Risk of hypertension in primary vesicoureteral reflux.

The aim of this report was to estimate the risk of hypertension in children with primary vesicoureteral reflux (VUR). Between 1970 and 2004, 735 patients were diagnosed with VUR at a single tertiary renal unit. Of 735 patients, 664 (90%) were systematically followed and had multiple measurements of blood pressure. Hypertension was defined as values persistently above 95th for age, sex, and height in three consecutive visits. Risk of hypertension was analyzed by the Kaplan-Meier method. Of 664 patients followed, 20 (3%) developed hypertension. The estimated probability of hypertension was 2% (95%CI, 0.5%-3%), 6% (95%CI, 2%-10%), 15% (95%CI, 11%-20%) at 10, 15, and 21 years of age, respectively. The prevalence of hypertension has increased with age: it was 1.7% for patients with 1 yr-9.9 yr, 1.8% for adolescents with 10 yr-14.9 yr, 4.7% for patients with 15-19.9 yr, and 35% for patients>20 years at the end of the follow-up (P<0.001). It was estimated by survival analysis that 50% of patients with unilateral and bilateral renal damage would have sustained hypertension at about 30 and 22 years of age, respectively. Hypertension increased with age and was strongly associated with renal damage at entry in an unselected population of primary VUR.

Predictive factors of chronic kidney disease in severe vesicoureteral reflux.

The aim of this retrospective cohort study was to evaluate independent predictive factors of chronic kidney disease (CKD) in children with severe bilateral primary vesicoureteral reflux (VUR). Between 1970 and 2004, 184 patients were diagnosed with VUR (grades III-V) and were systematically followed up at a single tertiary renal unit. CKD was defined as estimated glomerular filtration rate <75 ml/min per 1.73 m2 body surface area in two consecutive examinations. Risk of CKD was analyzed by the Kaplan-Meier method and Cox's regression model. The probability of CKD for patients with bilateral severe reflux was estimated at 15% by 10 years after VUR diagnosis. After adjustment, four variables remained independently associated with CKD during follow-up: age at diagnosis >24 months [relative risk (RR)=4.8, 95% confidence interval (95%CI), 1.8-12.7, P<0.001], VUR grade V (RR=3.5, 95%CI, 1.5-7.9, P=0.002), bilateral renal damage (RR=2.86, 95%CI, 1.3-6.1, P=0.007), and decade of admission after 1990 as a protective factor (RR=0.16, 95%CI 0.06-0.43, P<0.001). A delay in the diagnosis of VUR more than 12 months after urinary tract infection (UTI) was also a predictive factor in an alternative model (RR=2.2, 95%CI, 1.1-6.6, P=0.03). Prognosis regarding renal function was relatively poor after a long-term follow-up of patients with bilateral severe reflux.

[Baseline clinical features of 483 children and adolescents with primary vesicoureteral reflux: a retrospective study]. / Características clínicas e laboratoriais à admissão de 483 crianças e adolescentes com refluxo vésico-ureteral primário: estudo retrospectivo.

OBJECTIVES: To evaluate the clinical/radiological features of patients with primary vesicoureteral reflux (VUR) admitted to a single institution from 1969 to 1999. METHODS: At admission, after the institution of chemoprophylaxis, patients were investigated by CUM, DMSA, and US. The children were managed with periodical clinical and laboratory evaluations. Analyses were performed with the data obtained at admission. RESULTS: A total of 483 patients were enrolled in the protocol. There was a predominance of females (70%) and caucasian race (70%). Mean age at VUR diagnosis was 26 months and 92.5% of the patients had urinary infection before admission. A total of 710 refluxing units were analyzed. The distribution of reflux grade was: grade I (49; 7%); II (254; 36%); III (190; 26%); IV (161; 23%) e V (56; 8%). Approximately one half of the units analyzed were from patients presenting renal damage at admission. The distribution of the severity of renal damage was as follows: mild (36%), moderate (34%), and severe (30%). There was a significant risk of severe renal damage for the males (OR = 1.74, 95% CI = 1.2 - 2.5, p = 0.002). CONCLUSION: There was a predominance of VUR among females and most presented a mild or moderate degree. However, there was a high percentage of renal damage at admission and a tendency to greater morbidity for the males.

Características clínicas e laboratoriais à admissão de 483 crianças e adolescentes com refluxo vésico-ureteral primário: estudo retrospectivo / Baseline clinical features of 483 children and adolescents with primary vesicoureteral reflux: a retrospective study

OBJETIVOS: Avaliar retrospectivamente as características clínicas/radiológicas dos pacientes admitidos com refluxo vésico-ureteral primário (RVU) entre 1969-1999. MÉTODOS: Pacientes com RVU primário foram submetidos a um protocolo de avaliação clínica, laboratorial e radiológica e acompanhados longitudinalmente. Na admissão, após controle da bacteriúria e do início da quimioprofilaxia, foram realizados avaliação laboratorial e estudo de imagens do trato urinário. Esta consistiu de uretrocistografia miccional, urografia excretora, cintilografia renal (DMSA) e ultra-sonografia. Para o presente estudo foram utilizados os dados obtidos na admissão. RESULTADOS: Foram admitidos nesse período 483 pacientes. Houve predomínio do sexo feminino (70 por cento) e da cor branca (70 por cento). A média de idade ao diagnóstico foi de 26 meses, sendo que 92,5 por cento das crianças já haviam apresentado infecção urinária. Um grupo de 710 unidades renais foi analisado. A distribuição do grau de refluxo foi a seguinte: grau I (49; 7 por cento); II (254; 36 por cento); III (190; 26 por cento); IV (161; 23 por cento) e V (56; 8 por cento). Um total de 249 unidades renais apresentaram dano renal à admissão. A distribuição quanto à intensidade da lesão foi a seguinte: leve (36 por cento), moderada (34 por cento) e grave (30 por cento). Houve um risco significativo maior de lesão renal grave no sexo masculino (OR = 1,74, IC 95 por cento = 1,2 - 2,5, p = 0,002). CONCLUSÃO: O RVU predominou no sexo feminino e em sua maioria apresentou-se em graus leves a moderados. Contudo, houve um alto percentual de dano renal à admissão e uma tendência de maior morbidade para o sexo masculino.

Features of primary vesicoureteral reflux and renal damage in children at a single institution in Brazil from 1969 to 1999.

OBJECTIVES: The purpose of the study was to evaluate the clinical/radiological features of patients with primary vesicoureteral reflux (VUR) admitted to a single institution from 1969 to 1999. METHODS: The patients' records were retrospectively reviewed and the following clinical data obtained at admission were analyzed: age, gender, race, date of entry, previous symptoms, weight, height, blood pressure, and serum renal function. The renal imaging tests at baseline were also retrospectively analyzed including voiding cystourethrography, excretory urography, DMSA scan, and ultrasonography. For statistical analysis, reflux was classified into two categories: (1) mild/moderate (grade I/II/III) and (2) severe (grade IV/IV). Renal damage was categorized according to the following classification: (I) mild, focal damage; (II) moderate, more extensive scars, and (III) severe, generalized damage or shrunken kidney. The odds ratio (OR) and the respective confidence interval (95%CI) were calculated to compare the difference in risk between groups. RESULTS: A total of 461 patients were enrolled in the protocol. There was a predominance of female gender (71%) and white race (73%). Mean age at VUR diagnosis was 2.8 y and 93% of the patients had urinary infection before admission. Bilateral reflux was diagnosed in 249 (54%) children, for a total of 710 renal units for study. The distribution of reflux grade was as follows: grade I (7%); II (36%); III (26%); IV (23%), and V (8%). Of the 450 children investigated, 180 (40%) presented with renal damage, for a total of 234 (26%) units with renal scars. Renal damage was associated with the following factors: Diagnosis after 2 y of age (OR = 1.5, 95%CI = 1.08-2.1, p = 0.01), severe degree of reflux (OR = 6, 95%CI = 4-9, p < 0.001). There was a significant risk of severe renal damage for male gender (OR = 1.9, IC95% = 1.3-2.1, p = 0.001). CONCLUSION: There was a predominance of renal damage in children diagnosed above 2 y and with a high degree of reflux. Severe renal damage was associated with male gender.