Vesicoureteric reflux and reflux nephropathy

Abstract

Reflux nephropathy i.e. renal scarring associated with vesico-ureteric reflux (VUR) and urinary tract infection (UTI) was originally considered an acquired disease. The renal scarring seems to get worse with recurrent urine infections especially in the young. Therefore, in the past much effort was undertaken to correct the VUR surgically and minimize the number of recurrent urinary tract infections by antibiotic prophylaxis with the hope of reducing if not arresting the onset of complications that follow i.e. hypertension and renal failure. However, it is now becoming clear that reflux nephropathy encompass at least two major categories of disease; "acquired" renal scarring secondary to UTI and VUR predominantly affecting females and "congenital" scarring with dysplastic features associated with prenatal VUR but with no infection and predominantly affecting boys. The latter is much less common but is disproportionately represented in the group of patients with reflux nephropathy that go on to develop renal failure. Unfortunately, the susceptibility to renal scarring, the onset of hypertension and progression to renal failure seems to be significantly influenced by genetic factors and hence measures undertaken to prevent recurrence of UTI may not change the ultimate outcome although it will certainly improve the comfort of the individual. Therefore, the extensive investigation and management routines adopted today in these children may not be cost-effective in preventing end stage renal disease in VUR. The progression to renal failure, however, can be delayed but not halted with adequate control of high blood pressure and hence the need for life long follow-up.

The relationship between urinary tract infections and vesicoureteral reflux in Turkish children

“…However, prevention depends on early identification of at-risk patients who are young children after the first UTI and siblings of parents with VUR, aggressive and effective treatment of UTI, minimizing intravesical pressure, and education of patients, parents, and physicians [25]. Renal scarring with repetitive infection can result in hypertension, chronic renal failure, and ESRD [26][27][28].…”

Vesicoureteric reflux deterioration in monozygotic twins

“…Hypo-dysplastic kidneys with reduced size and/or 99m Tc-DMSA uptake -as in our cases -account for nearly 20% of all renal damage, prevail in higher VUR grades, and are commonly associated with prenatal intrauterine reflux/hydronephrosis. 2,3,14 No such history had been recorded for either sibling, though leading us to assume that hypo-dysplasia probably developed owing to "silent" reflux during the first years of life. Reflux and hypo-dysplasia were initially diagnosed ipsilaterally in girl A but contralaterally in girl B.…”

“…1 If not promptly recognized, VURmediated renal injury can lead to recurrent urinary tract infection (UTI), renal hypo-dysplasia, scarring, even endstage nephropathy. 2,3 This report describes the diagnosis and 3-year follow-up of a pair of monozygotic female siblings with primary VUR, exhibiting a remarkably parallel clinical course. The genetic grounds of the disorder, the role of age and dysfunctional voiding in its course, and the contribution of nuclear medicine in the clinical management are discussed.…”

Is a routine voiding cystourethrogram necessary in children after the first febrile urinary tract infection?

“…Vesicoureteral reflux is the most common urologic finding in children, occurring in approximately 1% of newborns, and occurs in as high as 30–45% of young children with a UTI (10). Mild degrees of reflux have a good chance of spontaneous resolution with age in over 80% of the children (11). Even cases of high‐grade reflux may resolve (12).…”