The primary concern for patients with vesicoureteral reflux (VUR) is the development of renal impairment and hypertension. The aim of this study was to evaluate adult patients treated for VUR during childhood in regards to renal function and blood pressure (BP).

They evaluated 147 (55%) of 267 patients with a mean age of 41 years who were treated for non-obstructive VUR of any grade as children. Twelve patients had died of kidney-related conditions and eight had gone into terminal uremia therefore excluded from the study population. A total of 127 patients participated in the study. No signs of renal scars were detected by ultrasound examination in 53 (42%) subjects. Unilateral scarring was seen in 44 (35%) and bilateral in 30 (24%) subjects. Glomerular filtration rate (GFR) showed moderate or severe renal insufficiency in four (3%) participants, all with bilateral scars. Normal GFR was found in one-third of the patients. Twenty-five (83%) subjects with bilateral scars and 60 (62%) of the other participants had abnormal GFR values (P < 0.05). Proteinuria was found in 12 (9%) and albuminuria in 30 (24%) participants. Hypertension was diagnosed earlier in 14 (11%) patients, eight having bilateral scarring (P < 0.01). Diastolic BP was significantly lower in subjects without scars compared with those having scars in one or both kidneys (P < 0.05).

The group concluded that renal function was slightly lowered in more than half of the participants. Findings of the participants with unilateral scarring or unscarred kidneys were similar, except for the increased tendency for hypertension in subjects with scars. A total of 83% of the patients with bilateral kidney scars had lowered kidney function, a quarter presented with proteinuria and a half with hypertension. They emphasized that a long-term follow-up for all the patients with earlier VUR is crucial.

It is difficult to determine whether these "scars" are truly scars or dysplasia. One would have to consider that if scar is present, then could it be that those patients would typically be the 3 to 5% of reflux patients who would benefit from correction to decrease the risk of hypertension or renal impairment. However, if it is dysplasia, then it may be possible that the fate of that kidney has been set embryologically and predetermined.

It has become my practice to get DMSA scans on all children diagnosed with VUR presenting with antenatal hydronephrosis or pyelonephritis. If the child with pyelonephritis has a negative DMSA scan, then it acts as a baseline. If it is positive, then it is difficult to delineate scar from dysplasia. The child with antenatal hydronephrosis is easier to delineate if there is no history of pyelonephritis.

If the DMSA is negative, then it acts as a baseline. If it is positive, it most likely represents dysplasia since pyelonephritis has not been part of the clinical scenario. It will become important to determine if it is the scar or dysplasia that leads to renal impairment or hypertension. At this point, we do not have a definitive way to distinguish the two without any question. MRI is beginning to emerge as a promising modality, but further investigation is paramount.

Reference:
Tuija Lahdes-Vasama, Kaija Niskanen and Kai Rönnholm.
Outcome of kidneys in patients treated for vesicoureteral reflux (VUR) during childhood.
Nephrology Dialysis Transplantation 21(9):2491-2497, Sept 2006.
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