Swedish investigators conducted a prospective observational study to determine the factors associated with resolution of high grade vesicoureteral reflux (HGVUR) in infants. Infants born between 1992 and 1997 diagnosed with high grade (III to V) VUR during the first year of life were enrolled. At the time of diagnosis, all patients were placed on prophylactic antibiotics and underwent serial investigations that included repeat examinations for determination of VUR grade, bladder function, renal abnormalities, and renal function. Surgical intervention for VUR was intentionally delayed. Patients were considered to have resolved their reflux if they had normal voiding cystometry (VCM) or downgrading of the VUR to grade I-II.
A total of 115 infants diagnosed with HGVUR with a mean age of 2.7 months were enrolled; 80 were male. Most infants were diagnosed after a UTI (71%). The maximum grade VUR was III in 16%, IV in 45% and V in 39%. Complete resolution was observed in 30 cases (26%) and downgrading to grade I-II occurred in 14 (20%), with a mean age of 27 months at the time of detection of spontaneous resolution or downgrading to grade I-II. Open surgery was performed on 35 patients (30%) for presumed breakthrough UTIs and persistence of reflux was documented at a median age of 42 months. Independent negative predictors for reflux resolution were bladder dysfunction (P<.0001), renal abnormalities (P<.0001), and breakthrough UTI (P=.009). If a patient lacked all three of these risk factors, he or she had a 91% chance of spontaneous reflux resolution by age 3 years. However, if all three risk factors were present, there was only a 7% chance of resolution by age 3. Gender, laterality, or timing of diagnosis did not predict resolution. The authors conclude that infants with HGVUR who have bladder dysfunction, renal abnormalities, and/or breakthrough UTI are unlikely to resolve their reflux.
The management of all grades of VUR is under scrutiny. Current management strategies include observation with prophylactic antibiotics. However, the effectiveness of antibiotics in children with VUR has been challenged recently.1 With concerns regarding long-term use of antibiotics and the rising use of endoscopic treatment of reflux, observation for VUR is being questioned, especially with high grade reflux. In this study, the authors sought to determine which factors predict failure of spontaneous resolution of reflux in infants diagnosed with HGVUR. Few studies have tried to define this group of patients. Identifying patients unlikely to resolve their reflux would allow early surgical intervention and thereby potentially limit their exposure to antibiotics and follow-up examinations.