Reflux Nephropathy/Chronic Pyelonephritis

Background

  • Specific type of chronic interstitial nephritis associated with vesico-ureteric reflux (VUR) in early life and the development of scarring of the kidney
  • Due to chronic reflux of urine from the bladder into the ureters, in association with recurrent UTI in childhood (although ascending UTI/pyelonephritis is not necessarily a cause of scarring; reflux thought to be more important)
    • Factors other than these (e.g. genetic susceptibility) may also play a role
  • VUR affects ~1% of neonates and 30-45% of children with a febrile UTI
    • Most children ‘grow out’ of this problem by age 5 (surgery is no longer routine)
  • Incompetent UV valves or mechanical obstruction are the main causes

Presentation

  • Renal scarring is usually asymptomatic (frequent UTIs as a child aside)
  • Can present at any age of features of CKD e.g. hypertension, proteinuria, oedema (particularly in bilateral disease); lower urinary tract symptoms may also be present e.g. frequency, nocturia, dysuria

UTI in childhood

  • A suspicion of VUR should be high in
    • UTI < 3 years
    • Febrile UTI <5 years
    • Recurrent UTIs in children

Investigations

  • Renal USS may show renal scarring (can be difficult to visualise)
    • Radionuclide DMSA scans are particularly sensitive at showing scarring of the kidney
    • MRI/CT may also be useful
    • Micturating cystourethrogram may also be useful at detecting reflux
  • Urinalysis
  • FBC and U&Es
  • (see also CKD)

Management

  • Prophylactic antibiotics if there are recurrent infections
    • Men- Trimethoprim 200mg BD/Nitrofurantoin 50mg QDS or 100mg MR BD
    • Women- Trimethoprim 100mg nocte/post-coital +/- cranberry juice
  • Manage CKD as appropriate
  • Nephrectomy may be appropriate in unilateral disease

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