Vesicoureteral reflux (VUR) is a complex disease as patient spectrum is variable. Some cases struggle with recurrent febrile urinary tract infections (UTI) and end-up with renal scars despite intervention. While others suffer no clinical problems and need no treatment. The detrimental effect of VUR on kidneys depends on many factors like grade of reflux, detrusor pressure, and presence of voiding dysfunction. The adverse effects of sterile VUR on kidneys is still under discussion. Thus, we assessed the impact of detrusor pressure at VUR onset on renal scarring in children with sterile reflux.
Materials and methods
We retrospectively reviewed the five years follow-up data of 38 children who had unilateral VUR without UTI under treatment. No febrile or afebrile UTIs were detected during the follow-up in any children. All children were assessed with annual video-urodynamics and renal scintigraphy for five consecutive years. The detrusor pressure at VUR onset, grade of VUR, presence of involuntary detrusor contractions, bladder capacity and the presence of renal scaring were recorded. All VURs were recorded during the voiding phase and children with VUR during the filling phase were excluded from the study.
In the first line of video-urodynamic studies, the mean detrusor pressure at VUR onset was 24.3 ± 14.8 cm/H2O (median 34.5 cm/H2O, min: 6 - max: 47). There was no relation between boys and girls regarding median detrusor pressure at VUR onset (p = 0.356). Eventually, 22 (57.9%) children developed renal scars and ended up with surgery. There was no relation between scar development and age at first presentation (p = 0.888) The cut-off value for detrusor pressure at VUR onset was noted as 26 cm/H2O (AUC: 0.849 [p < 0.01], Figure). In children who developed renal scars eventually, the median detrusor pressure at VUR onset was significantly higher (p < 0.01).
The detrimental effect of VUR on kidneys is associated with recurrent infections, bladder dysfunction, and detrusor pressure. Dispute over risk of renal scarring in patients with sterile VUR still continues.
Children in whom VUR start at higher voiding pressures suffer more renal scars. The threshold of voiding detrusor pressure for risky patients is identified as 26 cm/H2O. It is true that patients suffering recurrent febrile UTIs have higher risk of developing renal scarring. However, the impact of sterile reflux should not be underestimated, since renal scars due to sterile reflux may develop in patients under antibiotic prophylaxis.
Abbreviations:VUR (Vesicoureteral reflux), UTI (Urinary tract infection), DMSA (Dimercaptosuccinic acid), ROC (Receiver Operating Characteristics)
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- Renal parenchyma abnormalities in infants with dilating vesicoureteral reflux: relation to reflux severity and pressure at onset.J Urol. 2010; 183: 2367-2372
- Urodynamic dysfunction in infants with vesicoureteral reflux.J Pediatr. 2000; 136: 754-759
- Videourodynamic findings in young infants with severe primary reflux.J Urol. 2004; 171: 829-833
- The pressure at which reflux occurs, an important indicator of prognosis and treatment.J Urol. 1963; 89: 395-404
- Quantitation of vesico-ureteral reflux by radionuclide cystography and urodynamics.Pediatr Nephrol. 1990; 4: 485-490
- Renal papillary morphology and intrarenal reflux in the young pig.Urol Res. 1975; 3: 105-109
- Chronic pyelonephritis and vesico-ureteric reflux.Clin Radiol. 1960; 11: 219-231
- Vesicoureteral reflux and bladder dysfunction.Transl Androl Urol. 2012; 1: 153
- High-pressure bladder: an underlying factor mediating renal damage in the absence of reflux?.BJU Int. 2001; 87: 581-584
- Evaluation and management of vesicoureteral reflux: a decade of change.R I Med J. 2010; 93: 342
- New renal scars in children with urinary tract infections, vesicoureteral reflux and voiding dysfunction: a prospective evaluation.J Urol. 1997; 158: 566-568
- Prevalence of hypercontractility in male and female infants with vesico-ureteral reflux.Eur J Pediatr Surg. 2000; 10: 172-176
- Video cystometric recording of dilating reflux in infancy.J Urol. 1996; 155: 1711-1715
- Impact of urinary tract infection and detrusor pressure on renal tubular function in patients with vesicoureteral reflux.Eur Urol. 2001; 39: 337-342
- Current concepts in congenital vesico-ureteral reflux.S Afr Med J. 1978; 53: 584-586
- Reflux as a cause of end stage kidney disease: report of 32 cases.J Urol. 1977; 117: 441-443
- A novel propidium monoazide-based PCR assay can measure viable uropathogenic E. coli in vitro and in vivo.Front Cell Infect Microbiol. 2022; : 40
- Urodynamic patterns in infants with normal lower urinary tracts or primary vesico-ureteric reflux.Br J Urol. 1998; 81: 461-467
- Transient urodynamic dysfunction of infancy: relationship to urinary tract infections and vesicoureteral reflux.J Urol. 1996; 155: 673-677
- Vesico-ureteric reflux and other risk factors for renal damage: identification of high-and low-risk children.Acta Paediatr. 1999; 88: 31-39
- Bladder dynamics and vesicoureteral reflux: factors associated with idiopathic lower urinary tract dysfunction in children.J Urol. 2008; 179: 1564-1567
- 25. High pressure sterile vesicoureteral reflux and renal scarring: an experimental study in the pig and minipig. Reflux nephropathy update: 1983.Karger Publishers, 1984: 320-343
- High grade vesicoureteral reflux: analysis of observational therapy.J Urol. 1990; 144: 537-540
Published online: September 22, 2022
Accepted: September 18, 2022
Received in revised form: July 18, 2022
Received: January 5, 2022
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