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August 5, 2019

Association Between Recurrent Febrile Urinary Tract Infections and Renal Scarring: From Unquestioned Answers to Unanswered Questions

Author Affiliations
  • 1Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill
JAMA Pediatr. 2019;173(10):918-919. doi:10.1001/jamapediatrics.2019.2509

In this issue of JAMA Pediatrics, Shaikh et al1 continue to shed light on important aspects of urinary tract infections (UTIs) in children based on data gleaned from the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR)2 and Careful Urinary Tract Infection Evaluation (CUTIE)3 trials. The study by Shaikh et al1 addresses the likelihood of new renal scars developing after a first febrile UTI and after recurrent UTIs.1 Three decades ago, the pioneering group in Sweden identified a slight increase in renal scarring from the first UTI to the second and from the second to the third; only after 3 UTIs did the rate increase dramatically.4 However, as Shaikh et al1 point out, the data on the association between renal scars and recurrent UTIs were based on pyelography with an intravenous contrast agent (“intravenous pyelography,” or IVP). A decade after their original report, the group in Sweden compared the IVP results with the results using the newly available technetium 99m dimercaptosuccinic acid scan technique and found, as expected, that the latter was more sensitive.5 Until now, the original data on the association between recurrent UTIs and scarring stood unchallenged; Shaikh et al1 bring us up to date. The authors report an overall rate of scarring far lower than the rates in current trials and systematic reviews,6,7 at least in part because they took pains to focus on new scars, excluding individuals whose baseline scan on entry into the trials revealed a scar that might represent congenital dysplasia. The rate of scarring after a first febrile UTI in their study was only 2.8% but was much higher after a recurrence (25.7% after 2 febrile UTIs and 28.6% after ≥3 febrile UTIs).