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Reflux Nephropathy - Causes, Symptoms, Diagnosis and Treatment

Published on Aug 04, 2022 and last reviewed on Apr 11, 2023   -  5 min read


Reflux nephropathy is the impairment of kidney function caused by the backward flow of the urine to the kidney. Read the article to know more about it.

Reflux Nephropathy - Causes, Symptoms, Diagnosis and Treatment

What Is Reflux Nephropathy?

The urinary tract is divided into upper urinary tract and lower urinary tract. The upper urinary tract comprises a pair of kidneys and ureters. The lower urinary tract consists of the bladder and urethra. The urine found inside the kidney enters the bladder via ureters. The urine flow is always towards the bladder, guarded by the vesicoureteral valve. When the bladder is full, it constricts and carries the urine out of the bladder through the urethra. No urine should flow back to the ureter when the bladder is constricted. The backward flow of urine when the bladder is constricted is prevented by the vesicoureteral valve. But, in some people, urine flows back to the kidneys. This is called vesicoureteral reflux. Due to this condition, the kidneys get damaged or scarred. This is called reflux nephropathy.

Causes of reflux nephropathy

What Are the Causes of Reflux Nephropathy?

  • Improper Attachment of Ureter to the Bladder - In some people, the ureters may not attach properly to the bladder leading to the backflow of urine towards the kidney.

  • Defect in Vesicoureteral Valves - Ureterovisceral valves are one-way valves that allow the urine to flow into the urinary bladder and prevent it from flowing back to the ureter. Any defect in the vesicoureteral valve causes vesicoureteral reflux (VUR). VUR results in tubular atrophy of the kidneys, interstitial nephritis, and renal scarring with glomerular hypertrophy.

  • Bladder Outlet Obstruction - Reflux nephropathy can occur due to bladder obstruction that leads to blockage of urine flow. An enlarged prostate can cause bladder outlet obstruction in men.

  • Bladder Stones - Obstruction in the flow of urine due to the presence of stones in the bladder can occur. This leads to blockage of the urine flow.

  • Neurogenic Bladder - Nervous system or neurological conditions such as multiple sclerosis, spinal cord injury, and diabetes can obstruct urine flow.

  • Inflammation of the Ureter - Swelling of the ureter from injury or after a kidney transplant can cause reflux nephropathy.

  • Risk Factors - Some risk factors that increase the chance of reflux nephropathy constitute abnormalities of the urinary tract, family history of vesicoureteral reflux, and repeated urinary tract infections.

What Are the Symptoms of Reflux Nephropathy?

  • Urinary Tract Infection - Vesicoureteral reflux (VUR) is generally diagnosed in childhood or early adulthood due to recurrent urinary tract infections. VUR leads to high-pressure urine reflux, which prevents the natural growth of the kidneys.

  • Nephrotic Syndrome - Deterioration of kidney function occurs due to injury to the tiny blood vessels in the kidney. Damage to the renal vasculature occurs due to reflux of the urine. This can further lead to proteinuria (loss of protein in urine).

  • Chronic Kidney Failure - Retention of the symptoms of vesicoureteral reflux and failure of a prophylactic antibiotic regimen can lead to chronic renal failure.

  • High Blood Pressure - Disturbances in the renin-angiotensin mechanism can cause an increase in blood pressure (hypertension).

Other Symptoms Include :

  • A powerful urge to urinate.

  • A burning sensation during urination.

  • The desire to pass small quantities of urine repeatedly.

  • Foggy urine.

  • Fever.

  • Flank pain or pain in the abdomen.

How to Diagnose Reflux Nephropathy?

  • Blood Test - A blood test needs to be done to check for blood urea nitrogen (BUN), creatinine, and creatinine clearance.

  • Urine Test - Urinalysis or urine culture can be done for creatinine clearance and biomarkers of kidney function.

  • Imaging Tests:

    • Kidney Ultrasound - Kidney ultrasound uses sound waves to detect the presence of any obstruction present in the kidney and urinary bladder.

    • Abdominal Computed Tomography (CT) Scan - A computer tomography uses X-rays to detect the presence of an obstruction in the kidneys, bladder, and ureters.

    • Nuclear Cystography - It is used in the prevention of exposure to radiation in patients with post-surgical vesicoureteral reflux follow-up.

    • Radionuclide Scan - A radionuclide scan using dimercaptosuccinic acid is highly sensitive and can be used to diagnose acute pyelonephritis and renal scarring.

    • Voiding Cystourethrogram (VUC) - It is the primary method to diagnose and identify vesicoureteral reflux. It is used in patients with bilateral or unilateral hydronephrosis found on examination with ultrasound.

What Are the Complications Associated With Reflux Nephropathy?

The complications occur due to subtle onset and include -

  • Recurrent cystitis (three episodes of urinary tract infection in the past 12 months or two episodes in six months) and pyelonephritis (a type of urinary tract infection starting from the urethra or bladder and traveling to one or both kidneys) resulting in early growth retardation.

  • Hypertension is associated with renal impairment during pregnancy.

  • Reflux with renal scarring in women can lead to fetal morbidity.

  • Urine concentration defects, hyperkalemia, type one renal tubular acidosis, chronic kidney disease, and end-stage renal disease.

  • Chronic kidney disease from reflux nephropathy leads to increased chances of cardiovascular mortality and morbidity.

How to Treat Reflux Nephropathy?

  • Management of Mild Cases -

For patients with symptoms of VUR, the main goal of treatment is antimicrobial treatment, treatment of urinary tract infections, and surgical correction. Long-term treatment with antibiotics such as Trimethoprim and Sulfamethoxazole, Trimethoprim, and Cephalexin. Management of bladder and bowel dysfunction can be done by using laxative and stool softener drugs, frequent and timed voiding, anticholinergic drugs, pelvic floor exercises, and behavioral modification.

  • Management of Severe Cases -

In chronic and declined medical management of antimicrobial prophylaxis cases, re-implantation of the ureters into the bladder to retain the proficiency of the ureters is indicated. In advanced cases with renal scarring and chronic kidney disease, surgery plays no role. Surgical corrections can be done in recurrent infection despite prophylactic antibiotic regimen, worsening of the renal scars, and non-adherence to the antibiotic prophylaxis.

  • Management of Hypertension -

In patients with predominant reflux nephropathy, renin-angiotensin system blockade needs to be done to avoid glomerular hyperfiltration and proteinuria. Renal replacement therapy can be recommended in patients with end-stage renal disease.

Conclusion :

Every condition with vesicoureteral reflux does not result in reflux nephropathy. Early diagnosis, treatment, and maintenance of sterile urine in affected individuals with vesicoureteral reflux can help prevent reflux nephropathy. Patient and parent education for regular and periodic monitoring for disease progression is necessary. Encouragement for prophylactic antibiotic regimens to treat urinary tract infections can help prevent VUR. Patients with VUR should be made aware of the probability of their offspring and siblings having it.

Last reviewed at:
11 Apr 2023  -  5 min read




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