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17628

Not All Low-Grade Reflux Is Benign

Saturday, October 20, 2012
Grand Ballroom A/B (Hilton Riverside)
Daniela C. J. Sanchez, Brian M. Rosman, MD, Caio M. Oliveira, Sabrina T. Reis, Lorenzo F. M. Trevisani, Guilherme A. Rossini, Carlos A. O. Buchalla, Gustavo N. C. Inoue and Hiep T. Nguyen, MD, FAAP, Department of Urology, Children's Hospital Boston, Boston, MA

Purpose

Low-grade vesicoureteral reflux (VUR grades 1-3) is frequently considered to be a benign condition that will resolve without requiring monitoring or intervention. Despite this widely held belief, there is little evidence to corroborate this claim. The natural history of mild VUR has not been well characterized. The purpose of this study is to examine the clinical outcomes and possible risk factors for poor outcomes in patients with low grade VUR (grade 1-3).

Methods

From 2003 through 2006, the medical records of 558 children diagnosed with grade I-III VUR by voiding cystourethrography were retrospectively reviewed. Demographic factors (such as gender, age at presentation, initial presenting symptoms, and co-existing voiding dysfunction) and VUR characteristics (such as grade, laterality duplication) were ascertained. Outcomes were classified as either resolved vs. requiring treatment (either endoscopic injection or ureteral reimplantation). Uni- and multivariate analysis were performed to determine the risk factors for specific outcomes.

Results

The mean age at the diagnosis of VUR was 16.9 months and mean follow-up (F/U) period was 31 months.  83.3% of the patients were females. The frequency of spontaneous resolution, the incidence of worsening VUR grade in follow-up, the incidence of breakthrough UTI and the rate of ureteral reimplantation and endoscopic injection are listed in Table 1. We observed that female patients were more likely to require treatment than males (p=0.04). In addition, grade III VUR, the presence of breakthrough UTI, diverticulum and renal scarring were independent risk factors for requiring treatment on multivariate analysis (p<0.0001). Interestingly, initial presentation, the presence of voiding dysfunction, ureteral duplication and bilaterality were not risk factors for requiring treatment.

Conclusion

We observed that nearly 40% of all patients with low grade (I-III) VUR did not spontaneously resolve in follow-up. Of those that do not resolve, over 30% required surgery, and nearly 1 in 10 patients had worsening VUR. Breakthrough UTI, diverticulum and renal scarring were risk factors requiring treatment in children with low grade VUR. Thus, not all children with low grade VUR have a benign clinical course, and those with these risk factors should consequently be monitored more carefully as in those with high grade VUR.

Grade

Frequency

Spontaneous Resolution

Worsening VUR

Breakthrough UTI

Re-implantation

Endoscopic injection

I

6.99%

73.5%

9.4%

6.8%

11.8%

5.6%

II

52.3%

66.5%

8.2%

7.3%

18.1%

6.3%

III

47.5%

51.5%

12.4%

11.3%

32.4%

7.1%

Overall

59.4%

10.3%

9.2%

22.48%

5.76%