A 22-year-old female presents to the urgent care clinic with a three-day history of right loin pain associated with dysuria. Her history is significant for recurrent urinary tract infections and hypertension diagnosed in the first trimester of her first and only pregnancy. On exam, she appears ill. Temperature is 38.5 °C, right costovertebral angle tenderness, 1+ pitting ankle edema, the remainder of exam is unremarkable.

 

Lab Results: 
Creatinine, 2.4 mg/dL [0.6-1.1 mg/dL]

Urinalysis, +++ protein

Urine culture, >10⁵ CFU of **E. coli**

Treatment of acute urinary tract infection is initiated.

 

Which of the following investigation of tests are most appropriate to determine the cause of this patient’s recurrent urinary tract infection and impaired renal function?

A. Kidney-Ureter-Bladder X-ray (KUB)
B. 24-hour urine collection for protein
C. Serum Complement level
D. Contrast Voiding CystoUrethrogram (VCUG)

 

Rationale:

This patient likely has vesicoureteral reflux disease and reflux nephropathy. Vesicoureteral reflux disease and reflux nephropathy should be suspected when the onset of hypertension is during pregnancy and hypertension develop in a young adult, especially if there is a history of urinary tract infections. Reflux nephropathy also needs to be considered in patients with complicated urinary tract infection, persistent proteinuria, unexplained loin pain, or unclear etiology for chronic renal failure. VCUG and radionuclide cystogram (RNC) are used to confirm the diagnosis of vesicoureteral reflux disease by demonstrating reflux of urine from the bladder to the collecting system. Kidney ultrasonography can be used as a screening tool. KUB is not a sensitive test when approaching VUR. Proteinuria during active UTI is non-specific and urinalysis should be repeated before considering 24-hour urine collection for protein. The lack of hematuria makes nephritic syndrome unlikely. Therefore, measuring serum complement level would not be indicated at this point.

 

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