VUR Grade IV bilateral, 6 months Baby Girl

[Santi]

Our daughter birth on December 3,2003 (now 6 months) has been diagnosed with VUR Grade IV bilateral. It was detected when she was 3 months by VCUG. Prior to that she had UTI when she was 1 month old. She was born weighted 3.1 kgs, 49 cm, and now she is 6.8 kgs, 66 cm. She phisycally had a considerably good development. Now she is under treatment with profilaxys antibiotics (bactrim), and regular urine check (cultur). The problem has been escalated to urolog surgeon, and he recommended to do the stitoscopy simultaneously with reimplantation ureter when her urine is sterile. Since March (after VCUG) her urine has never been sterile, and the bacteri is Klebsielle Pneumoniae (always the same bacteri). After 3 times antibiotic treatment (with Urineg, Ammoxilyn Acid, and again Urineg) her urine is still not sterile. She wasn't always having fever, but sometimes she had mild diarrhoea. Our pediatric informed that the surgery could be done even with the unsterile urine condition with antibiotic protection pre-surgery, if the urolog surgeon agree with the condition. We are now in the stage of consult this matter to the urolog surgeon. Our question are :
1.  Does surgery the best solution for her condition )VUR Grade IV bilateral, repeated UTI), considering her age.
2. Is there still any possibility her VUR will disappear itself along with her growth.
3. How is the risk of waiting for the possibility compare to the risk of surgery in her early age?
4. Is this a common case, especially for infant? Is there any medical center specializing on this case (preferably around Asia)

THANK YOU.

[Kevin Pho, MD]

To answer your questions:
1) Both medical and surgical management of severe reflux appear to be of roughly equal efficacy and choosing between these options is dependent upon clinical judgment. Medical therapy in such children includes daily prophylactic antibiotics which are usually continued until the reflux resolves (as determined from annual radionuclide cystography), the child reaches the age of five to seven, the time at which repeat infection, if it occurs, is unlikely to produce new scars.

2) It is possible that the VUR may resolve.  

3) Surgery should be considered in the following case: the presence of gross reflux and ureteral dilatation in a young child (particularly if under two years of age) even without marked scarring, since new scars will develop in up to 60 percent of these cases.  It seems that your child may fall into this category, and the possibility of surgery should thusly be considered.  

4) VUR is present in approximately 1 percent of newborns, 30 to 45 percent of young children with a UTI, and in almost all children with renal scars.  Unfortunately, I am not familiar with the medical center in Asia.  

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

Bibliography:
Rose, et al.  Diagnosis and treatment of vesicoureteral reflux and chronic pyelonephritis.  UptoDate, 2004.

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