Vesicoureteral Reflux and Reflux Nephropathy

Abstract

Vesicoureteral reflux is an anatomic abnormality, mostly affecting a pediatric population, which may be the second leading cause of end-stage renal failure. Most cases of reflux are due to abnormalities in the insertion of the ureters into the bladder, either congenital or acquired. Most commonly, VUR is discovered during routine evaluation of urinary tract infections, but may also be present in patients with severe hypertension or chronic renal failure. The diagnosis is confirmed radiologically, utilizing either voiding cinecystography or radioisotopic methods. VUR can result in renal failure through scarring secondary to ‘chronic pyelonephritis’ or through a glomerulopathy, possibly immune in origin. In most series, the glomerulopathy is felt to be the cause of the end-stage renal failure. Treatment of VUR includes conservative (medical) management with the hope that maturation of the ureterovesical junction will cure reflux. Surgical therapy is reserved for those patients in whom this maturation is not expected to occur or in those whose urinary infections cannot be controlled. In those patients who have developed the glomerulopathy secondary to VUR, surgery may not halt the progression of the renal disease. VUR in a transplanted kidney may result in a higher risk of loss of the graft due to glomerulopathy or chronic rejection.

The evaluation of acute pyelonephritis and renal scarring with technetium 99m-dimercaptosuccinic acid renal scintigraphy: evolving concepts and future directions

“…Although the risk appears to be greatest in patients with multifocal scarring, these complications have also occurred in patients who initially had unilateral disease. Renal scarring associated with VUR has also been implicated in as many as 10% -20% of patients with end-stage renal disease [5,6]. As reported by Jacobson et al [7], the onset of these complications may not actually present until the 2nd or 3rd decade of life.…”

The Efficacy of Tc99m Dimercaptosuccinic Acid (Tc-DMSA) Scintigraphy and Ultrasonography in Detecting Renal Scars in Children with Primary Vesicoureteral Reflux (VUR)

“…The correlation between renal scars detected in childhood and occurrence of important co-morbidities such as proteinuria, hypertension and ultimate renal failure is well established [1][2][3][4]. The risk for renal parenchymal scar formation is especially increased in children diagnosed with high-grade VUR [5].…”

“…Co-existence with urinary tract infection even increases the risk [6,7]. Unless the reflux is corrected, most children with highgrade reflux ultimately become end stage renal failure patients [1][2][3][4][5]7]. Thus, early detection and follow-up of VUR and renal scars is of great importance.…”

Sensitivity of ultrasonography in detecting renal parenchymal defects: 6 years’ follow-up

“…Regardless of whether RPDs are primary or secondary, they are a major risk factor for progressive CKD [2,3,14,15]. Owing to the severity of the potential poor outcome, it has been generally accepted that children with RPDs should be followed for several years, regardless of when and why they had been detected.…”