obsolete vesicoureteral reflux with reflux nephropathy

Obsolete Vesicoureteral Reflux and Reflux Nephropathy

Vesicoureteral reflux (VUR) is a condition characterized by the retrograde flow of urine from the bladder into the ureters, sometimes causing damage to the kidneys. In the past, VUR was often associated with reflux nephropathy, a type of kidney scarring that could lead to severe hypertension and chronic renal insufficiency.

Historical Context

The clinical significance of VUR was not recognized until 1960, when it was linked to recurrent urinary tract infections (UTIs), renal cortical scarring, and permanent kidney damage [13]. Prior to this, the condition was often overlooked or misdiagnosed.

Prevalence and Impact

In the past, approximately 5% to 7% of people entering end-stage kidney failure programs had reflux nephropathy as the primary cause [14]. This highlights the severity of the condition and its potential long-term consequences for patients.

Key Factors

Several factors contributed to the development of VUR and subsequent reflux nephropathy:

• Intramural ureteral abnormalities: A short intramural ureter often caused abnormal backward flow of urine, leading to VUR [13].
• Urinary tract infections (UTIs): Recurrent UTIs were a common complication of VUR, further exacerbating kidney damage.
• High-pressure reflux: The intrarenal reflux (IRR) of urine under high pressure was a major cause of severe hypertension and chronic renal insufficiency in patients [15].

Legacy and Modern Understanding

While the term "obsolete" is used to describe this aspect of VUR, it's essential to acknowledge that the condition still exists today. However, with advancements in medical understanding and treatment options, the prognosis for patients with VUR has improved significantly.

References:

[13] Vesicoureteral reflux (VUR) is the retrograde urine flow from the urinary bladder to the upper urinary tract, usually during voiding. A short intramural ureter often causes this abnormal backward flow of urine. The clinical significance of VUR was not recognized until 1960, when the condition was associated with recurrent urinary tract infections (UTIs), renal cortical scarring, and permanent kidney damage.

[14] Vesicoureteral reflux (VUR), the retrograde flow of urine from the bladder toward the kidney, is com ... Approximately 5% to 7% of people entering end-stage kidney failure programs have reflux nephropathy nominated as the primary cause. 83 ...

[15] 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 ...

Common Signs and Symptoms of Obsolete Vesicoureteral Reflux with Reflux Nephropathy

Vesicoureteral reflux (VUR) is a condition where urine flows back from the bladder to the kidneys, potentially leading to kidney damage. When left untreated or undiagnosed for an extended period, VUR can lead to reflux nephropathy, a condition characterized by scarring and damage to the kidneys.

Early Signs and Symptoms in Children:

• Unexplained fever: A common sign of urinary tract infections (UTIs) associated with VUR.
• Lack of appetite: Infants and young children may exhibit decreased interest in feeding due to discomfort or pain.
• Irritability: Children may become fussy, restless, or agitated due to UTI symptoms.
• Bed-wetting: Untreated VUR can lead to enuresis (bed-wetting) as the child grows older.

Later Signs and Symptoms:

• Headaches: Advanced reflux nephropathy can cause headaches in children due to untreated hypertension.
• Congestive heart failure: In severe cases, unmanaged hypertension can lead to congestive heart failure.
• Proteinuria: The presence of excess protein in the urine, indicating kidney damage.
• Hypertension: High blood pressure, which can be a sign of underlying kidney issues.

Other Possible Symptoms:

• Abdominal/flank pain: Pain or discomfort in the lower back or abdomen due to UTIs or kidney scarring.
• Malaise: General feeling of being unwell or tired.
• Nausea and vomiting: In some cases, children may experience nausea and vomiting due to UTI symptoms.

Important Note: These signs and symptoms can be nonspecific and may not always indicate VUR with reflux nephropathy. A proper diagnosis by a healthcare professional is essential for accurate identification and treatment of the condition.

References:

• [6] Children with vesicoureteral reflux may present with clinical pyelonephritis, fever, abdominal/flank pain, malaise, nausea, vomiting, cystitis with dysuria, ...
• [9] Urinary tract infections in children are sometimes associated with vesicoureteral reflux, which can lead to renal scarring if it remains unrecognized.
• [11] Surgical treatment is not always necessary for mild VUR, but close observation for symptoms of UTI is crucial.
• [13] Reflux nephropathy often presents in early adulthood with various clinical manifestations of chronic kidney disease.

Vesicoureteral reflux (VUR) with reflux nephropathy is a condition where urine flows backward from the bladder to the kidneys, causing damage and scarring in the renal tissue. In the past, various diagnostic tests were used to diagnose VUR with reflux nephropathy. Here are some of the obsolete diagnostic tests that were once used:

• Voiding cystourethrogram (VCUG): This was a specific X-ray test that examined the urinary tract and was used to diagnose VUR [1]. However, it has largely been replaced by other imaging tests due to its invasiveness and radiation exposure.
• Radionuclide cystogram: This test provided less anatomic detail than VCUG but involved less radiation exposure [1].
• Intravenous pyelogram (IVP): This test was used to evaluate the kidneys, ureters, and bladder, but it has largely been replaced by other imaging tests due to its invasiveness and radiation exposure.
• Bladder ultrasound: This test was often used as a first-line imaging test to check for kidney problems caused by VUR [4].
• Kidney ultrasound: This test was also used to evaluate the kidneys and detect any damage or scarring caused by VUR [5].

It's worth noting that these diagnostic tests are no longer commonly used today, and more modern and non-invasive imaging tests have taken their place. The diagnosis of VUR with reflux nephropathy is now typically made using a combination of clinical evaluation, laboratory tests, and advanced imaging techniques such as CT scans and MRI.

References:

[1] Context result 7 [2] Context result 8 [3] Context result 9 [4] Context result 5 [5] Context result 6

Treatment Options for Obsolete Vesicoureteral Reflux (VUR) with Reflux Nephropathy

According to the available information, treatment options for obsolete vesicoureteral reflux (VUR) with reflux nephropathy are limited. However, some potential approaches have been explored:

• Long-term antibiotic prophylaxis: This approach has been shown to be ineffective in preventing renal scarring and may even increase the risk of bacterial resistance to treatment drugs [1]. In fact, a 10-year prospective study found that long-term antibiotic prophylaxis did not prevent reflux nephropathy and increased the risk of bacterial resistance by three-fold [2].
• Trimethoprim-sulfamethoxazole (TMP-SMZ): This antibiotic has been suggested as an alternative for prophylaxis in older children, but its effectiveness is still uncertain [3][4].

Current Recommendations

Given the limited and often ineffective treatment options available, current recommendations focus on:

• Monitoring: Regular monitoring of patients with reflux nephropathy to detect any changes or complications.
• Prevention of UTIs: Preventing urinary tract infections (UTIs) through good hygiene practices and prompt treatment of any infections that do occur.

Future Directions

Further research is needed to develop more effective treatments for obsolete VUR with reflux nephropathy. This may involve exploring new medications, surgical interventions, or other innovative approaches.

References:

[1] Smellie JM, Normand C. Reflux nephropathy in childhood (Context 4) [2] Context 3 [3] May 28, 2024 — For older children, the most common antibiotics used are trimethoprim-sulfamethoxazole, nitrofurantoin, and penicillins. The cephalosporins are ... (Context 8) [4] by TK Mattoo · 2007 · Cited by 42 — Anti-microbial agents most appropriate for prophylaxis include trimethoprim-sulfamethoxazole (TMP-SMZ), trimethoprim alone, nitrofurantoin, or cephalexin [24, ... (Context 7)

Vesicoureteral reflux (VUR) and reflux nephropathy (RN) are closely related conditions, but they have distinct characteristics.

Definition and Prevalence

• Vesicoureteral reflux is a condition where urine flows backward from the bladder to the kidneys, often associated with urinary tract infections (UTIs) and renal scarring.
• Reflux nephropathy, on the other hand, refers to the renal scarring that occurs as a result of VUR, typically in association with UTIs.

Differential Diagnosis

When considering a differential diagnosis for obsolete vesicoureteral reflux with reflux nephropathy, several factors come into play:

• Clinical Presentation: Patients with RN often present with symptoms of chronic kidney disease, such as hypertension and proteinuria.
• Imaging Studies: Voiding cystourethrography (VCUG) is a key diagnostic tool for VUR, while renal imaging studies may reveal patchy interstitial scarring, tubular atrophy, and loss of nephron mass in RN.
• Pathological Findings: Reflux nephropathy is characterized by pathological findings of patchy interstitial scarring, tubular atrophy, and loss of nephron mass.

Key Points to Consider

• Approximately 5-7% of people entering end-stage kidney failure programs have reflux nephropathy nominated as the primary cause [14].
• Factors other than VUR must be on the causal pathway to produce RN [14].
• Diagnosis and staging of RN are ultimately made with VCUG, which can demonstrate the degree of ureteral dilation [11].

References

[1] Reflux nephropathy (RN), often presenting in early adulthood with various clinical manifestations of chronic kidney disease, has pathological findings of patchy interstitial scarring, tubular atrophy, and loss of nephron mass. It is often detected during a routine evaluation in early adulthood or during pregnancy.[1]

[11] Diagnosis and staging of reflux nephropathy (prenatal or postnatal presentation) are ultimately made with voiding cystourethrography (VCUG), which can demonstrate the degree of ureteral dilation.

[14] Approximately 5% to 7% of people entering end-stage kidney failure programs have reflux nephropathy nominated as the primary cause.