Adjuvant corticosteroids for prevention of kidney scarring in children with acute pyelonephritis: a systematic review and meta-analysis [published online ahead of print February 25, 2021]
Arch Dis Child
; doi:

Investigators from the Post Graduate Institute of Medical Education and Research in Chandigarh, India, conducted a systematic review and meta-analysis to assess the efficacy and safety of adjuvant corticosteroid therapy for the prevention of kidney scarring in children with acute pyelonephritis. To identify randomized controlled trials (RCTs) evaluating corticosteroid therapy in children with acute pyelonephritis, investigators searched 4 electronic databases (PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials) from inception to 2020 using a predefined search strategy. RCTs were included if they reported the primary outcome as the number of children with kidney scarring following acute pyelonephritis and also compared adverse events in both the intervention and control groups. Eligible RCTs also needed to have the intervention be corticosteroid treatment adjunctive to standard antibiotic therapy for acute pyelonephritis, but any type, route, or duration of corticosteroid was allowed. After identifying RCTs that fit inclusion criteria, the investigators pooled data across studies to estimate the risk ratio (RR) of renal scarring with treatment of corticosteroids during acute pyelonephritis.

There were 3 RCTs that met eligibility criteria. The intervention in each study differed by type, route, and duration of corticosteroid: one involved administration of oral methylprednisolone for 3 days, another involved intravenous dexamethasone for 4 days, and the third involved oral dexamethasone for 3 days. Age of participants also varied across studies, with age ranges being 1 week to 16 years old in one study, 3 months to 12 years old in another, and 2 months to 6 years old in the third. The outcome measure in all 3 studies was kidney scarring on 99mTc dimercaptosuccinic acid (DMSA) scan at least 4 months after intervention.

Primary outcome data were available for 389 children. In pooled analyses, adjuvant corticosteroid therapy was associated with a significantly decreased risk of renal scarring at 4-month follow-up (RR, 0.57; 95% CI, 0.36, 0.90). There was no significant difference in adverse events (bacteremia, hospitalization, or gastrointestinal disturbances) between intervention and control groups.

The investigators conclude that there is moderate evidence that adjuvant corticosteroid therapy for acute pyelonephritis reduces the risk of renal scarring.

Dr Sanchez-Kazi has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

The etiology of kidney scarring after febrile urinary tract infection (fUTI) remains an enigma. Studies have shown that despite antibiotic prophylaxis, surgical correction of vesicoureteral reflux, and improvement of bladder bowel dysfunction, kidney scars still developed.1,2  Long-term complications associated with kidney scarring include hypertension and chronic kidney disease. Elevated cytokine levels including urinary interleukin-6 (UIL-6) and urinary interleukin-8 (UIL-8) have been reported in fUTI in both animals and humans.4,5  These cytokines can lead to parenchymal inflammation and subsequent...

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