Neuhauser lecture. Reflux nephropathy: a personal historical review.

High pressure reflux may be a major cause of chronic renal failure both with and without associated urinary tract infection. The concept of reflux nephropathy includes not only the entity previously known as "chronic atrophic pyelonephritis," but other forms of renal disease such as the Ask-Upmark kidney, renal segmental hypoplasia, and the generalized changes that resemble those of obstructive nephropathy but which are secondary to reflux. Lobar and papillary anatomic variations play an important role in predisposing certain kidneys or parts of a kidney to damage from high pressure reflux, with or without infection. Prolonged high pressure sterile reflux can not only cause focal scarring in papillae susceptible to intrarenal reflux, but can cause the conversion of nonsusceptible papillae, so that scarring may then become generalized. The mechanisms of scar production induced by intrarenal reflux remain unclear, but mechanical immunologic, bacterial, and vascular factors are current subjects of investigation. There is mounting evidence that it is in infancy that a train of events starts which culminates in this renal damage and that much of this may be well under way quite early in childhood and remain clinically undetected until later in life, when the end results (i.e., hypertension and/or renal failure) become manifest.