Vesicoureteral Reflux Common in Hypertensive Adults

Laurie Barclay, MD

June 11, 2004

June 11, 2004 -- A high percentage of hypertensive adults without evidence of renal disease have vesicoureteral reflux (VUR), according to the results of a retrospective study published in the June issue of Urology.

"Reflux nephropathy may be clinically latent and present in early adulthood as hypertension when superimposed confounding factors are added," write Sukanta Barai, from the All India Institute of Medical Sciences in New Delhi, and colleagues. "Direct radionuclide voiding cystoscintigraphy (DRVC) is a well-established screening procedure for the detection of VUR and is more sensitive than micturating cystourethrography with less radiation burden. Inclusion of the DRVC study in the routine diagnostic evaluation of adult patients with hypertension may allow the diagnosis of latent reflux nephropathy in a large patient population."

Between June 1998 and May 2003, 157 adult hypertensive patients with normal renal parameters and low-probability, captopril-enhanced renal dynamic scan findings underwent DRVC.

Retrospective analysis of their medical records revealed that VUR was documented in 30 patients (19.1%). Of those 30 patients, eight (26.6%) had mild VUR, six patients (20%) had moderate VUR, and 16 patients (53.3%) had severe VUR. Seven patients had bilateral VUR, which was graded as severe in all cases. VUR was present in 20% of patients aged 18 to 30 years, in 16.6% of patients aged 31 to 45 years, and in 20% of patients older than 45 years.

"The results of this study have shown that VUR is present in a significantly large proportion of adult patients with hypertension without any apparent renal parenchymal or renovascular involvement," the authors write.

In an accompanying editorial, Paul J. Scheel, Jr, MD, from Johns Hopkins University School of Medicine in Baltimore, Maryland, calls this "an exciting finding," but recommends additional research before suggesting that it is applicable to the larger hypertensive population.

Study limitations include retrospective design, inherent selection bias because there must have been some indication other than hypertension for the physician to order the DRVC, and lack of imaging studies to detect renal scarring.

Dr. Scheel also points out that VUR is inherited by a single dominant gene and that there is also a very strong genetic component to essential hypertension.

"Therefore, one cannot exclude a possible segregation of a genetic mutation for hypertension and VUR on the same chromosome, especially in a racially similar cohort. In this scenario, the patients would have both disease states but they would be pathophysiologically unrelated," Dr. Scheel writes. "Until prospective studies are available that are designed to study the relationship between essential hypertension and VUR, it would seem appropriate to screen for reflux nephropathy in young hypertensive patients without apparent risk factors or known secondary causes of hypertension."

Urology. 2004;63:1045-1049

Reviewed by Gary D. Vogin, MD

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