obsolete bilateral vesicoureteral reflux with reflux nephropathy

Obsolete Bilateral Vesicoureteral Reflux and Reflux Nephropathy

Bilateral vesicoureteral reflux (VUR) is a condition where urine flows backward from the bladder to both kidneys, causing potential damage to the renal tissue. This condition was once considered more prevalent than it actually is today.

Characteristics of Obsolete Bilateral VUR

• Retrograde flow: Urine flows from the bladder back into the ureters and sometimes into the kidneys.
• Bilateral involvement: Both kidneys are affected, leading to potential damage and scarring.
• Reflux nephropathy: The condition can lead to chronic tubulointerstitial nephritis as well as glomerular-mediated injury.

Mechanism of Renal Scarring

The exact mechanism for renal scarring following urinary tract infections (UTIs) is not fully understood. However, it is believed to be mediated by immunological mechanisms, macromolecular trapping, and mesangial dysfunction, vascular alterations, hypertension, and hemodynamic alterations [1][10].

Resolution of Reflux

Reflux resolves spontaneously in many children, especially those with low-grade reflux, unilateral involvement, or normal bladder function [12]. However, the likelihood of resolution is lower for moderate or severe reflux, bilateral involvement, or abnormal bladder function.

References

• [1] The exact mechanism for renal scarring following UTI is not known, but is believed to be mediated by immunological mechanisms, macromolecular trapping and mesangial dysfunction, vascular alterations, hypertension and hemodynamic alterations.
• [10] Renal scarring due to intrarenal reflux occurs mostly at the renal poles because the presence of extensively fused (compound) renal papillae, which are ...
• [12] Reflux resolves spontaneously in many children, and the likelihood of reflux resolution is greater with low-grade reflux compared to moderate or severe reflux, if it is unilateral as opposed to bilateral and if the child’s bladder function is normal.

Based on the available information, it appears that diagnostic tests for vesicoureteral reflux (VUR) and reflux nephropathy have evolved over time.

Voiding cystourethrography (VCUG) is considered a definitive method for diagnosing VUR [1][2]. However, its use has been declining in recent years due to the development of newer imaging techniques. Indirect radionuclide cystography (I-RNC) is another diagnostic tool used to diagnose VUR [4].

For patients with suspected reflux nephropathy, serum chemistries are used to assess baseline renal function, and a complete blood count (CBC) can assist in tracking the response to treatment [3]. DMSA scintigraphy is considered the accepted gold standard for diagnosing acute pyelonephritis and renal scarring, which may be associated with reflux nephropathy [9].

Nuclear cystography, obtained by instilling a radionuclide agent into the bladder and imaging with a gamma camera, can also be used to diagnose VUR [7]. However, this test is not as commonly used as VCUG or I-RNC.

It's worth noting that clinical practice guidelines for screening siblings of children with vesicoureteral reflux and neonates/infants with prenatal hydronephrosis have been established [5]. These guidelines may provide valuable information on the diagnostic approach to VUR and its associated conditions.

References: [1] G Läckgren (2021) - Voiding cystourethrography is generally considered the definitive method for diagnosing VUR. [2] G Läckgren (2021) - VCUG is helpful

Treatment Options for Obsolete Bilateral Vesicoureteral Reflux with Reflux Nephropathy

In cases where vesicoureteral reflux (VUR) has led to reflux nephropathy, treatment options are aimed at preventing further kidney damage. According to the available information, drug treatment is one of the approaches used to manage this condition.

Antibiotic Prophylaxis

The most commonly recommended drug treatment for obsolete bilateral VUR with reflux nephropathy is antibiotic prophylaxis. This involves administering antibiotics regularly to prevent bacterial infections that can exacerbate kidney damage.

• Trimethoprim-sulfamethoxazole, nitrofurantoin, and penicillins are the most common antibiotics used for this purpose [9].
• Cephalosporins are used less often due to concerns about antibiotic resistance [9].

Other Medications

In addition to antibiotic prophylaxis, other medications may be prescribed to manage symptoms or prevent further kidney damage. However, these options are not as well-established as antibiotic prophylaxis.

• No specific information is available on the use of other medications for this condition in the provided context.
• It is essential to consult a healthcare professional for personalized advice and treatment plans.

References

[1] - Not applicable (no relevant information found) [2] - Not applicable (no relevant information found) [3] - Not applicable (no relevant information found) [4] - Not applicable (no relevant information found) [5] - Not applicable (no relevant information found) [6] - Not applicable (no relevant information found) [7] - Not applicable (no relevant information found) [8] - Reflux nephropathy is a condition in which the kidneys are damaged by the backward flow of urine into the kidney [8]. [9] - The most common antibiotics used for antibiotic prophylaxis are trimethoprim-sulfamethoxazole, nitrofurantoin, and penicillins. Cephalosporins are used less often due to concerns about antibiotic resistance [9].

Based on the provided context, it appears that the differential diagnosis for obsolete bilateral vesicoureteral reflux (VUR) with reflux nephropathy involves considering various factors and conditions. Here are some possible differentials:

• Primary vs. secondary VUR: The context mentions that VUR can be primary or secondary to bladder outflow obstruction and can occur in several multiorgan congenital disorders [6]. This suggests that the differential diagnosis should consider whether the VUR is primary or secondary.
• Grade and laterality of VUR: The context notes that high-grade/bilateral VUR has a higher risk of complications compared to low-grade/unilateral VUR [10]. Therefore, the differential diagnosis should take into account the grade and laterality of the VUR.
• Presence of proteinuria: The context mentions that frequent/severe proteinuria is associated with VUR and reflux nephropathy [10]. This suggests that the presence or absence of proteinuria should be considered in the differential diagnosis.
• Other anatomic renal abnormalities: The context notes that VUR can occur in association with other anatomic renal abnormalities, such as multi-cystic dysplastic kidney, renal agenesis, and others [9]. Therefore, the differential diagnosis should consider whether there are any other underlying anatomic renal abnormalities.

In terms of specific conditions that may be considered in the differential diagnosis, these might include:

• Reflux nephropathy: This is a condition characterized by scarring of the kidneys due to VUR. The context notes that reflux nephropathy can lead to hypertension and chronic renal insufficiency [15].
• Pyelonephritis with scarring: The context mentions that pyelonephritis (inflammation of the kidney) can occur in association with VUR, leading to scarring [15].

It's worth noting that the differential diagnosis for obsolete bilateral vesicoureteral reflux with reflux nephropathy would likely involve a comprehensive evaluation of the patient's medical history, physical examination, and diagnostic imaging studies.

References:

[6] Context 6 [9] Context 9 [10] Context 10 [15] Context 15