REFLUX  UROPATHY (Nephropathy)

           Kidneys produce sterile urine. Ureters are the tubes (one on each side) connecting the kidneys to the bladder. Through these tubes the urine drains into the bladder. The urine in theKidney2.gif (17862 bytes) bladder is usually not sterile and is likely to contain bacteria. Usually the presence of very small numbers of bacteria does not cause infection. But when they proliferate and are large in numbers (more than 100000/cc) the bladder gets infected. When the bladder is infected, patient will experience pain or burning during urination. The urine may be cloudy or even bloody. When such urine is tested, it may contain blood, protein, white blood cells and bacteria.

            Normally, when a person's bladder is full then he or she has the urge to urinate and emptys the bladder. This emptying process involves muscles of the bladder. They contract and increase the pressure inside the bladder. Because of the increased pressure and due to the action of the bladder muscles the ureters are closed at their junction with the bladder (Vesico-Ureteral junction). This prevents backing up of the non-sterile urine into the ureter and all the way up to the kidney. At the same time the sphincter at the junction of the bladder and urethra relaxes and the urine in the bladder under pressure comes out through the urethra and is excreted.

            But in some, the above mechanism may be abnormal. Because of one or more of the following reasons, part of the urine in the bladder backs up into the ureter and only the remaining part of the urine comes out through the urethra:

    1. Tight sphincter at the junction of the bladder and ureter
    2. Weak bladder muscles unable to close the opening of the ureters
    3. When the bladder is infected and irritated
    4. Due to congenital abnormality of the ureters improperly inserted into the bladder

Such backing up of the urine into the ureters is called "REFLUX UROPATHY.*" More often this happens in children than adults. Among children this is more common in boys than girls. But it could happen to adults as well as girls. It could happen on only one side or both ureters may be involved. The reflux could be mild or might be severe.

When such reflux happens, it causes the following symptoms:

    1. Sensation of bladder being emptied incompletely
    2. Frequent urination
    3. Repeated and recurrent urinary tract infections** with the symptoms as mentioned above, as long as the reflux is uncorrected
    4. Chronic low grade back (loin) pain

Therefore, when there is recurrent urinary tract/bladder infections (also known as Pyelonephritis/Cystitis), it is an accepted procedure to investigate for the presence of "REFLUX UROPATHY" especially in children. An intravenous pyelogram with a voiding cysto-urethrogram (both are radiological procedures) will be needed. Some times the ultrasound*** or the CT-Scans could reveal some of the information needed.

Since the infection of the bladder itself could cause "REFLUX," it is advisable to

        1.  Treat the infection first
        2.  Prevent the infection from recurring for at least four to six months by continuous use of daily night-time antibiotics at low dose.  This, at times, may not completely prevent infection from recurring, but will reduce the number of episodes of infections.  When the infection do flare up while on nightly antibiotics the urine cultures need to be repeated and the infection needs to be treated with appropriate antibiotics.  No one antibiotic is proven to be superior to others in suppressing the infection when used at nightly doses.

        3. Repeat the Voiding cysto-urethrogram and IVP.  (There are other procedures including Radio-Nucleide studies of unproven values in evaluating the Reflux.  Cysto-urethrogram is the gold standard.)

If the reflux persists after 4 to 6 months of infection-free interval, it will require further evaluation and treatment. The treatment may be one of observation for the ill effects of the "reflux," (Ref: Consequences of Reflux), treating the recurrent urinary tract infections, preventing recurrent urinary tract infections by nightly antibiotics continuously until puberty;  or might involve surgically re-implanting the ureter in the bladder in such a way that it will prevent the reflux. Most often these decisions depend on whether  i)  any other abnormalities exists along with the reflux,   ii)  how often do the urinary tract infections occur,   iii) and also on the severity of the reflux.

In general, except under the circumstances listed below, surgical management and the medical managemet (as mentioned above) achieve the same results in preventing kidney failure. Sometimes the medical management might show increasing scarring in the kidneys.  But the significance of such scarring is not known but does not increase the chances of kidney failure.

Surgry may be indicated under following circumstances:

                1.   Severe Reflux with dilatation of the pelvis of the kidney on ultrasound or other imaging technique.
                2.   Repeated urinary tract infections despite continued night time antibiotics.
                3.   Repeated urinary tract infections because the child is not able to take the antibiotics for any reason (including noncompliance)

IN ADDITION TO TREATING THE PATIENT WITH REFLUX UROPATHY,
SINCE IT COULD BE FAMILIAL, OTHER CHILDREN IN THE FAMILY
SHOULD BE TESTED AND IF NEEDED SHOULD HAVE NEONATAL OR  
IN-UTERO ULTRASOUND STUDIES.

 

CONSEQUENCES OF REFLUX:

    1. Hypertension (High Blood Pressure)
    2. HydroNephrosis (Dilated ureters and the collecting area inside the kidneys)
    3. Kidney dysfunction due to the back pressure due to reflux (Baro-Trauma)
    4. Kidney dysfunction due to increased scarring within the kidneys (Scarring of pyelonephritis.) This could lead to CHRONIC RENAL FAILURE.
    5. Anemia when the kidney dysfunction is severe.
    6. Chronic low grade back pain (less common)
    7. Repeated episodes of Urinary tract infections

      *When the kidneys are affected because of reflux uropathy then the condition is  called "Reflux Nephropathy"

      **Recurrent urinary tract infections are common in girls and women (in part due to the anatomy and the close proximity of the urethral and anal orifices - besides other factors) and does not necessarily mean they have "Reflux Uropathy" or "Reflux Nephropathy."   Repeated urinary tract infections - in the absence of other conditions like stones, obstruction, Reflux  - almost never cause kidneys to fail and require dialysis or kidney transplant.

      ***Interpretation of ultrasound of the kidneys in small children should be done by physicians specially trained to read such ultrasounds. Sometimes the ultrasound will reveal changes that could be interpretated as scarring (due to lobulations of a growing kidney) or obstruction (hydronephrosis). Frequently, Ultrasound of the kidneys of small children are over-read and over-interpretated.