End-Stage Kidney Disease Following Reflux Nephropathy Since the 2011 AAP Guideline

In 2011, the American Academy of Pediatrics (AAP) published a clinical practice guideline for urinary tract infections (UTI) in which voiding cysto-urethrogram (VCUG) would no longer be the first-line imaging study after first febrile urinary tract infection in children.1 Instead, VCUG would be indicated if a renal bladder ultrasound (RBUS) reveals hydronephrosis, scarring, or other findings suggestive of high-grade vesico-ureteral reflux (VUR) or obstructive uropathy. RBUS was recommended for all febrile infants and could be done in the acute period if suppurative complications (eg, renal abscesses) were suspected. The guideline acknowledged that RBUS would not identify all children with high-grade VUR, but the risk of a missed case was low and balanced by the avoidance of a painful procedure that also involves radiation exposure. Subsequently, and as expected, the use of VCUGs has decreased. Even though the 2011 guideline was retired in 2021 as part of the AAP's work to eliminate race-based medicine, the proportion of children who receive a VCUG after a febrile UTI remains low. The question is whether this decrease in VCUG has led to any harm.