Renal dysplasia associated with grade IV/V of VUR has its own natural progression independent of pyelonephritis recurrences. The incidence of renal failure has been stable even in years of aggressive treatment approach. Interestingly, microalbumin excretion rate in children with high-grade of VUR (IV-V) was significantly increased than those with low-grade VUR and control

ZAFFANELLO, Marco

Marco Zaffanello

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Prospective in the Medical Treatment of Reduced Renal Growth and Function by High Grade Vesicoureteral Reflux in Children

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Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=irnf20Renal FailureISSN: 0886-022X (Print) 1525-6049 (Online) Journal homepage: https://www.tandfonline.com/loi/irnf20Prospective in the Medical Treatment of ReducedRenal Growth and Function by High GradeVesicoureteral Reflux in ChildrenMarco ZaffanelloTo cite this article: Marco Zaffanello (2009) Prospective in the Medical Treatment of ReducedRenal Growth and Function by High Grade Vesicoureteral Reflux in Children, Renal Failure, 31:2,178-179, DOI: 10.1080/08860220802595971To link to this article:  https://doi.org/10.1080/08860220802595971Published online: 07 Jul 2009.Submit your article to this journal Article views: 97Renal Failure, 31:178–179, 2009 Copyright © Informa Healthcare USA, Inc.ISSN: 0886-022X print / 1525-6049 onlineDOI: 10.1080/08860220802595971178LRNFLETTER TO THE EDITORProspective in the Medical Treatment of Reduced Renal Growth and Function by High Grade Vesicoureteral Reflux in ChildrenHigh Grade Vesicoureteral Reflux in ChildrenMarco ZaffanelloDepartment of Mother-Child and Biology-Genetics, University of Verona, Verona, ItalyVesicoureteric reflux (VUR) occurs when there is ret-rograde passing of urine back up the ureter. Urinary tractinfections (UTIs) have been considered the main cause ofpermanent renal parenchymal damage in children with VUreflux. Until now, management of this condition in chil-dren has been directed at preventing UTIs by antibioticprophylaxis and/or surgical correction of VUR. Therefore,Pennesi et al. reported in a recent multicenter, open label,randomized controlled trial the ineffectiveness of antibi-otic prophylaxis in avoiding new renal scars in childrenwith grade II/IV VUR. During a follow-up of four years,antimicrobial prophylaxis was unable to reduce the risk ofrecurring pyelonephritis and new renal scars in childrencompared to untreated controls.[1] However, one of ourobservational studies reported that surgical interventionand pharmaceutical approaches lead to similar renal out-come, quelling suspicions that today’s available measuresto limit renal damage are insufficient. In particular, wefound that high-grade VUR was associated with kidneysthat were already undersized at birth controlling/avoidingthe UTIs. In addition, both early antimicrobial prophylaxis,given after prenatal detection, and a surgical approach donot seem to alter the renal outcome: refluxing kidneysalways seem to grow slower than non-refluxing ones.[2]In agreement, it is uncertain whether the treatment ofchildren with VUR confers clinically important benefits.From a recent metaanalysis, the additional benefit ofsurgery over antibiotics alone was reported to be minimalat best, as no concomitant reduction in risk of new or pro-gressive renal damage was shown after 10 years.[3]Studies published in the last years, and in particularimprovements in prenatal diagnosis, have focused attentionon the association between renal dysplasia and VUR ascause of chronic renal failure.[4] On the basis of thesefindings, it is necessary to set new guidelines for the treat-ment of children with VUR, as emerging knowledgeagrees with the failure of antimicrobial prophylaxis inpreventing renal scars and recurrence of UTIs.[5]However, updated clinical information agrees with thesuspicions that moderate to severe VUR may be associ-ated with a prenatal renal programming, which leads to adelay in kidney growth. Obviously, when the VUR ismonolateral, the contra-lateral kidney often undergoes anadjunctive overgrowth in compensation, but when theVUR involves both kidneys, the renal growth delay maybe mutual.Renal dysplasia associated with grade IV/V of VURhas its own natural progression independent of pyelone-phritis recurrences. The incidence of renal failure hasbeen stable even in years of aggressive treatmentapproach. Interestingly, microalbumin excretion rate inchildren with high-grade of VUR (IV-V) was signifi-cantly increased than those with low-grade VUR andcontrol. In children with high-grade of VUR, bothmicroalbuminuria and reduction of renal function may bea possible consequence of retrograde urine flow, glomer-ulosclerosis, and hyperfiltration.[4] Perhaps therapy withACE-inhibitors in patients affected by proteinuria and/orhypertension could prevent the worsening of nephropathy.[6,7]but no studies about this item are yet available. At thepresent time, it is impossible to modify significantly thehistory of patients with severe bilateral nephropathyfrom VUR.DECLARATION OF INTERESTThe authors report no conflicts of interest. Theauthors alone are responsible for the content and writing ofthe paper.Received and accepted 24 October 2008.Address correspondence to Dr. Marco Zaffanello, Departmentof Mother-Child and Biology-Genetics, University of Verona,37134-I Verona, Italy; Tel.: ++39 45 8124387; Fax: ++39 45 8124790; E-mail: marco.zaffanello@univr.itHigh Grade Vesicoureteral Reflux in Children 179REFERENCES1. Pennesi M, Travan L, Peratoner L, Bordugo A, Cattaneo A,Ronfani L, Minisini S, Ventura A; North East Italy Prophy-laxis in VUR Study Group. Is antibiotic prophylaxis inchildren with vesicoureteral reflux effective in preventingpyelonephritis and renal scars? A randomized, controlled trial.Pediatrics. 2008;121:e1489–e1494.2. Zaffanello M, Brugnara M, Cecchetto M, Fedrizzi M, Fanos V.Renal involvement in children with vesicoureteral reflux: Areprenatal detection and surgical approaches preventive? ScandJ Urol Nephrol. 2008 May 8:1–7.3. Hodson EM, Wheeler DM, Vimalchandra D, Smith GH, Craig JC.Interventions for primary vesicoureteric reflux. CochraneDatabase Syst Rev. 2007 Jul 18; 3:CD001532.4. Basic J, Golubovic E, Miljkovic P, Bjelakovic G, Cvetkovic T,Milosevic V. Microalbuminuria in children with vesicoureteralreflux. Ren Fail. 2008;30:639–643.5. Hewitt K, Zucchetta P, Rigon L, Maschio F, Molinari PP,Tomasi L, Toffolo A, Pavanello L, Crivellaro C, Bellato S,Montini G. Early treatment of acute pyelonephritisin children fails to reduce renal scarring: Data from theItalian Renal Infection Study Trials. Pediatrics. 2008;122:486–490.6. Brakeman P. Vesicoureteral reflux, reflux nephropathy, andend-stage renal disease. Adv Urol. 2008:508949.7. Zaffanello M, Franchini M, Fanos V. New therapeuticstrategies with combined renin-angiotensin system inhibitorsfor pediatric nephropathy. Pharmacotherapy. 2008;28:125–130.

Prospective in the medical treatment of reduced renal growth and function by high grade vesicoureteral reflux in children

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Prospective in the medical treatment of reduced renal growth and function by high grade vesicoureteral reflux in children

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