Another post about reflux...

[Cyndi__0__0]

  My 13 month old has grade three reflux on the left side, discovered via a cystourethrogram after two kidney infections at age 6 months.  She has been on Septra since.  There have been two occasions of protein detected in the urine, at 300+ on the dipstick, and she now has traces of blood in her urine.  I was initially told not to worry about the protein, because it is not there consistently, but believe that this can't be normal.  Now that there is blood, with no leukocytes, I am doubly concerned.  Can you explain why this could be happening?  At 7 months, she also had a renal ultrasound which showed no scarring.  Could damage have been done by the initial infections, but not be evident until now?  I have always questioned whether or not the reflux itself could cause damage, but upon research figured that it would only occur in a grade four or five reflux.  Any input you could give would be much appreciated.

[hfhs M.D.-AK]

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Dear Cyndi,
Yes, it is possible that a scar may not be visualized after an infection of the kidney for many months.  Infact, many urologists would not order a follow-up ultrasound or nuclear scan (DMSA) to look specifically for a renal scar for at least six months after the infectious episode.  A lot of the time, the scars are not identifiable immediately after an infectious episode.
To address the protein in the urine, it sounds like the protein that is being detected was from a dip stick analysis.  Dipstick analysis often  is imprecise.  If your child has persistent protein in the urine or has medical problems suggestive of a protein losing condition, you may discuss with your family doctor possibly seeing a nephrologist, to properly work -up protein in the urine.  A twenty-four hour urine collection at her age would be very difficult, but there are ways of evaluating the urine with a spot urine and ratios.
To address the hematuria, a microscopic urinalysis needs to be performed.  If there is a persistent amount of RBC’s in the urine(>3-5 RBC/HPF), a full work-up consisting of an intravenous pyelogram and voiding cystourethrogram should be performed.  Labs evaluation would  include  a Sickle cell prep, ASO, IgA,IgG, C3 complement level, urine myoglobin, urine casts, PT,PTT.  Most common cause of pediatric microhematuria is glomerulonephritis. The way in which the urine was collected will certainly influence the microscopic picture.. A catheterized urine may well have some red cells from the trauma of the catheter. PUC (pediatric urine container) urines that are collected in plastic paste-on bags are poor samples in this regard. Needle aspirations of her bladder might well show blood also. I certainly think that she needs several urine samples to look for repeatability.
Before you panic, get the baseline urinalyses and speak with your family doctor to see if this work-up is necessary. Your next step would be a microscopic urinalysis.
This information is provided for general medical educational purposes only.  Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition.  More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-AK
*keyword:Reflux