Late Renal Scarring and Loss of Kidney Function despite Successful Therapy of Vesicoureteral Reflux in Childhood: Case Report and Review of Literature

We report on a 11 year old boy who was treated for bilateral vesicoureteral reflux grade II at our department by the age of 12 months by bilateral endoscopic injection with dextranomer / hyaluronic acid (Deflux). Because of reflux persistence on the right side an open antireflux surgery (Lich Gregoir) was performed. 10 years after initial treatment he developed serious deterioration of the left kidney function after three febrile urinary tract infections within one month. Diagnostic reevaluation revealed bilateral recurrence of grade II reflux, which was corrected consequently by open bilateral ureteral reimplantation (Cohen technique). We discuss the available literature as to renal scarring in older children and adults after initial reflux therapy in childhood and conclude that there is no age limit to possible scar formation and that there are possible implications on follow up after “curative” therapy of vesicoureteral reflux in childhood.


Introduction
There is evidence of a strong association between childhood urinary tract infection, vesicoureteral reflux and the development of renal scars with consecutive loss of kidney function.
The predisposing pathophysiological conditions that interfere with different clinical features in the individual child over time, however, are a widely discussed representing a complicated issue that renders

Abstract
We report on a 11 year old boy who was treated for bilateral vesicoureteral reflux grade II at our department by the age of 12 months by bilateral endoscopic injection with dextranomer / hyaluronic acid (Deflux ® ).Because of reflux persistence on the right side an open antireflux surgery (Lich Gregoir) was performed.10 years after initial treatment he developed serious deterioration of the left kidney function after three febrile urinary tract infections within one month.Diagnostic re-evaluation revealed bilateral recurrence of grade II reflux, which was corrected consequently by open bilateral ureteral reimplantation (Cohen technique).We discuss the available literature as to renal scarring in older children and adults after initial reflux therapy in childhood and conclude that there is no age limit to possible scar formation and that there are possible implications on follow up after "curative" therapy of vesicoureteral reflux in childhood.___________________________________________________________________________________________ Consequently, bilateral endoscopic therapy with injection of dextranomer/hyaluronic acid copolymer (Deflux®) was performed.The endoscopic evaluation of the urethra appeared normal without any sign of posterior urethral valves.In the control VCUG three months after therapy a persistent reflux grade II on the right side was verified.Consequently, four months after initial endoscopic therapy, at the age of 17 months, an open unilateral extravesical anti-reflux surgery (Lich Gregoir) was performed.In the follow up, for 10 years, no urinary tract infections occurred.There was no clinical sign of lower urinary tract dysfunction or bowel dysfunction.As well there were no other infections or signs of immunodeficiency.

Discussion
There is consensus on the fact that the development of renal scarring requires vesicoureteral -and probably intrarenalreflux as well as urinary tract infection simultaneously.On the other hand dysplastic renal changes, often associated to VRR and probably with a common embryologic background, are static and present since birth without change during further life.Older children are generally thought to be at considerably lower risk for new renal scar formation.One the one hand this may be due to a lesser risk of kidney scarring with older age.This concept of kidneys becoming resistant to new damage with age is challenged by numerous studies e.g. it has been proven in pigs as well as in transplanted adult kidneys that reflux together with urinary tract infections induces renal scars as detailed above.On the other hand, the lower risk of scarring in older patients may be mainly due to the maturation of reflux or respectively its successful treatment.Maturation of reflux is, as well as its origination not well understood and may depend on the one hand on anatomical changes of the vesicoureteral junction as shown by Oswald et

Conclusion
Other than it is commonly believed kidneys do not outgrow the risk of scarring and loss of function due to VRR and UTIs.Although the risk in older children seems to be considerably lower, a certain population of patients having no bladder or bowel dysfunction are still at risk for late recurrence of VRR and consecutive harm to kidney function.Our case report illustrates the importance of long term follow up and consequent diagnosis and treatment for patients after successful therapy of VRR in early childhood.

Figure 1 :
Figure 1: (A)DMSA renal scan 10 years after initial antireflux therapy with endoscopic injection of Dx/HA on the left side and open antireflux surgery (Lich-Gregoir) on the right side showing marked scarring on the left kidney; split renal function left/right 23%/77% (B) DMSA renal scan 4 years after initial therapy split renal function left/right 38%/62%.demonstrated a slightly decreased split function of 38% on the left side.eGFR was 85ml/min as calculated by Schwartz's formula (creatinin 0,67mg/dl, body height 103cm).Ten years after initial therapy our patient developed a prolonged (treated first orally and relapsed then) febrile urinary tract infection.There was no pathogen detected as our patient referred to community physicians where no urine
al. as well as on changes in intravesical pressure profile as illustrated by the results of the Swedish reflux Study (Silén et al. 2010).Our patient has mainly acquired loss of kidney function Renate Pichler, Tanja Becker, Mark Koen, Christoph Berger, Lisa Wagenhuber and Josef Oswald (2015), International Journal of Case Reports in Medicine, DOI: 10.5171/2015.737441 that after unilateral extravesical ureteral reimplantation bladder emptying could be harmed to an extent facilitating the onset of a UTI.