Adjunctive Oral Methylprednisolone in Pediatric Acute

Pyelonephritis Alleviates Renal Scarring

Oleh :
Indah Kusumo Wardani Puteri

PEMBIMBING :
dr. Tuty Rahayu, Sp.A

Pendahuluann
jaringan parut pada ginjal setelah APN adalah merupakan
kekhawatiran gejala sisa yang bersifat jangka panjang. Insiden
jaringan parut pada ginjal setelah APN berkisar dari 26,5%
sampai 57% . Beberapa telah menunjukkan bahwa proses
inflamasi berasal dari komponen bakteri yang bertanggung
jawab untuk kerusakan permanen pada ginjal Oleh karena itu,
Pencegahan scarring setelah pielonefritis akut tidak hanya
bergantung pada diagnosis awal dan perawatan segera untuk
eradikasi bakteri, tetapi juga pada cara mengatasi respons
inflamasi yang destruktif

Tujuan Peneliti
Uji klinis terbaru menunjukkan bahwa terapi pendamping
methylprednisolone

oral

dapat

menurunkan

kejadian

dan/atau keparahan renal scarring pada pielonefritis anak.

Tujuan studi ini adalah untuk meneliti apakah pemberian
glukokortikoid dapat mencegah pembentukan renal scarring
setelah episode pertama pielonefritis akut pada pasien anak
(<16 tahun) yang berisiko tinggi mengalami renal scarring.

Methods
Delapan puluh empat subjek secara acak menerima antibiotik plus
methylprednisolone sodium phosphate (1,6 mg/kg/hari; n=19) atau antibiotik
plus plasebo (n=65) setiap 6 jam selama 3 hari. Endpoint primernya adalah
renal scarring yang terlihat pada pemeriksaan 6 bulan kemudian.
Pada awal studi, kedua kelompok memiliki karakteristik, parameter inflamasi
akut, dan temuan DMSA yang mirip. Enam bulan kemudian, 33,3% anak yang
diberi methyl prednisolone memperlihatkan renal scarring pada pemeriksaan
DMSA, sedangkan pada kelompok kontrol, 60% menunjukkan renal scarring
pada pemeriksaan DMSA (p<0,05), dengan nilai median volume defek
kortikal berturut-turut 0,0 mL (0-4,5 mL) dan 1,5 mL (0-14,8 mL) (p <0,01).
Dibandingkan dengan kelompok kontrol, demam pasien di kelompok
methylprednisolone turun lebih cepat.

Results
Terapi
pendamping
methylprednisolone
oral
dengan
pemberian antibiotik yang kuat dapat menjadi terapi yang
potensial mencegah atau mengurangi kerusakan jaringan
permanen
pada
pasien
pielonefritis
akut.
(AGN)

Critical
Appraisal

1a. R- Was the assignment of patients

to treatments randomised?
Ya,
Pada halaman 499 bagian results disebutkan During the study period, 325
pediatric patients diagnosed with their first febrile UTI were screened for
enrollment. Of these, 304 underwent DMSA. Patients with an inflammatory
volume of _4.6 mL after DMSA or with renal parenchymal changes noted using
ultrasonography were enrolled consecutively. In total, 91 children underwent
DMSA within 48 hours of admission, and 122 underwent DMSA within 48
to103 patients met the inclusion criteria and were considered at high risk of
renal scar formation. 28,29 Of these, 19 declined to participate. The remaining
84 patients were enrolled and randomly assigned to either the MPD group
(antibiotics plus MPD) or the placebo group (antibiotics plus placebo).

1b. R- Were the groups similar at the

start of the trial?
Ya,
Pada halaman 499 bagian Demographic and Clinical Characteristics disebutkan Of
the 84 children enrolled in the study, 19 were assigned to the MPD group and 65 to
the placebo group. The MPD group consisted of 10 boys and 9 girls (median age: 7
months [range: 1168 months]; mean _ SD age: 24.6 _ 41.4 months) and the
placebo group consisted of 34 boys and 31 girls (median age: 8 months [range: 1
180 months]; mean _ SD age: 20.0 _ 32.4 months). The characteristics of the study
participants are summarized in Table 1. A high incidence of noncircumcision was
noted in the male participants (MPD versus placebo: 8 of 10 vs 31 of 34; P_ .33). Of
the 84 patients, 77 (91.7%) underwent VCUG. No significant differences were found
between the 2 groups in terms of age, gender distribution, duration of fever before
admission, history of breastfeeding, or prevalence of VUR. In addition, no
statistically significant differences were found between the 2 groups in clinical
inflammatory parameters, including degree of peripheral leukocytosis, left shift of
the white blood cell count, and C-reactive protein level (Table 1)

2a. A Aside from the allocated treatment,

were groups treated equally?
Ya
Pada halaman 498 bagian result disebutkan During the study period,
325 pediatric patients diagnosed with their first febrile UTI were
screened for enrollment. Of these, 304 underwent DMSA. Patients with
an inflammatory volume of _4.6 mL after DMSA or with renal
parenchymal changes noted using ultrasonography were enrolled
consecutively. In total, 91 children underwent DMSA within 48 hours of
admission, and 122 underwent DMSA within 48 to 72 hours.
Ultimately, 103 patients met the inclusion criteria and were
considered at high risk of renal scar formation. Of these, 19 declined
to participate. The remaining 84 patients were enrolled and randomly
assigned to either the MPD group (antibiotics plus MPD) or the placebo
group (antibiotics plus placebo).

2b. A Were all patients who entered the trial

accounted for? and were they analysed in the
groups to which they were randomised?
Tidak.
Karena di jelaskan pada halaman 497 bagian Methods, study population
Patients were included if: they were between 1 week and 16 years of age;
had evidence of UTI (ie, a core temperature of _38C, positive urine culture,
growth of microorganisms _105 colony-forming units per mL from a clean,
voided midstream urine in older children or_103 colony-forming units per mL
after bladder catheterization or any growth from a suprapubic puncture in
younger children; and _5 leukocyte cells per high-power field); and if they were
at high risk of renal scar formation. Children were considered at risk for renal
scar formation if either a focal or multifocal photon defect with a maximal
inflammatory volume of_4.6 mL on technetium-99mlabeled dimercaptosuccinic
acid scan (DMSA) performed within 48 hours of admission was noted28 or there
was an abnormal finding on renal ultrasonography, 29 if DMSA was performed to
diagnose APN between 48 and 72 hours after admission

 . Exclusion criteria included: a history of UTI; previous

treatment with either oral or intravenous antibiotics; there
was concurrent urogenital uropathy (except vesicoureteral
reflux [VUR]); DMSA was not performed within 72 hours of
admission; and there was no photopenic finding or diffuse
photopenic kidney on DMSA or space-occupying lesions on
ultrasonography, except those progressing to abscess
formation

3. M - Were measures objective or were the

patients and clinicians kept blind to which
treatment was being received?
Iya.
Dijelaskan

pada

halaman

497

bagian

method

study

population Children diagnosed with their first febrile UTI

admitted between January 2002 and December 2004 were
screened

for

enrollment

in

this

controlled prospective study (Fig 1)..

double-blind,

placebo-

What were the results?

How large was the treatment effect?
Terjadi Jaringan
parut pada renal
Antibiotic + MPD

6(a)

Tidak Terjadi
Total
jaringan parut pada
renal
12(b)
18

Antibiotik +
placebo

46(c)

19(d)

65

52

31

83

How precise was the estimate of the

treatment effect?
Dijelaskan pada halaman 500 bagian risk factor for renal scar
formation Risk factor analysis for renal scar formation in the
placebo and MPD groups was performed by using univariate
and multivariate analyses (Table 3). The initial inflammatory
volume on DMSA was a risk factor for renal scar formation in
the placebo group (OR: 1.13 [95% CI: 1.021.25]) but not in
the MPD group (OR: 1.06 [95% CI: 0.72 1.55]).

Will the results help me in caring for my

patient? (ExternalValidity/Applicability)
Is my patient so different to those in the study
that the results cannot apply?
Pasien yang saya temukan tidak jauh berbeda dengan
criteria pada

pasien jurnal tersebut sehingga pemberian

metilprednisolone dapat diberikan kepada pasien saya.

Is the treatment feasible in my

setting?
Ya, metilprednisole dapat di apotik di kota saya.

Will the potential benefits of treatment

outweigh the potential harms of treatment for
my patient?
Penelitian ini mengungkapkan bahwa obat antiinflamasi
MPD , bila dikombinasikan dengan antibiotik yang tepat
dapat memperbaiki kedua parameter klinis dan ginjal
dalam pembentukan bekas luka pada pasien pediatric
dengan APN. Selain itu, durasi yang lebih singkat dari
waktu pasien masuk untuk penurunan suhu badan sampai
normal juga dapat mengurangi durasi rawat inap dan
biaya.

THANK YOU..
ALHAMDULILLAH..