膀胱输尿管反流高危患儿的临床和影像学检查结果分析

Evaluation of the clinical and imaging examination in high-risk children with vesicoureteral reflux

目的对膀胱输尿管反流（VUR）高危患儿的临床表现和排泄性膀胱尿道造影（VCUG）检查结果进行分析，同时探讨应用无辐射的排泄性尿道超声检查（VUS）对VUR的诊断意义。方法以2007年7月-2010年4月于首都儿科研究所住院的VUR高危患儿93例为研究对象，包括首次或反复尿路感染58例、无尿路感染但胎儿期或生后B超发现肾积水者35例，所有患儿均行VCUG检查，22例患儿同时接受VUS检查，反流分级采用五级法进行评价。结果（1）58例尿路感染患儿中发现VUR20例，检出率为34．5％。反复尿路感染患儿中VUR的检出率明显高于首次尿路感染患儿中VUR的检出率。VUR分布为：≤1岁13例，其中男10例，双侧反流6例，Ⅳ＋V级反流占57．9％；1～5岁4例，其中男2例，双侧反流1例，Ⅳ＋Ⅴ级反流占40．0％；≥5岁3例，其中男1例，双侧反流1例，全部为Ⅲ级以下反流。35例无尿路感染的肾积水患儿中发现VUR6例，检出率为17．1％。（2）22例患儿同时行VCUG和VUS两种检查，与VCUG相比，VUS诊断VUR的敏感度为100％，特异度为92．1％，阳性预测值66．7％，阴性预测值100％，VUS和VCUG的检出一致性为93．2％。结论对儿童尤其是低年龄组男童的尿路感染、以及胎儿期或生后B超发现有肾积水的患儿应重视VUR的早期筛查。VUS是一种准确可靠的检查手段，且避免放射暴露，可作为儿童VUR的筛查或追踪观察的方法之一。

Objective To analyze the clinical data and result of voiding cystourethrography （VCUG） in high-risk children with vesicoureteral reflux （VUR） for better awareness of VUR, and to assess the usefulness of non-radioactive voiding ultrasonography （VUS） in the diagnosis of VUR. Method Ninety-three high-risk children with VUR who were hospitalized from July 2007 to April 2010 were studied. The study included 58 cases of urinary tract infection （UTI） and 35 cases of fetal or postnatal hydronephrosis detected on a B ultrasound scan. The results of urinalysis, urine culture, renal function, B ultrasound and VCUG were evaluated. Part of patients underwent VUS followed by VCUG immediately. Result （ 1 ） Sixty- two boys and 31 girls （aged 1 month to 11.5 years, mean age 2 years） were included. VUR was detected in 26 patients （28%） by VCUG. In terms of kidney-ureter units, VUR was detected in 36 of 186 kidney-ureter units, including 6 grade Ⅰ , 3 grade Ⅱ , 6 grade Ⅲ 15 grade Ⅳ and 6 grade Ⅴ. （2） VUR was detected in 20 of 58 UTI patients （34. 5% ） by VCUG. The proportion of VUR in recurrent UTI group was 61.1%, much higher than that in first UTI group （22. 5% ）. Thirteen of 20 VUR （65%） occurred in UTI patients under 1 year of age （ M/F 10/3 ）, with more bilateral VUR and severe grades of VUR than the older group. VUR was detected in 6 of 35 fetal or postnatal hydronephrosis patients （ 17.1% ） by VCUG. （3） Twenty-two patients underwent both VUS and VCUG. VUR was detected in 4 patients and 6 kidney-ureter units by VCUG, while in 6 patients and 9 kidney-ureter units by VUS. Taking VCUG as the reference standard, VUShad a sensitivity of 100% , specificity of 92. 1%, positive predictive value of 66. 7% , and negative predictive value of 100%. There was a concordance rate of 93.2% between VUS and VCUG. Conclusion It is important to early screen VUR in UTI, fetal or postnatal hydronephrosis patients. There are more VUR, especially more bilateral VUR and severe grades of VUR, occurred in UTI patients under l year of age eompared to older children. The incidence of VUR in recurrent UTI group was much higher than that in first UTI group. VUS is an accurate, reliable and radiation-free technique for the detection of VUR. It could be used to screen high-risk children for VUR and do the evaluation in the follow-up of VUR.