Vesicoureteral Reflux

  Our 10 month old son was diagnosed last week with bilateral
  Grade II reflux after having a severe UTI, which was initially
   thought to be related to a narrowing of his meatus following
   hypospadias repair in Dec of 1998.  The opening has been widened and he has been placed on a prophylactic dose of SMZ-TMP
  and we have been told that there is an excellent chance that he
  will outgrow this.  After doing a bit of research, I have several
  questions.
  How likely is it that he will have renal damage and/or
  renal growth failure, given the early detection and treatment?  
  Can his kidneys be damaged by the reflux of
  urine if there is no infection present?
  What is the longterm prognosis, in terms of renal function and in
  developing related problems, such as hypertension?
  What sort of testing should he have and when?
  What things can we do at home to give him optimum care?
  Thank you for taking the time to answer these questions
  as we really want to do the best for our child.

[hfhs M.D.-AK]

_
Dear Danielle,
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.  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.  If your child has not suffered any scarring after this initial infection, careful follow-up with his doctor should insure normal growth and renal function.  Approximately 30 to 50% of patients have renal scarring on initial evaluation.  Hypertension develops in those scared individuals about 10-20% of the time, and the severity of the hypertension usually is related to the degree of parenchymal damage.  Sometimes patients are placed on long-term prophylactic antibiotic therapy.  These regimens are usually safe as long they are tolerated well by the child.  It sounds like you have started TMP/SMZ in your child.  This is a very good antibiotic for prophylaxis and usually well tolerated.
If your child were to continue to be managed conservatively(medically) periodic follow-up studies must be done to ensure normal scar free growth.  Also a physical exam should be performed with  special inclusion of height, weight parameters and blood pressure measurements.  Laboratory studies should include a urinalysis and urine culture at each visit   In terms of radiology tests, an 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.  With grade one and grade two reflux, a normal caliber ureter is almost always the case.  This drops to 54% when the ureter is markedly dilated which is seen in grade four reflux.
There are several schools of thought on whether or not the reflux of sterile urine causes damage to the kidney and alters growth, most pediatric urologist do not believe it causes damage.  The decision to proceed either with conservative medical therapy verses surgical therapy will largely be up to you and your Urologist.  I don