What is reflux nephropathy?
VESICOURETERIC REFLUX (VUR) is when the one-way valve where the ureter meets the bladder doesn't work properly, so urine flows backward up the ureter towards the kidney during urination.
When this happens repeatedly — especially combined with childhood urinary tract infections (UTIs) — the kidneys can develop patchy scarring, called REFLUX NEPHROPATHY or 'chronic pyelonephritis'.
Grading Of Reflux (I-v)
- Grade I: into lower ureter only
- Grade II: up to renal pelvis without dilatation
- Grade III: mild dilatation
- Grade IV: moderate dilatation, blunting of calyces
- Grade V: severe dilatation, tortuous ureter, blunted calyces
Important Facts
- Reflux without infection rarely scars
- UTIs without reflux can still scar (especially infants < 1 year)
- Many young children outgrow reflux spontaneously
- Once scars form they are permanent
- ~10-15% of adult CKD has reflux nephropathy as the cause
FAMILIAL: ~30% of siblings and children of affected individuals also have reflux.
How it presents
In Childhood
- Recurrent UTIs (fever, foul urine, abdominal pain, vomiting in babies)
- Antenatal hydronephrosis (now picked up on routine 20-week scan)
- Failure to thrive
- Diagnosed by MCUG (micturating cystourethrogram) or indirect cystogram
- Renal ultrasound and DMSA scan show scarring
In Adolescence
- May resolve spontaneously by puberty
- High BP may emerge in late teens
- Microscopic blood/protein in urine
IN ADULTHOOD (often the first presentation in those without childhood diagnosis):
- High blood pressure in 20s-40s with no other cause
- Proteinuria
- Reduced eGFR — sometimes already CKD stage 3-4
- Recurrent UTIs
- Discovered during fertility, pregnancy or insurance medical
- Ultrasound shows small, scarred or asymmetric kidneys
- DMSA scan confirms cortical scars
In Pregnancy
- UTIs and pyelonephritis more common
- BP rise / pre-eclampsia
- Worsening proteinuria
- Sometimes irreversible drop in eGFR
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Investigations in adulthood
Baseline
- Urine ACR (proteinuria reflects scar burden)
- Creatinine, eGFR
- Blood pressure (often the trigger to investigate)
- Urine culture (rule out current infection)
- Ultrasound kidneys (small, scarred, asymmetric, reduced cortical thickness)
Further
- DMSA scan — quantifies scarring and split function
- MAG3 or DTPA scan — checks for obstruction
- MCUG only if active reflux suspected (rarely needed in adults)
- MR urogram in complex anatomy
Identify
- Number of kidneys affected
- Bilateral vs unilateral scarring
- Split function (% from each kidney)
- Concurrent VUR (uncommon in adults)
- Obstruction (occasionally found)
Management
BP CONTROL — the cornerstone:
- Target < 130/80 (lower if proteinuria > 1 g/day)
- ACE inhibitor or ARB FIRST-LINE (also reduces proteinuria)
- Salt restriction < 5 g/day
- Lifestyle: weight, exercise, alcohol
Proteinuria Reduction
- Maximise ACE/ARB
- Add SGLT2 inhibitor if ACR > 22.6 (NICE-approved)
- Statin
Uti Prevention
- Adequate fluids
- Prompt antibiotic treatment of every UTI
- Self-start antibiotics or 'rescue pack' in recurrent cases
- Consider continuous low-dose nitrofurantoin (50 mg nocte) in frequent UTIs — review annually
- Methenamine hippurate is another option
- Vaginal oestrogen post-menopause
- Avoid spermicides
- Treat constipation
General
- Avoid NSAIDs (worsen scarring)
- Pneumococcal vaccine if CKD stage 3+
- Annual flu, COVID
- Address mental health (chronic disease + repeated infections is hard)
SURGERY (rare in adults):
- Re-implantation of ureter only if VUR still active and severe
- Most adult reflux has 'burned out' by adulthood
Pregnancy and family planning
Pre-pregnancy
- Specialist renal review essential
- Optimise BP control
- Switch ACE/ARB to safer alternatives (labetalol, nifedipine, methyldopa) BEFORE conception
- Folic acid 5 mg daily (higher dose) if CKD
- Address UTIs first
In Pregnancy
- Joint renal-obstetric clinic from first trimester
- Monthly urine culture (asymptomatic bacteriuria treated)
- Low-dose aspirin from 12 weeks (pre-eclampsia prevention)
- Monitor BP, proteinuria, creatinine monthly
- Higher risk:
- Pre-eclampsia (2-3× background)
- Preterm delivery
- Pyelonephritis
- Worsening kidney function — sometimes permanent
Worst Prognosis
- Pre-pregnancy creatinine > 150 µmol/L
- Hypertension at baseline
- Heavy proteinuria
Family Screening
- Children of affected parent → renal ultrasound in first year of life (BAUS/EAU guidance)
- Treat UTIs promptly in children
- Genetic forms (rare) — referral to clinical genetics if other anomalies
