Antibiotics or surgery for vesicoureteric reflux in children.

CONTEXT: 1-2% of children have vesicoureteric reflux (VUR). VUR occurs in 25-40% of children with acute pyelonephritis. VUR can lead to renal scarring, hypertension, and end-stage renal disease. The best form of treatment for children with VUR is debated: no treatment, long-term antibiotic prophylaxis, surgery, or a combination of antibiotic prophylaxis and surgery. In children with recurrent urinary tract infections (UTIs) and progressive renal damage, despite antibiotic prophylaxis, surgical correction of VUR, especially high-grade VUR, is generally recommended.

STARTING POINT: Danielle Wheeler and colleagues recently did a meta-analysis of ten randomised controlled trials (964 children) to evaluate whether any intervention for VUR is better than no treatment (Cochrane Database Syst Rev 2004; 3: CD001532). The main endpoints were incidence of UTIs, new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate. They concluded that it is uncertain whether the identification of children with VUR is associated with clinically important benefit. The additional benefit of surgery over antibiotics is small. WHERE NEXT? New strategies for management will require a tailored diagnostic and therapeutic approach, including non-invasive or less invasive diagnostic procedures, and a less aggressive therapeutic approach. Whether the common practice of cystourethrography as a first-line investigation is warranted needs evaluation. The goal of paediatricians in the future, to prevent kidney damage, will probably be prevention of renal parenchymal injury and not necessarily the correction of ureterovesical junction anomalies. Because two main clinical pictures of VUR (diagnosed prenatally or postnatally with different age and sex distribution) can be identified, boys and girls will probably be managed differently. The factors responsible for congenital and acquired renal injury in children with VUR need to be studied.