Reflux Nephropathy

Reflux Nephropathy causes great deal of damage to kidney as a result of backflow of urine in to kidneys. This may result in various medical complications like proteinuria, hypertension, and eventually end stage renal disease. In this article, we will discuss in detail about the various causes, symptoms, and treatments for Reflux Nephropathy.

Reflux Nephropathy

How Do We Define Reflux Nephropathy?

  • Physiology of Urination- Urine is secreted by the kidney and passes through the ureter into urinary bladder. Urine is collected in bladder for a certain period of time until individual feels to discharge urine. The feeling of discharged urine depends on volume filled in bladder.
  • Reflux of Urine- Contraction of urinary bladder forces urine flows through urethra to discharge urine outside body. The force created by contraction of muscles of bladder pushes urine against ureter. Sphincter of ureter contracts and prevents urinary flow towards kidney.
  • Reflux Nephropathy- Reflux Nephropathy is a medical condition in which the kidneys get damaged as a result of backflow of urine into kidneys.
  • Kidney Damage- Symptoms caused by Reflux Nephropathy are the results of scarring of the kidney.
  • Age- This condition develops usually during the few years of life. Disease is presented with history of frequent urinary tract infection in children.
  • Genetic Predisposition1- The disease is considered to be predisposing by genetic mutations and observed in 1st degree relatives. The estimated gene frequency is 1:6000.
  • Effects of Kidney Damage- An affected individual with Reflux Nephropathy eventually ends up with having hypertension, proteinuria, and ultimately End Stage Renal Disease.

Causes Of Reflux Nephropathy

  • Weak Ureteral Sphincter Or Valve
    • Newborn Baby- Urine flows in reverse direction in 1 in 100 newborn babies. Reverse urine flow is also known as reflux. In most of the baby, the bladder squeezes ureter during contraction and prevents urine reflux.
    • Genetic Mutation1- The congenital defects of bladder mucosa and muscles results in open ureteral orifice during bladder contraction, which allows urinary reflux toward kidney.
    • Weak Ureter Valve- The opening of ureter into bladder is covered by bladder mucosa. The mucosal coverings function as a valve. The mucosal covering wraps around the ureter opening when bladder contracts and functions as a valve. The valve effects of bladder mucosa prevent urinary flow toward kidney. In few adults the mucosa does not wrap around the ureteral opening and do not function as a valve, which results in reflux of urine towards kidney.
  • Bladder Outlet Obstruction-
    • Prostate Hypertrophy- Prostate hypertrophy blocks urinary flow through urethra. The force created by bladder contraction eventually forces opening of ureter sphincter, which results in reverse urine flow through ureter to kidney or reflux of urine towards kidney.
    • Bladder Stone- Bladder stone causes obstruction of urine flow like prostate hypertrophy resulting in urinary reflux.
  • Neurogenic Bladder 2
    • Neurogenic bladder is the condition that results following miscommunication between nerve and bladder muscles. Bladder muscles do not contract when stimulated by bladder nerve. Urine is collected until bladder is filled to maximum capacity. Urine overflows through ureter towards (reflux) kidney and leaks outside (incontinence) through urethra.
  • Therapeutic Complication-
    • Surgery- Bladder, Prostate or Ureteral surgery can cause blockade of urinary outflow at ureteral opening or urethral output.
    • Radiation Treatment- Radiation treatment of bladder, lower end of ureter and prostate causes stricture of bladder, ureter and urethra. Stricture of ureter and urethra causes obstruction of urinary flow, which results in reflux. Bladder stricture causes blockade of urethra or ureter opening.

Risk Factors For Reflux Nephropathy

Risk Factors For Reflux Nephropathy Are As Follows-

  • A Family History of Vesicoureteral Reflux
  • Frequent Episodes of Urinary Tract Infections
  • Pregnancy- Women with reflux nephropathy normally have successful pregnancies. However, there is an increased risk of urine infection during pregnancy. If there is protein in the urine or scarring on the kidneys, there is an increased risk of high blood pressure, and this requires careful management. If someone with severely damaged kidneys from reflux nephropathy wants to get pregnant, the risks depend upon the exact level of kidney function. Some larger hospitals have clinics run by a kidney specialist and an obstetrician working together, to provide extra care for pregnant women with kidney diseases.

Symptoms Of Reflux Nephropathy

Non-Specific Symptoms Of Reflux Nephropathy Are-

  • Loss of appetite
  • Loss of weight
  • Fatigue and weakness
  • Insomnia- unable to sleep

Specific Symptoms of Reflux Nephropathy:

Urinary Tract Infection3-

  • Pain- Suprapubic and occasionally in flank, it is severe and occasionally colicky pain.
  • Urinary incontinence or bed wetting.

Chronic Renal Failure

  • Nausea and Vomiting
  • Decreased urine output
  • Decreased mental sharpness
  • Muscle twitches and cramps
  • Hiccups
  • Swelling of feet and ankles
  • Persistent itching
  • Palpitation and Chest pain caused by fluid around heart (cardiac effusion)
  • Shortness of breath caused by fluid around lungs (pleural effusion)

Nephrotic Syndrome

  • Pitting edema of feet
  • Puffy face and eyes
  • Short of breath because of pleural effusion (fluid collection around the lungs)
  • Proteinuria, hematuria and oliguria

Signs of Reflux Nephropathy

Following Are Reflux Nephropathy Signs:

  • High blood pressure (hypertension)
  • Edema of feet
  • Ascites (fluid collection in abdominal cavity)
  • Anemia

Diagnosis Of Reflux Nephropathy

Reflux Nephropathy is generally found when a child is being investigated for frequent bladder infections.

Urine Examination-

  • Urinalysis
  • Urine culture
  • Protein in urine

Blood Examination-

  • Hemoglobin- Low hemoglobin if anemia is associated with the reflux nephropathy.
  • Complete Blood Count (RBC)- Low hemoglobin and red blood cell count observed if anemia is associated with low RBC's
  • Electrolytes- Low sodium and high potassium may indicate signs of renal failure
  • BUN- Elevated
  • Creatinine- Elevated
  • Creatinine clearance- Elevated

Electrocardiogram and Echocardiogram-

  • Abnormal findings are observed in cardiac effusion

Radiological Studies-

  • Chest X-Ray- Abnormal findings are observed in pleural and pericardial effusion,
  • CT scan of the abdomen
  • Ultrasound of the bladder and kidney
  • Intravenous pyelogram (IVP)- Dye study of the kidney following intravenous dye injection,
  • Cystogram- Urinary Bladder study and
  • Retrograde pyelogram

Prophylactic Test-

  • Sibling of affected child should be tested for Vesicoureteral Reflux

Treatment For Reflux Nephropathy

Treatment For Pain In Reflux Nephropathy-

  • Pain is treated with pain medications such as NSAIDs or opioids

Treatment For Infection In Reflux Nephropathy4-

  • Infection is treated after blood test, culture and antibiotic sensitivity test.
  • Appropriate antibiotics are selected for treatment of infection.

Treatment For Edema Feet In Reflux Nephropathy-

  • Edema feet are treated with electrolyte management and diuretics.

Treatment For Pleura Effusion In Reflux Nephropathy-

  • Fluid around lungs is treated with diuretics or removal of fluid by inserting needle in to space where fluid is collected.
  • The procedure is known as therapeutic thoracentesis.

Treatment For Cardiac Effusion in Reflux Nephropathy-

  • Fluid around the heart is removed by inserting needle in the pericardial sac where fluid is accumulated and interferes with cardiac function. Procedure is known as pericardiocentesis.

Treatment For Hypertension in Reflux Nephropathy-

  • Antihypertensive medications.

Kidney Dialysis As A Treatment For Reflux Nephropathy-

  • Ureteric reimplantation to reduce or eliminate vesico-ureteric reflux in the adult.5

Kidney Transplant As A Treatment For Reflux Nephropathy-

  • Kidney transplant is a last choice of treatment and indicated for kidney failure.

Prognosis Of Reflux Nephropathy

  • The overall prognosis of Reflux nephropathy depends upon the severity of the disease.
  • The disease may or may not cause kidney damage in children. Kidney damage caused by the disease may result in decreased renal (kidney) function, which eventually results in kidney failure.
  • Reflux Nephropathy can affect both children as well as adults.

Complications Of Reflux Nephropathy

Complications of Reflux Nephropathy Are As Follows:

  • Ureter blockage
  • Chronic renal failure
  • Frequent bladder and ureteral infection
  • Kidney infection
  • Hypertension
  • Scarring of kidney

References:

1. Gene discovery and vesicoureteric reflux.

Murawski IJ1, Gupta IR.

Pediatr Nephrol. 2008 Jul;23(7):1021-7.

2. Vesicouretral reflux with neuropathic bladder: studying the resolution rate after ileocystoplasty.

Helmy TE1, Hafez AT.

Urology. 2013 Aug;82(2):425-8.

3. Clinical characteristics of primary vesicoureteral reflux in infants: multicenter retrospective study in Japan.

Nakai H1, Kakizaki H, Konda R, Hayashi Y, Hosokawa S, Kawaguchi S, Matsuoka H, Nonomura K, Shimada K, Kawamura T; Prospective Study Committee of Reflux Nephropathy Forum, Japan.

J Urol. 2003 Jan;169(1):309-12.

4. Early management and long-term outcomes in primary vesico-ureteric reflux.

Coleman R.

BJU Int. 2011 Nov;108 Suppl 2:3-8.

5. Ureteric reimplantation for vesico-ureteric reflux in the adult.

Dounis A, Dunn M, Smith PJ.

Br J Urol. 1978 Jun;50(4):233-6.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: May 2, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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