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Physician Update - A Re-Boot for Vesicoureteral Reflux

Physician Update Fall 2009

A Re-Boot for Vesicoureteral Reflux

By: Ramsey Flynn
Date: October 15, 2009

It’s rare for an entire specialty to consider overhauling its approach to a time-honored treatment protocol, but pediatric urologist Ranjiv Mathews says the data leave no choice. He and about 30 other U.S. experts pored over mixed outcomes and debated study plans for more than 18 months. All agree it’s time for new answers.

The condition at hand is vesicoureteral reflux, the urinary tract disorder that afflicts more than 1 in 10 people, most under age 12. At VUR’s most advanced stage, urine can flow back into the kidneys, eventually scarring them with infection and sometimes escalating to the need for a kidney transplant. Mathews says about half the children who come to Johns Hopkins with urinary tract infections are confirmed as having VUR. His group treats about 150 of them every year.

The trouble, says Mathews, is that he and others now suspect that they could be managing the condition much better. In mild cases, doctors have used prophylactic antibiotics to reduce infections, hoping the condition resolves spontaneously. In the more significant grades of VUR cases, surgeons reroute the patient’s ureters. But the interventions can be costly and aren’t always effective. Even the surgical repairs—effective in preventing VUR—don’t always reduce the incidence of infections and scarring. And, says Mathews, recent data show that antibiotics may not prevent scarring and infections.

Several years ago, the National Institutes of Health demanded a new look and in 2007 backed a national study (RIVUR, for Randomized Intervention for VUR) that now involves 20 centers across the country. It will start with the antibiotics question and then proceed to others, including gauging surgical outcomes and hunting for a suspected genetic component.

“We really should know more about this,” says Mathews, “because it not only has an impact on this generation, but an even bigger impact on future generations of children.”

RIVUR Eligibility
Study candidates must be 2 months to 6 years of age, have been diagnosed with first or second febrile or symptomatic urinary tract infection within 112 days of randomization, exhibit grade I-IV VUR based on radiographic VCUG performed within 112 days of diagnosis of index UTI, and have undergone appropriate treatment.
Call 410-955-3693 to refer a patient.

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