Reflux nephropathy

Jutley RS, Youngson GG, Eremin O, Ninan GK. Serum cytokine profile in reflux nephropathy. Ped Surg Interna 2000 16 64-68. 

Proteinuria is a common finding in patients with kidney disease, and the use of a dipstick assay is an important screening test in any patient suspected of having renal disease. Among patients with suspected or proven CKD, including reflux nephropathy and early glomerulonephritis, and those with hypertension or previously detected asymptomatic hematuria, annual urinalysis for proteinuria is accepted as a useful way of identifying patients at risk of... 

Najmaldin A, Burge DM, Atwell JD (1990) Reflux nephropathy secondary to intrauterine vesicoureteric reflux. J Pediatr Surg 25 387-390... 

Stock JA, Wilson D, Hanna MK (1998) Congenital reflux nephropathy and severe unilateral fetal reflux. J Urol 160, Pt 2 1017-1018... 

The so-called reflux nephropathy (RN) of the lower pole is commonly associated with VUR. It may be present already at birth with no pre-existing urinary tract infection (fetal RN). VUR may occur simultaneously in both moieties this implies that the ureteral openings within the bladder are very close or even common. VUR that flows into the upper pole usually only corresponds to an ectopic ureteral opening into the urethra close to the bladder neck (Bissett and Strife 1987). 

Renal ultrasound, including 3D-ultrasound and volumetry, will allow noninvasive monitoring of kidney growth. Furthermore, dilatation of the pel-vico-caliceal system can be detected. In cases of suspected reflux nephropathy, isotope studies (DMSA scans) or MR urography should be performed (Riccabona 2007). 

Complications of VUR 228 Fetal Reflux Nephropathy 229 Imaging Reflux Nephropathy and the Progression of Renal Disease 229... 

Fig. 11.14. Intravenous urography in a case of bilateral reflux nephropathy showing thinned parenchyma and clubbed calices...

VUR may occur in both moieties of a duplex kidney, but it is much more frequent into the lower pole (Fig. 11.24). This is associated with the more lateral opening of the corresponding ureteral orifice. This type of VUR may be associated with renal damage at the corresponding lower pole (reflux nephropathy see below). Severe VUR into the lower pole may be associated with significant ureterohydronephrosis, which may obscure the presence of a duplex system. VUR into a lower pole still has a potential of spontaneous resolution just as VUR can spontaneously resolve into a single collecting system (Ben-Ami et al. 1989 Bisset and Strife 1987 Claudon et al. 1999). 

Imaging Reflux Nephropathy and the Progression of Renal Disease... 

Fig. 11.31. Fetal reflux nephropathy. MR urography shows a small left kidney in a 2-month-old baby boy with VUR (SPIR T2 sequence)...

The role of imaging is to detect not only VUR, but also its complications reflux nephropathy. Presently, DMSA scanning and IVU are the best techniques available for this purpose. 

Fig. 11.38a-c. Localized pseudotumoral pattern of glomerular hyperfiltration in a case of reflux nephropathy, a US transverse scan of the left kidney hyperechoic ill-defined area in the external part of the kidney (marked by arrows), b MR imaging T2 weighted sequence displays bilateral small irregular kidneys with distorted pelvi-calyceal systems and a tumoral appearance of the left kidney, c Tc 99 DMSA-SPECT-CT the outer part of the left kidney highlights suggesting hyperfunction... 

Assael BM, Guez S, Marra G et al (1998) Congenital reflux nephropathy follow-up of 108 cases diagnosed perina-tally. Br J Urol 82 252-257... 

Farnsworth RH, Rossleigh MA, Leighton DM et al (1991) The detection of reflux nephropathy in infants by Tc DMSA studies. J Urol 145 542-546... 

Jungers P, Houilier P, Chauveau D et al (1996) Pregnancy in women with reflux nephropathy. Kidney Int 50 393-399 Kaefer M, Keating MA, Adams MC et al (1995) Posterior urethral valves, pressure pop-off and bladder function. J Urol 154 708-711... 

Marra G, Barbieri G, Moioli C et al (1994) Mild fetal hydrone-phrosis indicating VUR. Arch Dis Child 70 147-150 Marshall FF, Jeffs RD, Sarafyan WK (1979) Urogenital sinus abnormalities in the female patient. J Urol 122 568-572 Matsumo T, Fukushima Motoyama H, Higushi E et al (1996) Color flow imaging for detection of VUR. Lancet 347 757 Matsuoka H, Oshima K, Sakamoto K et al (1994) Renal pathology in patients with reflux nephropathy. Eur Urol 26 153-159... 

Stocks A, Richards D, Frentzen B et al (1996) Correlation of prenatal renal pelvic antero-posterior diameter with outcome in infancy J Urol 155 1050-1052 Stokland E, Hellstrom M, Hansson S et al (1994) Reliability of US in identification of reflux nephropathy in children. BMJ 309 235-239... 

Wyly JB, Lebowitz RL (1984) Refluxing urethral ectopic ureters recognition by the cyclic VCU. AJR 142 1263-1267 Yeung CK, Godley ML, Dhillon HK et al (1997) The characteristics of primary VUR in male and female infants with prenatal hydronephrosis. Br J Urol 80 319-327 Yu TJ, Chen W, Chen HY (1997) Early versus late surgical management of fetal reflux nephropathy. J Urol 157 1416-1419... 

Functional obstruction is the central problem in nonneurogenic bladder-sphincter dysfunction. Bladder distortion, VUR, upper urinary tract dilatation, UTI and reflux nephropathy are potential consequences. 

Of greatest importance is the observation by Naseer and Steinhardt (1997) who, in their study on 538 patients with a history of daytime urinary incontinence, identified 51 children with VUR, UTI and dysfunctional voiding in whom new renal scars had developed while they were under care. They concluded that voiding dysfunction is a significant risk factor not only for UTI and VUR development and perpetuation, but also for the development of new renal scars when associated with infection and VUR. An association between urinary tract dysfunction and reflux nephropathy was also demonstrated by Nielsen (1984). 

It is accepted that evaluation of the child with wetting with a history of infection is indicated because some 30%-50% of children who present with UTI will have VUR demonstrated on voiding cystourethrography (VCU). However, no clear guidelines have been established for the evaluation of wetting children with sterile urine demonstrated at the time of admission or without a history of UTI. In a study on children with enuresis, Sujka et al. (1991) demonstrated that no one symptom or combination of symptoms segregated these patients likely to have VUR 16% of their 83 patients with sterile urine and no history of infection had VUR out of those, 16 showed reflux nephropathy as well. They concluded that one of six children who present with enuresis and sterile urine will have VUR. 

It is interesting in this context that Risdon et al. (1993) found that in children with gross VUR submitted to unilateral nephrectomy, evidence of dysplas-tic renal development was confined to male patients. This corresponds to other studies that indicate a marked male preponderance among patients with reflux nephropathy diagnosed early in life, particularly those detected by antenatal ultrasound. Studies... 

Chandra M (1995) Reflux nephropathy, urinary tract infection, and voiding disorders. Curr Opin Pediatr 7 164-170... 

Risdon RA, Yeung CK, Ransley PG (1993) Reflux nephropathy in children submitted to unilateral nephrectomy a clinicopathological study. Clin Nephrol 6 308-314 Savage JP (1973) The deleterious effect of constipation upon the reimplanted ureter. J Urol 109 501-503 Saxton HM, Borzyskowski M, Mundy AR et al (1988) Spinning top urethra not a normal variant. Radiology 168 147-150... 

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