Asymptomatic high grade VUR with hypo plastic/dysplastic right kidney in 7 year boy

Case Summary:

A 7-year-old boy, asymptomatic, underwent an abdominal ultrasound (USG) 4 months ago for left hydrocele. The USG findings revealed:

A smaller-sized right kidney

Mild to moderate right hydronephrosis (HUN)

Maintained corticomedullary differentiation


Clinical Details:

No history of UTI

No voiding complaints

No constipation

Circumcision was performed 4 months ago

Normal spine examination

Normal BP

Weight and height are less compared to peers of the same age


Investigations:

Urine culture: Sterile

Serum creatinine: 0.43 mg/dL

Recent VCUG and DMSA scan images will follow


Management Query:

Please discuss the management of this case with reasoning.


Thanks 

Asymptomatic high grade VUR with hypo plastic/dysplastic right kidney in 7 year boyAsymptomatic high grade VUR with hypo plastic/dysplastic right kidney in 7 year boyAsymptomatic high grade VUR with hypo plastic/dysplastic right kidney in 7 year boy

Comments(12)

  • Dr. Anil Takvani
    Dr. Anil Takvani
    25 Nov 2024 07:22:59 AM

    Additional USG information: post void residual 25 to 30 cc

  • Ravindra Sabnis
    Ravindra Sabnis
    25 Nov 2024 08:26:11 AM

    I feel in asymptomatic primary vur whatever is grade - no role of surgery. In this case constipation should be treated. As it may add element of dysfunctional voiding which may complicate the matter 

  • Rajesh Kukreja
    Rajesh Kukreja
    25 Nov 2024 08:27:05 AM

    Would manage conservative as of now. Asymptomatic, no UTI. Bladder appears normal and no PVR. The right kidney maybe taking the brunt of reflux and protecting the left kidney as a pop off mechanism. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    25 Nov 2024 09:45:06 AM

    So a 7 year old boy with bilateral high grade VUR, right > left. 
    Maintained rft with right shrunken kidney and left ? Compensatory hypertrophy
    Post circumcision.


    The child has quite a bit of constipation in my opinion in MCU.  A scout/plain film would make it more clear sir.
    Treat the constipation. 
    Plan for Bilateral ureteric reimplantation with tapering. 
    Hydrocele/congenital hernia can be dealt with at same time.

    From Dr Kaushik from Bangalore 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    25 Nov 2024 09:45:51 AM

    Good morning 

    Treat the BBD

    Bladder diary 
    Constipation 
    Urotherapy 

    Reevaluate after 3 months and then proceed for surgery 

    Yes all can be done the same time

    From Dr Prasanna, Bangalore 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    25 Nov 2024 09:47:17 AM

    Interesting approach sir. Seems like that thought process is having a lit of traction sir.
    In the on 2nd thought scientific program recently in bangalore there was a session questioning ir VUR is even a surgical pathology.

    So a bilateral reflux grade 5 in filling phase doesn't mandate surgery sir? Even sterile reflux can damage the well preserved left side is it not sir?

    From Dr Kaushik, Banglore 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    25 Nov 2024 09:47:53 AM

    Sterile reflux damaging the kidney is being questioned.  If no UTI then no damage.  
    Kidney will deteriorate as per amount of dysplasia in kidney. Not is our hand. 
    Even if you do anti reflux surgery, courses of disease will be same.

    Dr R B Sabnis

  • Dr. Anil Takvani
    Dr. Anil Takvani
    25 Nov 2024 09:50:01 AM

    Eau guidelines 2024 still suggest surgery be offered if reflux persists are lutd treatment sir.


    Dr Vinayn Kaushik

  • Ritesh Mehta
    Ritesh Mehta
    25 Nov 2024 03:01:18 PM

    Looks like primary bilateral reflux (Rt<lt) with Lt. Poorly functioning kidney as a result of reflux nephropathy but considerable residual function. In my view, Patient should undergo Rt. Ureteric reimplantation to limit further insult.

  • Yaqoub jafar
    Yaqoub jafar
    26 Nov 2024 12:31:02 AM

    Good morning , it’s interesting case . 

    The child is asymptomatic , no FUTI . 
    The ultrasound showing right Hydroneohrosis . 
    The VCUG : high grade VUR . Smooth bladder wall . 
    I agree that the child look constipated . 
    This is could be either a congenital High grad VUR discovered accidentally . And according to the evidence , high grade VUR have cortical abnormality ( congenital renal dysplasia ) that could be considered as renal scarring . 
    I would make sure that the child dose not have BBD . 
    I would do the following for the kid : 
    1: bladder calendar
    2. Urotherapy . 
    3. Treat constipation . 
    4, follow the child if she present with FUTI . I will consider surgery but otherwise I don’t believe it could be beneficial . 
    VUR but itself if asymptomatic and not causing any concern on the child health I will not intervene. 

  • Dr. Aadil Farooq
    Dr. Aadil Farooq
    27 Nov 2024 11:50:11 AM

    Good morning,

    Respected teachers,
    Looking at the VCUG,
    I would like to treat the Constipation first, Bowel program to be explained to parents.
    Bladder Diary then teach proper 
    Toilet Training.
    I always do Uroflowmetry with EMG & PVR in children who can follow the commands.
    Then Cystoscopy for evaluation of Urethra along with Sphincters.
    Conservative approach till 6 months keeping the urine sterile.


  • Dr. Anil Takvani
    Dr. Anil Takvani
    28 Nov 2024 02:38:26 PM

     The child has a congenital dysplastic kidney with high grade reflux. Usually boys are affected. As long as the child is asymptomatic no invasive therapy is required.
    Best. Margit

    From Prof Margit ( Germany)

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