Background: We determined the urinary levels of vascular endothelial growth factor (VEGF) in patients with reflux nephropathy to elucidate its clinical significance as a predictor of the development of renal damage. Patients and Methods: Seventy-two patients (47 boys and 25 girls) aged 10–18 years with reflux nephropathy were studied. Vesicoureteral reflux was resolved surgically in all cases at least 2 years before enrollment. Urinary VEGF, α<sub>1</sub>-microglobulin and albumin levels were determined using morning spot urine samples. Plasma VEGF, serum creatinine and β<sub>2</sub>-microglobulin levels were measured simultaneously. The severity of renal scarring and right and left kidney function were assessed by <sup>99m</sup>Tc dimercaptosuccinic acid renal scan. Results: No significant correlation was found between the plasma and urinary VEGF levels. Urinary VEGF increased significantly with the increase in severity of renal scarring (p < 0.0001). Urinary VEGF levels correlated significantly with serum β<sub>2</sub>-microglobulin (p < 0.002) and urinary α<sub>1</sub>-microglobulin (p < 0.03). No significant correlation of urinary VEGF levels with serum creatinine and urinary albumin levels was found. Nearly 60% of the patients with elevated urinary VEGF had normal levels of serum β<sub>2</sub>-microglobulin and/or urinary α<sub>1</sub>-miocroglobulin. Conclusions: Urinary VEGF level appears to reflect its production in the kidney. Since urinary VEGF shows a propensity to elevate before the increase in serum β<sub>2</sub>-microglobulin and/or urinary α<sub>1</sub>-microglobulin, urinary VEGF may serve as an early indicator of the development of reflux nephropathy.