Vesicoureteric reflux and reflux nephropathy as seen at a tertiary care adult nephrology service in India - An analysis of 86 patients
Severity of Illness Index
Clinical features and risk factors for renal failure in patients with reflux nephropathy (RN) as seen in an adult nephrology service are likely to be different than those seen in a pediatric service. There are only a few studies on adults with vesicoureteric reflux (VUR) and RN and data on RN as seen in developing countries is still evolving. Retrospective analysis of records of patients diagnosed to have VUR by conventional micturating cystourethrogram over a 13 year period, as seen in the adult nephrology services of this tertiary care hospital in north India was carried out. Results are presented as mean +/- 2 SD. Unpaired t-test was used to compare means, chi-square test to define associations, and logistic regression analysis was done to define risk factors. Out of 86 patients diagnosed to have VUR, 69 (80.2%) were males and 22 (25.6%) were children. The mean age at presentation was 24.3 +/- 14.5 years and at onset of symptoms was 19.64 +/- 14.8 years. Sixty-nine (80.2%) patients had chronic renal failure (CRF) at presentation, including 33 (38.4%) patients who already had end stage renal failure (ESRF) at presentation in whom reflux was diagnosed during routine pretransplant evaluation and these constituted 5.5% of all ESRF patients. The clinical features at presentation were hypertension in 51 (59.3%), recurrent urinary tract infection (UTI) in 31 (36.1%), history of stones in 7 (8.1%), and gross hematuria in 4 (4.7%). Patients with history of recurrent UTI were more likely to be females (p < 0.01) and to present without renal failure (p < 0.05). Proteinuria > 1 g/day was significantly associated (p < 0.02) with hypertension at presentation. Patients who presented with renal failure were more likely to be males (p < 0.05), not to have history of recurrent UTI (p < 0.05), have proteinuria > 1 g/day (p < 0.02) and higher grades (grades IV and V) of reflux (p < 0.05). On logistic regression analysis, higher age of onset (odds ratio 4.6, p < 0.03), proteinuria > 1 g/day (odds ratio 3.8, p < 0.05), and male gender (odds ratio 3.5, p < 0.05) were significant risk factors for presentation for the first time with renal failure. The clinical features and course of VUR and RN as seen in India are different from those reported from elsewhere. The vast majority of patients in India are males and almost two thirds do not have a past history of UTI. Renal failure is present in more than three fourths of patients when a diagnosis of reflux is made and one third of all patients present with ESRD. Patients with a prior history of UTI are more commonly females and are less likely to have renal failure at presentation. Higher age of onset of symptoms, proteinuria > 1 g/day and male gender were risk factors for the development of renal failure. It is likely that these asymptomatic patients remain undetected during childhood, presenting late only after having incurred severe renal damage.