Reflux nephropathy
Chronic atrophic pyelonephritis; Vesicoureteric reflux; Nephropathy - reflux; Ureteral refluxReflux nephropathy is a condition in which the kidneys are damaged by the backward flow of urine into the kidney.
Causes
Urine flows from each kidney through tubes called ureters and into the bladder. When the bladder is full, it squeezes and sends the urine out through the urethra. No urine should flow back into the ureter when the bladder is squeezing. Each ureter has a one-way valve where it enters the bladder that prevents urine from flowing back up the ureter.
But in some people, urine flows back up to the kidney. This is called vesicoureteral reflux.
Over time, the kidneys may be damaged or scarred by this reflux. This is called reflux nephropathy.
Reflux can occur in people whose ureters do not attach properly to the bladder or whose valves do not work well. Children may be born with this problem or may have other birth defects of the urinary system that cause reflux nephropathy.
Reflux nephropathy can occur with other conditions that lead to a blockage of urine flow, including:
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Bladder outlet obstruction, such as an enlarged prostate in men
Bladder outlet obstruction
Bladder outlet obstruction (BOO) is a blockage at the base of the bladder. It reduces or stops the flow of urine into the urethra. The urethra is t...
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Bladder stones
Bladder stones
Bladder stones are hard buildups of minerals. These form in the urinary bladder.
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Neurogenic bladder, which can occur in people with multiple sclerosis, spinal cord injury, diabetes, or other nervous system (neurological) conditions
Neurogenic bladder
Neurogenic bladder is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition.
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Reflux nephropathy can also occur from swelling of the ureters after a kidney transplant or from injury to the ureter.
Risk factors for reflux nephropathy include:
- Abnormalities of the urinary tract
- Personal or family history of vesicoureteral reflux
- Repeat urinary tract infections
Symptoms
Some people have no symptoms of reflux nephropathy. The problem may be found when kidney tests are done for other reasons.
If symptoms do occur, they might be similar to those of:
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Chronic kidney failure
Chronic kidney failure
Chronic kidney disease is the slow loss of kidney function over time. The main job of the kidneys is to remove wastes and excess water from the body...
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Nephrotic syndrome
Nephrotic syndrome
Nephrotic syndrome is a group of symptoms and abnormal test results that include protein in the urine, low blood protein levels in the blood, high ch...
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Urinary tract infection
Urinary tract infection
A urinary tract infection, or UTI, is an infection of the urinary tract. The infection can occur at different points in the urinary tract, including...
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Exams and Tests
Reflux nephropathy is often found when a child is checked for repeated bladder infections. If vesicoureteral reflux is discovered, the child's siblings may also be checked, because reflux can run in families.
Blood pressure may be high, and there may be signs and symptoms of long-term (chronic) kidney disease.
Blood and urine tests will be done, and may include:
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BUN -- blood
BUN
BUN stands for blood urea nitrogen. Urea nitrogen is what forms when protein breaks down. A test can be done to measure the amount of urea nitrogen ...
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Creatinine -- blood
Creatinine
The creatinine blood test measures the level of creatinine in the blood. This test is done to see how well your kidneys are working. Creatinine in t...
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Creatinine clearance -- urine and blood
Creatinine clearance
The creatinine clearance test helps provide information about how well the kidneys are working. The test compares the creatinine level in urine with...
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Urinalysis or 24-hour urine studies
Urinalysis
Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds th...
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Urine culture
Urine culture
A urine culture is a lab test to check for bacteria or other germs in a urine sample. It can be used to check for a urinary tract infection in adults...
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Imaging tests that may be done include:
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Abdominal CT scan
Abdominal CT scan
An abdominal CT scan is an imaging method. This test uses x-rays to create cross-sectional pictures of the belly area. CT stands for computed tomog...
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Intravenous pyelogram (IVP)
Intravenous pyelogram
An intravenous pyelogram (IVP) is a special x-ray exam of the kidneys, bladder, and ureters (the tubes that carry urine from the kidneys to the bladd...
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Kidney ultrasound
Kidney ultrasound
Abdominal ultrasound is a type of imaging test. It is used to look at organs in the abdomen, including the liver, gallbladder, spleen, pancreas, and...
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Radionuclide cystogram
Radionuclide cystogram
A radionuclide cystogram is a special imaging nuclear scan test. It checks how well your bladder and urinary tract work.
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Voiding cystourethrogram
Voiding cystourethrogram
A voiding cystourethrogram is an x-ray study of the bladder and urethra. It is done while the bladder is emptying.
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Treatment
Vesicoureteral reflux is separated into five different grades. Simple or mild reflux often falls into grade I or II. The severity of the reflux and amount of damage to the kidney help determine treatment.
Simple, uncomplicated vesicoureteral reflux (called primary reflux) can be treated with:
- Antibiotics taken every day to prevent urinary tract infections
- Careful monitoring of kidney function
- Repeated urine cultures
- Yearly ultrasound of the kidneys
Ultrasound
Ultrasound uses high-frequency sound waves to make images of organs and structures inside the body.
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Controlling blood pressure is the most important way to slow kidney damage. Your health care provider may prescribe medicines to control high blood pressure. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are often used.
Surgery is usually only used in children who have not responded to medical therapy.
More severe vesicoureteral reflux may need surgery, especially in children who do not respond to medical therapy. Surgery to place the ureter back into the bladder (ureteral reimplantation) can stop reflux nephropathy in some cases.
More severe reflux may need reconstructive surgery. This type of surgery may reduce the number and severity of urinary tract infections.
If needed, people will be treated for chronic kidney disease.
Outlook (Prognosis)
Outcome varies, depending on the severity of the reflux. Some people with reflux nephropathy will not lose kidney function over time, even though their kidneys are damaged. However, kidney damage may be permanent. If only one kidney is involved, the other kidney should keep working normally.
Reflux nephropathy may cause kidney failure in children and adults.
Possible Complications
Complications that may result from this condition or its treatment include:
- Blockage of the ureter after surgery
- Chronic kidney disease
- Chronic or repeat urinary tract infections
- Chronic kidney failure if both kidneys are involved (can progress to end-stage kidney disease)
End-stage kidney disease
End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's...
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- High blood pressure
- Nephrotic syndrome
- Persistent reflux
- Scarring of the kidneys
When to Contact a Medical Professional
Contact your provider if you:
- Have symptoms of reflux nephropathy
- Have other new symptoms
- Are producing less urine than normal
Prevention
Quickly treating conditions that cause reflux of urine into the kidney may prevent reflux nephropathy.
References
Alexander T, Licht C, Smoyer WE, Rosenblum ND. Diseases of the kidney and upper urinary tract in children. In: Yu ASL, Chertow GM, Luyckx VA, Marsden PA, Skorecki K, Taal MW, eds. Brenner and Rector's The Kidney. 11th ed. Philadelphia, PA: Elsevier; 2020:chap 72.
Mathews R, Damm T, Mattoo TK. Primary vesicoureteral reflux and reflux nephropathy. In: Johnson RJ, Floege J, Tonelli M, eds. Comprehensive Clinical Nephrology. 7th ed. Philadelphia, PA: Elsevier; 2024:chap 62.
Yaqoob MM, Ashman N. Kidney and urinary tract disease. In: Feather A, Randall D, Waterhouse M, eds. Kumar and Clark's Clinical Medicine. 10th ed. Philadelphia, PA: Elsevier; 2021:chap 36.
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Female urinary tract - illustration
The female and male urinary tracts are relatively the same except for the length of the urethra.
Female urinary tract
illustration
-
Male urinary tract - illustration
The male and female urinary tracts are relatively the same except for the length of the urethra.
Male urinary tract
illustration
-
Voiding cystourethrogram - illustration
One method of examining bladder function is by injecting dye that is visible on X-rays through a tube (catheter) to fill the bladder. X-rays are taken while the bladder is full and while the patient is urinating (voiding) to determine if fluid is forced out of the bladder through the urethra (normal) or up through the ureters into the kidney (vesicoureteral reflux). This study is usually done with the patient lying on an X-ray table.
Voiding cystourethrogram
illustration
-
Vesicoureteral reflux - illustration
When the ureters enter the bladder, they travel through the wall of the bladder for a distance in such a way that they create a tunnel so that a flap-like valve is created inside the bladder. This valve prevents urine from backing-up into the ureters and kidneys. In some children, the valves may be abnormal or the ureters in the bladder may not travel long enough in the bladder wall, which can cause vesicoureteral reflux. Vesicoureteral reflux is a condition that allows urine to go back up into the ureters and kidneys causing repeated urinary tract infections. The reflux of urine exposes the ureters and kidney to infection from bacteria and high-pressure, which is generated by the bladder during urination. If left untreated, urinary infections can cause kidney damage and renal scarring with the loss of potential growth of the kidney and high blood pressure later in life. Vesicoureteral reflux is treated with antibiotics, and in severe cases surgically.
Vesicoureteral reflux
illustration
-
Female urinary tract - illustration
The female and male urinary tracts are relatively the same except for the length of the urethra.
Female urinary tract
illustration
-
Male urinary tract - illustration
The male and female urinary tracts are relatively the same except for the length of the urethra.
Male urinary tract
illustration
-
Voiding cystourethrogram - illustration
One method of examining bladder function is by injecting dye that is visible on X-rays through a tube (catheter) to fill the bladder. X-rays are taken while the bladder is full and while the patient is urinating (voiding) to determine if fluid is forced out of the bladder through the urethra (normal) or up through the ureters into the kidney (vesicoureteral reflux). This study is usually done with the patient lying on an X-ray table.
Voiding cystourethrogram
illustration
-
Vesicoureteral reflux - illustration
When the ureters enter the bladder, they travel through the wall of the bladder for a distance in such a way that they create a tunnel so that a flap-like valve is created inside the bladder. This valve prevents urine from backing-up into the ureters and kidneys. In some children, the valves may be abnormal or the ureters in the bladder may not travel long enough in the bladder wall, which can cause vesicoureteral reflux. Vesicoureteral reflux is a condition that allows urine to go back up into the ureters and kidneys causing repeated urinary tract infections. The reflux of urine exposes the ureters and kidney to infection from bacteria and high-pressure, which is generated by the bladder during urination. If left untreated, urinary infections can cause kidney damage and renal scarring with the loss of potential growth of the kidney and high blood pressure later in life. Vesicoureteral reflux is treated with antibiotics, and in severe cases surgically.
Vesicoureteral reflux
illustration
Review Date: 8/28/2023
Reviewed By: Walead Latif, MD, Nephrologist and Clinical Associate Professor, Rutgers Medical School, Newark, NJ. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.