Disappearance of vesicoureteric reflux during long-term prophylaxis of urinary tract infection in children

Urinary infection and stone formation as complications of Gil-Vernet's antireflux procedure

The authors describe two cases of urinary infection and stone formation as late complications of Gil-Vernet's antireflux treatment. The immediate cause of these complications was the migration to the mucosal surface of the nonabsorbable sutures employed in this technique.

Medical management of mild and moderate vesicoureteral reflux: followup studies of infants and young children. A preliminary report of the Southwest Pediatric Nephrology Study Group

Mild and moderate vesicoureteral reflux is expected to resolve spontaneously in most children treated medically; however, maximum benefit or minimum risk of such therapy has not been defined. A prospective 5-year followup study of infants and children younger than 5 years at entry with primary vesicoureteral reflux (grades I to III/V) and radiographically normal kidneys after the first recognized urinary tract infection was initiated in 1984. A total of 113 patients was entered from 5 centers and 61% of the patients were less than 2 years old. Vesicoureteral reflux was unilateral in 65 cases (58%) and bilateral in 48 (42%). Of the 226 renal units reflux was grade IV in 4 (2%), III in 51 (22%), II in 81 (36%) and I in 25 (11%), and 65 (29%) had no vesicoureteral reflux. Data on 59 patients who have completed the protocol were analyzed for this report. Breakthrough urinary tract infection occurred in 20 patients. Of the 84 ureters with vesicoureteral reflux at diagnosis reflux resolved in 67%, and it was of lower grade in 22%, same grade in 8% and higher grade in 2%. Grade I vesicoureteral reflux resolved in 82%, grade II in 80% and grade III in 46% of the ureters. Resolution was better when vesicoureteral reflux was unilateral left (74%) than unilateral right (46%) or bilateral (60%). Renal scarring occurred, on average, in 10% of the kidneys without known vesicoureteral reflux or exposed only to nondilating (grades I and II) reflux and in 28% of those with dilating (grade III) reflux. Thirteen cases had breakthrough urinary tract infection but only after the scar was noted in 5. We conclude that under good medical management during 5 years of followup, even mild and moderate vesicoureteral reflux can be associated with renal injury.

Vesicoureteral Reflux in Childhood: Preventing urinary tract infections

Vesicoureteral reflux (VUR) is the most common anatomical predisposition to pyelonephritis. A retrograde voiding cystourethrogram is the preferred study to assess the severity of VUR. Most children with VUR will respond to medical management. The prevention of urinary tract infections is fundamental to the management of children with VUR.

Renal scarring following reflux and nonreflux pyelonephritis in children: evaluation with 99mtechnetium-dimercaptosuccinic acid scintigraphy

99mTechnetium dimercaptosuccinic acid (DMSA) scintigraphy is the imaging modality of choice for the detection of acute pyelonephritis and chronic renal scarring in children. Using the DMSA scan we prospectively evaluated renal scarring after reflux and nonreflux pyelonephritis in children. The study population consisted of 33 patients with acute pyelonephritis documented by a DMSA renal scan at infection. The children were evaluated for renal scarring with a followup DMSA scan 4 to 42 months (mean 10.7 months) after the acute infection. All new scarring on followup DMSA scans occurred at sites corresponding exactly to areas of acute inflammation on the initial DMSA scan. Therefore, only those kidneys with acute changes on the initial scan were subsequently analyzed. Of 38 kidneys new or progressive scarring developed in 16 (42%), including 6 of 15 (40%) with associated vesicoureteral reflux and 10 of 23 (43%) without demonstrable reflux. New renal scarring developed in 6 of the 7 kidneys (86%) associated with a neuropathic bladder or posterior urethral valves. In contrast, new scarring developed in only 10 of 31 kidneys (32%) associated with a normal bladder (p = 0.028). Excluding the kidneys associated with a neuropathic bladder or posterior urethral valves, new renal scarring developed in 3 of 12 (25%) with primary reflux, compared with 7 of 19 (37%) without vesicoureteral reflux. Except for the white blood count and the species of infecting bacteria, no other statistically significant differences could be found between those cases in which scars did or did not develop. We conclude that acquired renal scarring only occurs at sites corresponding to previous areas of acute pyelonephritis, the acute parenchymal inflammatory changes of acute pyelonephritis are reversible and do not lead to new renal scarring in the majority of cases, and once acute pyelonephritis has occurred ultimate renal scarring is independent of the presence or absence of vesicoureteral reflux.

Renal cortical scintigraphy in the diagnosis of acute pyelonephritis

Comparative clinical studies have shown renal cortical scintigraphy, using technetium-99m (99mTc)-labeled glucoheptonate or dimercaptosuccinic acid (DMSA), to be significantly more sensitive than either intravenous pyelography or renal sonography in the diagnosis of acute pyelonephritis. However, due to uncertainties about the diagnostic accuracy of the clinical and laboratory parameters used in these studies, true sensitivity of renal cortical scintigraphy was unknown. Therefore, we evaluated the accuracy of [99mTc]DMSA scintigraphy in the diagnosis of experimentally induced acute pyelonephritis in piglets using strict histopathologic criteria as the standard of reference. The sensitivity and specificity of the DMSA scan for the diagnosis of acute pyelonephritis were 91% and 99%, respectively, with an overall 97% agreement between the scintigraphic and histopathologic findings. Based on the results of this experimental study, we used the [99mTc]DMSA scan as the standard of reference for the diagnosis of acute pyelonephritis, and conducted a prospective clinical study of 94 children hospitalized with the diagnosis of acute febrile urinary tract infection (UTI). The aims of this study were (1) to determine the relationship among vesicoureteral reflux, P-fimbriated Escherichia coli, acute pyelonephritis, and renal scarring, and (2) to evaluate the diagnostic reliability of the clinical and laboratory parameters commonly used in the diagnosis of acute pyelonephritis. We documented acute pyelonephritis in 62 (66%) of 94 patients. Vesicoureteral reflux was demonstrated in 29 (31%) of the total group and in only 23 (37%) of 62 patients with acute pyelonephritis. The prevalence of P-fimbriae in the E coli isolates was 64% in the patients with acute pyelonephritis and 78% in those with a normal DMSA scan. Even in patients without reflux, P-fimbriae were found in 71% of isolates from the patients with acute pyelonephritis and in 75% of those with a normal renal scan. Follow-up DMSA scans were obtained in 33 patients with acute pyelonephritis in 38 kidneys. We found complete resolution of the acute inflammatory changes in 58% of the involved kidneys and renal scarring in the remaining 42%, including 40% of the kidneys associated with reflux and 43% of those without reflux.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparison of DMSA scintigraphy with intravenous urography for the detection of renal scarring and its correlation with vesicoureteric reflux

A series of 208 patients was prospectively assessed for reflux nephropathy by intravenous urography (IVU) and 99mTc-dimercaptosuccinate (DMSA) scintigraphy. All patients were studied at least 3 months after their most recent urinary tract infection and micturating cystourethrography (MCU) was performed prior to the scintigraphic studies. DMSA scintigraphy detected significantly more cortical abnormalities than did IVU. There was also a correlation between cortical abnormalities in the DMSA studies and the degree of reflux on MCU. The validity of DMSA as a cortical imaging agent is evaluated and the histological evidence for its efficacy derived from the animal model is reviewed, lending weight to its establishment as the "gold standard" for renal cortical scarring.

Radiological imaging of urinary tract infection in Malaysian children--a private hospital experience

The results of radiological investigations performed on 81 children with urinary tract infection (UTI) were reviewed. Investigations included 91 voiding cystourethrograms (VCU), 59 intravenous urograms (IVU) and 36 ultrasonograms (US). The aim was to study the local spectrum of renal tract abnormalities in childhood UTI and to compare the diagnostic yield of combining US and VCU against IVU and VCU. Renal tract abnormalities were detected in 37%. Vesico-ureteric reflux (VUR) was the commonest, detected in 26%, with renal scarring found in 9% of refluxing units. Ultrasound should replace IVU in the initial diagnostic work-up of these children.

Familial reflux: vesicoureteral reflux in all siblings of a family

A family is presented in which 4 of 4 (100%) siblings demonstrate vesicoureteral reflux on voiding cystogram. Mechanisms of inheritance are reviewed.

Vesicoureteric reflux and renal injury

Renal injury associated with the intrarenal reflux (IRR) of urine that is either infected, under high pressure, or both, is a major cause of severe hypertension during childhood and adolescence and of chronic renal insufficiency in patients less than 30 years of age. Many, but not all, adolescent and adult patients with reflux nephropathy (RN) give a history of urinary tract infection (UTI) or unexplained fevers in infancy or early childhood, when the kidney is thought to be at greatest risk of injury. Although vesicoureteric reflux (VUR) is observed more commonly in infants than children with UTI, it is rare in uninfected patients at any age and should never be considered a normal finding during human development. Renal scarring may not be obvious in radiographic or radionuclear studies to medical management alone, no definite benefit of one over the other was observed, regardless of the grade of VUR. Moreover, progressive renal injury in scarred kidneys has been noted even after VUR had been corrected, when infection had been prevented, and while hypertension had been controlled satisfactorily. Focal glomerular sclerosis, a lesion found in patients with proteinuria and RN, has been identified not only in scarred kidneys, but also may be seen in contralateral, unscarred kidneys without VUR, which might suggest a humoral factor or, perhaps, a hyperfiltration phenomenon. RN is one of the most frequent causes of end-stage renal disease (ESRD) in children, adolescents, and young adults, which is potentially preventable. However, prevention will depend on early identification of patients at risk--infants and young children after the first UTI and siblings of patients with VUR--aggressive and effective treatment of UTI, minimizing intravesical pressure, and education of patients, parents, and physicians.

Epidemiology and natural history of urinary tract infections in children

Recent retrospective surveys have supported previous investigations in demonstrating the incidence of UTI during infancy; 0.3% to 1.2% of infants develop symptomatic UTI during the first year of life. Boys are more commonly infected during the first 3 months of life. After the first year, symptomatic UTI is much more frequent among girls. Similarly, asymptomatic bacteriuria is more frequently detected in boys than in girls during the first 12 months of life. Thereafter, the incidence decreases markedly in boys but increases in girls. Recent investigations indicate that lack of circumcision is a risk factor for UTI among male infants. Recurrent UTI is common and frequently asymptomatic. The most important microbiologic factor that is associated with E. coli causing acute pyelonephritis is adherence mediated by P fimbriae. Other factors, such as capsule, lipopolysaccharide, aerobactin production, and serum resistance, also determine the invasiveness of E. coli. Vesicoureteral reflux appears to be an important host factor predisposing to UTI. Microbiologic and host factors that are determinants of renal scarring are under investigation.

High grade vesicoureteral reflux: analysis of observational therapy

Between 1981 and 1987, 300 patients with high grade (III, IV and V international classification) vesicoureteral reflux were treated at a single pediatric hospital. Only patients with primary vesicoureteral reflux were included in the study. The guiding principle during this period was that all patients with high grade vesicoureteral reflux would be observed on prophylactic antibiotics (observational therapy) and surgical correction would be reserved for specific indications. Of the 300 patients 132 received observational therapy alone and 168 required surgical correction for specific indications after varying periods of observation. In both groups the duration of persistent reflux was analyzed using a life-table method. In patients with grade V reflux we observed resolution in 3 patients whereas 23 required surgical correction. Of those patients in the observation group with grade IV reflux 83% had persistent reflux at 2 years and 70% still had reflux at 5 years. For those with grade III reflux the persistence rate was 83% and 50%, respectively. Neither age, sex nor side of reflux had a correlation with the rate of resolution. When tested grade of reflux correlated loosely (p = 0.07). During the period of observational therapy new renal scars developed in 23 patients (8%). We conclude that high grade vesicoureteral reflux can resolve in a minority of patients over a protracted interval. On the basis of this analysis, we advocate consideration of surgical correction in these patients after a 4-year period of observational therapy and for specific indications.

Relation of urinary tract infection and vesicoureteral reflux to scars: follow-up of thirty-eight patients

A prospective study compared the outcome of vesicoureteral reflux and recurrent urinary tract infections in children (3 boys, 62 girls) who received medical prophylaxis or underwent surgical correction of reflux. Thirty-eight children returned for reevaluation 6 to 13 years (average 9.5 years) after entry. There was a marked decrease in prevalence and severity of reflux. At entry, 13 had significant scarring that had progressed at follow-up. New scars were documented by dimercaptosuccinic acid scan at follow-up in eight children on the medical regimen and two who were initially treated with surgical correction of reflux. Four patients with high-grade sterile reflux were followed for 6 to 10 years without the development of cortical scars. Our data support the role of urinary tract infection and vesicoureteral reflux, but not sterile reflux, in the pathogenesis of chronic pyelonephritis and reflux nephropathy.

Prenatally diagnosed reflux: a follow-up study

This report analyses the characteristics and outcome of 25 infants with vesicoureteric reflux detected prenatally on the basis of dilatation of the fetal urinary tract. Sixteen infants had bilateral reflux--a total of 41 refluxing units. The high proportion of males (84%) contrasts with clinically presenting reflux, which is dominated by females. Prenatally diagnosed reflux is generally of a higher grade--usually grade IV. Eight children (32%) had coexistent congenital abnormalities. Chemoprophylaxis was completely effective in 17 children (68%), who remained infection-free; 3 children (12%) had a single urinary infection and were managed conservatively whilst 5 (20%) experienced 2 or more infections and required reimplantation or vesicostomy. Spontaneous cessation of reflux was observed in 6 (35%) of 17 refluxing ureters reassessed after a mean interval of 2.1 years. The significance of isotope findings was sometimes difficult to assess but results in 30 refluxing units support the concept that focal renal scarring is usually a consequence of infected reflux in postnatal life.

Pregnancies in women with and without renal scarring after urinary infections in childhood

OBJECTIVE

To compare the outcome of pregnancy in women with and without renal scarring after childhood urinary infections with that in unmatched controls.

DESIGN

Retrospective study of pregnancies in women prospectively followed up from their first recognised urinary infection.

SETTING

Tertiary referral centre in Gothenburg.

SUBJECTS

111 Women attending an outpatient clinic for women with urinary infection during 1975-83, of whom 41 (65 pregnancies) were studied (19 women with renal scarring (32), 22 without scarring (33)), and 65 controls (65) randomly selected and matched for parity, age, smoking habits, and date of delivery.

MAIN OUTCOME MEASURES

Urinary infections and complications in pregnancy.

RESULTS

The incidence of bacteriuria during first pregnancies was significantly greater in women with (9, 47%) and without (6, 27%) renal scarring after childhood urinary infection than in controls (1, 2%) (p less than 0.001, 0.01 respectively). Symptomatic infections were seen only among women with a history of urinary infection: four women with renal scarring (three of whom had vesicoureteric reflux) developed pyelonephritis and three cystitis, and one woman without scarring developed pyelonephritis. Mean blood pressure was higher among women with severe renal scarring than controls (4/11 v 3/44; p less than 0.05) before and during pregnancy. There was no significant difference in the incidence of pre-eclampsia, operative delivery, prematurity, or birth weight.

CONCLUSIONS

Women with a history of previous urinary infections had a high incidence of bacteriuria during pregnancy, and those with renal scarring and persistent reflux were prone to develop acute pyelonephritis. The risk of serious complications in pregnancy, however, was not increased in women with severe renal scarring, possibly owing to their continuous clinical supervision.

Children with urinary tract infection; a critical diagnostic pathway

A protocol for the radiological investigation of children with urinary tract infection was introduced in a district general hospital in 1985. Every boy, and every girl under 5 years was investigated after one documented infection, and every girl over 5 years after two infections. Each child had an abdominal radiograph and a sonar scan of the urinary tract. Four years later the results were assessed by reviewing the radiology file or contacting the general practitioner of each of the first 200 children examined. Ten of 15 children diagnosed as not normal on screening and investigated further had an abnormality confirmed. Four of 25 children thought normal on screening had minor abnormalities shown on further examination. The results are assessed in the light of a review of recent literature and indicate that this screening protocol is efficient and effective.

Vesicoureteral reflux and voiding dysfunction: a prospective study

We prospectively studied 53 young children (45 less than 4 years old) between 1985 and 1988 with primary vesicoureteral reflux (grades I to V, 74 ureters). All patients had elevated bladder pressures during bladder filling and/or voiding on urodynamic evaluation, which sometimes were associated with abnormal perineal muscle activity. Baclofen, flavoxate, dicyclomine and diazepam were given individually or in combination for each type of dysfunction for 12 to 30 months. Reflux disappeared in 68 ureters (91.8 per cent) and it was downgraded in 6 (8.2 per cent). Urodynamic evaluation at the end of treatment revealed normal bladder pressures in 46 children (83.7 per cent of the ureters in which reflux resolved). Another group of 48 children with primary vesicoureteral reflux (grades I to IV, 67 ureters) seen between 1980 and 1985 was reviewed retrospectively. All patients had been treated with prophylactic antibiotics only. Reflux resolved in 53.7 per cent of the ureters, and it was downgraded in 19.4 per cent, unchanged in 22.4 per cent and upgraded in 4.5 per cent. Urodynamic studies performed in 1985 showed that all persistent cases of reflux in the retrospective group had urodynamic findings similar to those found in the prospective group. These data suggest that vesicoperineal incoordination as well as bladder instability can be important factors in causing and perpetuating reflux, and that medical treatment of these factors individually or in combination may affect therapeutic perspectives of this pathological condition.

Physical growth velocity during conservative treatment and following subsequent surgical treatment for primary vesicoureteric reflux

Physical growth was studied in 6 males and 16 females during 1 year of antimicrobial prophylaxis and during the 2 years following subsequent surgical treatment for severe primary vesicoureteric reflux. Surgery was performed between the ages of 2 and 8 because of either repeated breakthrough infection or persistence of grade III or IV reflux. Height and weight velocities were calculated as yearly rates and then converted into interquartile ratios (IQRs). Neither the mean centile height nor weight attained varied significantly between that at entry, after 1 year of medical treatment and at 2 years after surgery. However, the mean IQR for height velocity (+/- sem) rose significantly from -0.61 (+/- 0.45) during antimicrobial prophylaxis to 0.54 (+/- 0.25) following surgery. Similarly, the mean IQR for weight velocity rose significantly from -0.63 (+/- 0.50) during medical treatment to 0.47 (+/- 0.24) following surgery. These results suggest that surgical treatment is preferable to continued medical treatment in patients with severe primary vesicoureteric reflux who fail to respond to a trial of antimicrobial prophylaxis.

New development and progression of renal scarring in children with primary VUR

To study the development of new scars and progression of previous scarring, we analysed 711 children with primary VUR. New scar or progression of previous scarring was observed in 7.3% of the kidneys with reflux. Factors which promote the formation of new scars are high-grade VUR, recurrent UTIs and high-pressure bladder which results in high-pressure reflux. The average age of new scarring was from 7 to 9 years. We emphasize the importance of the follow-up study until the age of 15 years, even after reflux has stopped following surgery.

Vesicoureteral reflux in boys

The natural history of vesicoureteral reflux in children is well documented. In most series girls comprise the majority of the children followed. We reviewed the presentation and course of 86 boys with primary vesicoureteral reflux to define the nature of reflux in that selected population. Of the boys 25 per cent presented when they were less than 3 months old and the youngest tended to have the most severe reflux. Presentation was usually with urinary tract infection but 14 per cent had dysfunctional voiding symptoms without urinary tract infection. Based upon their presentation and initial evaluation the patients were allocated to 1 of 3 treatment protocols: observation, chemoprophylaxis or surgery. No renal parenchymal loss was detected in the boys on observation. Surgical therapy was free of serious complications. Over-all, this modified approach to the management of reflux in boys is acceptable although further followup will be required to confirm these initial conclusions.

Reflux nephropathy and pregnancy

Reflux nephropathy is one of the most frequent renal diseases encountered in women of childbearing age. Patients with severe bilateral atrophy are the most likely to develop proteinuria, hypertension, focal glomerular sclerosis and progressive chronic renal failure, and those with persistent vesicoureteral reflux are the most likely to suffer recurrent pyelonephritic episodes. Often the disease is clinically latent and first manifests itself in pregnancy, mainly by urinary tract infection but also by proteinuria, hypertension, pre-eclampsia or renal failure. Pregnancy is most often successful and uneventful whenever renal function is normal or near normal and hypertension is absent at conception. Urinary tract infection accounts for frequent morbidity but rarely results in fetal mortality. By contrast, when renal function is significantly impaired, that is in patients whose plasma creatinine concentration is in excess of 0.18-0.20 mmol/l at conception, especially when hypertension is also present, there is clearly a high risk of severe fetal growth retardation or intrauterine death. Moreover, there is a striking risk of rapid worsening of renal function and hypertension, with accelerated progression towards end-stage renal failure. Thus, women with reflux nephropathy should attempt to conceive before the plasma creatinine concentration has reached 0.18 mmol/l, and patients with values higher than these should be clearly advised of the high risk for both the pregnancy and the progression of the disease.

Reflux uropathy

Although much remains to be learned, most pediatric nephrologists and urologists are now in comfortable agreement with the following assumptions: (1) Most reflux (primary reflux) is due to a congenital anatomic abnormality of the bladder trigone. (2) In many instances this anomaly improves with growth and development of the child so that the reflux may cease spontaneously. In low-grade (I-II) reflux with undilated ureters, approximately 75 to 85 per cent will stop refluxing. In higher grades (III-V) with dilated ureters, the cessation rate is in the range of only 25-30 per cent. (3) Although radiologic grading is helpful in predicting the likelihood of spontaneous cessation, it is possible to improve that predictability by cystoscopic evaluation of the size, configuration, and position of the ureteral orifice plus the length of the submucosal tunnel. (4) Reflux in combination with bacteriuria can and does lead to renal scarring. (5) Renal scarring probably does not occur in patients with primary reflux and normal voiding pressures in the absence of bacteriuria. (6) Renal growth may proceed normally despite sterile reflux. (7) A few refluxing patients, perhaps 10 per cent, will have bacteriuria despite continuous antimicrobials, and these "breakthrough" infections may cause renal scars. (8) Other patients prove either unwilling or unable to comply with continuous medications and are also vulnerable to scars. (9) A successful antireflux operation may not change the recurrence rate of urinary tract infections per se, but it almost eliminates the likelihood of pyelonephritic episodes and the necessity for further continuous antibiotics. Unfortunately, in patients with intermediate grades of reflux, it is not presently known whether an early surgical correction might be more effective in allowing normal renal growth, in avoiding renal scars, and in preventing eventual hypertension, which is present as a late complication in almost 20 per cent of the patients. The data to answer this important question should ultimately be forthcoming from the current International Collaborative Reflux Study.

A nonsurgical approach to the management of primary vesicoureteral reflux

We performed a retrospective review to evaluate the results of a nonsurgical approach to the management of primary vesicoureteral reflux during a 10-year period (1976 to 1986). During that interval patients with reflux were studied initially with a standard voiding cystourethrogram and either an excretory urogram or a renal scan with glomerular filtration rate and/or differential renal function determination. Height, weight, blood pressure, urine cultures and serum creatinine measurements also were obtained. Isotope cystography was used for followup examinations. A single, negative isotope cystogram was the radiological criterion for cessation of reflux. The charts of 545 children (55 per cent had bilateral reflux) with 844 refluxing ureters were reviewed. Based upon the international classification vesicoureteral reflux was grade I in 6.6 per cent of the cases, grade II in 54.2 per cent, grade III in 31.6 per cent, grade IV in 5.7 per cent and grade V in 1.9 per cent. All children were kept on long-term continuous prophylactic antibiotics and they were re-evaluated annually with isotope cystography. The followup rate for the entire group was 88 per cent. During the observation period spontaneous resolution of reflux was noted in 36 per cent of the patients and 39 per cent of the total refluxing ureters. Only 13 per cent of the entire group underwent surgical correction of reflux. Presently, 39 per cent (215) of the patients continue to be followed with reflux. Of the total group 66 patients (12 per cent) were lost to followup. In the 194 patients with spontaneous resolution of reflux the mean duration of reflux was 1.69 years, with 30 to 35 per cent resolving each year. Based on Student's t test there was a significant difference in duration of reflux in patients with grade II compared to grade III reflux (1.56 versus 1.97 years, p less than 0.04). When age at presentation was compared with duration of reflux there was a significantly shorter duration of reflux only in those patients presenting from age 0 to 12 months, compared to those 13 months and older (1.44 versus 1.85 years, p less than 0.02). Renal function was evaluated by serum creatinine, calculated glomerular filtration rate or differential diethylenetriaminepentaacetic acid scan results.(ABSTRACT TRUNCATED AT 400 WORDS)

The small scarred kidney of childhood. A congenital or an acquired lesion?

The vast majority of small segmentally scarred kidneys seen in childhood are now recognised to be associated with vesicoureteric reflux and the term "reflux nephropathy" has been accorded general recognition as a description of this renal lesion. With regard to the pathogenic mechanisms responsible for the scarring process, the possible roles of intrauterine renal maldevelopment, bladder dysfunction, functional urinary obstruction and infection in relation to vesicoureteric reflux and the associated phenomenon of intrarenal reflux must all be considered. It is probable that in different clinical circumstances all of these factors may be important to varying degrees and discussion of their contributions to the spectrum of reflex nephropathy is the basis of this communication.

Vesico-uretero-renal reflux and the kidney

The most frequent complications of non-obstructive vesico-uretero-renal reflux (VUR) are segmental renal scars. These scars are confined to segments with intrarenal reflux which are, in addition, exposed to bacterial infection. Primarily, only gaping collecting duct orifices, confined to compound papillae and mainly situated at the kidney poles, allow intrarenal reflux. Scar contraction and obstruction seem to be able to transform closed collecting duct orifices into gaping ones, thereby enlarging the parenchymal area prone to intrarenal reflux and to renal scarring. Contrary to earlier reports, a recent survey has documented that new scars in children develop with significant frequency beyond 5 years of age. There is a greater tendency for scarring to develop with more severe VUR, but new renal scars can develop with all grades of VUR. Early and adequate antibiotic treatment decreases the extent of scarring. The results of experimental studies in which renal scarring developed in piglets with bladder decompensation resulting from intravesical obstruction but without bacterial infection may be relevant to the few children with proximal urethral valves and hypertonic neurogenic bladders but not to the large number with non-neurogenic detrusor instability or detrusor sphincter dyssynergia. Prospective studies have not shown different recurrence rates of urinary tract infections in medically managed compared with surgically managed children. The frequency of acute pyelonephritic attacks decreased significantly after operation.

Reflux nephropathy

This article reviews current concepts of reflux nephropathy, including the pathophysiology, diagnosis, relationship to infection, role in causing end-stage renal disease, and appropriate treatment and management. The condition is defined from a epidemiologic point of view herein, and attention also is given to possible progressions this condition can take.

Relevance of vesico-ureteric reflux in development of lipid A antibodies in recurrent urinary tract infections in children--a preliminary study

The serum titres of IgG and IgM antibodies to lipid A were measured in 24 children with chronic pyelonephritis (PN), 55 with recurrent lower urinary tract infections (LUTI), 13 with gram-negative sepsis (S), and in 50 control children using an enzyme-linked immunosorbent assay (ELISA). Children ranged in age from 1 month-17 years. Patients with PN were differentiated by the presence or absence of an acute infectious episode and/or vesico-ureteric reflux (VUR). During an acute episode in PN and LUTI, IgG titres were significantly higher than in controls, but only PN patients with an acute infectious episode also had significantly elevated IgM titres. Overall, children with LUTI showed a significantly lower frequency of detectable IgG lipid A antibodies (27%) than in PN (63%). In PN children with VUR not accompanied by an infectious episode, lipid A antibody was found at relatively low titres, while an episode not accompanied by VUR displayed significantly elevated IgG titres, and an episode accompanied by VUR showed elevation of both IgG and IgM anti-lipid A antibody titres.

Familial vesicoureteral reflux: a study of 16 families

Siblings of patients with vesicoureteral reflux (VUR) are reported to have an increased incidence of reflux. We present 16 families with 33 affected children out of a total of 493 patients with VUR. Twenty-seven had urinary tract infection and 6 were asymptomatic and were examined because a sibling had VUR. Renal scarring was present in 19 cases; reflux was more marked and more often bilateral in the siblings than in sporadically affected children. In view of our findings we suggest that siblings of patients with VUR be screened early for reflux to prevent renal damage from untreated VUR.

Constipation associated with vesicoureteral reflux

Seventeen children who had vesicoureteral reflux underwent urodynamic and rectal manometric studies. All had uninhibited bladder contractions. All had rectal dilatation confirming the presence of constipation by rectal balloon manometry. The recurrent association of constipation with ureteral reflux suggests the possibility of a nonfortuitous association.

Nonneurogenic neurogenic bladder (the Hinman syndrome)--15 years later

Every child with day and night wetting is a suspect for vesicourethral dysfunction on a behavioral basis, which, when severe, appears as a syndrome that we have called the nonneurogenic neurogenic bladder. Futile attempts by the child at sphincteric urinary control in the face of uncontrollable bladder contractions not only produce the symptoms but also the anatomical and functional changes: vesical trabeculation, distortion of the ureterovesical orifices and dilatation of the upper tracts, along with residual urine and consequent bacteriuria. These changes are indistinguishable from obstructive or, particularly, neurogenic factors, although these causes must be ruled out. Urodynamic investigations in these children show incoordination between detrusor contraction and the expected but not forthcoming urethral sphincteric relaxation. Since these children usually are toilet trained initially, the incoordination appears to be a learned behavior or habit, perhaps as a response to under-appreciated detrusor contractions. Reversal of the syndrome is achieved by suitable medication and by some form of suggestion or retraining. Reparative operations will fail if done before the system is balanced.

Transitional neonatal hydronephrosis: fact or fantasy?

Hydronephrosis secondary to an anomalous ureteropelvic junction was detected antenatally in more than 60 neonatal renal units Those 21 units that exhibited partial obstruction or dilatation without obstruction were selected for this study. They were assessed and followed by serial diuretic isotope renography (99mtechnetium-diethylenetriaminepentaacetic acid augmented with furosemide) and ultrasonography. Excretory urography was used selectively. Of the 17 renal units that could be assessed 88 per cent demonstrated labile ureteropelvic junctions. Indeed, in 3 to 6 months, when the definitive status seemed to be attained, 41 per cent (7 units) had deteriorated, 12 per cent (2 units) remained stable and 47 per cent (8 units) underwent spontaneous improvement. We recommend a 3 to 6-month observation period for patients with hydronephrosis secondary to ureteropelvic junction anomalies when definite obstruction cannot be confirmed by isotope renography.

Is there need for both intravenous urography and voiding cystography in the evaluation of children with recurrent urinary tract infections?

In a prospective study 33 children (aged 6-14 years) consecutively referred for recurrent urinary tract infections (RUTI), underwent intravenous urography (IVU) as well as voiding cystography (VC). Seven children had unilateral and two children had bilateral renal scarring, while ten children had unilateral and six children had bilateral vesico-ureteral reflux (VUR). Following normal IVU VUR was demonstrated in 22% of the ureters, but in all cases of low grade. In abnormal IVU, i.e. renal scarring or dilatation of the ureters, VC showed high grade VUR in 54% of the ureters. Based on these results and the current theories on the significance of patient age and grade of VUR, we conclude that in case of a normal IVU in children with RUTI and age of at least 6 years, there is no reason to supplement the pre-treatment evaluation with VC.

Ureteral diameter in low-risk vesicoureteral reflux in infancy and childhood

In order to improve the accuracy of the grading of vesicoureteral reflux (VUR), reference values for ureteral diameter at micturition cystourethrography (MCUG) were established in infants and children with low-risk VUR. Low-risk VUR was defined as VUR not associated with infection, obstruction, calculi, duplication, malformations (except for hypospadia) or neurogenic bladder disturbances. Forty-six children (age 1 day-14 years) were selected by examining the records of 12000 MCUG:s performed 1960-1983. Ureteral diameter was measured at the widest point of the ureter on the films from MCUG:s and urographies. Ureteral diameter was slightly larger at MCUG than at urography in the same individuals but the difference was not significant. The ureteral diameter at MCUG also correlated closely to normal values at urography in a previous study. It is proposed that the reference values obtained at MCUG in the present investigation can be used for the differentiation between dilatation and no dilatation in the grading of VUR.

Relationship between hair/eye color and primary vesicoureteral reflux in children

The relationship between hair/eye color and primary vesicoureteral reflux was analyzed in more than 900 children. Children with blonde hair/blue eyes did not show an increased prevalence of reflux nor did any other hair/eye combination. With the possible exception of rufous coloring, the color of the hair and eyes are poor predictors of the competence of the ureteral orifice.

Effects of oxybutynin on vesicoureteral reflux in children

We reviewed retrospectively 40 children seen from 1980 to 1984 with vesicoureteral reflux in 53 ureters. All patients had a hyperreflexic bladder on urodynamic evaluation with or without vesicoperineal dyssynergia but they were otherwise neurologically normal. All except 1 child received prophylactic antibiotics. Of the children 37 received oxybutynin therapy for bladder hyperreflexia for 3 to 18 months. Reflux disappeared or became grade I in 62.3 per cent of the ureters. Of the children manifesting urinary incontinence at the time of urodynamic study reflux disappeared or became grade I in 78.6 per cent. Reflux resolved or became grade I in 20 per cent of the children with no urinary incontinence. Of those patients with recurrent reflux at the onset of urinary incontinence and bladder instability reflux resolved or became grade I in 80 per cent. Oxybutynin therapy for hyperreflexic bladder resulted in an average increase in bladder capacity of 97 cc (54.2 per cent), which was maintained after cessation of treatment. These data suggest that bladder instability can be an important factor in causing and perpetuating reflux. Therapy aimed at decreasing intravesical pressure will enhance resolution or downgrading of reflux.

Radionuclide imaging in pediatrics

This article presents an overview of some of the pediatric clinical problems in which radionuclide studies play a major role in diagnosis and treatment.

Current concepts in the management of common urologic problems in infants and children

Vesicoureteral reflux has the potential to cause irreversible renal damage if undiagnosed and untreated. It is important to have a high index of suspicion for the existence of a urinary tract infection in infants and children with any nonspecific generalized illness. Once a UTI is documented, appropriate antibiotic therapy must be started and continued until the urinary tract has been adequately evaluated radiographically. If vesicoureteral reflux is found to exist, appropriate medical or surgical therapy must be instituted to prevent further episodes of pyelonephritis.

Urinary infections in children 1985

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[Clinical course and scar development in operated vesico-renal reflux in a long-term study]

62 patients (14 boys, 48 girls) representing 85 refluxive renal units (Grade 2-4) were investigated after successful operation for the development of further urinary tract infections (UTI) and renal scars (RS). The mean follow-up was 9.3 years. With the exception of one boy, none of the male patients developed any UTI or new RS. A similar result was obtained for about 45% of the girls. These two groups of patients presented with high-grade reflux before surgery. The remaining female patients (about 55%), however, presenting with lower-grade reflux before surgical treatment, developed further UTI as well as new RS despite surgical correction of their reflux. Investigations on the capacity of uroepithelial cells (UEC) to suppress bacterial growth revealed a deficient antibacterial effect of UEC in these patients. Such an UEC defect has also been shown in patients with asymptomatic bacteriuria. In conclusion, different reasons seem to be responsible for recurrent UTI and the development of RS in patients with reflux.