Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) - Full Text View

Purpose

In this 2-year, multisite, randomized, placebo-controlled trial involving 607 children with vesicoureteral reflux that was diagnosed after a first or second febrile or symptomatic urinary tract infecton, we evaluated the efficacy of Trimethoprim-Sulfamethoxazole (TMP-SMZ) prophylaxis in preventing recurrences (primary outcome). Secondary outcomes were renal scarring, treatment failure (a composite of recurrences and scarring), and antimicrobial resistance.

Condition	Intervention	Phase
Vesicoureteral Reflux Urinary Tract Infections	Drug: Trimethoprim-Sulfamethoxazole Drug: Placebo	Phase 3


Study Type:	Interventional
Study Design:	Allocation: Randomized Intervention Model: Parallel Assignment Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor) Primary Purpose: Prevention
Official Title:	Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR)

Resource links provided by NLM:

MedlinePlus related topics: GERD Urinary Tract Infections

Drug Information available for: Sulfamethoxazole Trimethoprim Trimethoprim hydrochloride

U.S. FDA Resources

Further study details as provided by National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK):

Primary Outcome Measures:

Recurrent Febrile or Symptomatic Urinary Tract Infection During 2-year Follow-up [ Time Frame: 2 years ]

Secondary Outcome Measures:

Outcome Renal Scarring [ Time Frame: 2 years ]
Renal scarring was defined as a decreased uptake of tracer that was associated with loss of contours or the presence of cortical thinning. Outcome dimercaptosuccinic acid (DMSA) scan was performed at 2 years after enrollment or 3-4 months after the child had met treatment failure criteria.
Severe Renal Scarring on Outcome Scan [ Time Frame: 2 years ]
Severe renal scarring was defined as scarring in more than 4 of 12 segments in at least one kidney or global atrophy characterized by diffusely scarred and shrunken kidney. Outcome DMSA scan performed at 2 years after enrollment or 3-4 months after the child had met treatment failure criteria.
New Renal Scarring on Outcome Scan [ Time Frame: 2 years ]
New renal scarring was defined as scarring on the outcome renal scan with technetium -99m-labeled dimercaptosuccinic acid that was not present at baseline. Outcome DMSA scan performed at 2 years after enrollment or 3-4 months after the child had met treatment failure criteria.
Treatment Failure Composite [ Time Frame: 2 years ]
Treatment failure was defined as the occurrence of two febrile urinary tract infections (UTIs), one febrile UTI and three symptomatic UTIs, four symptomatic UTIs, or new or worsening renal scarring on an interim scan (e.g,, the 12-month visit); renal scans from the 2-year visit are NOT considered in the treatment failure criteria.
Presence of E.Coli Resistant to Trimethoprim-Sulfamethoxazole (TMP-SMZ) (Based on Rectal Swab) [ Time Frame: 2 years ]
Recurrent Febrile or Symptomatic UTI With Resistant E. Coli [ Time Frame: 2 years ]
Recurrent Febrile or Symptomatic UTI With Any Resistant Pathogen [ Time Frame: 2 years ]


Enrollment:	607
Study Start Date:	May 2007
Study Completion Date:	May 2014
Primary Completion Date:	June 2013 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
Active Comparator: Trimethoprim-Sulfamethoxazole Cherry-flavored liquid suspension with 3 mg of trimethoprim plus 15 mg sulfamethoxazole per kilogram of body weight, taken once daily.	Drug: Trimethoprim-Sulfamethoxazole Cherry-flavored liquid suspension with 3 mg of trimethoprim plus 15 mg sulfamethoxazole per kilogram of body weight, taken once daily. Other Names: Sulfatrim Bactrim
Placebo Comparator: Placebo Cherry-flavored liquid suspension matched to active comparator.	Drug: Placebo Cherry flavored liquid suspension matched to active comparator.

Detailed Description:

This multicenter, randomized, double-blind, placebo-controlled trial was designed to determine whether daily antimicrobial prophylaxis is superior to placebo in preventing recurrence of urinary tract infection (UTI) in children with vesicoureteral reflux (VUR). Eligibility criteria are described elsewhere. Patients were randomly assigned to treatment for 2 years with daily antimicrobial prophylaxis (trimethoprim-sulfamethoxazole) or placebo. The study was designed to recruit 600 children (approximately 300 in each treatment group). The protocol encouraged prompt evaluation of children with UTI symptoms and early therapy of culture-proven UTIs. It was expected that approximately 10% of children will have to discontinue study medication due to allergic reactions. Assuming a 20% placebo event rate and 10% non-compliance rate, the study has 83% power to detect an absolute 10% event rate in the antimicrobial prophylaxis group. If the placebo event rate is instead 25%, power is 97% to detect an absolute 10% event rate in the treated group, even if non-compliance is as high as 15%. The primary analysis is intention-to-treat with missing outcome data analyzed as UTI.

In addition to collecting follow-up data on urinary tract infections, renal scarring and antimicrobial resistance, quality of life, compliance, safety parameters, utilization of health resources, and change in VUR were assessed periodically throughout the study.

Eligibility

Information from the National Library of Medicine

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Ages Eligible for Study:	2 Months to 71 Months (Child)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

Age at randomization: at least 2 months, but less than 6 years of age. Note that children as young as 1 month were screened for the study.
Diagnosed first or second febrile or symptomatic UTI within 112 days prior to randomization
Presence of Grade I- IV VUR based on radiographic voiding cystourethrogram (VCUG) performed within 112 days of diagnosis of index UTI.
Appropriately treated index febrile or symptomatic UTI

Exclusion Criteria:

Index UTI diagnosis more than 112 days prior to randomization
History of more than two UTIs prior to randomization
For patients less than 6 months of age at randomization, gestational age less than 34 weeks
Co-morbid urologic anomalies
Hydronephrosis, SFU Grade 4
Ureterocele
Urethral valve
Solitary kidney
Profoundly decreased renal size unilaterally on ultrasound (based on 2 standard deviations below the mean for age and length) performed within 112 days after diagnosis of index UTI
Multicystic dysplastic kidney
Neurogenic bladder
Pelvic kidney or fused kidney
Known sulfa allergy, inadequate renal or hepatic function, Glucose-6-phosphate dehydrogenase deficiency or other conditions that are contraindications for use of TMP-SMZ
History of other renal injury/disease
Unable to complete the study protocol
Congenital or acquired immunodeficiency
Underlying anomalies or chronic diseases that could potentially interfere with response to therapy such as chronic gastrointestinal conditions (i.e., malabsorption, inflammatory bowel disease), liver or kidney failure, or malignancy.
Complex cardiac disease as defined in the Manual of Procedures.
Any known syndromes associated with VUR or bladder dysfunction
Index UTI not successfully treated
Unlikely to complete follow-up
Family history of anaphylactic reaction to sulfa medications

Contacts and Locations

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT00405704

Show 19 Study Locations

Sponsors and Collaborators

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Investigators


Principal Investigator:	Sahar Fathallah, MD	University of Alabama, Birmingham, AL
Principal Investigator:	Myra A Carpenter, PhD	University of NC at Chapel Hill, Chapel Hill, NC
Principal Investigator:	Caleb P. Nelson, MD, MPH	Children's Hospital of Boston, Boston, MA
Principal Investigator:	Eileen Brewer, MD	Texas Children's Hospital, Houston, TX
Principal Investigator:	Saul P Greenfield, MD	Women and Children's Hospital of Buffalo, Buffalo, NY
Principal Investigator:	Alejandro Hoberman, MD	Children's Hospital of Pittsburgh, Pittsburgh, PA
Principal Investigator:	Ron Keren, MD, MPH	Children's Hospital of Philadelphia, Philadelphia, PA
Principal Investigator:	Bradley P Kropp, MD	University of Oklahoma, Oklahoma City, OK
Principal Investigator:	Ranjiv Mathews, MD	Johns Hopkins University
Principal Investigator:	Tej K Mattoo, MD,DCH, FRCP	Wayne State University School of Medicine, Detroit, MI
Principal Investigator:	H. Gil Rushton, MD, FAAP	Children's Research Institute
Principal Investigator:	Mary Ann Queen, MD	Children's Mercy Hospital Kansas City
Study Chair:	Russell W Chesney, MD	Le Bonheur Children's Medical Center, Memphis, TN
Principal Investigator:	Steven J Skoog, MD FACS,FAAP	Oregon Health & Science University, Portland, OR
Principal Investigator:	Amy Renwick, MD	Alfred I. duPont Hospital for Children, Wilmington, DE
Principal Investigator:	Earl Y. Cheng, MD	Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
Principal Investigator:	Milan Nadkarni, MD	Wake Forest University Baptist Medical Center, Winston-Salem, NC
Principal Investigator:	Caleb P Nelson, MD, MPH	Children's Hospital of Boston, Boston, MA
Principal Investigator:	William R DeFoor, Jr, MD, MPH	Cincinnati Children's Hospital, Cincinnati, OH
Principal Investigator:	Dan McMahon, MD	Akron Children's Hospital, Akron, OH
Principal Investigator:	Ross Decter, MD	Penn State Hershey Medical Center, Hershey, PA
Principal Investigator:	Sharon M Bartosh, MD	University of Wisconsin, Madison

More Information

Publications:

Carpenter MA, Hoberman A, Mattoo TK, Mathews R, Keren R, Chesney RW, Moxey-Mims M, Greenfield SP; RIVUR Trial Investigators. The RIVUR trial: profile and baseline clinical associations of children with vesicoureteral reflux. Pediatrics. 2013 Jul;132(1):e34-45. doi: 10.1542/peds.2012-2301. Epub 2013 Jun 10.

RIVUR Trial Investigators, Hoberman A, Greenfield SP, Mattoo TK, Keren R, Mathews R, Pohl HG, Kropp BP, Skoog SJ, Nelson CP, Moxey-Mims M, Chesney RW, Carpenter MA. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014 Jun 19;370(25):2367-76. doi: 10.1056/NEJMoa1401811. Epub 2014 May 4.

Ziessman HA, Majd M. Importance of methodology on (99m)technetium dimercapto-succinic acid scintigraphic image quality: imaging pilot study for RIVUR (Randomized Intervention for Children With Vesicoureteral Reflux) multicenter investigation. J Urol. 2009 Jul;182(1):272-9. doi: 10.1016/j.juro.2009.02.144. Epub 2009 May 17.

Mathews R, Carpenter M, Chesney R, Hoberman A, Keren R, Mattoo T, Moxey-Mims M, Nyberg L, Greenfield S. Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study. J Pediatr Urol. 2009 Oct;5(5):336-41. doi: 10.1016/j.jpurol.2009.05.010. Epub 2009 Jul 1. Review.

Keren R, Carpenter MA, Hoberman A, Shaikh N, Matoo TK, Chesney RW, Matthews R, Gerson AC, Greenfield SP, Fivush B, McLurie GA, Rushton HG, Canning D, Nelson CP, Greenbaum L, Bukowski T, Primack W, Sutherland R, Hosking J, Stewart D, Elder J, Moxey-Mims M, Nyberg L. Rationale and design issues of the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. Pediatrics. 2008 Dec;122 Suppl 5:S240-50. doi: 10.1542/peds.2008-1285d.

Greenfield SP, Chesney RW, Carpenter M, Moxey-Mims M, Nyberg L, Hoberman A, Keren R, Matthews R, Mattoo T. Vesicoureteral reflux: the RIVUR study and the way forward. J Urol. 2008 Feb;179(2):405-7.

Chesney RW, Carpenter MA, Moxey-Mims M, Nyberg L, Greenfield SP, Hoberman A, Keren R, Matthews R, Matoo TK; members of the RIVUR Steering Committee. Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR): background commentary of RIVUR investigators. Pediatrics. 2008 Dec;122 Suppl 5:S233-9. doi: 10.1542/peds.2008-1285c.

Keren R. Pediatrics. RIVUR trial. Introduction. Pediatrics. 2008 Dec;122 Suppl 5:S231-2.

Greenfield SP, Carpenter MA, Chesney RW, Zerin JM, Chow J. The RIVUR voiding cystourethrogram pilot study: experience with radiologic reading concordance. J Urol. 2012 Oct;188(4 Suppl):1608-12. doi: 10.1016/j.juro.2012.06.032. Epub 2012 Aug 19.

Hoberman A, Shaikh N, Bhatnagar S, Haralam MA, Kearney DH, Colborn DK, Kienholz ML, Wang L, Bunker CH, Keren R, Carpenter MA, Greenfield SP, Pohl HG, Mathews R, Moxey-Mims M, Chesney RW. Factors that influence parental decisions to participate in clinical research: consenters vs nonconsenters. JAMA Pediatr. 2013 Jun;167(6):561-6. doi: 10.1001/jamapediatrics.2013.1050.

Bhatnagar S, Hoberman A, Kearney DH, Shaikh N, Moxey-Mims MM, Chesney RW, Carpenter MA, Greenfield SP, Keren R, Mattoo TK, Mathews R, Gravens-Mueller L, Ivanova A. Development and impact of an intervention to boost recruitment in a multicenter pediatric randomized clinical trial. Clin Pediatr (Phila). 2014 Feb;53(2):151-7. doi: 10.1177/0009922813506961. Epub 2013 Oct 22.

Chesney RW, Patters AB. Childhood vesicoureteral reflux studies: registries and repositories sources and nosology. J Pediatr Urol. 2013 Dec;9(6 Pt A):731-7. doi: 10.1016/j.jpurol.2012.09.003. Epub 2012 Oct 5. Review.

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Keren R, Shaikh N, Pohl H, Gravens-Mueller L, Ivanova A, Zaoutis L, Patel M, deBerardinis R, Parker A, Bhatnagar S, Haralam MA, Pope M, Kearney D, Sprague B, Barrera R, Viteri B, Egigueron M, Shah N, Hoberman A. Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring. Pediatrics. 2015 Jul;136(1):e13-21. doi: 10.1542/peds.2015-0409. Epub 2015 Jun 8.


Responsible Party:	National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
ClinicalTrials.gov Identifier:	NCT00405704 History of Changes
Other Study ID Numbers:	DK074059 (IND) U01DK074059 ( U.S. NIH Grant/Contract )
First Submitted:	November 29, 2006
First Posted:	November 30, 2006
Results First Submitted:	December 4, 2014
Results First Posted:	April 16, 2015
Last Update Posted:	April 16, 2015
Last Verified:	April 2015

Keywords provided by National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK):


Vesicoureteral Reflux Urinary Tract Infections Renal Scarring Antibiotic Resistance	Controlled Clinical Trial Trimethoprim-Sulfamethoxazole Children

Additional relevant MeSH terms:


Gastroesophageal Reflux Urinary Tract Infections Vesico-Ureteral Reflux Esophageal Motility Disorders Deglutition Disorders Esophageal Diseases Gastrointestinal Diseases Digestive System Diseases Infection Urologic Diseases Urinary Bladder Diseases Trimethoprim Trimethoprim, Sulfamethoxazole Drug Combination	Sulfamethoxazole Anti-Infective Agents, Urinary Anti-Infective Agents Renal Agents Antimalarials Antiprotozoal Agents Antiparasitic Agents Folic Acid Antagonists Enzyme Inhibitors Molecular Mechanisms of Pharmacological Action Cytochrome P-450 CYP2C8 Inhibitors Cytochrome P-450 Enzyme Inhibitors Anti-Bacterial Agents

Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) (RIVUR)