CUA: Antenatal hydronephrosis (2017): Difference between revisions
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=== Hydronephrosis === | === Hydronephrosis === | ||
*''' | *'''Grading systems for the severity of antenatal hydronephrosis (3):''' | ||
*# '''Antero-posterior renal pelvic diameter (APD)''' | *# '''Antero-posterior renal pelvic diameter (APD)''' | ||
*#'''Society of Fetal Ultrasound (SFU) classification''' | *#'''Society of Fetal Ultrasound (SFU) classification''' | ||
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#** ''Verbatim (RBUS section): All children with AHN should have a complete abdominopelvic US, with particular attention to both the kidneys and bladder. [likely meant “significant” ANH rather than "all" patients]'' | #** ''Verbatim (RBUS section): All children with AHN should have a complete abdominopelvic US, with particular attention to both the kidneys and bladder. [likely meant “significant” ANH rather than "all" patients]'' | ||
===== | ===== Timing ===== | ||
* '''Avoid US in the first 2 days of life due to concern of understaging secondary to neonatal oliguria.''' | * '''Avoid US in the first 2 days of life due to concern of understaging secondary to neonatal oliguria.''' | ||
* The acceptable delay in the timing of the first postnatal US is controversial, with the SFU suggesting anywhere from 1‒4 weeks (see Figure 1 from Original Guideline for details, discussed below). '''In cases where immediate postnatal management is required such as PUV, US should not be delayed.''' | * The acceptable delay in the timing of the first postnatal US is controversial, with the SFU suggesting anywhere from 1‒4 weeks (see Figure 1 from Original Guideline for details, discussed below). '''In cases where immediate postnatal management is required such as PUV, US should not be delayed.''' | ||
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==== Diuretic renography ==== | ==== Diuretic renography ==== | ||
* '''<span style="color:#ff0000">MAG3 diuretic renogram is test of choice for the assessment of the function of a hydronephrotic kidney''' | * '''<span style="color:#ff0000">Nuclear tracer''' | ||
** | **'''<span style="color:#ff0000">MAG3 diuretic renogram is test of choice for the assessment of the function of a hydronephrotic kidney''' | ||
** Dimercaptosuccinic acid (DMSA) study can be considered to establish early split function in cases of neonates or premature infants, since the DRF in this study is not influenced by an immature GFR. | ***Permits assessment of both the differential renal function (DRF) and the drainage time | ||
* Renogram should include a report of | *** Dimercaptosuccinic acid (DMSA) study can be considered to establish early split function in cases of neonates or premature infants, since the DRF in this study is not influenced by an immature GFR. | ||
* '''<span style="color:#ff0000">Indications (1)''' | |||
*# '''<span style="color:#ff0000">APD >15 mm or high-grade hydronephrosis (SFU 3-4) with VCUG was negative for VUR''' | |||
*#*'''To identify other potential causes of hydronephrosis (such as UPJO, UVJO)''' | |||
**'''Not necessary in the evaluation of isolated LGHN (SFU 1‒2) with normal renal parenchyma and symmetric renal size''' | |||
*Renogram should include a report of | |||
**Differential renal function, which can vary from 45‒55% | **Differential renal function, which can vary from 45‒55% | ||
**Cortical transit time, which is normal up to 5 minutes | **Cortical transit time, which is normal up to 5 minutes | ||
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** '''Dilated distal ureter''' | ** '''Dilated distal ureter''' | ||
* Renograms can be performed at any age, as long as they are used as a baseline study for serial comparison'''.''' | * Renograms can be performed at any age, as long as they are used as a baseline study for serial comparison'''.''' | ||
=== Other === | === Other === | ||
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* '''The role of CAP initiated at birth is controversial''' | * '''The role of CAP initiated at birth is controversial''' | ||
* ''' | * '''cCAP may be of benefit in (4):''' | ||
*# '''<span style="color:#ff0000">HGHN (SFU 3-4)''' | *# '''<span style="color:#ff0000">HGHN (SFU 3-4)''' | ||
*# '''<span style="color:#ff0000">Females with ANH''' | *# '''<span style="color:#ff0000">Females with ANH''' | ||
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** '''See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905549/figure/f1-cuaj-4-85/ Figure 1] from Original Guideline''' | ** '''See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905549/figure/f1-cuaj-4-85/ Figure 1] from Original Guideline''' | ||
=== High-grade hydronephrosis (SFU Grades 3 and 4) or APD >15 mm === | === High-grade hydronephrosis (SFU Grades 3 and 4) or APD >15 mm on 3rd Trimester Ultrasound === | ||
* '''Initial post-natal RBUS''' | * '''<span style="color:#ff0000">Initial post-natal RBUS''' | ||
** '''Should be done as soon as feasible after day 2 of life''' (most centres recommend '''within 2 weeks of life''') as this represents the cohort most likely to require surgery and to experience UTI. | ** '''<span style="color:#ff0000">Should be done as soon as feasible after day 2 of life</span>''' (most centres recommend '''<span style="color:#ff0000">within 2 weeks of life</span>''') as this represents the cohort most likely to require surgery and to experience UTI. | ||
** '''If the postnatal US reveals persistent high-grade hydronephrosis, these cases should be referred to a pediatric urologist for immediate consultation.''' | ** '''<span style="color:#ff0000">If the postnatal US reveals persistent high-grade hydronephrosis, these cases should be referred to a pediatric urologist for immediate consultation.''' | ||
*** Bilateral HGHN requires more urgent consultation. | *** Bilateral HGHN requires more urgent consultation. | ||
* '''Additional investigations''' | * '''<span style="color:#ff0000">Additional investigations''' | ||
** '''Patients should have a VCUG''' | ** '''<span style="color:#ff0000">Patients should have a VCUG''' | ||
*** '''MAG3 renal scan should be done if the VCUG is negative for VUR''' | *** '''<span style="color:#ff0000">MAG3 renal scan should be done if the VCUG is negative for VUR''' | ||
* '''These cases are most likely to benefit from CAP''' | * '''<span style="color:#ff0000">These cases are most likely to benefit from CAP''' | ||
* '''In the absence of any pathology requiring immediate intervention, repeat US and MAG3 should be performed within 3 months,''' although a repeat MAG3 is optional if the first exam is normal. '''If improvement is not seen, close follow-up should continue to at least 18 months of age,''' by which time most childhood UPJO becomes apparent. | * '''<span style="color:#ff0000">In the absence of any pathology requiring immediate intervention, repeat US and MAG3 should be performed within 3 months,</span>''' although a repeat MAG3 is optional if the first exam is normal. '''If improvement is not seen, close follow-up should continue to at least 18 months of age,''' by which time most childhood UPJO becomes apparent. | ||
* For cases with antenatal APD 10‒15 mm, the SFU grading is suggested to clarify which follow-up protocol should be used | * For cases with antenatal APD 10‒15 mm, the SFU grading is suggested to clarify which follow-up protocol should be used | ||
=== Low-grade hydronephrosis (SFU Grade 1 and 2) or APD <10 mm === | === Low-grade hydronephrosis (SFU Grade 1 and 2) or APD <10 mm on 3rd Trimester Ultrasound === | ||
* '''Initial post-natal RBUS''' | * '''<span style="color:#ff0000">Initial post-natal RBUS''' | ||
** Timing open to debate; '''most physicians will obtain an US within the first months of life and a follow-up can be obtained 6 months later.''' | ** Timing open to debate; '''<span style="color:#ff0000">most physicians will obtain an US within the first months of life and a follow-up can be obtained 6 months later.''' | ||
*** In the absence of deterioration, follow-up US can then be performed on an annual basis. | *** In the absence of deterioration, follow-up US can then be performed on an annual basis. | ||
* '''Additional investigations''' | * '''<span style="color:#ff0000">Additional investigations''' | ||
** '''VCUG and MAG3 are not required''' | ** '''<span style="color:#ff0000">VCUG and MAG3 are not required''' | ||
* '''CAP is unnecessary''' | * '''<span style="color:#ff0000">CAP is unnecessary''' | ||
* '''The majority of such cases improve by age 2'''. Since the majority of congenital UPJO progresses to pyeloplasty by 18 months of age, '''continue follow-up to at least until age 2.''' | * '''The majority of such cases improve by age 2'''. Since the majority of congenital UPJO progresses to pyeloplasty by 18 months of age, '''continue follow-up to at least until age 2.''' | ||
** There is controversy on the need for follow-up beyond 2 years of age in patients who have persistent LGHN. | ** There is controversy on the need for follow-up beyond 2 years of age in patients who have persistent LGHN. | ||
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=== SFU Grade 0 === | === SFU Grade 0 === | ||
* '''Up to 50% of ANH can resolve at birth and is referred to as SFU Grade 0 HN.''' | * '''Up to 50% of ANH can resolve at birth and is referred to as SFU Grade 0 HN.''' | ||
* '''SFU guidelines recommend a repeat US within the first month of life.''' | * '''<span style="color:#ff0000">SFU guidelines recommend a repeat US within the first month of life.''' | ||
** Many centres will discharge the patient after a normal post-natal US, since the majority of late or recurrent HN are symptomatic and can be counselled as such. | ** Many centres will discharge the patient after a normal post-natal US, since the majority of late or recurrent HN are symptomatic and can be counselled as such. | ||
* '''In patients with a history of mild to moderate fetal hydronephrosis and a normal post-partum ultrasound (obtained at 1-2 months), additional evaluations are unnecessary.''' | **"it appears contradictory to follow up a documented LGHN within six months, whereas a normal US is followed up within one month." | ||
* '''In patients with a history of moderate to severe fetal hydronephrosis and a normal post-partum ultrasound, additional evaluations are necessary.''' | *'''<span style="color:#ff0000">[In patients with a history of mild to moderate fetal hydronephrosis and a normal post-partum ultrasound (obtained at 1-2 months), additional evaluations are unnecessary.]''' | ||
* '''<span style="color:#ff0000">[In patients with a history of moderate to severe fetal hydronephrosis and a normal post-partum ultrasound, additional evaluations are necessary.]''' | |||
** '''The presence of ureteral dilation on the pre-natal ultrasound has been found to be associated with a significant increased risk for neonatal UTIs and high-grade vesicoureteral reflux despite a normal post-partum renal ultrasound.''' | ** '''The presence of ureteral dilation on the pre-natal ultrasound has been found to be associated with a significant increased risk for neonatal UTIs and high-grade vesicoureteral reflux despite a normal post-partum renal ultrasound.''' | ||
** A neonatal VCUG is recommended if ureteral dilation is found on the fetal ultrasound. | ** A neonatal VCUG is recommended if ureteral dilation is found on the fetal ultrasound. | ||
== Indications for surgery in Obstructive Hydronephrosis and Hydroureteronephrosis == | == Indications for surgery in Obstructive Hydronephrosis and Hydroureteronephrosis == | ||
* Appropriate counselling of families should include a discussion of the risks of observation vs. immediate surgery. | * Appropriate counselling of families should include a discussion of the risks of observation vs. immediate surgery. | ||
* '''Strong indications for reconstructive surgery include (2):''' | * '''<span style="color:#ff0000">Strong indications for reconstructive surgery include (2):''' | ||
*# '''Loss of | *# '''<span style="color:#ff0000">Loss of differential renal function of >5% on serial renography''' | ||
*# '''Worsening | *# '''<span style="color:#ff0000">Worsening hydronephrosis with worsening drainage times on renography''' | ||
*#* In older children, flank pain or vomiting are also suggestive of obstruction, especially if exacerbated by fluid intake. Hypertension and renal calculi can rarely be signs of obstruction. | *#* In older children, flank pain or vomiting are also suggestive of obstruction, especially if exacerbated by fluid intake. Hypertension and renal calculi can rarely be signs of obstruction. | ||
* '''Relative indications for surgery (5):''' | * '''Relative indications for surgery (5):''' | ||
*# '''UTI''' | *# '''UTI''' | ||
*# '''Low | *# '''Low differential renal function on initial renogram''' | ||
*# '''Palpable giant HN''' | *# '''Palpable giant HN''' | ||
*# Concern over '''non-compliance with follow-up imaging protocols''' | *# Concern over '''non-compliance with follow-up imaging protocols''' | ||