Original article J Korean Soc Pediatr Nephrol 2012;16: ISSN (print) ISSN (online

Size: px

Start display at page:

Download "Original article J Korean Soc Pediatr Nephrol 2012;16: ISSN (print) ISSN (online"

규필 수
5 years ago
Views:

1 Original article J Korean Soc Pediatr Nephrol 2012;16: ISSN (print) ISSN (online) 방광요관역류를가진소아에서의신초음파소견 연세대학교의과대학소아과학교실 *, 아주대학교의과대학소아과학교실, 국민건강보험공단일산병원소아청소년과 최민정 * 박세진 *, 신재일 * 김기혁 Min Jung Choi, M.D.*, Se Jin Park, M.D.*,, Jae Il Shin, M.D.*, and Kee Hyuck Kim, M.D. The Institute of Kidney Disease, Department of Pediatrics*, Yonsei University College of Medicine, Severance Children s Hospital, Seoul, Korea, Department of Pediatrics, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea, Department of Pediatrics, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea Corresponding Author: Kee Hyuck Kim Department of Pediatrics, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea Tel: , Fax: kkim@nhimc.or.kr Min Jung Choi and Se Jin Park contributed equally to this work Received: 5 October 2011 Revised: 7 October 2011 Accepted: 1 December 2011 Ultrasonographic Findings in Children with Vesicoureteral Reflux Purpose: The aim of this study is to investigate the renal ultrasono graphic findings in children with vesicoureteral reflux (VUR). Methods: We retrospectively reviewed the medical records of 83 patients who were diagnosed with VUR and underwent ultrasono graphy at Ilsan hospital between January 2000 and December Results: Among 166 renal units, 108 (65.0%) were found to have vesicoureteral reflux (VUR). Fifty-one (73.9%) had VUR in renal units with abnormal ultrasonography (USG), whereas 57 (58.7%) had VUR in renal units with normal USG. Abnormal USG findings were independent risk factors for VUR (Odds ratio, 1.98; 95% CI, ; P=0.045). In renal units with VUR, the number of normal USG finding was 52.8%, and the abnormal findings were as follows; increased cortical echogenicity 16.7%, hydronephrosis 17.6%, megaureter or ureter dilatation 8.3%, hydronephrosis and ureter dilatation 1.9%, duplication of ureter 1.9%, and atrophic kidney 0.9%. The prevalence of VUR was relatively higher in renal units with hydronephrosis (23/19, 82.6%), ureter dilatation (9/9, 100%), duplication of ureter (2/3, 66.6%), and atrophic kidney (1/1, 100%). Conclusion: Our study indicates that VUR was associated with abnormal USG findings. When there are abnormal USG findings such as hydronephrosis, ureter dilatation, duplication of ureter, and atrophic kidney in children with UTI, VCUG is recommended to detect VUR after controlling UTI. Key Words: Vesicoureteral reflux, Renal ultrasonography, Children This is an open-access article distributed under the terms of the Creative Commons Attribu tion Non- Commercial License ( tivecom mons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론방광요관역류는소아요로감염과신반흔을일으키는중요한원인중의하나이며, 요로감염이있는소아의약 25-50% 에서역류가있으며, 방광요관역류가있는소아의 30-49% 에서신반흔이동반된다 [1, 2]. 배뇨성방광요도조 Copyright 2012 The Korean Society of Pediatric Nephrology

2 Choi MJ, et al.: Two Cases of C1q Nephropathy in Siblings 33 영술 (voiding cystourethrography, VCUG) 은소아에서요로감염이있을때, 선천성수신증, 후부요도판막, 방광게실등기타선천성신장질환등이있을때동반된방광요관역류를확인하기위해시행하는검사로 [3] 미국소아과학회에서는어린소아 (2 개월에서 2세 ) 에서방광요관역류의진단을위해조기에배뇨성방광요도조영술을시행할것을권고하고있다 [4]. 그러나배뇨성방광요도조영술은침습적인도뇨관삽입과대량의 X- 선에대한노출등이문제가될뿐아니라대부분의방광요관역류는자연소실율이높은 I등급이나 II등급이라는연구결과들이있어서, 모든요로감염소아에게배뇨성방광요도조영술이반드시필요한가? 에는논란이있다 [5]. 지금까지침습적인배뇨성방광요도조영술을대체할임상적, 영상학적, 혈액학적예측지표에대한여러가지보고가있었으나 [5, 6] 아직까지는소아에서방광요관역류의진단을위해배뇨성방광요도조영술을시행하는것이일반적인방법이다 [7]. Mahant 등 [8] 과 Alshamsan 등 [9] 은신초음파가첫요로감염을가진소아에서방광요관역류를예측하는데크게의미가없다고하였으나, 최근 Ismaili 등 [10] 은신초음파소견과중증방광요관역류사이의연관성이있다고하였다. 본연구는방광요관역류가있는소아에서신초음파이상유무와방광요관역류와의연관성을알아보고, 신초음파이상소견을방광요관역류의예측지표로사용할수있는지알아보고자시행하였다. 역류등급분류 (International Reflux Study of Committee, 1981) 에따라 grade I-II 를경도 (low grade), grade III 를증등도 (moderate grade), grade IV-V 를증증 (high grade) 으로분류하였다 [5]. 자료의통계학적분석은 SPSS for windows version 16 (Chicago, Illinois, USA) 를이용하였으며, 방광요관역류와신초음파이상소견과의관계는 t-test, chi-square test, 로지스틱회귀모형 (logistic regression anaylsis) 을이용하여분석하였다. 통계적유의수준은 P값이 0.05 미만인경우를유의한것으로정의하였다. 결과 1. 연구대상소아의연령과성별분포대상소아는모두 83 명으로전체 166 신단위 (renal unit) 중방광요관역류는 108신단위에서관찰되었으며, 남아가 43명 (51.8%), 여아는 40명 (48.2%) 으로전체남녀비는 1.1:1 이었다. 이중 1세미만의평균나이는 3.1±2.56 개월 (median 2개월, range 1-12 개월 ) 이었으며, 1세이상의평균나이는 58.9±43.01 개월 (median 32 개월, range 개월 ) 이었다. 2. 방광요관역류의빈도 대상과방법 2000 년 1월부터 2010 년 12 월까지일산병원소아청소년과에내원하여요로감염증으로입원한후배뇨성방광요도조영술을시행하여방광요관역류를진단받은총 83명의소아를대상으로후향적분석을시행하였다 [11]. 대상소아들은요로감염을처음진단받았으며, 영상검사로신초음파 (renal ultrasonography), 배뇨성방광요도조영술 (voiding cystourethrography) 를시행하였다. 영상검사는영상의학과의사와핵의학과의사각각 1명에의해판독되었다. 신초음파검사의이상소견은증가된신피질음영, 수신증, 요관확장또는거대요관, 수신증과요관확장이같이있는경우, 중복요관, 신장무형성, 손상된위축신으로구분하였다. 배뇨성방광요도조영술은소변배양검사가음성으로확인된후시행하여방광요관역류여부를검사하였고, 방관요관역류의세부등급은국제소아역류연구회의방광요관 방광요관역류를 5단계로나누어보았을때, 정상소견을보이는경우는 58신단위 (34.9%), 1단계방광요관역류는 26 신단위 (15.7%), 2단계방광요관역류는 39 신단위 (23.5%), 3 단계방광요관역류는 25 신단위 (15.1%), 4단계방광요관역류는 12 신단위 (7.2%), 5단계방광요관역류는 6 신단위 (3.6%) 로각각관찰되었다 (Fig. 1) Normal VUR 1 VUR 2 VUR 3 VUR 4 VUR 5 Fig. 1. Prevalence according to the grade of vesicoureteral reflux.

3 34 J Korean Soc Pediatr Nephrol Vol. 16, No. 1, 32-37, 나이, 성별과방광요관역류와의관련성 방광요관역류가없는 58 신단위에서의평균나이는 41.8± 46.8 개월이었고, 방광요관역류가있는 108 신단위에서의평균나이는 37.0±41.7 개월이었으며, 두그룹은통계적으로유의한차이가없었다 (P=0.502). 또한심한방광요관역류가있는 18 신단위에서의평균나이는 24.1±34.19 개월이었고, 심한방광요관역류가없는 90 신단위에서의평균나이는 39± 개월이었으며, 두그룹은통계적으로유의한차이가없었다 (P=0.151). 남아에서방광요관역류소견이없는신단위와방광요관역류를보이는신단위는각각 32.5% (28/86), 67.4% (58/86) 였고, 여아에서방광요관역류소견이없는신단위와방광요관역류를보이는신단위는각각 37.5% (30/80), 62.5% (50/80) 이었다. 역류가있는남녀신단위에서두그룹은통계적으로유의하지않았다 (P=0.519). 또한심한방광요관역류가있는남아의신단위는 22.4 % (13/58), 여아의신단위는 10% (5/50) 이었으며두그룹은통계적으로유의한차이가없었다 (P=0.12). 4. 신초음파이상소견과방광요관역류의유무 신초음파이상소견을보이는경우방광요관역류가있는신단위는 73.9% (51/69), 신초음파정상소견인경우방광요관역류가있는신단위는 58.7% (57/97) 이었다 (Table 1). 신초음파이상소견유무에따른두그룹간에는통계적으로유의한 Table 1. Results of Vesicoureteral Reflux in Relation to Ultrasonographic Findings Findings VUR (-) VUR (+) Total renal units Abnormal USG 18 (26.0%) 51 (73.9%) 69 (100%) Normal USG 40 (41.2%) 57 (58.7%) 97 (100%) Abbreviation: VUR, vesicoureteral reflux 차이가있었다 (P=0.049). 신초음파이상소견이방광요관역류를예측하는독립인자가되는지알아보기위해로지스틱회귀분석을시행하였을때, 신초음파이상소견이있으면방광요관역류가있을확률은약 2배가량증가하였으며이는통계적으로유의하였다 (Odds ratio 1.98; 95% confidence interval ; P=0.045). 방광요관역류가있는신단위에서초음파정상소견을보이는경우는 52.8% (57/108), 피질음영증가 16.7% (18/108), 수신증 17.6 % (19/108), 요관확장 8.3% (9/108), 수신증을동반한요관확장 1.9% (2/108), 중복요관 1.9% (2/108), 신장무형성 0% (0/108), 손상된위축신 0.9% (1/108) 이었다 (Table 2). 이중수신증 (57/97, 82.6%), 요관확장 (9/9, 100%), 중복요관 (2/3, 66.6%), 손상된위축신 (1/1, 100%) 이있는경우방광요관역류가발견될빈도가상대적으로높았다. 고찰소아요로감염의진단에방사선검사가중요한이유는요로감염에선행되는선천성기형, 신반흔그리고기능적이상등을찾아내는데큰역할을하기때문이다. 요로감염은소아기의흔한세균성감염으로성인과달리요로계의선천기형을동반하는경우가많다. Hsieh 등 [12] 은 130 명의첫발열성요로감염소아들을대상으로한연구에서 81.6% 에서비뇨기계기형을발견하였다고보고하였으며, 이를바탕으로첫번째요로감염소아들에게서신속한영상의학적평가가중요하다고언급하였다. 영유아의요로감염은요로기형동반문제외에도 10-30% 의소아에서급성신우신염과신반흔을일으키게되며, 추후고혈압과만성신부전까지도초래할수있으므로요로감염발생시영상의학적조기진단과치료가매우중요하다 [5]. 방광요관역류는요관방광이행부의판막기능부전으로인 Table 2. Ultrasonographic Findings in Renal Units with VUR USG findings VUR (-) VUR (+) Total renal units Normal 40 (41.2%) 57 (58.7%) 97 (100%) Increased cortical echogenicity 10 (35.7%) 18 (64.2%) 28 (100%) Hydronephrosis 4 (17.4%) 19 (82.6%) 23 (100%) Megaureter or Ureter dilatation 0 (0%) 9 (100%) 9 (100%) Hydronephrosis + Ureter dilatation 2 (50%) 2 (50%) 4 (100%) Duplication of ureter 1 (33.3%) 2 (66.6%) 3 (100%) Renal agenesis 1 (100%) 0 (0%) 1 (100%) Atrophic kidney 0 (0%) 1 (100%) 1 (100%) Abbreviation: VUR, vesicoureteral reflux

4 Choi MJ, et al.: Two Cases of C1q Nephropathy in Siblings 35 해소변이방광에서요관, 신우로역류되어나타나는질환으로, 신손상의위험성이있는발열성요로감염소아에서방광요관역류를확인하는것은매우중요한문제이나, 방광요관검사와관련되어일부연구에서는시술후소변배양검사를실시한후요로감염, 전신적알레르기반응, 접촉성피부염, 요도관꼬임등의발생을보고하였다 [13, 14]. 또한, Zerin 등 [15] 에의하면배뇨성방광요관조영술시행후일부소아에서방광요관검사와관련되어배뇨곤란, 보챔, 발열, 빈뇨등의증상을보였다. 따라서요로감염환자, 특히처음으로요로감염에이환된소아에서일률적으로침습적인배뇨성방광요도조영술을시행해야할것인가에대한검토가요구된다. 또한첫발열성요로감염소아에게발생한신손상에대한영상의학적평가에대해지속적인연구가이루어지고있으나, 아직공통되는진단방법은확립되어있지않은상태로, 1999 년미국소아과학회에서는첫발열성요로감염소아에게복부초음파와배뇨성방광요도조영술을시행하는것을권고하였으나 [4], Hansson 등 [16] 은복부초음파와 99m Tc-DMSA 신스캔을, Kass 등 [17] 복부초음파, 배뇨성방광요관조영술과 99m Tc-DMSA 신스캔을시행하도록권장하였다. 과거영아요로감염에서방광요관역류를예측하는데있어컬러도플러초음파가유용하다는연구결과 [18] 와첫발열성요로감염소아에서방광요관역류를예측하는데배뇨중신초음파가유용하다는연구 [19] 가있었으나이후에는신초음파가방광요관역류를예측하는데도움이되지않는다는의견이대부분이었다. Foresman 등 [20] 은영아요로감염에서급성기의신우신염에시행한신초음파는방광요관역류의유무나정도와상관성이떨어진다고하였고 Mahant 등 [8], Alshamsam 등 [9], Zamir 등 [21] 도첫발열성요로감염의소아에서방광요관역류를예측하는데신초음파의민감도와특이도가낮다고하여신초음파가방광요관역류를예측하는데있어서그효용성이떨어진다고보았다. 뿐만아니라 Kang 등 [22] 은 1개월이상 3개월미만의남아 (30 명 ) 에서초음파소견이정상인경우방광요관역류가있을위험도가유의하게낮았다고하였다. 그러나방광요관역류를예측하기위한신초음파의효용성연구는지속되었으며신초음파소견중원위요관확장이나신배의간헐적인확장은방광요관역류의중요한예측인자가될수있다는연구결과가있었다 [23, 24]. 최근 Lee 등 [6] 은첫발열성요로감염으로진단받은 220 명의소아를대상으로한후향적연구에서신초음파를통한경도의방광요관역류예측도는 41.7%, 중등도의방광요관역류예측도는 86% 이라고하였으며, Ismaili 등 [10] 역시신초음파 를통한중등도의방광요관역류민감도는 97%, 특이도는 94% 로경도의방광요관역류를제외한방광요관역류를진단하는데신초음파가유용하다고하였다. Hannula 등 [25] 도첫발열성요로감염소아에서신초음파는방광요관역류를진단하기위한일차적선별검사로서이용될수있다고하였으며, 더나아가간접배뇨초음파 (indirect voiding US) 와요관제트도플러파형분석 (ureteral jet Doppler waveform analysis) 은배뇨성방광요도조영술에비해방사선노출이적고덜침습적으로 3세이상의소아에서배뇨성방광요도조영술을대신할수있는비교적안전하고유용한검사라고하였다 [26]. 신초음파는비침습적이고방사선에대한노출이없으며비용이비교적적게들어수신증등의폐색성병변이있을때요로계의구조와이상유무를비교적손쉽게알아볼수있는장점이있으나 [5], 방광요관역류나신실질의이상을정확히평가하기에어렵다는단점이있다 [7]. 본연구에서는, 나이, 성별은방광요관역류와 4단계이상의심한방광요관역류와연관성을보이지않았고, 신초음파이상이있는신단위에서방광요관역류의빈도가상대적으로높았다 (73.9% vs. 58.7%; P=0.049). 또한신초음파이상소견은방광요관역류을예측하는독립적인자였다. 그러므로신초음파이상소견이방광요관역류의중증도까지예측하는것은가능하지않으나어느정도방광요관역류자체를예측하는것은가능하였다. 또한방광요관역류가있는신단위의경우, 나타나는신초음파이상소견으로는수신증 17.6% (19/108), 피질음영증가 16.7% (18/108), 요관확장 8.3% (9/108) 순으로많아이러한신초음파이상소견이보일때배뇨성방광요도조영술의시행이필요할것으로사료된다. 요약목적 : 본연구는방광요관역류를보이는소아에서신초음파이상소견에대해알아보고자하였다. 방법 : 2000 년 1월부터 2010 년 12월까지일산병원소아청소년과에내원하여요로감염증으로입원한후배뇨성방광요도조영술을시행하여방광요관역류를진단받은 83 명의소아를대상으로총 166 신단위를후향적으로분석하였다. 결과 : 대상소아중 1세미만의평균나이는 3.1±2.56 개월이었고, 1세이상의평균나이는 58.9±43.01 개월이었다. 신초음파이상소견을보이는신단위에서방광요관역류가

5 36 J Korean Soc Pediatr Nephrol Vol. 16, No. 1, 32-37, 2012 있는경우는 73.9% 였고, 신초음파정상소견을보이는신단위에서방광요관역류가있는경우는 58.7% 였으며이는통계적으로유의한차이를보였다 (P=0.049). 로지스틱회귀분석에서신초음파이상소견이있을경우방광요관역류가있을확률은약 2배증가하였다. 방광요관역류가있는신단위에서신초음파정상소견을보이는경우는 52.8%, 피질음영증가 16.7%, 수신증 17.6%, 요관확장 8.3%, 수신증을동반한요관확장 1.9% 등이었다. 이중수신증 (82.6%), 요관확장 (100%), 중복요관 (66.6%), 손상된위축신 (100 %) 이있는경우방광요관역류의빈도가상대적으로높았다. 결론 : 방광요관역류가있는신단위에서신초음파이상소견으로방광요관역류의중증도를예측하는것은가능하지않으나방광요관역류의존재를예측하는것은가능하다. 그러므로수신증, 요관확장같은신초음파이상소견이있을시, 배뇨성방광요도조영술의시행이필요할것이다. References 1) Weiss R, Tamminen-Mobius T, Koskimies O, Olbing H, Smellie JM, Hirche H, et al. Characteristics at entry of children with severe primary vesicoureteral reflux recruited for a multicenter, international therapeutic trial comparing me dical and surgical management. The international Reflux Study in children. J Urol 1992;148: ) Smellie JM, Ransley PG, Normand IC, Prescod N, Edwards D. Development of new renal scars : a collaborative study. BMJ Clin Res Ed 1985;290: ) Pattaragarn A, Alon US. Urinary tract infection in childhood. Review of guidelines and recommendations. Minerva Pediatr 2002;54: ) American Academy of Pediatrics, Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics 1999;103: ) Soylu A, Kasap B, Demir K, Türkmen M, Kavukçu S. Predictive value of clinical and laboratory variables for vesicoureteral reflux in children. Pediatr Nephrol 2007;22: ) Lee HY, Soh BH, Hong CH, Kim MJ, Han SW. The efficacy of ultrasound and dimercaptosuccinic acid scan in predicting vesicoureteral reflux in children below the age of 2 years with their first febrile urinary tract infection. Pediatr Nephrol 2009;24: ) Berrocal T, Pinilla I, Gutiérrez J, Prieto C, de-pablo L, Del- Hoyo ML. Mild hydronephrosis in newborns and infants: can ultrasound predict the presence of vesicoureteral reflux. Pediatr Nephol 2007;22: ) Mahant S, Friedman J, MacArthur C. Renal ultrasound findings and vesicoureteral reflux in children hospitalized with urinary tract infection. Arch Dis Child 2002;86: ) Alshamsam L, Al Harbi A, Fakeeh K, Al Banyan E. The value of renal ultrasound in children with a first episode of urinary tract infection. Ann Saudi Med 2009;29: ) Ismaili K, Wissing KM, Lolin K, Le PQ, Christophe C, Lepage P, Hall M. Characteristics of first urinary tract infection with fever in children: a prospective clinical and imaging study. Pediatr Infect Dis J 2011;30: ) Oh YS, Choi MJ, Park SJ, Lee JS, Shin JI, Kim KH. Prevalence of vesicoureteral reflux according to the timing of voiding cystourethrography in infantile urinary tract infection with renal cortical defect in 99mTc-2, 3-dimercap tosuccinic acid scintigraphy: a bicentric study. J Korean Soc Pediatr Nephrol 2011 Nov. [Epub ahead of print] 12) Hsieh MH, Madden-Fuentes RJ, Roth DR. Urologic diagnoses among infants hospitalized for urinary tract infection. Urology 2009;74: ) Rachmiel M, Aladjem M, Starinsky R, Strauss S, Villa Y, Goldman M. Symptomatic urinary tract infections following voiding cystourethrography. Pediatr Nephrol 2005;20: ) Glynn B, Gordon IR. The risk of infection of the urinary tract as a result of micturating cystourethrography in children. Ann Radiol (Paris) 1970;13: ) Zerin JM, Shulkin BL. Postprocedural symptoms in children who undergo imaging studies of the urinary tract: is it the contrast material or the catheter? Radiology 1992;182: ) Hansson S, Dhamey M, Sigström O, Sixt R, Stokland E, Wennerström M. Dimercaptosuccinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. J urol 2004;172: ) Kass EJ, Kernen KM, Carey JM. Pediatric urinary tract infection and the necessity of complete urological imaging. BJU Int 2000;86: ) Salih M, Baltaci S, Kiliç S, Anafarta K, Bedük Y. Color flow Doppler sonography in the diagnosis of vesicoureteric reflux. Eur Urol 1994;26: ) Hiraoka M, Hashimoto G, Hayashi S, Hori C, Tsuchida S, Tsukahara H, Konishi Y, Sudo M. Ultrasonography for the de tection of ureteric reflux in infants with urinary infection. Acta Paediatr Jpn 1996;38: ) Foresman WH, Hulbert WC Jr, Rabinowitz R. Does urinary tract ultrasonography at hospitalization for acute pyelonephritis predict vesicoureteral reflux? J Urol 2001;165: ) Zamir G, Sakran W, Horowitz Y, Koren A, Miron D. Urinary tract infection: is there a need for routine renal ultra sonography? Arch Dis Child 2004;89: ) Kang HG, Kim NH, Kang JH, Ha IS, Cheong HI, Choi Y.

6 Choi MJ, et al.: Two Cases of C1q Nephropathy in Siblings 37 Characteristics and recurrence risk factors of urinary tract infection in early infancy. J Korean Soc Pediatr Nephrol 2004;8: ) Weinberg B, Yeung N. Sonographic sign of intermittent dilatation of the renal collecting system in 10 patients with vesicoureteral reflux. J Clin Ultrasound 1998;26: ) Kenney IJ, Negus AS, Miller FN. Is sonographically demon strated mild distal ureteric dilatation predictive of vesicoureteric reflux as seen on micturating cystourethrography? Pediatr Radiol 2002;32: ) Hannula A, Venhola M, Perhomaa M, Pokka T, Renko M, Uhari M. Imaging the urinary tract in children with urinary tract infection. Acta Paediatr 2011 Jun 28. doi: /j x. 26) Novljan G, Levart TK, Kljucevsek D, Kenig A, Kenda RB. Ultrasound detection of vesicoureteral reflux in children. J Urol 2010;184:

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar