Grade 2B vesicoureteral reflux

[Kathy-H]

  my 13 month old daughter was just diagnosed with grade 2 b reflux in her left kidney.  She has had one Dx. UTI.
  - What is the difference between grade 2 and grade 2B?
  - Does the condition ever progress to a higher grade?
  - At what age does this resolve or can it continue into adult-hood?
  -I also have twin daughters age 6.  Should they be evaluated as well?
  -Is there any long-term problem with taking prophylatic antibiotics?
  Thank you

[hfhs M.D.-AK]

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Dear Kathy,
To begin with, I do not know the terminology you are referring to.  I ask some of my collegues and they are not familiar with this 2B classification.  I’m not sure what the difference between 2 and 2B is, nor does it mean much to me.  Grade 2 reflux is a more mild type reflux and by definition there is no dilation of the kidney.  I beleive your daughter has a good chance of spontaneous resolution, however, she will still need the appropriate follow-up.
One of the most difficult decisions regarding a child with vesicoureteral reflux is deciding between medical and surgical management.  Spontaneous disappearance of reflux is related to the age of the child and degree of reflux.  It has been reported that 63% of grade two, 53% of grade three , and 33% of grade four reflux patients have resolved spontaneously if infection is controlled.  Another study showed that in children of growing age that unilateral grade four reflux had spontaneous resolution 61% on the time, where as in bilateral patients resolution occurred in only 9%.  Reflux that persists in adolescence or adulthood is unlikely to disappear spontaneously.
The most important issue with children with reflux is preservation of the renal function and allowing for normal and complete growth of both kidneys.  This means avoiding infections of the kidneys to prevent harmful scarring.  Sometimes patients are placed on long-term prophylactic antibiotic therapy.  These regimens are usually safe as long they are tolerated well by the child.  If your child were managed conservatively(medically) periodic follow-up studies must be done to ensure normal scar free growth.
Also a physical exam sure be performed an special inclusion of height and weight parameters and blood pressure measurements.  Laboratory studies should include a urinalysis and urine culture at each visit  In terms of radiology tests, a IVP or ultrasound should be obtained every 18-24 months.  After the initial VCUG has been performed to establish to current grade, a follow-up study should be performed to establish an interval relationship.
On the other hand surgery or reimplantation of the ureters is a very successful procedure.  One should expect success rates as high as 95-98% in patients with normal caliber ureters and normal bladders.  This drops to 54% when the ureter is markedly dilated which is seen in grade four reflux.
There are several schools of thought on weather or not the reflux of sterile urine causes damage to the kidney and alters growth.  The decision to proceed either with conservative medical therapy verses surgical therapy will largely be up to your Urologist and how he was trained.  I don’t think there is a right or wrong decision; however, if inadequate follow-up could become an issue, the one time surgical procedure would probably be the safer option.  I think with your child being young and only grade2 reflux, I would certainly give her a trial of conservative management.
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