Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials

Abstract

Aims: To evaluate the benefits and harms of treatments for vesicoureteric reflux in children. Methods: Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate. Results: Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment. Conclusion: It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage. P rimary vesicoureteric reflux is thought to be caused by a maturational abnormality of the vesicoureteric junction, so that urine passes in a retrograde manner up the ureter. Although the exact prevalence in the general childhood population is unknown, about a third of children with urinary tract infection are consistently found to have reflux.1 Urinary tract infection occurs in approximately 5-10% of children, and so 1-3% of children are identified with vesicoureteric reflux.

Vesicoureteral Reflux

“…Meta-analysis of randomized controlled trials of antibiotics versus no treatment/surveillance for the outcome of urinary tract infection. 98 BRIEF REVIEW www.jasn.org ling pairs with VUR (http://www.vur.org.uk). Details on the diagnostic criteria or detail of phenotypic syndrome are not provided on the web site.…”

Impacto de la apación de una guía clínica basada en la evidencia en el tratamiento del reflujo vesicoureteral primario en el niño

“…E n l a ú l t i m a d é c a d a , e l t r a t a m i e n t o conservador, basado en medidas higiénicas y profilaxis antibiótica nocturna, [12][13][14] se ha posicionado, sin duda, como tratamiento inicial de elección. La eficacia de esta estrategia terapéutica y, lo que es más importante, su capacidad de protección del parénquima renal y, secundariamente, de la función renal a largo plazo han sido reiteradamente ponderadas y analizadas.…”

Impact of using an evidence-based clinical guideline for the management of primary vesicoureteral reflux in children

“…The systematic reviews by Wheeler et al 14 and Nagler et al 15 highlight three clinical assays that attempted to elucidate the effectiveness of surgical and conservative treatment and the advantages of one over the other in terms of permanent kidney damage. These are the International Reflux Study in Children (IRSC), 16 the Birmingham Reflux Study (Great Britain), and the Swedish Reflux Trial in Children.…”

“…In the last decade, conservative treatment, based on hygiene measures and nocturnal antibiotic prophylaxis, [12][13][14] has definitely positioned as the initial treatment of choice. The effectiveness of this therapeutic strategy and, most importantly, its ability to protect the renal parenchyma and, secondarily, long-term kidney function, have been repeatedly weighed up and analyzed.…”