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CUA: Antenatal hydronephrosis (2017): Difference between revisions

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=== Hydronephrosis ===
=== Hydronephrosis ===
*'''Various grading systems for the severity of antenatal hydronephrosis exist (3):'''
*'''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''' =====
===== 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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** '''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 ===
* '''<span style="color:#ff0000">Initial post-natal RBUS'''
* '''<span style="color:#ff0000">Initial post-natal RBUS'''
** '''<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.
** '''<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.
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* 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 ===
* '''<span style="color:#ff0000">Initial post-natal RBUS'''
* '''<span style="color:#ff0000">Initial post-natal RBUS'''
** 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.'''
** 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.'''
*** <span style="color:#ff0000">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.
* '''<span style="color:#ff0000">Additional investigations'''
* '''<span style="color:#ff0000">Additional investigations'''
** '''<span style="color:#ff0000">VCUG and MAG3 are not required'''
** '''<span style="color:#ff0000">VCUG and MAG3 are not required'''
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* '''<span style="color:#ff0000">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.
* '''<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.'''
**"it appears contradictory to follow up a documented LGHN within six months, whereas a normal US is followed up within one month."
* '''<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.'''
*'''<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.
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* 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 DRF of >5% on serial renography'''
*# '''<span style="color:#ff0000">Loss of differential renal function of >5% on serial renography'''
*# '''Worsening HN with worsening drainage times on renography'''
*# '''<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 DRF on initial renogram'''
*# '''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'''
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