Chronic pyelonephritis and vesico-ureteric reflux

doi:10.1016/S0009-9260(60)80047-5

Clinical Radiology

Volume 11, Issue 4, October 1960, Pages 219-231

https://doi.org/10.1016/S0009-9260(60)80047-5 Get rights and content

Summary

Attention is drawn to the frequent association between chronic pyelonephritis and vesico-ureteric reflux.

Among the wide variety of clinical manifestations seen in these patients, pain in the loin during micturition is the only one which positively suggests reflux.

In many cases there is no obvious aetiological factor causing reflux.

Radiological signs which indicate the presence of reflux are described.

The clinical and radiological findings in ten patients are reviewed and those in another ten are tabulated.

The relationship between chronic pyelonephritis and reflux is discussed with particular reference to precedence and infection. The implications with regard to treatment are mentioned briefly.

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There are more references available in the full text version of this article.

Cited by (229)

The impact of reflux pressure on renal scarring in children with sterile vesicoureteral reflux
2023, Journal of Pediatric Urology
Citation Excerpt :
The VUR itself and the mechanism of renal scarring are complex phenomena. The scarring effect of VUR is documented by numerous animal and clinical studies with histological and radiological evidence [6,7]. The occurrence of VUR is in close relation with lower urinary tract function.
Vesicoureteral reflux (VUR) is a complex disease as patient spectrum is variable. Some cases struggle with recurrent febrile urinary tract infections (UTI) and end-up with renal scars despite intervention. While others suffer no clinical problems and need no treatment. The detrimental effect of VUR on kidneys depends on many factors like grade of reflux, detrusor pressure, and presence of voiding dysfunction. The adverse effects of sterile VUR on kidneys is still under discussion. Thus, we assessed the impact of detrusor pressure at VUR onset on renal scarring in children with sterile reflux.
We retrospectively reviewed the five years follow-up data of 38 children who had unilateral VUR without UTI under treatment. No febrile or afebrile UTIs were detected during the follow-up in any children. All children were assessed with annual video-urodynamics and renal scintigraphy for five consecutive years. The detrusor pressure at VUR onset, grade of VUR, presence of involuntary detrusor contractions, bladder capacity and the presence of renal scaring were recorded. All VURs were recorded during the voiding phase and children with VUR during the filling phase were excluded from the study.
In the first line of video-urodynamic studies, the mean detrusor pressure at VUR onset was 24.3 ± 14.8 cm/H₂O (median 34.5 cm/H₂O, min: 6 - max: 47). There was no relation between boys and girls regarding median detrusor pressure at VUR onset (p = 0.356). Eventually, 22 (57.9%) children developed renal scars and ended up with surgery. There was no relation between scar development and age at first presentation (p = 0.888) The cut-off value for detrusor pressure at VUR onset was noted as 26 cm/H₂O (AUC: 0.849 [p < 0.01], Figure). In children who developed renal scars eventually, the median detrusor pressure at VUR onset was significantly higher (p < 0.01).
The detrimental effect of VUR on kidneys is associated with recurrent infections, bladder dysfunction, and detrusor pressure. Dispute over risk of renal scarring in patients with sterile VUR still continues.
Children in whom VUR start at higher voiding pressures suffer more renal scars. The threshold of voiding detrusor pressure for risky patients is identified as 26 cm/H₂O. It is true that patients suffering recurrent febrile UTIs have higher risk of developing renal scarring. However, the impact of sterile reflux should not be underestimated, since renal scars due to sterile reflux may develop in patients under antibiotic prophylaxis.
Reflux nephropathy and scarring nephropathy: So close and yet so different
2022, Anales de Pediatria
La nefropatía de reflujo es el término radiológico que se utilizó para expresar la existencia de lesiones morfológicas renales en pacientes con reflujo vesicoureteral (RVU). Este concepto morfológico se acuñó a partir de los datos de imagen recogidos, aunque sin realizar estudios complementarios básicos de función renal. Este estudio se diseñó para demostrar que las pruebas de función renal básicas muestran resultados distintos en presencia de RVU activo y una vez desaparecido.
Estudio descriptivo retrospectivo longitudinal en el que se incluyeron 89 niños (46 V, 43 M) con RVU diagnosticado mediante cistouretrografía miccional seriada. Las pruebas básicas de función renal recogidas fueron la osmolalidad urinaria máxima (UOsm) y los cocientes urinarios albúmina/creatinina y NAG/creatinina. Los datos acopiados correspondían a dos momentos: al diagnosticarse el RVU y cuando ya se había curado.
Se comprobaron diferencias cuantitativas en los tres parámetros funcionales al comparar los correspondientes a ambos momentos del estudio. En el análisis cualitativo, en relación con la intensidad del RVU, se apreciaron diferencias en UOsm al diagnóstico y en el cociente albúmina/creatinina una vez desaparecido el RVU. En este último momento se observó un aumento significativo en el cociente albúmina/creatinina en los pacientes con pérdida de parénquima renal en relación con aquellos sin lesiones morfológicas residuales.
El defecto en la capacidad de concentración renal es el hallazgo más frecuente en niños con RVU activo (auténtica nefropatía de reflujo), mientras que una vez curado el RVU la alteración funcional más frecuente es el aumento de la excreción de albúmina, en relación con el daño residual existente en el parénquima renal. Puesto que la alteración funcional es diferente en los niños con RVU activo y cuando ya no está presente, no se debería utilizar el mismo término para ambas situaciones puesto que, aunque próximas, son entidades distintas. El término nefropatía displásico-cicatricial reflejaría mejor las características de estos pacientes una vez curado el RVU.
Reflux nephropathy is a radiologic condition commonly used to express the existence of renal morphological lesions in patients who have or had vesicoureteral reflux (VUR). This morphological concept is used based on the image data collected, without conducting basic complementary renal function studies. The present study was designed to demonstrate that patients with active VUR present different functional renal alterations from those shown by patients with disappeared VUR.
Longitudinal descriptive retrospective analysis including 89 children (46 M, 43 F) with VUR diagnosis through a standard voiding cystourethrogram (VCUG). The basic renal function tests collected were the maximum urinary osmolality (UOsm) and the urinary albumin/creatinine and NAG/creatinine ratios. The data collected corresponded to two moments, when VUR was diagnosed and when it had already disappeared.
Quantitative differences were verified in the three functional parameters when comparing those corresponding to both moments of the study. In the qualitative analysis, in relation to the intensity of the VUR, differences were observed in UOsm at diagnosis and in the albumin/creatinine ratio once the VUR had cured. At this last moment, a significant increase in the albumin/creatinine ratio was observed in patients with loss of renal parenchyma in relation to those without residual morphological lesions.
Concentrating ability defect is the most frequent finding in children with active reflux (true reflux nephropathy), whereas the most frequent functional disturbance found, once VUR has cured, is an increase in urinary albumin excretion, related to parenchymal damage. The term dysplastic-scarring nephropathy, could be more appropriate for patients with residual morphological lesions and impaired renal function, once VUR is cured.
Nonneoplastic Diseases of the Kidney
2020, Urologic Surgical Pathology
In keeping with the spirit of Marcello Malpighi, this chapter also aspires to reveal “the manner of Nature’s operation” as it affects the kidney.¹ However, unlike Malpighi, today’s knowledge draws extensively on the labors, discoveries, and insights of investigators of the past centuries.
Knowledge of the normal structure and function of the kidney has been acquired over centuries of scholarly effort. We have come a long way since Aristotle taught that urine was formed by the bladder and that kidneys were present “not of actual necessity, but as matters of greater finish and perfection.”¹ Reference to the excretory functions of the bladders and kidneys can be found in early Indian Ayurveda, Chinese, or Egyptian literature.2, 3, 4 Some of the earliest scientifically valid experimental methods are described in The Canon of Medicine by the famous Persian Muslim physician Abu Ali Sina, also known as “Avicenna.”5, 6, 7, 8, 9, 10, 11, 12, 13 He meticulously described the layers of the bladder and its two-stage function, the intramural ureter and antireflux mechanisms, and scientifically classified urethral and bladder diseases, notably calculi. The foundation of modern urology was established in the sixteenth century by Leonardo da Vinci and Vesalius, who provided the first accurate and detailed drawings of the female and male genitourinary tracts (Fig. 1.1).14, 15 More than 300 years passed before William Bowman, in 1842, coupled intravascular dye injection with microscopic examination to demonstrate the structural organization of the nephron and its vascular supply (Fig. 1.2).16, 17 Bowman’s observations provided morphologic support for Malpighi’s seventeenth-century speculation of a filtration function for the malpighian body (the glomerulus).1, 18 Sixty years later the embryologic development of the nephron was demonstrated by Huber in a thin-section serial reconstruction study of embryos (Fig. 1.3).¹⁹ Huber’s observations were refined and elegantly illustrated by Brödel in 1907.²⁰
Coming full circle with vesicoureteral reflux: From Hutch to bladder and bowel dysfunction
2017, Journal of Pediatric Urology
Vesicoureteral reflux: A historical perspective
2017, African Journal of Urology
Citation Excerpt :
John Sampson determined that it was the detrusor backing of the ureter that allowed for one-way urine flow [3]. It was not until the 1950s, however, that Hodson and Edwards discovered the association of VUR with renal scarring from bacterial infection [4]. This discovery was backed by an abundance of research demonstrating an exponential relationship between number of urinary tract infections, the grade of reflux and renal scarring.
The management of vesicoureteral reflux is a mainstay of pediatric urology. This management however, has evolved considerably throughout the years due to a dynamic understanding of both pathology and the relationship between surgical and medical therapies. The purpose of this article is to provide the reader with a historical perspective on management and delineate how its past has shaped current therapies and guidelines.
Sonographic assessment of the effect of vesicoureteral reflux and urinary tract infections on growth of the pediatric solitary kidney
2015, Journal of Pediatric Urology
Citation Excerpt :
A refluxing solitary kidney with UTI showed significantly lower rate at 0.27 cm/year (SE 0.04) than the rate of a non-refluxing kidney without UTI, a non-refluxing kidney with UTI, and a refluxing kidney without UTI (p < 0.001). Since Hodson reported on the likelihood of VUR in children with pyelonephritis and renal scarring in 1960 [1], several studies have associated decreased renal size and growth with the presence of VUR in patients with two functional renal units [7,8]. Historically, some workers reported increased growth after VUR correction procedures [9,10].
Perusal of recent guidelines relating to proper evaluation of infants and children with urinary tract infection (UTI) suggests that the occurrence of vesicoureteral reflux (VUR) may not have the clinical import previously ascribed to this anatomic abnormality. Patients with a solitary kidney uniquely allow investigation of the effects of both vesicoureteral reflux (VUR) and urinary tract infection (UTI) on renal growth unencumbered with the inevitable questions of laterality that confound analysis in patients with two kidneys. Several previous studies with conflicting results have addressed whether vesicoureteral reflux (VUR) impacts ultimate renal size in children with a solitary kidney. Few published studies have considered the occurrence of both urinary tract infection (UTI) and VUR on the degree of compensatory hypertrophy. This is the largest series to date investigating the effect of both UTI and VUR on the degree of compensatory hypertrophy with time.
Our objective was to analyze sonographically determined renal growth in patients with a solitary kidney, stratifying for both the occurrence and severity of UTIs and the occurrence and severity of VUR.
We retrospectively reviewed the clinical history (including bladder and bowel dysfunction (BBD)) and radiology reports of 145 patients identified as having either a congenital or acquired solitary kidney in our pediatric urology practice from the prior 10 years. UTIs were tabulated by severity, where possible, and the grade of VUR was recorded based on the initial cystogram. Sonographically determined renal length was tabulated for all ultrasounds obtained throughout the study. Based on a mixed-effects model, we investigated the influence of UTI and VUR on renal growth.
Of the 145 patients analyzed, 105 had no VUR and 39 had VUR (16 = Gr I&II, 11 = GIII, 12 = GIV&V). Comparison showed that there was no difference in the occurrence of UTI between those without VUR (27/105 with UTI) and those with VUR (15/39 with UTI; p = 0.14). There was no difference in the occurrence of BBD in patients with VUR (15/39) and those without VUR (36/106, p = 0.62). While neither VUR nor UTI alone affected renal growth in the solitary kidney, the three-way interaction term among age, VUR, and UTI was significant (p = 0.016). The growth of the kidneys in the various patient groups is depicted in the table. From the analysis, a refluxing solitary kidney with UTI showed a significantly lower growth rate than the other groups (p < 0.001).
This study is limited by the inherent selection bias of retrospective studies. Additionally, the variability of sonographic renal measurement is well recognized. Lastly, our sample size did not allow us to incorporate the severity of the UTIs and the grades of VUR in our final regression model. Nevertheless, the overall patterns suggest that when both VUR and UTI are present, the solitary kidney demonstrates less renal growth with time. Study of larger cohorts of patients with solitary kidneys will be necessary to confirm our observations and discern what, if any, are the consequences of high-grade VUR and upper tract UTI in these patients.
In the largest series to date we were able to discern no independent effect of either VUR or UTI on sonographically determined renal growth in patients with a solitary kidney. However, UTI and VUR together result in kidneys that are smaller than other solitary kidneys not so affected. Follow-up studies of larger cohorts seem warranted to confirm these findings and discern the clinical import of these smaller kidneys.

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Chronic pyelonephritis and vesico-ureteric reflux

Summary

J. Urol. (Baltimore)

J. Urol. (Baltimore)

J. Urol. (Baltimore)

J. Urol. (Baltimore)

J. Urol. (Baltimore)

J. Urol. cutan. Rev.