The RiVUR Study Outcomes and Implications on the Management of Vesicoureteral Reflux

The Randomized intervention for Vesicoureteral Reflux (RiVUR) study was an effort by the National Institute of Health to identify the most significant question on the management of vesicoureteral reflux (VUR), i.e. Did antibiotic prophylaxis reduce the incidence of recurrent urinary tract infections (UTI) in children with VUR? During the initial phases of the RiVUR study, several similar studies were performed that seemed to indicate a lack of benefit of antibiotic prophylaxis in VUR. However, few of these studies had the rigorous methodology and true randomization of the pediatric cohort that was studied in RiVUR. Additionally, many of these studies included children of wide age ranges and inconsistent assessments were used for identification of UTI and VUR. In 2011, the American Academy of Pediatrics (AAP) published a guideline statement for the evaluation of initial UTI in febrile children aged 2 to 24 months, which recommended against performing a Voiding Cystourethrogram (VCUG) in all children with a confirmed UTI. The goal of the AAP guidelines was to reduce the number of VCUGs being performed and potentially to reduce the number of children diagnosed with low grade VUR that seems to have low potential to cause renal injury. The RiVUR study included over 600 children identified with VUR after a 1st or 2nd febrile UTI randomized to prophylaxis with trimethoprim/sulfamethoxazole (TMP/SMZ), or placebo and followed over a study timeline for 2 years. Overall, a 50% reduction was noted in the incidence of recurrent febrile UTI with the utilization of prophylaxis as compared to placebo. Additional sub-group analyses have been performed on the cohorts of the study; these are also evaluated in this review to determine the overall impact of the RiVUR study on the current management of VUR.