Introduction: The sacral bone anomalies have an important effect on urinary and gastrointestinal tract and sacral ratio was defined as an indicator for estimating the anorectal abnormalities in children. This study was carried out for determining the association between sacral ratio and Urinary Tract Infections (UTI) among children. Material and Methods: In a cross sectional study, 100 children under 15 years with proven febrile UTI were referred to a referral children center considering the presence and grading of VUR according to VCUG enrolled in this study. Sacral ratio was measured for all cases and the data were compared by student T test, Chi 2 and Mann Whitney tests. SPSS 16.0 software was used for data analysis. P values less than 0.05 were considered significant. Results: 41 boys and 59 girls with mean age 4.8 years were enrolled in this study. The average range of sacral ratio was 0.82. There was no staistical difference between two different genders and ages (p > 0.05). The values of SR in patients with VUR were lower than patients without VUR(PË�0.05) but there was no statistically significant difference between both bilateral and unilateral VUR and SR (p > 0.05). Conclusion: The risk of sacral bone abnormality in patients with VUR is more than patients without VUR. Therefore, in patients with UTI and low SR simultaneously, tighter evaluation for VUR and treatment should be considered. Â© 2018 Kandarini et al

Ehsanipour, F.

Movahedi, Z.

Noorbakhsh, S.

Taherinia, L.

eprints Iran University of Medical Sciences

Send Orders for Reprints to reprints@benthamscience.ae541874-303X/18 2018  Bentham OpenThe Open Urology & NephrologyJournalContent list available at: www.benthamopen.com/TOUNJ/DOI: 10.2174/1874303X01811010054, 2018, 11, 54-59RESEARCH ARTICLECorrelation of Sacral Ratio and Urinary Tract Infection in ChildrenFahimeh Ehsanipour1, Zahra Movahedi2, Leila Taherinia3 and Samileh Noorbakhsh1,*1Department of Pediatric Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran2Department of Pediatric Infectious Diseases, Qom University of Medical Sciences and Health Services, Qom, Iran3Tehran University of Medical Sciences,Tehran, IranReceived: June 3, 2018 Revised: August 11, 2018 Accepted: August 15, 2018Abstract:Introduction:The sacral bone anomalies have an important effect on urinary and gastrointestinal tract and sacral ratio was defined as an indicatorfor estimating the anorectal abnormalities in children. This study was carried out for determining the association between sacral ratioand Urinary Tract Infections (UTI) among children.Material and Methods:In a cross sectional study, 100 children under 15 years with proven febrile UTI were referred to a referral children center consideringthe presence and grading of VUR according to VCUG enrolled in this study.Sacral ratio was measured for all cases and the data were compared by student T test, Chi 2 and Mann Whitney tests. SPSS 16.0software was used for data analysis. P values less than 0.05 were considered significant.Results:41 boys and 59 girls with mean age 4.8 years were enrolled in this study. The average range of sacral ratio was 0.82. There was nostaistical difference between two different genders and ages (p > 0.05).The values of SR in patients with VUR were lower than patients without VUR(P˂0.05) but there was no statistically significantdifference between both bilateral and unilateral VUR and SR (p > 0.05).Conclusion:The risk of sacral bone abnormality in patients with VUR is more than patients without VUR. Therefore, in patients with UTI andlow SR simultaneously, tighter evaluation for VUR and treatment should be considered.Keywords: Sacral Ratio, UTI, VUR, Children, Bone abnormality, Urinary Tract Infections.1. INTRODUCTIONUrinary  Tract  Infections  (UTI)  are  considered  as  the  most  common  bacterial  infections  among  children.  Theprevalence of UTI is estimated 2% in boys and 8% in girls [1, 2]. UTI can predispose the patients to increase the risk ofrenal failure due to renal scarring and hypertension and end stage renal disease in pediatric population. Sacral boneabnormality like hypoplasia or agenesis is one of the important risk factors for urinary dysfunction [2]. Recurrent UTI isdefined  as  a  further  infection  by  a  new  organism.  Relapsing  UTI  is  defined  as  a  further  infection  with  the  sameorganism. The recurrent infections can result in renal scarring, which can lead to renal hypertension and end-stage renaldisease [3]. Although  using new  diagnostic  tests  and appropriate  treatment, the  mortality  and morbidity of  UTI  are* Address correspondence to this author at  the Department  of Pediatric  Infectious  Diseases,  Iran  University  of Medical  Sciences, Tehran,  Iran,Tel: 098-21-66525328, E-mail: samileh_noorbakhsh@yahoo.comSacral Ratio and Urinary Tract Infection The Open Urology & Nephrology Journal, 2018, Volume 11   55diminished significantly,  but UTI is an important factor producing structural dysfunction, progressive renal failure,hypertension and also renal stones [2]. Although the complication does not occur in most patients after treatment, butalso identifying the susceptible patients is very important for the prevention of complication [3, 4]. Acute pyelonephritisand VUR are diagnosed as two synergistic factors producing the destruction in pediatric kidneys [4]. VesicoureteralReflux (VUR) is an important urological abnormality which can cause recurrent febrile UTI in childhood. Obstructiveanomalies  are  found  in  up  to  4%,  and  VUR in  8%  to  40% of  children  being  investigated  for  their  first  UTI.  Therecurrent UTI can be complicated by renal scarring, which can lead to renal hypertension and end-stage renal disease[5].  Many  authors  consider  the  Long-term  antibiotics  for  preventing  recurrent  urinary  tract  infection  in  pediatricpopulation  [6,  7].  In  some  investigations  antibiotics  of  choice  for  preventing  gram  negative  microorganisms  aresuggested by authors [8, 9], although Ian et al. showed early treatment of acute pyelonephritis in children fails to reducerenal scarring [10]. In purpose to detect urinary tract anomalies, VCUG (voiding cystourethrogram) is the most usefulmethods in children ([11, 12] The potential role for MRU (Magnetic Resonance Urogram) in the diagnostic work-up ofupper  urinary  tract  dilatation  in  infants  and  children  is  showed  by  some  authors  [13,  14].  Diagnostic  strategies  ofinterstitial cystitis due to infections were described by Patnaik [15]. Sacral bone abnormality like hypoplasia or agenesisis one of the important risk factors for urinary dysfunction [2].The relationship between sacral agenesis and VUR, enuresis, voiding dysfunction, and neurogenic bladder is wellknown previously [16 - 20].Pena  et  al.  suggested  the  Sacral  Ratio  (SR)  for  evaluation  of  sacral  development.  Sacral  ratio  was  calculatedaccording  to  Pena  criteria  in  plain  lumbosacral  spinal  radiography  [16].  Three  lines  were  drawn  for  each  pelvicradiograph, a line is drawn connecting the upper zone of both iliac crests, the second line was connecting the mostinferior point of the sacroiliac joints and the third line parallel to other lines across the inferior points of the sacrum. Bydividing the distance between the two baseline (on the distance between the two upper lines sacral ratio were calculated[16]. MC Lellan et al. reported the relationship between sacral anomalies and urinary dysfunction [17]. Sacral index is amarker which were used for identifying the predisposing risk factors for UTI, urinary dysfunction, VUR, constipationand also urinary incontinence [17]. Correlation between SR and anorectal anomalies were evaluated by Macedo et al.and others [18 - 20].UTI is a common cause for hospital admission among Iranian children [21 - 24]. A prospective clinical study bysome Iranian workers determined the incidence of renal scarring following acute pyelonephritis and previously well-known risk factors such as VUR, age and recurrent urinary tract infections [21]. Association of voiding dysfunctionfollowing sacral anomalies was considered in the previous Iranian studies [24, 25].The aim of present study was determination of average SR among children with UTI admitted in pediatric ward ofRasul Akram Hospital during 2008-2016.2. MATERIALS & METHODSThis cross sectional study were performed upon 100 children (< 15 years old) with proven febrile UTI who wereadmitted in pediatric department in Rasoul Akram Hospital, Tehran, Iran during 2008-2016.The  patients  with  structural  sacrum  anomaly  included  myelomeningocele  and  sacrococcygeal  teratoma,imperforated anus, lipomeningocele and all children with history of trauma or pelvic fracture were excluded from thestudy.Diagnostic  criteria:  UTI  was  diagnosed  as  positive  urine  culture  with  more  than  105  colony-forming  units  permilliliter of a single pathogen or 104 colonies in a symptomatic patients or > 50000 colonies of a single pathogen inobtained samples via suprapubic or catheter [1].VCUG  was  performed  for  all  cases  within  6  weeks  after  urinary  tract  infection.  Sacral  ratios  were  calculatedaccording  to  Pena  criteria  in  plain  lumbosacral  spinal  radiography  [16].  Three  lines  were  drawn  for  each  pelvicradiograph, a line is drawn connecting the upper zone of both iliac crests, the second line was connecting the mostinferior point of the sacroiliac joints and the third line parallel to other lines across the inferior points of the sacrum. Bydividing the distance between the two baseline (BC) on the distance between the two upper lines (AB), sacral ratio wascalculated.  The  normal  limits  of  SR  were  considered  as  >/=  0.74  in  anteroposterior  and  >/=  0.77  in  lateral  viewaccording to Pena et al. criteria [16].All data were entered in the check list and finally were analyzed by SPSS 16.0 software.56   The Open Urology & Nephrology Journal, 2018, Volume 11 Ehsanipour et al.3. RESULTSOne hundred children (mean age 4.8 years and SD of 3.2 years) were enrolled in the study. 41 (41%) of the totalcases were male and 59 (59%) were female.The patients were divided to 3 groups according to age. The average SR in patients between 2-5 years was 0.80 with0.079 SD and for cases between 5-10 years and 10-15 years was 0.84 (SD : 0.076) and 0.83 (SD : 0.07) respectively(Fig. 1). The average SR in girls was 0.81 with 0.076 SD and in boys was 0.85 with 0.08 SD. There was no significantdifference between SR and age and gender (p > 0.05).Fig. (1). Correlation between SR and age.The cases were divided into four groups according to the existence of VUR and also VUR grading. The SR scales inrelation to VUR and grading were compared which are shown in Table 1.Table 1. SR scale in relation to VUR and grading.VUR Mean Minimum MaximumGrade 1 0.85 0.63 0.90Grade 2 0.82 0.64 0.92Grade 3 0.80 0.70 0.95Without VUR 0.87 0.62 0.94There was no significant difference among the patients with unilateral VUR and SR (average = 0.81 and SD 0.076)and also the patients with bilateral VUR and SR (average = 0.84 with SD 0.71 (P > 0.05). But SRI decreases in parallelto increasing VUR grading. This index in patients without VUR has higher mean level in comparison to children withVUR.4. DISCUSSIONIn the present study we investigated the relation between SRI and VUR in children (< 15 years old) with provenUTI. According to our results no significant difference was observed between age and gender with SRI. No correlationbetween unilateral VUR and SRI (average = 0.81 and SD 0.076) and bilateral VUR and SR (average = 0.84 with SD0.071) had found in our studied cases.  SRI decreases in parallel  to increasing VUR grading.  This index in patientswithout VUR has higher mean level in comparison to children with VUR.SRI (Sacral index) was a marker which were used for identifying the predisposing risk factors for UTI, urinarydysfunction, VUR, constipation and also urinary incontinence [16 - 18] and low SR index which represent the sacralbone development can in turn create urinary system disorders [16]. 0.780.790.80.810.820.830.840.852-5y 5-10y 10-15yCorrelation between SR and AgeMean SRSacral Ratio and Urinary Tract Infection The Open Urology & Nephrology Journal, 2018, Volume 11   57Kajbafzadeh et al. investigated the correlation of SR index and results of VUR among 30 children with UTI andcontrols.  They  found  no  significant  difference  between  age  and  this  index,  compatible  to  our  results  [19].Yousefichaijan  et  al.  reported  the  sacral  Index  in  children  suffering  from  different  grades  of  VUR  [20].According  to  the  results  of  the  present  study,  in  parallel  to  increasing  the  VUR  grading,  the  sacral  index  isdiminished, but because existence of sacral bone anomalies was not considered, SR was used as an independent factorin relation to VUR and considering the chance of simultaneous occurrence of abnormal SR and VUR, in the absence ofsacral anomaly due to close embryonic origin of sacral bone and bladder or neurogenic infrastructural abnormality inpatients with abnormal SR and also insufficient sample size, other studies with higher sample size are needed. On theother hand, abnormal SR can be recognized as a risk factor for predicting UTI occurrence, therefore these cases can beevaluated for UTI occurrence from earlier ages.CONCLUSIONThe risk of sacral bone abnormality in patients with VUR is more than patients without VUR. According to theresults of present study, SR decreases in parallel to increasing VUR grading. This index in patients without VUR hashigher mean level in comparison to children with VUR.Therefore, in patients with UTI and low SR simultaneously, tighter evaluation for VUR and treatment should beconsidered.Considering  relationship  between  SR  and  occurrence  of  VUR,  correlation  of  this  index  with  UTI,  point  ofdetermination  and  also  prediction  of  prognosis,  the  treatment  programs  can  be  planned  meticulously.LIMITATION OF THE STUDYOur study included a relatively small sample size and lacked of long-term follow up.ETHICS APPROVAL AND CONSENT TO PARTICIPATEEthical  Committee  in  the  Pediatric  Infectiuos  Diseases  (affiliates  by  Iran  University  of  Medical  Sciences)  hasreviewed and approved the Waiver of Authorization for use of protected health information (PHI) for research purposesfor the following study and the number is 92-01-131-25731.HUMAN AND ANIMAL RIGHTSAnimals did not participate in this research. All human research procedures followed were in accordance with theethical standards of the committee responsible for human experimentation (institutional and national),  and with theHelsinki Declaration of 1975, as revised in 2008.CONSENT FOR PUBLICATIONConsent for publication was obtained.CONFLICTS OF INTERESTThe authors declare no conflict of interest, financial or otherwise.ACKNOWLEDGEMENTSThe research team wish to thank vice chancellor of research for their financial support and also children and theirparents who contribute to this research.58   The Open Urology & Nephrology Journal, 2018, Volume 11 Ehsanipour et al.REFERENCES[1] Masson P, Matheson S, Webster AC, Craig JC. Meta-analyses in prevention and treatment of urinary tract infections. Infect Dis Clin NorthAm 2009; 23(2): 355-85.[http://dx.doi.org/10.1016/j.idc.2009.01.001] [PMID: 19393914][2] Tenke  P.  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Iran JPediatr 2008; 18(1): 57-61.© 2018 Kandarini et al.This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), acopy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, andreproduction in any medium, provided the original author and source are credited.

Correlation of sacral ratio and urinary tract infection in children

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Correlation of sacral ratio and urinary tract infection in children

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