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Renal damage in children has been found to be more congenital in origin than was previously thought. Congenital anomalies of the kidney and urinary tract (CAKUT) involve renal dysplasia, renal hypoplasia, urinary tract obstruction and vesicoureteral reflux. CAKUT are sometimes bilateral and different types often coexist. Depending on their types and severity, children with CAKUT often have varying degrees of a reduced number of nephrons at birth. CAKUTare now the leading cause of renal failure in children. Children with renal dysplasia or obstructive uropathy may have abnormal renal tubules, and tend to lose essential water and sodium in urine. This can lead to poor body growth unless they are supplemented with water and sodium. Children with severe ureteric reflux often develop urinary infection and renal scarring. Renal scarring can further increase the risk of renal failure in children who already have other CAKUTand fewer nephrons than normal. Hypertension and proteinuria may develop in children with renal dysplasia and further aggravate renal function unless they are treated. Recent advances in the understanding and management of CAKUT make it possible for children with CAKUT to grow normally, have fewer complications such as urinary infection, have longer renal survival, and survive even with end-stage renal diseases through renal replacement therapy.
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PMID:Medical management of congenital anomalies of the kidney and urinary tract. 1452 48

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. The current indications for the surgical correction of VUR depend on the presence or absence of renal scars. If no scars are present, primary ureteral reimplantation is only indicated in high-grade bilateral VUR, whereas in the presence of renal scars surgical correction is indicated in low/high grade reflux at a young age. Since there are numerous techniques for antireflux surgery available, it is the purpose of this article to critically review these techniques with their specific advantages, typical complications and postoperative management. In general, all surgical technique have a high success rate of 92-98%. The extravesical Lich-Gregoir technique is primarily indicated in unilateral VUR. Children with a high-grade VUR, who are under the age of 3 years and boys are prone to the development of postoperative urinary retention and might be considered for intravesical surgical techniques. The Politano-Leadbetter technique is very helpful in correcting bilateral VUR of any grade in one session to create a neo-ostium in an anatomically correct position which is easily accessible for endourological manipulations. The Psoas hitch ureteroneocystotomy is an excellent technique to correct VUR associated with megaureter, or with duplicated ureters, and VUR failures. Endoscopic subureteral injections are primarily reserved for low grade VUR with a one session success rate of >90%. Endoscopic subureteral injections appear to be an alternative to long-term antibiotics in grade I-III VUR. Laparoscopic antireflux surgery has not gained widespread use due to the very long operating times. Contralateral VUR will occur in about 20% of children undergoing unilateral antireflux surgery; risk factors are severe VUR and VUR into a duplicated system. Postoperative follow-up nowadays consists of urinalysis and ultrasonography; voiding cystourethrography is only indicated in case of febrile urinary tract infection. Despite the excellent success rates following antireflux surgery one has to keep in mind that surgery only corrects the anatomical abnormality. The long-term outcome with regard to renal function, posttherapeutic febrile urinary tract infections and arterial hypertension does not differ significantly from the medication group except for those patients with a demonstrated a genetic background. Therefore, the indication for surgery and the surgical technique applied have to be discussed thoroughly and must be associated with a minimal complication rate.
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PMID:Surgical management of vesicoureteral reflux in pediatric patients. 1522 Dec 60

Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the ureter and towards the kidneys. VUR is the most common cause of end stage renal failure in both children and adults and it is a major cause of severe hypertension in children. VUR is seen in approximately 1-2% of newborn Caucasians. Substantial evidence exists that VUR is a genetic disorder. Uroplakins are integral membrane proteins found in the bladder wall. Knockout studies in mice have suggested uroplakin III (UPK3) as a candidate gene for VUR. We have used parametric and nonparametric linkage analysis and tests for association, to investigate this possibility in a cohort of 126 sibling pairs affected with primary VUR. None of the analyses showed any substantial evidence for linkage or association of markers at the UPK3 locus to VUR. Our results do not support a role for UPK3 in primary VUR.
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PMID:Uroplakin III is not a major candidate gene for primary vesicoureteral reflux. 1552 93

Urinary tract infection (UTI) is one of the most common childhood bacterial infections, after upper respiratory tract and middle ear infections. The current goal of management is to prevent detrimental effects of UTI by early detection and treatment. Recommendations for the imaging of children depend upon age at presentation and sex. All children aged <5 years who have had a febrile UTI require a radiologic evaluation to identify any underlying genitourinary pathology. Older children can undergo a more tailored work-up depending on whether there is a febrile UTI or cystitis-type symptoms. Dysfunctional voiding and urge syndrome significantly increase the risk of developing UTIs in children. Vesicoureteral reflux can increase the risk of pyelonephritis and renal scarring in children with UTIs. For the most part, pyelonephritis can be diagnosed on clinical grounds in the majority of patients and a subsequent (99m)Tc-dimercaptosuccinic acid scan can be reserved to identify post-nephritic renal scarring. When renal scarring is identified, the child and parents need to be educated regarding the possibility of hypertension, proteinuria, progressive nephropathy, and the risk of complications in future pregnancies. Treatment of UTI is started in the unwell child before the culture results are available and subsequently changed to culture-specific antimicrobial therapy. A short course of treatment is required for acute uncomplicated UTIs. A child with acute pyelonephritis requires 10-14 days of antibacterial treatment. The oral route in young children often causes vomiting, which implies therapeutic delay, a well known risk factor for scarring.
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PMID:Controversies in the diagnosis and management of urinary tract infections in children. 1635 21

Vesicoureteral reflux (VUR) in children is associated with increased risk of urinary tract infection (UTI). Recurrent UTI in the presence of the VUR is believed to cause renal scarring, which carries a risk of subsequent hypertension, toxemia of pregnancy, and significant renal damage, including end-stage renal disease. The natural history of VUR is to improve or resolve completely with time in most of the patients. The traditional management consists of prompt treatment of UTI, long-term anti-microbial prophylaxis until the VUR resolves, or surgical intervention in those with persistent high grade VUR, recurrent UTI in spite of prophylaxis with anti-microbial agent, allergy to anti-microbial agents, and patient/parent non-compliance with the medical management. Voiding dysfunction and constipation play an important role, and their diagnosis and appropriate management helps reduce the frequency of UTI and promote the resolution of the VUR. Patients with renal scarring need to be monitored for potential complications such as hypertension, proteinuria, and progression of the renal damage. In patients with hypertension and/or proteinuria, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are the drugs of choice, because of their reno-protective properties. Recent studies have revealed that there is no convincing evidence that UTI in the presence of VUR predicts renal injury or that the use of long-term anti-microbial prophylaxis or surgical intervention prevents renal scarring or its progression. However, until proven otherwise by a prospective, placebo-controlled, randomized study, it is advisable to err on the side of caution and consider VUR and UTI risk factors for renal scarring and treat each patient on individual basis.
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PMID:Medical management of vesicoureteral reflux--quiz within the article. Don't overlook placebos. 1748 66

Vesico-ureteric reflux (VUR) is a urinary tract abnormality that affects roughly one-third of patients with renal-coloboma syndrome, an autosomal dominant condition caused by a mutation in PAX2. Here, we report that a mouse model with an identical mutation, the Pax2 1Neu+/- mouse, has a 30% incidence of VUR. In VUR, urine flows retrogradely from the bladder to the ureter and is associated with urinary tract infections, hypertension, and renal failure. The propensity to reflux in the Pax2 1Neu+/- mouse is correlated with a shortened intravesical ureter that has lost its oblique angle of entry into the bladder wall compared with wild-type mice. Normally, the kidney and urinary tract develop from the ureteric bud, which grows from a predetermined position on the mesonephric duct. In Pax2 1Neu+/- mice, this position is shifted caudally while surrounding metanephric mesenchyme markers remain unaffected. Mutant offspring from crosses between Pax2 1Neu+/- and Hoxb7/GFP+/- mice have delayed union of the ureter with the bladder and delayed separation of the ureter from the mesonephric duct. These events are not caused by a change in apoptosis within the developing urinary tract. Our results provide the first evidence that VUR may arise from a delay in urinary tract maturation and an explanation for the clinical observation that VUR resolves over time in some affected children.
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PMID:Vesico-ureteric reflux and urinary tract development in the Pax2 1Neu+/- mouse. 1788 63

Vesicoureteric reflux (VUR) is a congenital urinary tract defect caused by abnormal insertion of the ureter within the bladder wall. This leads to a defective ureterovesical junction in which urine flows retrogradely from the bladder to the kidneys. Although VUR is associated with recurrent urinary tract infections, renal malformations, hypertension, and reflux nephropathy, its relationship to each of these clinical entities is poorly understood. Mutations in genes expressed by the developing kidney and urinary tract can cause VUR in mice, and some of these same genes have been identified in humans with VUR. By discovering the genes that are associated with VUR, new hypotheses will be generated such that, eventually, the relationship between VUR and its complications will be understood.
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PMID:Gene discovery and vesicoureteric reflux. 1825 65

To evaluate the presence of vesico ureteric reflux (VUR) and renal scarring in children with documented symptomatic urinary tract infection (UTI), and the importance of age at time of presentation, we studied 29 patients with UTI. Nineteen patients were females and 10 were males. Three patients were below one year of age, 13 were between one and five years, and 13 were above five years. None of the patients had systemic hypertension or renal insufficiency. All patients had renal ultrasound and renal scintigraphy with dimercapto succinic acid (DMSA). Micturating cystourethrogram was done in all children below age of five, and in patients above age of five if renal scintigraphy showed evidence of scarring. Of the 29 UTI patients 10 (34%) had VUR. Of the patients with VUR, seven were below age of five while three were above five. Renal scarring was found in 3/7 patients with VUR below age of five years, but was in all patients with VUR above age of five years. All patients with grade 3 and 4 reflux nephropathy had renal scarring, while it was found in half of the patients with grade 1 and 2 reflux. We conclude that in UTI patients VUR is not uncommon finding, which needs further investigations and follow-up.
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PMID:Vesico ureteric reflux and renal scarring in children with urinary tract infection. 1841 12

Vesicoureteral reflux (VUR) refers to the retrograde flow of urine from the bladder into the ureter and renal pelvis. It generally results from congenital maldevelopment of the ureterovesical junction, although VUR may develop in individuals with abnormally high detrusor pressure. VUR increases a child's susceptibility to pyelonephritis and renal scarring. Treatment goals include the prevention of pyelonephritis, reflux nephropathy, and other complications of reflux. Treatment alternatives include antibiotic prophylaxis, urotherapy (correction of voiding dysfunction), and surgical correction (open, injection therapy, or laparoscopic). Recent studies have challenged the presumed benefit of prophylaxis in children with VUR, while long-term retrospective studies have documented a high rate of hypertension in adults with reflux nephropathy. In addition, the risk of persistent VUR in adulthood is unresolved. These reports have stimulated a reevaluation of the role of various treatment options in children with VUR.
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PMID:Therapy for vesicoureteral reflux: antibiotic prophylaxis, urotherapy, open surgery, endoscopic injection, or observation? 1841 99

Vesicoureteral reflux may be associated with abnormalities of the renal parenchyma. The purpose of this review is to define what the parenchymal abnormalities are histologically, what their etiologies may be, how they are identified and what their long-term clinical impact may be. Two categories are recognized, renal dysplasia and post-infection, chronic pyelonephritis. The diagnostic gold standard is microscopic evaluation of biopsy specimens but renal scintigraphy can be used in the diagnosis of renal dysplasia versus chronic pyelonephritis. Potential long-term sequelae of reflux nephropathy include hypertension and renal insufficiency although these may occur infrequently. A review of the current literature is provided.
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PMID:Reflux nephropathy. 1877 77


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