200211. Bonnin, F., Lottmann, H., Sauty, L., Garel, C., Archambaud, F.,

Baudouin, V. et al: Scintigraphic screening for renal damagein siblings of children with symptomatic primary vesi-coureteric reflux. BJU Int, 87: 463, 2001

12. Noe, H. N.: The relationship of sibling reflux to index patientdysfunctional voiding. J Urol, 140: 119, 1988

13. Connolly, L. P., Treves, S. T., Zurakowski, D. and Bauer, S. B.:Natural history of vesicoureteral reflux in siblings. J Urol,156: 1805, 1996

14. Olbing, H. Claesson, I., Ebel, K.-D., Seppanen, U., Smellie, J. M.,Tamminen-Mobius, T. et al: Renal scars and parenchymalthinning in children with vesicoureteral reflux: a 5-year reportof International Reflux Study in Children (European branch)J Urol, 148: 1653, 1992

15. Fennell, R. S., Wilson, S. G., Garin, E. H., Pryor, N. D., Sorgen,C. D., Walker, R. D. et al: Bacteriuria in families of girls withrecurrent bacteriuria. A survey of 112 family members showedsimilar infections in 14% of the female siblings. Clin Pediatr,16: 1132, 1977

16. Winberg, J., Bergstrom, T. and Jacobsson, B.: Morbidity, age andsex distribution, recurrences and renal scarring in symptom-atic urinary tract infection in childhood. Kidney Int, 4: S101,1975

17. Hellstrom, A., Hanson, E., Hansson, S., Hjalmas, K. and Jodal,U.: Association between urinary symptoms at 7 years old andprevious urinary tract infection. Arch Dis Child, 66: 232, 1991

18. Shortliffe, L. M. D.: Urinary tract infections in infants and chil-dren. In: Campbell’s Urology, 7th ed. Edited by P. C. Walsh,A. B. Retik, E. D. Vaughan, Jr. and A. J. Wein. Philadelphia:W. B. Saunders Co., vol. 2, chapt. 57, pp. 1681–1707, 1998

EDITORIAL COMMENT

This author summarized the literature regarding the incidence ofsibling reflux and associated alterations in upper tract morphology.While impartial, the author hints at skepticism of such preemptivescreening. It is probably true that those who advocate screening do sowith some prejudices of their own. However, there are 2 sides to thiscoin and neither should be ignored. Most reflux identified in siblingsis low grade but so is the overwhelming majority of reflux discoveredin affected population. In our study of approximately 1,000 childrenwith vesicoureteral reflux 88% of ureters had grade I (20%), II (46%)or III (22%) reflux.1 Intermediate grades II and III nondilating refluxaccounts for most children with reflux in all subsets of presentationexcept prenatally identified probands. While renal scarring is moreprevalent in higher grades IV and V, up to 50% of all scarred kidneyscan be associated with the lower grades and new scars secondary toinfection can develop in these children.

Many years ago, Smellie et al described older children who pre-sented with significant reflux nephropathy.2 A number of them werethe siblings of known patients with reflux whose families balked atsibling screening when the children were younger. The fact that themajority of siblings in the accumulated data did not have scars orrenal insufficiency is not in any way to suggest that screening isunwarranted. The point of identifying these children earlier is tobegin on antibiotic prophylaxis to prevent the development of scars.It is impossible to say whether the risk of infection in these siblingsis less than in other children with reflux. It would be difficult toperform a controlled study, as suggested by the author, in which agroup of siblings, especially younger than age 5 years, with knownreflux would be observed off of prophylaxis.

The definition of acceptable risk is subjective. This article remindsus of the genetic basis of vesicoureteral reflux. Individual families,clinicians, health care systems and societies may infer differentcourses of action based on these data. There is no mathematicalformula from which an absolute recommendation can be derived.However, certainly in the absence of sibling screening there may bechildren with renal scars that could have been prevented.

Saul P. GreenfieldChildren’s Hospital of BuffaloBuffalo, New York

1. Greenfield, S. P., Ng, M. and Wan, J.: Experience with vesi-coureteral reflux in children: clinical characteristics. J Urol,158: 574, 1997

2. Smellie, J. M., Poulton, A. and Prescod, N.: Retrospective studyof children with renal scarring associated with reflux anduri-nary tract infection. BMJ, 308: 1193, 1994

REPLY BY AUTHORS

As noted, finding sibling reflux to be low grade in the majority ofcases is similar to findings in the population presenting with infec-tion and does not render screening invaluable. However, screeningfor and treating it stand to benefit only patients in whom urinaryinfection and renal scarring with first infection will develop. Risk ofurinary infection is where the populations differ. Data on urinaryinfection in sibling population are limited but suggest that it is aboutthe same as in the general childhood population (references 1 and 11in article), which is dramatically less than in children who have hadurinary infection (reference 18 in article). Low incidence of renaldamage in siblings, most of whom were asymptomatic, further em-phasizes the role urinary infection plays in evolution of renal dam-age. Thus, risk factors for urinary infection as well as risk for refluxshould be considered when selecting children for screening.

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