Prediction of moderate and high grade vesicoureteral reflux after a first febrile urinary tract infection in children: Construction and internal validation of a clinical decision rule

Sandrine Leroy, Carla Romanello, Vladislav Smolkin, Annick Galetto-Lacour, Bartosz Korczowski, David Tuerlinckx, Carlos Rodrigo, Vincent Gajdos, Florence Moulin, Paolo Pecile, Raphal Halevy, Alain Gervaix, Barbara Duhl, Thierry Vander Borght, Cristina Prat, Laurence Foix-L'Hélias, Douglas G. Altman, Dominique Gendrel, Gérard Bréart, Martin Chalumeau

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10 Citations (Scopus)

Abstract

Purpose: Urinary tract infection leads to a diagnosis of moderate or high grade (III or higher) vesicoureteral reflux in approximately 15% of children. Predicting reflux grade III or higher would make it possible to restrict cystography to high risk cases. We aimed to derive a clinical decision rule to predict vesicoureteral reflux grade III or higher in children with a first febrile urinary tract infection. Materials and Methods: We conducted a secondary analysis of prospective series including all children with a first febrile urinary tract infection from the 8 European participating university hospitals. Results: A total of 494 patients (197 boys, reflux grade III or higher in 11%) were included. Procalcitonin and ureteral dilatation on ultrasound were significantly associated with reflux grade III or higher and then combined into a prediction model with an ROC AUC of 0.75 (95% CI 0.690.81). Given the prespecified constraint of achieving at least 85% sensitivity, our model led to the clinical decision rule, for children with a first febrile urinary tract infection cystography should be performed in cases with ureteral dilatation and serum procalcitonin level 0.17 ng/ml or higher, or without ureteral dilatation (ie ureter not visible) when serum procalcitonin level is 0.63 ng/ml or higher. The rule had 86% sensitivity (95% CI 7493) with 47% specificity (95% CI 4251). Internal cross-validation produced 86% sensitivity (95% CI 7993) and 43% specificity (95% CI 3947). Conclusions: A clinical decision rule was derived to enable a selective approach to cystography in children with urinary tract infection. The rule predicts high grade vesicoureteral reflux with approximately 85% sensitivity and avoids half of the cystograms that do not find reflux grade III or higher. Further validation is needed before its widespread use. © 2012 American Urological Association Education and Research, Inc.
Original languageEnglish
Pages (from-to)265-271
JournalJournal of Urology
Volume187
Issue number1
DOIs
Publication statusPublished - 1 Jan 2012

Keywords

  • child
  • decision support techniques
  • forecasting
  • urinary tract infections
  • vesico-ureteral reflux

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