It is believed that end-stage renal disease (ESRD) attributable to reflux nephropathy is preventable by the active treatment of vesicoureteric reflux in childhood with long-term antibiotics and ureteric reimplantation surgery. We aimed to test this belief.
The Australia and New Zealand Dialysis and Transplant Registry of new patients 5 to 44 years of age treated for ESRD between 1971 and 1998, categorized by age and primary renal disease, was used to analyze the age-specific incidences of ESRD attributable to reflux nephropathy using a before–after study design. The early 1960s were regarded as the introduction period for the active treatment of childhood vesicoureteric reflux. A time-delay in treatment effect was expected. Patients with ESRD attributable to other causes were used as a comparative group.
The incidence of ESRD attributable to reflux nephropathy and nonreflux nephropathy has increased. For reflux nephropathy, the rate of change was significantly associated with age, with a downward trend in incidence with decreasing age suggesting a minor treatment effect. This trend was no longer evident when adjustment was made for changing diagnostic practices. An opposite trend was observed for the nonreflux nephropathy group, who demonstrated an upward trend in incidence with decreasing age.
Treatment of children with vesicoureteric reflux has not been accompanied by the hoped-for reduction in the incidence of ESRD attributable to reflux nephropathy. A randomized trial with a control (no-treatment) arm is required to appropriately assess the medical belief that long-term antibiotics and surgery improve the natural history of vesicoureteric reflux.
Dear Editor
The subject of VUR to prevent the ESRD has always been controversial. As the authors indicate, unless a randomised controlled trial is undertaken there won't be clear answers. On the other hand, the treatment of VUR even though it may or may not prevent the ESRD, does it prevent the late onset hypertension or not and the associated morbidities - how do we answer questions like this to the family and how do we answer it to ourselves. Is it more academic question and what do the general paediatricians like us do meantime? I think the answer to lots of these questions is we don't know. Until we know the answers clearly we should continue to treat the VUR aggressively (especially grade 3 and above) as they may not prevent the ESRD, they certainly will prvent or should prevent/reduce later morbidities. We don't do any harm by aggressive management, but we may do harm by leaving them with conservative management. Lot of these children may be lost for follow up which may complicate the issues of treatment.
The Royal Colleges of the respective countries should come out with recommendations each year with the available EBM for the use of the general paediatricians, otherwise it may only lead to more confusion with more controversies stemmming out in the literature.
With sincere regards Kishore
Dr.R.Kishore Kumar