From the Guidelines
Treatment for kidney reflux, or vesicoureteral reflux (VUR), should be based on the severity of the condition and the patient's symptoms, with a focus on preserving renal function and preventing recurrent febrile UTIs, as recommended by the most recent guidelines 1.
Overview of Treatment Approaches
The main treatment approaches for VUR include:
- Nonsurgical approach: watchful waiting, intermittent antibiotic prophylaxis or continuous antibiotic prophylaxis (CAP), and bladder and bowel dysfunction (BBD) rehabilitation in those with lower urinary tract dysfunction (LUTD)
- Surgical approach: endoscopic injection of bulking agents or ureteral reimplantation (open vs minimally invasive)
Nonsurgical Approach
For mild cases, a watchful waiting approach with preventive antibiotics is often recommended, with low-dose antibiotics such as trimethoprim-sulfamethoxazole (Bactrim) at 2-3 mg/kg once daily or nitrofurantoin at 1-2 mg/kg once daily 1. Regular urine cultures every 3-6 months and annual ultrasounds are important for monitoring.
Surgical Approach
For moderate to severe cases or when infections persist despite antibiotics, surgical intervention may be necessary, with endoscopic treatment involving injecting a bulking agent near the ureter opening, while open surgical reimplantation (ureteroneocystostomy) repositions the ureter to prevent backflow 1.
Key Considerations
- Maintaining good hydration, practicing proper bathroom habits (complete bladder emptying), and promptly treating any urinary tract infections are essential supportive measures
- Treatment is important because untreated reflux can lead to kidney scarring, hypertension, and potential kidney damage over time as bacteria from the bladder repeatedly flow back up to the kidneys
- The presence of BBD and VUR doubles the risk of recurrent febrile UTI, so all children presenting with UTI should be carefully evaluated for BBD and managed accordingly, before treatment of VUR 1
From the Research
Treatment Options for Kidney Reflux
- The treatment of vesicoureteral reflux (VUR) aims to prevent the occurrence of febrile urinary tract infections and formation of scars in the renal parenchyma 2.
- Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with lower urinary tract dysfunction (LUTD) 3.
- Interventional therapies include injection of bulking agents and ureteral reimplantation, which can be performed using a number of different surgical approaches, including minimally invasive techniques 3.
- The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection 3.
Antibiotic Prophylaxis
- Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use 4.
- Continuous antibiotic prophylaxis was found to be effective in reducing recurrent urinary tract infection rate, emergency room visits, and hospital admissions due to UTI 5.
- Trimethoprim/sulfamethoxazole was the most frequently used prophylactic antibiotic 5.
- Daily prophylaxis with trimethoprim-sulfamethoxazole was not associated with an increased or decreased risk of skin and soft tissue infections, pharyngitis, or sinopulmonary infections in otherwise healthy children 6.
Surgical Options
- Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity 4.
- Endoscopic injection has been found to be effective in managing patients with VUR, and long-term studies have helped understand factors influencing its use and effectiveness 4.
- Laparoscopic and robot-assisted laparoscopic reimplantations have been shown to be safe and effective 2.
Individualized Approach
- Patient individualization in the contemporary management of VUR seems to be the keyword 2.
- The approach should be risk-adapted and individualized according to current knowledge, taking into account factors such as presentation age, sex, history of pyelonephritis and renal damage, grade of reflux, bladder bowel dysfunction, and circumcision status 2.