 역류 등급은 3등급 이상으로 역류 정도가 심할수록 신반흔 발생이 유의하게 높았다(P<0.05). 3) 나이에 따른 신반흔 발생은 1세 이하와 1세 이상으로 나누었을 때 유의한 차이를 보이지 않았다(P>0.05). 4) 치료 전 발열 기간이 길수록 신반흔 형성이 유의하게 높았다(P<0.05). 5) 진단시의 CRP, ESR 염증수치는 신반흔 형성 신단위에서 $12.8{\pm}7.3mg/dL$, $56.3{\pm}23.8mm/hr$이고 신반흔 무형성군에서 $3.9{\pm}3.8mg/dL$, $27.9{\pm}18.1mm/hr$으로 신반흔 형성군에서 유의하게 높았다(P<0.05). 결 론 : 신반흔의 형성에는 방광 요관 역류와 강한 연관성이 있었고 이외에 방광 요관 역류 정도, 발열 기간, CRP, ESR 등과 유의한 관련성을 가졌고 나이와는 무관하였다. 요로 감염 뒤의 신반흔 형성에 방광 요관 역류가 큰 영향을 미치므로 요로 감염을 앓은 환아에서 VCUG 검사를 통하여 방광 요관 역류의 유무를 알아내어 적절하게 치료함으로써 신반흔을 예방하여 고혈압, 신부전과 같은 합병증의 발생을 막는 것이 중요할 것으로 생각된다.

Purpose : We evaluated the occurrence of renal scarring in children with unilateral vesicoureteral reflux(VUR), and the relationships between renal scar formation and risk factors such as VUR, duration of fever, acute-phase reactant, age, and sex. Methods : We retrospectively analyzed the data of 35 children newly diagnosed with unilateral vesicoureteral reflux after urinary tract infection(UTI) in Wallace Memorial Baptist Hospital between January 1996 and December 2004. Ultrasonography, Erythrocyte sedimentation rate(ESR), and C-reactive protein(CRP) were performed initially. Voiding cystourethrography(VCUG) was performed 1 to 3 weeks after treatment with UTI. $^{99m}Tc$-dimercaptosuccinic acid(DMSA) scan was performed 4 to 6 months after treatment. Results : Scintigraphic renal damage was present in 29 percent of the refluxing and in 3 percent of the nonrefluxing kidneys(P<0.05). The severity of VUR was significantly correlated with renal scar formation(P<0.05). The duration of fever before treatmen($5.0{\pm}1.3$ vs $2.6{\pm}1.3$) and prolonged fever of over 5 days were significantly different between renal scar group and non-renal scar group(P<0.05). ESR($56.3{\pm}23.8$ vs $27.9{\pm}18.1mm/hr$, P<0.05) and CRP($12.8{\pm}7.3$ vs $3.9{\pm}3.8mg/dL$, P<0.05) at the diagnosis of UTI in the renal scar group were higher, compared to those of the non-renal scar group. There were no significant differences in age and sex between the two groups. Conclusion : The presence and grade of VUR, the duration of fever before treatment, prolonged fever over 5 days, ESR, and CRP were risk factors for renal scarring, irrespective of age and sex. Diagnosis and management of VUR, in children with UTI, is important to prevent renal scars.

키워드

참고문헌

  1. Jakobsson B, Berg U, Svensson L. Renal scarring after acute pyelonephritis. Arch Dis Child 1994;70:111-5 https://doi.org/10.1136/adc.70.2.111
  2. Rushton HG. Urinary tract infections in children. Epidemiology, evaluation, and management. Pediatr Clin North Am 1997;44:1133-69 https://doi.org/10.1016/S0031-3955(05)70551-4
  3. Esbjorner E, Berg U, Hansson S. Epidemiology of chronic renal failure in children : a report from Sweden 1986-94. Pediatr Nephrol 1997;11:438-42 https://doi.org/10.1007/s004670050312
  4. Sreenarasimhaiah S. Hellerstein S. Urinary tract infections per se do not cause end-stage kideny disease. Pediatr Nephrol 1998;12:210-3
  5. Imam A, Roberts R, Verrier Jones K. Chronic renal failure in children in Wales : a prospective epidemiological study 1994-97 [abstract]. Pediatr Nephrol 1998;12:C182.
  6. Rushton HG, Majd M, Jantausch B, Wiedermann BL, Belman AB. Renal scarring following reflux and nonreflux pyelonephritis in children : evaluation with $^{99m}Tc-$dimercaptosuccinic acid scintigraphy. J Urol 1992;147:1327-32
  7. Goldraich NP, Goldraich IH. Update on dimercaptosuccinic acid renal scanning in children with urinary tract infection. Pediatr Nephrol 1995;9:221-6 https://doi.org/10.1007/BF00860755
  8. Rushton HG. The evaluation of acute pyelonephritis and renal scarring with $^{99m}$Tc-dimercaptosuccinic acid renal scintigraphy : evolving concepts and future directions. Pediatr Nephrol 1997;11:108-20 https://doi.org/10.1007/s004670050243
  9. Orellana P, Baquedano P, Rangarajan V, Zhao JH, Eng ND, Fettich J, et al. Relationship between acute pyelonephritis, renal scarring, and vesicoureteral reflux. Pediatr Nephrol 2004;19:1122-6
  10. Gonzalez E, Papazyan J, Girardin E. Impact of vesicoureteral reflux on the size of renal lesions after an episode of acute pyelonephritis. J Urol 2005;173:571-5 https://doi.org/10.1097/01.ju.0000151263.36909.91
  11. Majd M, Rushton HG, Jantausch B, Wiedermann BL. Relationship among vesicoureteral reflux, P-fimbriated E. coli and acute pyelonephritis in children with febrile urinary tract infection. J Pediatr 1991;119:578-85 https://doi.org/10.1016/S0022-3476(05)82407-2
  12. Winberg J, Bollgren I, Kallenius G, Mollby R, Svenson SB. Clinical pyelonephritis and focal renal scarring, a selected review of pathogenesis, prevention and prognosis. Pediatr Clin North Am 1982;29:801-14
  13. Hodson CJ, Edwards D. Chronic pyelonephritis and vesicoureteric reflex. Clin Radiol 1960;11:219-31 https://doi.org/10.1016/S0009-9260(60)80047-5
  14. Bailey RR. The relationship of vesicoureteral reflux to urinary tract infection in chronic pyelonephritis-reflux nephropathy. Clin Nephrol 1973;1:132-41
  15. Ransley PG, Risdon RA. Renal papillary morphology and intrarenal reflux in the young pig. Urol Res 1975;3:111-3
  16. Heale WF, Ferguson RS. Pathogenesis of renal scarring. In : Kass ED, Brumfitt W, eds. Infections of the urinary tract : proceedings of the Third International Symposium on Pyelonephritis. Chicago University of Chicago Press 1975; 201-4
  17. Roberts JA, Suarez GM, Kaack B, Kallenius G, Svenson SB. Experimental pyelonephritis in the monkey. VII. Ascending pyelonephritis in the absence of vesicoureteral reflux. J Urol 1985;133:1068-75
  18. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol 1993;23:478-80 https://doi.org/10.1007/BF02012459
  19. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Mobius TE. International Reflux Study in Children. International system of radiographic grading of vesicoureteral reflux. Pediatr Radiol 1985;15:105-9. https://doi.org/10.1007/BF02388714
  20. Winberg J. Bollgren I, Kallenius G, Mollby R, Svenson SB. Clinical pyelonephritis and focal renal scarring. A selected review of pathogenesis, Prevention and prognosis. Pediatr Clin North Am 1982;29:801-14
  21. Londe S. Causes of hypertension in the young. Pediatr Clin North Am 1978;25:55-65
  22. Dillon MJ. Recent advances in evaluation and management of childhood hypertension. Eur J Pediatr 1979;132:133-9 https://doi.org/10.1007/BF00442428
  23. Crabbe DC, Thomas DF, Gordon AC, Irving HC, Arthur RJ, Smith SE. Use of $^{99m}$Tc-dimercaptosuccinic acid to study patterns of renal damage associated with prenatally detected vesicoureteral reflux. J Urol 1992;148:1229-31
  24. Jacobson SH, Eklof O, Eriksson CG, Lins LE, Tidgren B, Winberg J. Development of uremia and hypertension after pyelonephritis in children a 27-year follow up. BMJ 1989; 299:703-6. https://doi.org/10.1136/bmj.299.6701.703
  25. Lerner GR, Fleischmann LE, Perlmutter AD. Reflux nephropathy. Pediatr Clin North Am 1987;34:747-70
  26. Yu JY, Suck HC, Song JY, Park MS, Pai KS, Kim YS. Incidence of vesicoureteral reflux and renal scar in asymptomatic siblings of patients with primary vesicoureteral reflux. J Korean Soc Pediatr Nephrol 2003;7:181-8
  27. Gutteberg TJ, Stromme P, Saebo-Larsen J, Flaegstad T. Unilateral vesicoureteral reflux in children. Study on urine specific gravity, osmolarity, beta-2-microglobulin and lactoferrin. Eur Urol 1987;13:390-2
  28. Sparr KE, Balcom AH, Mesrobian HG. Incidence and natural history of contralateral vesicoureteral reflux in patients presenting with unilateral disease. J Urol 1998;160: 1023-5 https://doi.org/10.1016/S0022-5347(01)62680-6
  29. Giorgi LJ Jr, Bratslavsky G, Kogan BA. Febrile urinary tract infections in infants : Renal Ultrasound remains necessary. J Urol 2005;173:568-70 https://doi.org/10.1097/01.ju.0000149826.70405.c5
  30. Goldman M, Bistritzer T, Horne T, Zoareft I, Aladjem M. The etiology of renal scars in infants with pyelonephritis and vesicoureteral reflux. Pediatr nephrol 2000;14:385-8 https://doi.org/10.1007/s004670050779
  31. Polito C, Rambaldi PF, Mansi L, Di Toro R, La Manna A. Unilateral vesicoureteral reflux : Low prevalence of contralateral renal damage. J Pediatr 2001;138:875-9 https://doi.org/10.1067/mpd.2001.114336
  32. Hwang SJ, Lee SJ. The risk factors of renal scar in childhood acute pyelonephritis. J Korean Pediatr Soc 1999;42: 545-52
  33. Ahn SH, Yoon SY, Yoon JH, Moon DH, Park YS. Changes in the findings of $^{99m}$Tc-dimercaptosuccinic Acid(DMSA) scan after acute pyelonephritis in childhood and renal scar. J Korean Pediatr Soc 2000;43:543-9
  34. Kim KH, Jang SH, Lee DY. Factors associated with renal scar in children with vesicoureteral reflux. J Korean Soc Pediatr Nephrol 2001;5:43-50
  35. Lee SY, Lim SH, Lee DY. Initial $^{99m}$Tc-dimercaptosuccinic acid(DMSA) renal scan finding and vesicoureteral reflux as predicting factor of renal scarring. J Korean Soc Pediatr Nephrol 2003;7:44-51
  36. Polito C, Moggio G, La Manna A, Cioce F, Cappabianca S, Di Toro R. Cyclic voiding cystourethrography in the diagnosis of occult vesicoureteric reflux. Pediatr Nephrol 2000; 14:39-41 https://doi.org/10.1007/s004670050010
  37. Stokland E, Hellstrom M, Jacobsson B, Jodal U, Sixt R. Renal damage one year after first urinary tract infection: role of dimercaptosuccinic acid scintigraphy. J Pediatr 1996; 129:815-20 https://doi.org/10.1016/S0022-3476(96)70024-0
  38. Funston MR, Cremin BJ. Intrarenal reflux-papillary morphology and pressure relationships in children's necropsy kidneys. Br J Radiol 1978;51:665-70 https://doi.org/10.1259/0007-1285-51-609-665
  39. Smellie JM, Poulton A, Prescod NP. Retrospective study of children with renal scarring associated with reflux and urinary tract infection. BMJ 1994;308:1193-6 https://doi.org/10.1136/bmj.308.6938.1193
  40. Whitaker RH, Sherwood T. Another look at diagnostic pathways in children with urinary tract infection. BMJ 1984;288:839-41 https://doi.org/10.1136/bmj.288.6420.839
  41. Roberts JA. Mechanisms of renal damage in chronic pyelonephritis. Curr Top Pathol 1995;88:265-87
  42. Roberts JA, Roth JK, Domingue G, Lewis RW, Kaack B, Baskin G. Immunology of pyelonephritis in the primate model. VI. Effect of complement depletion. J Urol 1983;129: 193-6
  43. Shimamura T. Mechanisms of renal tissue destruction in an experimental acute pyelonephritis. Exp Mol Pathol 1981; 34:34-42 https://doi.org/10.1016/0014-4800(81)90033-2
  44. Ransley PG, Risdon R. Reflux and renal scarring. Br J Radiol 1978;51(14 suppl):1-34 https://doi.org/10.1259/0007-1285-51-601-1