Management Of Antenatal Hydronephrosis Research Articles

Updates in the Management of Antenatal Hydronephrosis—from Current Practices to On-going Challenges

Updates in the Management of Antenatal Hydronephrosis—from Current Practices to On-going Challenges

Outcome of infants with antenatally detected hydronephrosis

Background: It is estimated that genitourinary anomalies comprise 20% of all antenatally detected fetal anomalies, of which hydronephrosis is the most common anomaly affecting 1–5% of all pregnancies. Depending on diagnostic criteria and gestation, the prevalence of antenatal hydronephrosis (ANH) ranges from 0.6 to 5.4%. Aim: The aim of the study was to find the causes and outcome of antenatally detected hydronephrosis. Methods: Babies diagnosed with antenatally detected hydronephrosis from January 2016 to December 2016 were followed up for 6 months postnatally. Based on anteroposterior diameter of renal pelvis babies were classified as mild, moderate and severe according to Society for Fetal Urology consensus statement on evaluation and management of ANH and these babies were followed up. Results: Two percent of babies born during the study period had significant ANH (68/3251). Three were lost to follow-up. Among the remaining 65 babies, three (4.6%) had severe, 13 (20%) had moderate, and 49 (75.4%) had mild ANH. During follow-up 39 (60%) resolved spontaneously, ten (15.3%) showed resolving hydronephrosis and 16 (24.6%) required some form of intervention. All babies with severe ANH required intervention (100%). Nine (69.2%) babies with moderate and four (8.1%) babies with mild ANH required intervention. Among babies who required intervention, majority had vesicoureteric reflux (12.3%) and pelviureteric junction obstruction (9.2%). Sixteen babies (24.6%) developed urinary tract infection. Conclusion: Majority of the ANH are mild and resolve spontaneously. Size at detection decides the likelihood of need for intervention as all those with severe hydronephrosis required intervention. Majority of babies with ANH are asymptomatic at birth and postnatal abnormality could be detected only by follow-up scans. Hence, this study reinforces on the regular follow-up of babies with ANH.

Can urinary biomarkers detect obstruction defined by renal functional loss in antenatal hydronephrosis?

Diagnosing obstruction and thus, assessment of need for surgery in the management of antenatal hydronephrosis may be challenging. Current diagnostic tests are not capable of indicating which patients are at risk for obstructive nephropathy. Biomarkers may play an important role in distinguishing these patients. The aim of this study is to evaluate if urinary biomarkers could differentiate obstruction (OBS) from non-obstructive dilation (NOD) in patients with antenatal hydronephrosis (AH) that underwent pyeloplasty due to loss of differential renal function (DRF). Children with a history of AH and postnatal anteroposterior (AP) diameter ≥15mm were included in this study of prospectively collected data between 2010 and 2018. The OBS group included patients who underwent pyeloplasty due to solely ≥10% subsequent decrease in DRF on a MAG-3 scan during follow-up. Patients with stable or improving hydronephrosis with no significant reduction in ipsilateral DRF (<10%) during follow-up formed the NOD group. Healthy children with no history of AH and a normal urinary ultrasound were taken as the control group. Urinary IP-10, MCP-1, KIM-1, NGAL, and Ca19-9 levels using ELISA were measured. In the OBS group, urine samples were obtained preoperatively and at 3rd post operative-month whereas in the NOD and control groups, samples were collected at the time of enrollment. There were 24 children in the OBS and 27 children in the NOD groups. The control group consisted of 27 healthy children. The pre-operative bladder urine levels of biomarkers of the OBS group were significantly higher than in the NOD and control group (p<0.05, for all). In terms of differentiating OBS from NOD, results of ROC analyses for the given cut-off values were as follows: 135.06 ng/mgCr (sensitivity 75%; specificity 66%, AUC=0.735) for IP-10, 0.89 ng/mgCr (sensitivity 79.2%; specificity 88%, AUC=0.802) for KIM-1, 367.65 pg/mgCr (sensitivity 62.5%; specificity 52%, AUC=0.660) for MCP-1, 16.15 ng/mgCr (sensitivity 70.8%; specificity 70.4%, AUC=0.669) for NGAL, and 55.5 U/mgCr (sensitivity 75%; specificity 66%, AUC=0.676) for Ca 19-9. Moreover, when KIM-1 was combined with IP-10 and Ca19-9, sensitivity and specificity levels were 83% and 85% (AUC=0.919), respectively. In this novel study, which focused on scintigraphic DRF loss, KIM-1 was the most successful among all the biomarkers evaluated. Combination of IP-10, Ca19-9 and KIM-1 resulted increased diagnostic ability.

Role of Antibiotic Prophylaxis in the Management of Antenatal Hydronephrosis, Vesicoureteral Reflux, and Ureterocele in Infants.

Widespread prenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. Antenatal hydronephrosis (AHN) and vesicoureteral reflux (VUR) are among the most common congenital anomalies diagnosed in utero or after birth. Pediatric urologists frequently rely on continuous antibiotic prophylaxis (CAP) for managing AHN, VUR, and ureterocele, unless definitive treatment is performed. The main aim of antibiotic prophylaxis (ABP) is to prevent urinary tract infection and long-term complications. Nevertheless, the efficacy of ABP has been a source of considerable debate, and pediatricians have varied opinions on who would benefit from ABP. In this review article, we searched the currently available literature, for evidence of the role of ABP in the setting of AHN, VUR, and ureterocele. Most of our studies showed a limited benefit of ABP for HN and VUR. The data on the use of CAP in the management of ureterocele is scarce. However, due to the involvement of independent risk factors and other variables, a conclusion cannot be drawn from these studies alone. Pediatric urologists are urged to conduct randomized controlled trials to compare patients followed up with and without ABP. Given the lack of guidelines, an individualized approach should be used for the use of ABP, until precise guidelines and recommendations are developed.

Management of antenatal hydronephrosis.

Antenatal hydronephrosis (AHN) is the most frequently detected abnormality by prenatal ultrasonography. Differential diagnosis of AHN includes a wide variety of congenital abnormalities of the kidney and urinary tract ranging from mild abnormalities such as transient or isolated AHN to more important ones as high-grade congenital vesicoureteral reflux or ureteropelvic junction obstruction. It is well known that the outcome depends on the underlying etiology. Various grading systems have been proposed for the classification of AHN on prenatal and postnatal ultrasonography. Mild isolated AHN represents up to 80% of cases, is considered to be benign, and majority of them resolve, stabilize, or improve during follow-up. Controversies exist regarding the diagnosis and management of some important and severe causes of AHN such as high-grade vesicoureteral reflux and ureteropelvic junction obstruction. Current approach is becoming increasingly conservative during diagnosis and follow-up of these patients with less imaging and close follow-up. However, there is still no consensus regarding the clinical significance, postnatal evaluation, and management of infants with AHN. The aim of this review is to discuss the controversies and provide an overview on the management of AHN.

The Current Consensus on the Evaluation and Management of Antenatal Hydronephrosis

The Current Consensus on the Evaluation and Management of Antenatal Hydronephrosis

Antenatal hydronephrosis and fetal urine sampling.

The aim of this study is to evaluate the significance of renal pelvis aspiration (RPA) in the management of antenatal hydronephrosis (AHN). This study enrolled 15 AHN cases (one twin pregnancy) that necessitated RPA for AHN. Chromosomal abnormalities, gene disorders, and additional life-threatening congenital abnormalities were eliminated prior to intrauterine interventions. Urine analysis were performed for the evaluation of renal function. Normal renal function was observed in six neonates/infants (40%) (group 1), whereas impaired renal function and various type of urinary system anomalies were observed in 9 neonates/infants (60%) (group 2) during the short-term and longitudinal follow-up periods. There were statistically significant differences in the oligohydroamniosis rate, mean fetal urine sodium value, mean fetal urine β2-microglobulin, mean gestational week at birth, and mean birthweight values between the groups (P = 0.007, P < 0.001, P = 0.035, P < 0.001, and P = 0.001, respectively). Renal pelvis aspiration and urine analysis were substantial for the management of AHN in necessary cases. β2-microglobulin and sodium are clinically useful markers to detect the presence of severe renal damage due to obstructive uropathy and thus, important adjuvants in the proper selection of fetuses for further antenatal interventions.

Transverse Comparisons Between Ultrasound and Radionuclide Parameters in Children with Pelvi-Ureteric Junction Obstruction

Pelvi-ureteric junction (PUJ) obstruction is one of the causes of an obstructive uropathy which may be congenital or acquired. Ureteropelvic junction (UPJ) obstruction is a blockage at the point where ureters attaches to the bladder. This blocks the flow of urine out of the kidney, Urine can build up and damage the kidney, so radiologic imaging is crucial in diagnosing UPJ obstruction. It seemed therefore interesting to determine if some US parameters could predict the radionuclide parameters and which ultrasound parameter most influencing the kidney function. The initial step was to grade the severity of hydronephrosis, calyceal dilatation and cortical thinning, although it was easy for us to classify the importance of hydronephrosis in three groups according to anteroposterior diameter (APD). AP diameter of renal pelvis and differential renal function were the most effective parameters for surgical decision. These parameters can be used for appropriate management of antenatal hydronephrosis.

Effective predictors for surgical decision in antenatal hydronephrosis: a prospective multiparameter analysis.

The majority of antenatal hydronephrosis disappears spontaneously. In our study, we have investigated the effective predictors for surgical decision in antenatal hydronephrosis. Forty-four patients found to have renal pelvic anteroposterior (AP) diameter more than 10-mm on antenatal ultrasonograpy were followed after birth. The study groups were divided into two groups: follow-up and surgery group. On follow-up, longitudinal diameter of the kidney, parenchymal thickness of the kidney, AP diameter of renal pelvis, AP diameter of middle calyces on ultrasonograpy, and differential renal function, 20th minute clearance, half-life of radionuclide tracer (T1/2), Tmax, Tmax-T1/2, normalised residual activity (NORA) on diuretic renography were evaluated. Ultrasonograpy and diuretic renography measurements were compared in patients whose hydronephrosis resolve or proceeded to surgery. Forty-four patients were diagnosed as antenatal hydronephrosis, spontaneous resolution occurred in 23 (52%), and surgery was performed in 21 patients (48%). Mean age at operation was 8.5±6.5 months (3-24 months). Mean AP diameter of renal pelvis was 29.5±14.2 mm for surgery group, 13.6±4.2 mm for follow-up group (p<0.001). Univariate analyses showed significance for all ultrasonographic measurements and only the differential renal function by diuretic renography. Multivariate logistic regression analysis showed significance for AP diameter of renal pelvis (odds ratio 1.37; 95% Cl 1.13-1.66), and differential renal function (odds ratio 1.14; 95% Cl 1.01-1.29). AP diameter of renal pelvis and differential renal function were the most effective parameters for surgical decision. These parameters can be used for appropriate management of antenatal hydronephrosis.

Evaluation and Management of Antenatal Hydronephrosis

Antenatal hydronephrosis (ANH) is one of the most common abnormal findings detected on prenatal ultrasound (US), and it has been reported in 1-5% of all pregnancies. The likelihood of significant postnatal pathologic abnormality in the urinary tract correlates with the degree of anterior-posterior diameter (APD) according to the gestational age. Detection of urologic anomalies prenatally permits fetal interventions that avoid complications in rare cases of bladder outlet obstruction with oligohydramnios even though their final benefits still remain controversial. There is no clear consensus on the extent and mode of postnatal imaging after a diagnosis of ANH. US is the mainstay of the postnatal evaluation and helps guide further testing with voiding cystourethrography (VCUG) and diuretic renography. Although most algorithms continue to recommend generous VCUG for identification of lower urinary tract anomalies, VCUG may be safely reserved for high grade ANH cases or any grade of ANH with dilated distal ureter without increasing the risk of urinary tract infection (UTI). There are conflicting studies about efficacy of postnatal prophylactic antibiotics. It still seems reasonable to consider use of a prophylactic antibiotic to prevent infant UTIs in high-risk populations, such as females and uncircumcised males with high grades of hydronephrosis, hydroureteronephrosis, or vesicouretral reflux.

The management of antenatal hydronephrosis detected on routine prenatal ultrasound

Antenatal hydronephrosis (ANH) is a common abnormality seen on routine prenatal ultrasound. Although this condition is invariably transient and benign, it can result in a deterioration in renal function and other significant co-morbidities. Once detected, careful ultrasound monitoring of the ANH is recommended during pregnancy. Postnatal antibiotic prophylaxis should be commenced after birth whilst investigating in a stepwise fashion in order to elucidate the underlying cause of the hydronephrosis. The aim is to preserve renal function, prevent urinary tract infection, and protect the upper tracts.

Revised guidelines on management of antenatal hydronephrosis

Widespread antenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. The present guidelines update the recommendations published in 2000. Antenatal hydronephrosis (ANH) is transient and resolves by the third trimester in almost one-half cases. The presence of oligohydramnios and additional renal or extrarenal anomalies suggests significant pathology. All patients with ANH should undergo postnatal ultrasonography; the intensity of subsequent evaluation depends on anteroposterior diameter (APD) of the renal pelvis and/or Society for Fetal Urology (SFU) grading. Patients with postnatal APD exceeding 10 mm and/or SFU grade 3-4 should be screened for upper or lower urinary tract obstruction and vesicoureteric reflux. Infants with vesicoureteric reflux should receive antibiotic prophylaxis through the first year of life, and their parents counseled regarding the risk of urinary tract infections. The management of patients with pelviureteric junction or vesicoureteric junction obstruction depends on clinical features and results of sequential ultrasonography and radionuclide renography. Surgery is considered in patients with increasing renal pelvic APD and/or an obstructed renogram with differential renal function <35-40% or its subsequent decline. Further studies are necessary to clarify the role of prenatal intervention, frequency of follow up investigations and indications for surgery in these patients.

Revised guidelines on management of antenatal hydronephrosis.

Widespread antenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. The present guidelines update the recommendations published in 2000. Antenatal hydronephrosis (ANH) is transient and resolves by the third trimester in almost one-half cases. The presence of oligohydramnios and additional renal or extrarenal anomalies suggests significant pathology. All patients with ANH should undergo postnatal ultrasonography; the intensity of subsequent evaluation depends on anteroposterior diameter (APD) of the renal pelvis and/or Society for Fetal Urology (SFU) grading. Patients with postnatal APD exceeding 10 mm and/or SFU grade 3-4 should be screened for upper or lower urinary tract obstruction and vesicoureteric reflux (VUR). Infants with VUR should receive antibiotic prophylaxis through the first year of life, and their parents counseled regarding the risk of urinary tract infections. The management of patients with pelviureteric junction or vesicoureteric junction obstruction depends on clinical features and results of sequential ultrasonography and radionuclide renography. Surgery is considered in patients with increasing renal pelvic APD and/or an obstructed renogram with differential renal function <35-40% or its subsequent decline. Further studies are necessary to clarify the role of prenatal intervention, frequency of follow-up investigations and indications for surgery in these patients.

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis

The evaluation and management of fetuses/children with antenatal hydronephrosis (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation, intervention or observation? Though the literature is quite extensive, it is plagued with bias and conflicting data, creating much confusion as to the optimal care of patients with ANH. In this article, we summarized the literature and proposed recommendations for the evaluation and management of ANH.

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis

Antenatal Hydronephrosis: Differential Diagnosis, Evaluation, and Treatment Options

The diagnosis, evaluation and management of antenatal hydronephrosis has undergone a two stage paradigm shift since the advent of prenatal ultrasonography in the early 1980s. Initially the identification of a large number of asymptomatic infants appeared to afford the surgeon the opportunity for preemptive intervention. However, it has now become apparent that antenatal hydronephrosis (AH) is far more difficult to interpret thanoriginally perceived. The initial enthusiasm for surgery has now been replaced by a much more conservative approach to ureteropelvic junction(UPJ) obstruction, multi-cystic dysplastic kidney(MCDK), vesicoureteral reflux and the non-refluxing megaureter. This review will highlight the postnatal evaluation of AH and include an overview of the Society for Fetal Urology grading system for hydronephrosis. The differential diagnosis and treatment options for UPJ obstruction, vesicoureteral reflux, MCDK, duplication anomalies, megaureter, and posterior urethral valves will be discussed.

Chronic renal failure — is modern management of urinary tract infection and antenatal hydronephrosis affecting the outcome?

End stage renal failure (ESRF) due to urinary tract infection (UTI) is the commonest potentially preventable cause of ESRF in children and adults. Despite this the simple answer to the question posed in the title is that there is no good evidence to support the proposition that modem management of UTI has affected the incidence of ESRF either in children or in adults. There is, however, overwhelming evidence that modem approaches to UTI should reduce the incidence of ESRF. This paradox is worth exploring because in many respects UTI could be considered a paradigm of present day paediatrics. It is difficult to demonstrate a direct link between UTI and the remote outcome of ESRF which may be delayed for decades after the initial insult and even more difficult, if not impossible, to demonstrate that any intervention has affected this outcome. There is a danger if health provision is increasingly dependent on demonstration of measurable, often short-term, improvements in outcome that problems such as UTI that cannot be encapsulated in such a simple way will not receive the attention they deserve. There are many other problems in paediatrics which are similarly threatened. A further difficulty is that almost all reports of management of UTI have identified deficiencies in clinical practice which reduce the impact of rational management based on research findings and this further hinders the demonstration of an improving outcome. For a variety of reasons the evidence with regards to the impact of the management of antenatal hydronephrosis is even more debatable.