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Reflux uropathy
1Emory University School of Medicine, Atlanta, Georgia.
Insights
Most pediatric reflux cases stem from congenital bladder abnormalities and often resolve spontaneously. While low-grade reflux has a high spontaneous resolution rate, higher grades have a lower chance, with renal scarring linked to infections.
Area of Science:
- Pediatric Urology
- Nephrology
Background:
- Primary reflux is often linked to congenital bladder trigone abnormalities.
- Spontaneous resolution of reflux occurs with child development, particularly in low-grade cases.
- Radiologic and cystoscopic evaluations aid in predicting reflux cessation.
Purpose of the Study:
- To review current understanding of pediatric reflux.
- To discuss the relationship between reflux, bacteriuria, and renal scarring.
- To highlight the uncertainties in managing intermediate-grade reflux.
Main Methods:
- Literature review and consensus among pediatric nephrologists and urologists.
- Analysis of factors influencing spontaneous reflux cessation.
- Discussion of outcomes associated with reflux, infection, and surgical intervention.
Main Results:
- 75-85% of low-grade reflux cases resolve spontaneously; only 25-30% of high-grade cases do.
- Renal scarring is associated with reflux and bacteriuria.
- Antireflux surgery reduces pyelonephritis risk but its effect on long-term growth and hypertension is unclear.
Conclusions:
- Reflux management involves understanding spontaneous resolution rates and risks of renal scarring.
- Further data from studies like the International Collaborative Reflux Study are needed for intermediate-grade reflux management.
- Long-term outcomes, including hypertension, require ongoing investigation.
Abstract:
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.