Vesicoureteral Reflux Nephropathy Research Articles

Subureteric injection for the treatment of vesicoureteral reflux in transplant kidneys.

Treatment of de novo vesicoureteral reflux (VUR) into the transplanted kidney constitutes a clinical challenge. Herein, we present our data on patients who underwent endoscopic subureteric injection for the treatment of VUR following renal transplantation (RT) in our center. The patients who underwent endoscopic subureteric injection for VUR into the transplanted kidney after RT in our department between 2008 and 2023 were reviewed retrospectively. Indication for subureteric injection, age, gender, laterality, number of injections, amount of material used, renal failure etiology, auxiliary procedures, and treatment success were noted. All interventions were performed by pediatric urologists who also perform RT. During a median followup of 27.5 (4-160) months, 22 patients (17 women, 77.2%) and 23 transplanted ureters (13 right, eight left, one bilateral) were treated with subureteric injections. In all patients, the indications for subureteric injection were recurrent febrile urinary tract infection (UTI), and the grades of VUR varied between I and IV. Patients received a median of 1.65 cc (0.7-2.7) dextranomer-hyaluronic acid copolymer. In total, 10 RTs (eight from living donors, two from cadaveric donors) were performed in another center, whereas 13 RTs were carried out in our center (eight from cadaveric donors and five from living donors). Among the patients who were transplanted in our center, the rate of subureteric injections due to de novo symptomatic VUR after RT was 2.2% (13/593 patients). After subureteric injections, five patients required a second injection due to the recurrence of VUR. Ureteroureterostomy (to the native ureter) was performed in two patients who had further UTIs after the second endoscopic treatment. Eventually, 19/21 patients (90.4%) benefited clinically from the endoscopic treatment and none of the patients underwent re-do ureteroneocystostomy. It is noteworthy that the etiology of renal failure was VUR nephropathy in seven (31.8%) patients. Subureteric injection provides a high clinical success for the treatment of de novo VUR after RT.

Investigation of the Effects of N-acetylcysteine and Selenium on Vesicoureteral Reflux Nephropathy: An Experimental Study

IntroductionThis study aimed to investigate the effects of N-acetylcysteine (NAC) and selenium (Se) on vesicoureteral reflux (VUR) nephropathy. MethodsA total of 44 rabbits in 7 groups, namely group 1 (Control), group 2 (VUR + sterile urine), group 3 (VUR + sterile urine + NAC), group 4 (VUR + sterile urine + Se), group 5 (VUR + infected urine), group 6 (VUR + infected urine + NAC) and group 7 (VUR + infected urine + Se), were used. 99mTc Dimercaptosuccinic acid renal scan (DMSA), cystogram and urine culture were performed both at the beginning and end of the study. Left VUR was created surgically, and E. coli was inoculated in infected urine groups. NAC and Se were administered daily for 21 days. Malondialdehyde (MDA) measurement, inflammatory response scores (IRSs), and cicatrization response scores (CRSs) in renal tissues were evaluated. ResultsVUR did not reduce left renal uptake values in neither group 2 nor group 5. MDA levels of the left kidney were significantly higher in group 5 compared to group 1 (p = 0.001). There was no significant difference in MDA levels between group 5 and group 6, and between group 5 and group 7. Left kidney IRSs were found to be higher in all other groups except group 2 compared to the control group (p < 0.001). Left kidney CRSs were significantly higher in group 5 compared to group 2 (p = 0.026), group 6 (p < 0.001) and group 7 (p = 0.006). ConclusionA decrease in renal functions was not observed in VUR, even if there was infection. When CRSs were evaluated, NAC and Se had protective effects in terms of scar formation in VUR nephropathy. Type of StudyExperimental animal study. Levels of EvidenceN/A.

Graft Survival in Patients With Lower Urinary Tract Dysfunction.

We aimed to the determine urinary tract infection and graft survival rates in pediatric renal transplant recipients with lower urinary tract dysfunction with particular focus on neurogenic bladder, posterior urethral valve, and vesicoureteral reflux nephropathy. Patients were grouped according to primary diseases as those with and without lower urinary tract dysfunction. Urinary tract infections during year 1 posttransplant were investigated. Estimated glomerular filtration rate was calculated using Schwartz formula. Our study investigated 133 kidney transplant recipients. Lower urinary tract dysfunction was found in 58 patients (43.6%): 25 with posterior urethral valve, 24 with vesicoureteral reflux nephropathy, and 9 with neurogenic bladder. Rates of posttransplant urinary tract infection were higher in patients with lower urinary tract dysfunction than in those without during both the first 6 months posttransplant (24.6% vs 10.8%; P = .037) and between posttransplant months 6 and 12 (24.6% vs 8.2%; P = .01). Patients with neurogenic bladder had the highest rate of urinary tract infections, and their estimated glomerular filtrations rates were lower compared with patients with posterior urethral valve and vesicoureteral reflux nephropathy at month 6 and years 1, 2, and 5 posttransplant (P < .001). The 5-year graft survival rates of patients without lower urinary tract dysfunction and those with vesicoureteral reflux nephropathy were similar (51.3% vs 51.6%; P = .891). Graft survival rates of patients with posterior urethral valve and vesicoureteral reflux nephropathy were similar to those shown in patients without lower urinary system dysfunction; however, patients with neurogenic bladder had worse graft survival and urinary tract infection rates.

Decreased Identification of Vesicoureteral Reflux: A Cautionary Tale.

To find the trend in patient's visits to our centers for vesicoureteral reflux (VUR). We hypothesize that VUR diagnosis and hence possible nephropathy recognition may be diminishing because of changing practice patterns. Data were extracted from electronic medical records for new and follow-up patients aged 0-18 years with ICD-9/10 codes to correspond with VUR, VUR unilateral, VUR bilateral, and VUR with reflux nephropathy, as well as new patients with diagnoses of urinary tract infections (UTI) and pyelonephritis at two major pediatric centers from 2012 to 2015. Figures and statistics to reflect absolute clinic visits and annual trends were created with SPSS 2010. Linear regression was applied. Annually, Le Bonheur Children's Hospital and Nationwide Children's Hospital experienced an average decrease of 13 and 17% in total VUR visits, and an average decrease of 22 and 27% in VUR nephropathy visits, respectively, for each institution. Patient visits for UTIs were reduced an average of 16% annually in both centers. Linear regression demonstrated that number of patients (patients/year ± SE) decreased annually 69 ± 19 (P = 0.02), 7 ± 2 (P = 0.02), and 67 ± 25 (P = 0.04) for VUR, VUR nephropathy, and UTI, respectively. We conclude that the decreased number of VUR and VUR nephropathy cases identified in subspecialty clinics (Nephrology/Urology) at two major children's hospitals reflect a possible decreased identification of VUR. This trend may also be due to decreased referral of low grade cases of VUR. We cannot conclude that "undifferentiated UTI" referrals increased concomitantly to account for the decreased VUR as our data reflects a decreased trend in those visits as well. We suggest that clinicians following the American Academy of Pediatrics guidelines ensure that all UTI are accounted for and surveillance is appropriately escalated for recurrent UTI or abnormal imaging results.

Arterial hypertension syndrome sustained by an unexpected association of pheochromocytoma and vesicoureteral reflux nephropathy

Arterial hypertension syndrome sustained by an unexpected association of pheochromocytoma and vesicoureteral reflux nephropathy

Vaginal mass caused by a lately recognized congenital bladder diverticulum

Congenital bladder diverticula are strongly associated with vesicoureteral reflux (VUR), and are mostly present in childhood. The most common symptom is urinary tract infection at the time of admission. The diverticulum is usually solitary and its location is near the ureteral orifice, which is probably the main cause of VUR. We report a woman who presented with a vaginal mass located on the right inferior part of the external urethral meatus. The patient had a history of recurrent urinary tract infection and right nephrectomy due to VUR nephropathy. We examined her with cystography, computerized tomography, and cystoscopy. The cystoscopic examination was very diagnostic in our patient. The patient underwent diverticulectomy, and after 6 months of follow-up, her complaints had completely disappeared.

Aggressive blood pressure control for chronic kidney disease unmasks moyamoya!

Hypertensive crises in children or adolescents are rare, but chronic kidney disease (CKD) is a major risk factor for occurrence. Vesicoureteral reflux nephropathy is a common cause of pediatric renal failure and is associated with hypertension. Aggressive blood pressure (BP) control has been shown to delay progression of CKD and treatment is targeted for the 50th percentile for height when compared with a target below the 90th percentile for the general pediatric hypertensive patient. We present a case of an adolescent presenting with seizures and renal failure due to a hypertensive crisis. Hypertension was thought to be secondary to CKD as she had scarred echogenic kidneys due to known reflux nephropathy. However, aggressive BP treatment improved kidney function which is inconsistent with CKD from reflux nephropathy. Secondly, aggressive BP control caused transient neurological symptoms. Further imaging identified moyamoya disease. We present this case to highlight the consideration of moyamoya as a diagnosis in the setting of renal failure and hypertensive crisis.

Refers to: Association of Nocturnal Enuresis With Vesico-ureteral Reflux and Renal Cortical Damage

Dear Editor, In the mid-1980’s, the Aarhus group headed by the two pioneers in Nocturnal Enuresis research Jens-Christian Djurhuus and Jens Peter Norgaard, reported the first data correlating the degree of Vesicoureteral Reflux (VUR) and associated nephropathy to the presence of enuresis (1). The material showed that one half of the patients with reflux also had enuresis, and that in spite of identical demographics and medical history, patients with enuresis presented a significantly lower degree of reflux nephropathy, leading to the hypothesis that enuresis might act as a safety valve mechanism reducing the possibility of VUR nephropathy. The new data presented by Dr. Naseri suggest that VUR is uncommon in children with monosymptomatic nocturnal enuresis (MNE) and in daytime continent non-monosymptomatic nocturnal enuresis (NMNE) while being relatively more common in enuretic children who have daytime incontinence. In contrast to previous studies, no correlation between VUR and urinary tract infection (UTI), secondary enuresis, or any other daytime symptoms except for incontinence was found. This finding warrants further research. Also, the finding of (a) gender difference in VUR being significantly more frequent in enuretic girls raises important clinical questions. Is the apparent association between gender and VUR in enuretic children, if proved in future research, acquired or genetic? Some studies have suggested the presence of a modified VUR gene (s) on the X-chromosome, accounting for the higher incidence of this disorder among female members, while on the other hand male-to-male transmission and a higher ratio of females to males has provided arguments against X-linked inheritance (2). If X-linked inheritance of VUR is the case, this will be an intriguing exception to the general finding that in genetic kidney diseases males are often more vulnerable to mutations in their single copy of X-linked genes, whereas females having a mixture of cells expressing different sets of X-linked genes are often protected from severe clinical manifestations due to X-linked mutations (3). For future genetic research it will be interesting to explore if a genetically distinct subgroup of VUR with severe reflux exist with female preponderance.

The detection of vesicoureteral reflux in a nonfunctioning kidney on a Tc-99m DTPA renal function study.

A 7-year-old child who had previously undergone a left pyeloplasty because of vesicoureteral reflux (VUR) underwent dynamic Tc-99m-DTPA imaging for an evaluation of renal function. Dynamic images showed a nonfunctioning left kidney and a normally functioning right kidney with pelvicaliceal stasis. Following furosemide injection, the right pelvicaliceal stasis disappeared in a few minutes, while the left ureteral and subsequently left pelvicaliceal system was filling with the activity that came from the right kidney that had passed through the bladder. This drainage demonstrated a high degree VUR (Grade III) on the side of the nonfunctioning kidney. Extensive parenchymal damage was thought to be due to a high degree VUR in the left kidney. A static Tc-99m DMSA study and ultrasonography revealed the presence of left VUR nephropathy.

Irreversible Renal Failure Following Vesicoureteral Reflux

Antireflux surgery was performed in five patients with vesicoureteral reflux at a time when renal insufficiency was present. Notable proteinuria was present in four of the patients, and a kidney biopsy specimen showed glomerular lesions in one. Despite the eradication of reflux and of infection, all five patients continued to have progressive renal insufficiency culminating in renal failure. Vesicoureteral reflux nephropathy may include a glomerulopathy leading to progressive glomerular sclerosis. Antireflux surgery would not alter this ongoing process and therefore would not halt progressive renal failure.

Vesicoureteral reflux nephropathy Evidence for immunologically mediated glomerular injury

A retrospective clinicopathologic analysis was done on 8 patients with bilateral vesicoureteral reflux, bacteriuria, and renal failure. Although none of the patients had a history of glomerulonephritis, quantitative urinary protein excretion of the 6 patients examined exceeded 2.3 Gm. per day and was greater than 5.2 Gm. per day in 4. Examination of the resected kidneys revealed an interstitial nephritis consistent with chronic pyelonephritis along with significant degrees of glomerular sclerosis. In addition, a granular deposition of immunoglobulin M and complement was seen in glomeruli of all 5 cases examined by immunofluorescence microscopy, and 2 cases had subendothelial electron dense deposits along glomerular capillary walls. The heavy proteinuria along with the deposition of immunoglobulin M and complement along glomerular capillary walls suggests that the terminal renal disease associated with vesicoureteral reflux has a component of glomerular injury possibly related to immunologic mechanisms.