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Adjuvant corticosteroids for prevention of kidney scarring in children with acute pyelonephritis: a systematic review and meta-analysis

Background Acute pyelonephritis in children may result in permanent kidney scarring that is primarily caused by inflammation during acute infection. Antibiotic therapy alone is not enough to significantly reduce kidney scarring, and adjuvant corticosteroid therapy has shown a significant reduction in inflammatory cytokines in urine prompting its evaluation in randomised controlled trials. A few clinical trials showed a trend towards a reduction in renal scarring but did not have an adequate sample size to show a significant effect. Therefore, we planned to synthesise the available evidence on the role of corticosteroids as adjuvant therapy in reducing kidney scarring. Objective To assess the efficacy and safety of adjuvant corticosteroid therapy for the prevention of kidney scarring in children with acute pyelonephritis. Design Systematic review and meta-analysis. Setting Community-acquired febrile urinary tract infections. Patients Children (less than 18 years) with acute pyelonephritis. Intervention Adjuvant corticosteroid therapy (along with antibiotic treatment). Main outcome measures Primary: efficacy in preventing kidney scarring; secondary: serious adverse events associated with corticosteroid therapy. Results Three randomised trials (529 children) were included. Corticosteroids are effective in lowering the risk of kidney scarring as compared with placebo (risk ratio (RR): 0.57; 95% CI 0.36 to 0.90). No significant increase risk of bacteraemia (RR: 1.38; 95% CI 0.23 to 8.23) and hospitalisation (RR: 0.87; 95% CI 0.3 to 2.55) was observed in corticosteroid group. Conclusion Moderate quality evidence suggests that short duration ‘adjuvant corticosteroid therapy’ along with routine antibiotic therapy in acute febrile urinary tract infection significantly reduces the risk of kidney scarring without any significant adverse effects. In this systematic review and meta-analysis, the authors found that adjuvant corticosteroids can prevent renal scarring to antibiotic therapy in febrile UTI. Because of moderate-quality evidence, further multicentric randomized trials with adequate sample size are needed.