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Published on: January 7, 2019
Obstructive nephropathy in children: long-term progression after relief of posterior urethral valve
K S Roth1, W H Carter, J C Chan
1Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia 23298-0498, USA.
Insights
Children with posterior urethral valves often develop end-stage renal disease. This study shows a slow, steady progression of kidney disease in these patients, suggesting a target for future therapeutic interventions.
Area of Science:
- Pediatric Nephrology
- Urology
- Renal Disease Research
Background:
- Urinary tract malformations cause end-stage renal disease in one-third of pediatric cases.
- Improved prenatal diagnosis and care have reduced infant mortality from obstructive uropathies.
- Long-term outcomes of obstructive uropathies require reevaluation.
Purpose of the Study:
- To examine the long-term progression of obstructive nephropathy after neonatal posterior urethral valve relief.
- To identify patterns in renal function decline in patients with congenital uropathies.
Main Methods:
- Retrospective analysis of 10 pediatric cases with posterior urethral valves over 21 years.
- Primary valve ablation and vesicostomy were the main surgical interventions.
- Serum creatinine levels and time to end-stage renal disease were tracked.
Main Results:
- Posterior urethral valves accounted for 7% of congenital malformative uropathies.
- 70% of patients progressed to end-stage renal disease within 11.3 years.
- Kidney function declined steadily, particularly after serum creatinine exceeded 5 mg/dL.
Conclusions:
- Obstructive nephropathy after posterior urethral valve relief shows a prolonged, steady progression.
- A progression rate of 0.5 mg/dL per year (serum creatinine 1.5-5 mg/dL) is identified.
- This steady progression rate presents an optimal target for therapeutic intervention studies.
Background:
Approximately one third of children with end-stage renal disease have the illness because of urinary tract malformations, obstructive uropathy, and hypoplasia/dysplasia. The significant drop in infant mortality from obstructive uropathies in recent decades, attributable to prenatal diagnosis with renal ultrasonography and coordinated surgical and medical care, necessitated a reevaluation of the long-term outcome.
Methods:
To that end, we examined the long-term progression of obstructive nephropathy after neonatal relief of posterior urethral valves in our center over a span of 21 years, with diagnosis and care being provided by the same pediatric and urology team.
Results:
The 10 consecutive cases of posterior urethral valves represented 7% of all patients with congenital malformative uropathies seen over this period. The following procedures were performed: primary valve ablation (90%) and vesicostomy (40%). Seventy percent of patients progressed to end-stage renal disease over a (mean +/- standard error of the mean) follow-up of 11.3 +/- 2.1 years. The linear plot of the log of the inverse of serum creatinine versus time suggested unrelenting progression. The rate of progression was rapid after serum creatinine exceeded 5 mg/dL but the rate was slow and steady from serum creatinine of 1.5 to 5 mg/dL.
Conclusions:
To test the effect of a therapeutic intervention to ameliorate the rate of progression, this steady and prolonged progression of 0.5 mg/dL per year between serum creatinine concentration of 1.5 to 5 mg/dL would seem the optimal study.
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