1
|
Cotten SW, Block DR. A Review of Current Practices and Future Trends in Body Fluid Testing. J Appl Lab Med 2023; 8:962-983. [PMID: 37207691 DOI: 10.1093/jalm/jfad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/27/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Body fluid testing in the clinical chemistry laboratory is a cornerstone in the diagnostic workup of pathological effusions. Laboratorians may not be aware of the preanalytical workflows used in the collection of body fluids though the value is evident whenever processes change or issues arise. The analytical validation requirements can vary depending on the regulations dictated by the laboratories' jurisdiction and accreditor requirements. Much of analytical validation hinges on how useful testing is to clinical care. Usefulness of testing varies with how well established and incorporated the tests and interpretation are in practice guidelines. CONTENT Body fluid collections are depicted and described so clinical laboratorians have a basic appreciation of what specimens are submitted to the laboratory for testing. A review of validation requirements by major laboratory accreditation entities is presented. A review of the usefulness and proposed decision limits for common body fluid chemistry analytes is presented. Body fluid tests that show promise and those that are losing (or lost long ago) value are also reviewed. SUMMARY The total testing process from collection to result interpretation can be complicated and easily overlooked by the clinical laboratory. This review aims to improve the understanding and awareness of collections, validation, result interpretation, and provide an update on recent trends.
Collapse
Affiliation(s)
- Steven W Cotten
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Darci R Block
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
2
|
Slagle C, Schuh M, Grisotti G, Riddle S, Reddy P, Claes D, Lim FY, VanderBrink B. In utero renal failure. Semin Pediatr Surg 2022; 31:151195. [PMID: 35725056 DOI: 10.1016/j.sempedsurg.2022.151195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Cara Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7009, United States.
| | - Meredith Schuh
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, United States
| | - Gabriella Grisotti
- Division of Pediatric General and Thoracic Surgery and Center for Fetal Care, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Stefanie Riddle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7009, United States
| | - Pramod Reddy
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Donna Claes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, United States
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery and Center for Fetal Care, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| | - Brian VanderBrink
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, United States
| |
Collapse
|
3
|
Vincent K, Murphy HJ, Twombley KE. Urinary Tract Dilation in the Fetus and Neonate. Neoreviews 2022; 23:e159-e174. [PMID: 35229134 DOI: 10.1542/neo.23-3-e159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Urinary tract dilation (UTD), previously known as hydronephrosis, is the most common congenital condition identified on prenatal ultrasonography. UTD can be physiologic and resolve spontaneously or can be caused by various congenital anomalies of the urinary tract, which can lead to renal failure if not treated properly. In 2014, a multidisciplinary consensus group established UTD definitions, a classification system, and a standardized scheme for perinatal evaluation. Various imaging modalities are available to help diagnose the cause of UTD in fetuses and neonates and to help identify those patients who may benefit from fetal or early postnatal intervention. In this article, we will review the diagnosis and quantification of antenatal and postnatal UTD based on the UTD classification system, outline the imaging studies available to both evaluateUTD and determine its cause, briefly review the most common causes of UTD in the fetus and neonate, outline management strategies for UTD including the role for fetal intervention and prophylactic antibiotics, and report on the outcome and prognosis in patients with UTD.
Collapse
Affiliation(s)
- Katherine Vincent
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Heidi J Murphy
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Katherine E Twombley
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| |
Collapse
|
4
|
Irfan A, O'Hare E, Jelin E. Fetal interventions for congenital renal anomalies. Transl Pediatr 2021; 10:1506-1517. [PMID: 34189109 PMCID: PMC8192995 DOI: 10.21037/tp-2020-fs-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Congenital abnormalities of the kidney and urinary tract (CAKUT) represent 20% of prenatally diagnosed congenital abnormalities. Although the majority of these abnormalities do not require intervention either pre or postnatally, there is a subset of patients whose disease is so severe that it may warrant intervention prior to delivery to prevent morbidity and mortality. These cases consist of patients with moderate lower urinary tract obstruction (LUTO) in which vesicocentesis, shunting or cystoscopy are options and patients with early pregnancy renal anhydramnios (EPRA) in whom amnioinfusion therapy may be an option. The main causes of EPRA are congenital bilateral renal agenesis (CoBRA), cystic kidney disease (CKD) and severe LUTO. Untreated, EPRA is universally fatal secondary to anhydramnios induced pulmonary hypoplasia. The evidence regarding therapy for LUTO is limited and the stopped early PLUTO (Percutaneous Shunting in Lower Urinary Tract Obstruction) trial was unable to provide definitive answers about patient selection. Evidence for EPRA therapy is also scant. Serial amnioinfusions have shown promise in cases of EPRA due to CoBRA or renal failure and this treatment modality forms the basis of the ongoing NIH funded RAFT (Renal Anhydramnios Fetal Therapy) trial. At present, there is consensus that treatment for EPRA should only occur in the setting of a clinical trial.
Collapse
Affiliation(s)
- Ahmer Irfan
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth O'Hare
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Eric Jelin
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| |
Collapse
|
5
|
Espinoza AF, Sun RC, Krispin E, Nassr A, Shamshirsaz AA. Fetal Lower Urinary Tract Obstruction Complicated by Bladder Perforation. Neoreviews 2021; 22:e279-e283. [PMID: 33795406 DOI: 10.1542/neo.22-4-e279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Andres F Espinoza
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Raphael C Sun
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.,Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Eyal Krispin
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Ahmed Nassr
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Alireza A Shamshirsaz
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.,Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| |
Collapse
|
6
|
Warring SK, Novoa V, Shazly S, Trinidad MC, Sas DJ, Schiltz B, Prieto M, Terzic A, Ruano R. Serial Amnioinfusion as Regenerative Therapy for Pulmonary Hypoplasia in Fetuses With Intrauterine Renal Failure or Severe Renal Anomalies: Systematic Review and Future Perspectives. Mayo Clin Proc Innov Qual Outcomes 2020; 4:391-409. [PMID: 32793867 PMCID: PMC7411166 DOI: 10.1016/j.mayocpiqo.2020.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The aim of this study was to investigate the effect of serial amnioinfusion therapy (SAT) for pulmonary hypoplasia in lower urinary tract obstruction (LUTO) or congenital renal anomalies (CRAs), introduce patient selection criteria, and present a case of SAT in bilateral renal agenesis. We conducted a search of the MEDLINE, EMBASE, Web of Science, and Scopus databases for articles published from database inception to November 10, 2017. Eight studies with 17 patients (7 LUTO, 8 CRA, and 2 LUTO + CRA) were included in the study. The median age of the mothers was 31 years (N=9; interquartile range [IQR], 29-33.5 years), the number of amnioinfusions was 7 (N=17; IQR, 4.5-21), gestational age at first amnioinfusion was 23 weeks and 4 days (N=17; IQR, 21-24.07), gestational age at delivery was 32 weeks and 2 days (N=17; IQR, 30 weeks to 35 weeks and 6.5 days), birthweight of newborns was 3.7 kg (N= 9; IQR, 2.7-3.7 kg), Apgar score at 1 minute was 2.5 (N=8; IQR, 1-6.5), and Apgar score at 5 minutes was 5.5 (N=8; IQR, 0-7.75). In conclusion, SAT may provide fetal pulmonary palliation by reducing the risk of newborn pulmonary compromise secondary to oligohydramnios. Multidisciplinary research efforts are required to further inform treatment and counseling guidelines. We propose a multidisciplinary approach to prenatal classification of fetuses with LUTO to inform patient selection.
Collapse
Key Words
- AF, amniotic fluid
- AFI, AF index
- AFV, AF volume
- BRA, bilateral renal agenesis
- CRA, congenital renal anomaly
- DOL, day of life
- GA, gestational age
- IQR, interquartile range
- LUTO, lower urinary tract obstruction
- MVP, maximal vertical pocket
- PD, peritoneal dialysis
- PPROM, preterm premature rupture of membranes
- SAT, serial amnioinfusion therapy
- WHO, World Health Organization
Collapse
Affiliation(s)
- Simrit K Warring
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
| | - Victoria Novoa
- Department of Obstetrics & Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Sherif Shazly
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
| | - Mari Charisse Trinidad
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - David J Sas
- Division of Pediatric Nephrology, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Brenda Schiltz
- Division of Pediatric Critical Care Medicine, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Mikel Prieto
- Department of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Andre Terzic
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Rodrigo Ruano
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| |
Collapse
|
7
|
Abstract
Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.
Collapse
Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
8
|
Jeong BD, Won HS, Lee MY. Perinatal Outcomes of Fetal Lower Urinary Tract Obstruction After Vesicoamniotic Shunting Using a Double-Basket Catheter. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2147-2156. [PMID: 29498072 DOI: 10.1002/jum.14565] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/17/2017] [Accepted: 12/06/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To evaluate the perinatal survival and renal function of fetuses with lower urinary tract obstruction (LUTO) who underwent vesicoamniotic shunting using a double-basket catheter METHODS: We retrospectively reviewed 32 fetuses with LUTO who underwent vesicoamniotic shunting using a double-basket catheter between 1998 and 2013. RESULTS Among the 32 fetuses examined, 5 died because of termination of pregnancy, and 2 died in utero. The median gestational age at diagnosis was 15.5 (range, 10.0-27.3) weeks, and that at initial shunting was 17.1 (range, 12.3-32.2) weeks. Shunt dislocation or occlusion occurred in 18 of 42 procedures (42.8%). The median gestational age at delivery for the 25 live births was 35.5 (range, 28-40) weeks. Postnatal diagnosis revealed posterior urethral valves in 15 fetuses, a cloacal anomaly in 7, and urethral stenosis in 3. Three neonatal deaths occurred, resulting in an overall perinatal survival rate of 68.8% (22 of 32). The rates of normal renal function were 40.6% (13 of 32) at 28 days and 40% (10 of 25) at 2 years after birth. The absence of oligohydramnios after shunting was the only prognostic factor for normal renal function at 2 years (P < .05). CONCLUSIONS Vesicoamniotic shunting may be helpful for fetuses with LUTO.
Collapse
Affiliation(s)
- Ba-Da Jeong
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
9
|
Pena J, Quinn KH, Jorizzo JR, Nitsche JF, Denney JM. Megacystis-Microcolon-Intestinal Hypoperistalsis Syndrome: An Unusual In Utero Presentation. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1283-1286. [PMID: 29027710 DOI: 10.1002/jum.14450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/14/2017] [Accepted: 07/21/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Juan Pena
- Section for Maternal-Fetal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kristen H Quinn
- Section for Maternal-Fetal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Johanna R Jorizzo
- Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Joshua F Nitsche
- Section for Maternal-Fetal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeffrey M Denney
- Section for Maternal-Fetal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
10
|
Abstract
PURPOSE OF THE REVIEW In this article, we explore the origins of intervention of fetal lower urinary tract obstruction, and we specifically discuss the background and recent outcomes of vesicoamniotic shunt placement and fetal cystoscopy. The article seeks to provide a comprehensive overview of the field while bringing the reader quickly up to speed on the pertinent literature and the critical data that are available to guide decision-making regarding intervention. RECENT FINDINGS Appropriate patient selection for fetal intervention remains challenging despite advances in prenatal imaging. Both a randomized controlled trial and multiple systematic reviews show evidence of a perinatal survival benefit following fetal intervention but rates of renal morbidity remain very high. Despite 30 years of research, fetal lower urinary tract obstruction remains a difficulty entity to treat. Intervention may lead to survival, but physicians and caregivers must remain alert for the distinct possibility of long-term renal morbidity in survivors.
Collapse
Affiliation(s)
- Douglass B Clayton
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, 4102 Doctor's Office Tower, Nashville, TN, 37232, USA.
| | - John W Brock
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, 4102 Doctor's Office Tower, Nashville, TN, 37232, USA
| |
Collapse
|
11
|
Johnson MP, Wilson RD. Shunt-based interventions: Why, how, and when to place a shunt. Semin Fetal Neonatal Med 2017; 22:391-398. [PMID: 28964685 DOI: 10.1016/j.siny.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The broad categories of surgical fetal therapy can be separated into either open surgical techniques or minimally invasive endoscopic/ultrasound-guided techniques that require only puncture of the uterus with single or multiple small ports. Benefits of fetoscopic or ultrasound-guided fetal intervention include decreased uterine irritability, decreased incidence of preterm labor, and avoidance of risks associated with hysterotomy and commitment to cesarean delivery for future pregnancies. Fetal abnormalities potentially amenable to ultrasound-guided drainage techniques include thoracic fluid-filled lesions and lower urinary tract obstruction.
Collapse
Affiliation(s)
- Mark P Johnson
- The Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - R Douglas Wilson
- Departments of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
12
|
Ruano R, Dunn T, Braun MC, Angelo JR, Safdar A. Lower urinary tract obstruction: fetal intervention based on prenatal staging. Pediatr Nephrol 2017; 32:1871-1878. [PMID: 28730376 DOI: 10.1007/s00467-017-3593-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/28/2016] [Accepted: 12/30/2016] [Indexed: 11/25/2022]
Abstract
The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.
Collapse
Affiliation(s)
- Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Timothy Dunn
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Michael C Braun
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Joseph R Angelo
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Adnan Safdar
- Renal Section, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| |
Collapse
|
13
|
Ruano R, Sananes N, Wilson C, Au J, Koh CJ, Gargollo P, Shamshirsaz AA, Espinoza J, Safdar A, Moaddab A, Meyer N, Cass DL, Olutoye OO, Olutoye OA, Welty S, Roth DR, Braun MC, Belfort MA. Fetal lower urinary tract obstruction: proposal for standardized multidisciplinary prenatal management based on disease severity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:476-482. [PMID: 26690832 DOI: 10.1002/uog.15844] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/31/2015] [Accepted: 12/15/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To present a single center experience of a standardized prenatal multidisciplinary management protocol for fetal lower urinary tract obstruction (LUTO) and to propose a classification of fetal LUTO based on disease severity. METHODS This was a retrospective cohort study of 25 consecutive fetal patients with prenatal diagnosis of primary LUTO. Fetal intervention was offered after evaluation by a multidisciplinary team. Analyses were conducted using Bayesian methodology to determine predictors of survival at 6 months postpartum. Odds ratios (ORs) with 95% credibility intervals are reported. RESULTS Fifteen (60.0%) of the 25 patients referred for assessment survived to postnatal evaluation. Fetal vesicoamniotic shunt was placed in 14 (56.0%) patients with 12 survivors. Multivariable analysis suggested that fetal intervention (OR, 6.97 (0.88-70.16), Pr(OR > 1) = 96.7%), anhydramnios (OR, 0.12 (0.04-0.35), Pr(OR < 1) = 99.9%), favorable fetal urine analysis (OR, 3.98 (0.63-25.15), Pr(OR > 1) = 92.7%) and absence of renal cortical cysts (OR, 3.9 (0.66-24.2), Pr(OR > 1) = 93.3%) were predictors of survival. CONCLUSIONS Fetal intervention and fetal renal function were independently associated with postnatal survival of fetuses with LUTO. A classification based on the severity of disease is proposed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA. ,
| | - N Sananes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - C Wilson
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - J Au
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - C J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - P Gargollo
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A Safdar
- Division of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - A Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - N Meyer
- Department of Public Health, Strasbourg University Hospital, Strasbourg, France
| | - D L Cass
- Department of Pediatric Surgery, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - O O Olutoye
- Department of Pediatric Surgery, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - O A Olutoye
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - S Welty
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - D R Roth
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - M C Braun
- Division of Pediatric Nephrology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center - Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| |
Collapse
|
14
|
Abstract
This article summarizes the most recent literature regarding congenital lower urinary tract obstruction in the fetus and newborn. Lower urinary tract obstruction is a heterogeneous group of rare diagnoses that have significant potential for in utero mortality and long-term morbidity in survivors. The diagnosis and management of the most common causes are reviewed. In addition, the current state of prenatal intervention for congenital lower urinary tract obstruction is discussed.
Collapse
Affiliation(s)
- Douglass B Clayton
- Division of Pediatric Urologic Surgery, Department of Urologic Surgery, Monroe Carrel Jr. Children's Hospital, 2200 Children's Way, 4102 DOT, Nashville, TN 37232, USA.
| | - John W Brock
- Division of Pediatric Urologic Surgery, Department of Urologic Surgery, Monroe Carrel Jr. Children's Hospital, 2200 Children's Way, 4102 DOT, Nashville, TN 37232, USA
| |
Collapse
|
15
|
Pico H, Dabadie A, Bourliere-Najean B, Philip N, Capelle M, Aschero A, Quarello E, Guys JM, Hery G, Petit P, Gorincour G. Contribution of the foetal uro-MRI in the prenatal diagnosis of uronephropathies. Diagn Interv Imaging 2014; 95:573-8. [DOI: 10.1016/j.diii.2014.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
16
|
Korucuoğlu Ü, Saygi AI, Akpak YK, Özdamar Ö, Biri A. Successful treatment of lower urinary tract obstruction with peritoneal-amniotic and vesicoamniotic shunting. JOURNAL OF ACUTE DISEASE 2014. [DOI: 10.1016/s2221-6189(14)60071-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
17
|
Hu S, Wu J, Lu D, Dai Y, Mai M, Wei R, Liu Q, Jiang W, Zhong Y. Reference values of fetal serum β2-microglobulin in the Chinese: evaluation of its clinical usefulness. ACTA ACUST UNITED AC 2013; 52:413-7. [PMID: 24129106 DOI: 10.1515/cclm-2013-0505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 09/23/2013] [Indexed: 11/15/2022]
Abstract
Abstract
Background: The level of β2-microglobulin was generally used to evaluate the renal function in adults. Elevated levels of β2-microglobulin were also applied to assess the perinatal situations in neonates and fetuses. The aim of our study was to establish and determine the reference values of fetal serum β2-microglobulin in the Chinese and to assess its clinical benefits in abnormal fetuses.
Methods: Data from 308 normal cord blood samples were obtained to calculate the normal reference values of fetal serum β2-microglobulin. According to the equations we obtained, we analyzed the level of β2-microglobulin in four case groups: renal malformation, hydrops, cytomegalovirus (CMV) infection and rubella virus (RV) infection.
Results: In the normal group, the concentration of β2-microglobulin decreased with the gestational age, with a mean value of 4.35±0.59 mg/L. The upper limit of β2-microglobulin was calculated as 7.55–0.074×gestational age in weeks. The levels of β2-microglobulin were significantly higher in the four case groups than the normal group. For the four groups, the sensitivity is 72.7%, 69.6%, 86.7% and 100%, respectively.
Conclusions: Fetal serum β2-microglobulin may be used as a predictor to evaluate the situations of fetal diseases.
Collapse
Affiliation(s)
- Suwei Hu
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, P. R. China
- Department of Prenatal Diagnosis, Guangdong Women and Children Hospital, Guangzhou, P. R. China
| | - Jing Wu
- Department of Prenatal Diagnosis, Guangdong Women and Children Hospital, Guangzhou, P. R. China
| | - Dan Lu
- Subei People’s Hospital of Jiangsu Province, Clinical Medical School of Yangzhou University, Yangzhou, P. R. China
| | - Yan Dai
- Subei People’s Hospital of Jiangsu Province, Clinical Medical School of Yangzhou University, Yangzhou, P. R. China
| | - Mingqin Mai
- Department of Prenatal Diagnosis, Guangdong Women and Children Hospital, Guangzhou, P. R. China
| | - Ran Wei
- Department of Prenatal Diagnosis, Guangdong Women and Children Hospital, Guangzhou, P. R. China
| | - Qian Liu
- Department of Prenatal Diagnosis, Guangdong Women and Children Hospital, Guangzhou, P. R. China
| | - Wei Jiang
- Department of Ultrasonography, Guangdong Women and Children Hospital, Guangzhou, P. R. China
| | - Yanfang Zhong
- Department of Prenatal Diagnosis, Guangdong Women and Children Hospital, Guangzhou, P. R. China
| |
Collapse
|
18
|
Luton D, Delezoide A, Leguy M, Gobeaux C, Vuillard E, Grangé G, Guibourdenche J. Foetal serum but not urinary β2-microglobulin correlates with histological injury to the kidney. Clin Biochem 2013; 46:1607-10. [DOI: 10.1016/j.clinbiochem.2013.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 03/30/2013] [Accepted: 04/13/2013] [Indexed: 10/26/2022]
|
19
|
Abstract
Congenital urinary tract obstruction (diagnosed antenatally by ultrasound screening) is one of the main causes of end-stage kidney disease in children. The extent of kidney injury in early gestation and the resultant abnormality in kidney development determine fetal outcome and postnatal renal function. Unfortunately, the current approach to diagnostic evaluation of the severity of injury has inherently poor diagnostic and prognostic value because it is based on the assessment of fetal tubular function from fetal urine samples rather than on estimates of the dysplastic changes in the injured developing kidney. To improve the outcome in children with congenital urinary tract obstruction, new biomarkers reflecting these structural changes are needed. Genomic and proteomic techniques that have emerged in the past decade can help identify the key genes and proteins from biological fluids, including amniotic fluid, that might reflect the extent of injury to the developing kidney.
Collapse
|
20
|
Tzschoppe A, Rauh M, Goecke TW, Yazdi B, Hart N, Siemer J, Schild RL, Dötsch J. Sex-specific differences in the concentration of tubular parameters in the amniotic fluid of second trimester fetuses. Prenat Diagn 2012; 32:476-9. [DOI: 10.1002/pd.3846] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Anja Tzschoppe
- Department of Paediatrics and Adolescent Medicine; University of Erlangen-Nuremberg; Erlangen; Germany
| | - Manfred Rauh
- Department of Paediatrics and Adolescent Medicine; University of Erlangen-Nuremberg; Erlangen; Germany
| | - Tamme W. Goecke
- Department of Obstetrics & Gynaecology; University of Erlangen-Nuremberg; Erlangen; Germany
| | - Britta Yazdi
- Department of Obstetrics & Gynaecology; University of Freiburg; Freiburg; Germany
| | - Nicola Hart
- Department of Obstetrics & Gynaecology; Städtisches Klinikum München; Munich; Germany
| | - Jörn Siemer
- Department of Obstetrics & Gynaecology; Ludmillenstift Meppen; Meppen; Germany
| | - Ralf L. Schild
- Department of Obstetrics & Gynaecology; Diakonische Dienste Hannover; Hannover; Germany
| | - Jörg Dötsch
- Department of Paediatrics and Adolescent Medicine; University of Cologne; Cologne; Germany
| |
Collapse
|
21
|
Bernardes LS, Francisco RPV, Saada J, Salomon R, Ruano R, Lortad-Jacob S, Zugaib M, Benachi A. Quantitative analysis of renal vascularization in fetuses with urinary tract obstruction by three-dimensional power-Doppler. Am J Obstet Gynecol 2011; 205:572.e1-7. [PMID: 21861967 DOI: 10.1016/j.ajog.2011.06.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 02/20/2011] [Accepted: 06/15/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the applicability of 3-dimensional evaluation of renal vascularization for predicting postnatal renal function in fetuses with suspected urinary obstruction. STUDY DESIGN Fetuses were evaluated by 3-dimensional power-Doppler histogram, and vascular indices were estimated. Depth between the probe and the renal cortex was also evaluated. Postnatal follow-up was obtained in all cases and the main outcome was renal impairment. RESULTS Twenty-three fetuses with urinary dilatation (cases) and 73 with normal renal morphology (controls) were included in the current study. Five (21.7%) cases developed renal impairment. Vascularization index and vascularization and flow index were significantly lower in fetuses that developed renal impairment compared with those with normal renal function (P = .009 and P = .036, respectively). The 3 vascular indexes correlated with depth. Percentage of depth-corrected vascularization index and vascularization flow index were lower in fetuses developing postnatal renal failure. CONCLUSION Fetal renal vascularity (vascularization index and vascularization and flow index) was significantly lower in fetuses that developed renal impairment.
Collapse
Affiliation(s)
- Lisandra Stein Bernardes
- Departamento de Obstetrícia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Ryckewaert-D'Halluin A, Le Bouar G, Odent S, Milon J, D'Hervé D, Lucas J, Rouget F, Loget P, Poulain P, Le Gall E, Taque S. Diagnosis of fetal urinary tract malformations: prenatal management and postnatal outcome. Prenat Diagn 2011; 31:1013-20. [DOI: 10.1002/pd.2824] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 06/06/2011] [Accepted: 06/06/2011] [Indexed: 11/07/2022]
|
23
|
Bernardes LS, Salomon R, Aksnes G, Lortat-Jacob S, Benachi A. Ultrasound evaluation of prognosis in fetuses with posterior urethral valves. J Pediatr Surg 2011; 46:1412-8. [PMID: 21763844 DOI: 10.1016/j.jpedsurg.2010.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 11/30/2010] [Accepted: 12/10/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of this study was to evaluate the ability of prenatal ultrasound markers to predict postnatal renal prognosis in fetuses with posterior urethral valves. METHODS Medical files on fetuses with prenatal diagnosis of posterior urethral valves from 2000 to 2006 were reviewed retrospectively. Data from prenatal follow-up included gestational age at diagnosis, ultrasound renal parenchyma evaluation, and presence and time of oligohydramnios onset. Prenatal parameters studied were correlated to postnatal renal function. RESULTS Thirty-one male fetuses were included. Six pregnancies were terminated. Of the remaining 25 pregnancies that were continued, 4 children had abnormal creatine and 21 normal creatinine levels at follow-up. Presence and time of oligohydramnios onset did not differ between groups (P = .43). Ultrasound detected bilateral renal abnormalities in 3 fetuses (75%) with altered renal function, and 10 fetuses (55%) with normal creatinine, at follow-up. CONCLUSIONS None of the ultrasound parameters evaluated were able to reliably predict postnatal renal function.
Collapse
|
24
|
Ruano R. Fetal surgery for severe lower urinary tract obstruction. Prenat Diagn 2011; 31:667-74. [PMID: 21413041 DOI: 10.1002/pd.2736] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/21/2011] [Accepted: 02/13/2011] [Indexed: 11/11/2022]
Abstract
Fetal interventions have been proposed for treatment of severe lower urinary tract obstruction (LUTO), as this condition is associated with high rates of perinatal mortality and postnatal renal impairment. The rationale for in utero treatment for those cases is based on the possibility of relieving the obstruction, improving the amniotic fluid volume, and preventing renal and bladder damage. Candidates for fetal intervention should be rigorously selected based on the confirmation of severe LUTO (dilated bladder and bilateral hydronephrosis), oligohydramnios or anyhydramnios and 'favorable' fetal urinalysis (dependent on gestational age). Nowadays there are two different therapeutic options with specific technical approaches. Vesico-amniotic shunting is an easier procedure, but with a higher frequency of related complications. Fetal cystoscopy can be used for diagnostic purpose and for treatment of posterior urethral valves, with suggestive advantage of allowing a more physiological release of the obstruction. According to the literature, estimated survival rates and postnatal normal renal function frequencies are approximately 40 and 50% after vesico-amniotic shunting and 75 and 65% after fetal cystoscopy, respectively.
Collapse
Affiliation(s)
- Rodrigo Ruano
- Obstetrics Department, Faculty of Medicine, São Paulo University, São Paulo, Brazil.
| |
Collapse
|
25
|
Quintero RA, Gomez Castro LA, Bermudez C, Chmait RH, Kontopoulos EV. In utero management of fetal lower urinary tract obstruction with a novel shunt: a landmark development in fetal therapy. J Matern Fetal Neonatal Med 2010; 23:806-12. [PMID: 19968590 DOI: 10.3109/14767050903443491] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Fetal lower urinary tract obstruction occurs in approximately 1:3000 pregnancies. Standard vesicoamniotic shunting is fraught with malfunctioning in upto 60% of cases. We hereby report the development and application of a novel and reliable shunt. MATERIALS AND METHODS Patients with lower urinary tract obstruction were offered the novel shunt among other standard management options. Shunting involved the placement of a double disk device with a standard double pig-tail catheter. All patients signed informed consent. RESULTS Four patients have been treated with the novel shunt. In three patients, shunting was conducted between the bladder and amniotic cavity. In one patient (dichorionic-discordant twins) with a prior dislodged shunt causing urinary ascites, shunting was conducted between the peritoneal and amniotic cavities ('bridge shunt'). In all cases, correct and stable shunt placement was confirmed endoscopically and sonographically and in all patients, the fetal bladder remains effectively drained. CONCLUSION Reliable and effective vesico or peritoneoamniotic shunting can be achieved with the novel shunt. This shunt cannot become dislodged into the peritoneal cavity or the amniotic cavity, and cannot be pulled out by the fetus. Further experience is necessary to determine the risks and benefits of this novel treatment for fetal lower urinary tract obstruction.
Collapse
Affiliation(s)
- Ruben A Quintero
- Department of Obstetrics and Gynecology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA.
| | | | | | | | | |
Collapse
|
26
|
Guyot A, Rosenblatt J, Bidat L, Bensman A, Bénifla JL, Jouannic JM. [Impact of fetal urinary ascites on serum beta2 microglobuline in obstructive uropathies: a case report]. J Gynecol Obstet Hum Reprod 2010; 39:418-421. [PMID: 20605369 DOI: 10.1016/j.jgyn.2010.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 04/09/2010] [Accepted: 04/28/2010] [Indexed: 05/29/2023]
Abstract
We report a posterior urethral valves case diagnosed at 33 week's gestation on a fetus presenting with anamnios and urinary ascites. In this fetus, the serum beta2 microglobuline rate was high, suggesting a very poor renal prognosis. At 1-year-old, the creatinine rate is nearly normal. In case of urinary ascites, the serum beta2 microglobuline rate could be improved in relation with the transperitoneal reabsorption of this protein.
Collapse
Affiliation(s)
- A Guyot
- Service de gynécologie-obstétrique, centre pluridisciplinaire de diagnostic prénatal de l'est parisien, hôpital Armand-Trousseau, AP-HP, Paris-6, 26, avenue Arnold-Netter, 75012 Paris, France
| | | | | | | | | | | |
Collapse
|
27
|
Deprest JA, Devlieger R, Srisupundit K, Beck V, Sandaite I, Rusconi S, Claus F, Naulaers G, Van de Velde M, Brady P, Devriendt K, Vermeesch J, Toelen J, Carlon M, Debyser Z, De Catte L, Lewi L. Fetal surgery is a clinical reality. Semin Fetal Neonatal Med 2010; 15:58-67. [PMID: 19913467 DOI: 10.1016/j.siny.2009.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An increasing number of fetal anomalies are being diagnosed prior to birth, some of them amenable to fetal surgical intervention. We discuss the current clinical status and recent advances in endoscopic and open surgical interventions. In Europe, fetoscopic interventions are widely embraced, whereas the uptake of open fetal surgery is much less. The indications for each access modality are different, hence they cannot substitute each other. Although the stage of technical experimentation is over, most interventions remain investigational. Today there is level I evidence that fetoscopic laser surgery for twin-to-twin transfusion syndrome is the preferred therapy, but this operation actually takes place on the placenta. In terms of surgery on the fetus, an increasingly frequent indication is severe congenital diaphragmatic hernia as well as myelomeningocele. Overall maternal safety is high, but rupture of the membranes and preterm delivery remain a problem. The increasing application of fetal surgery and its mediagenicity has triggered the interest to embark on fetal surgical therapy, although the complexity as well as the overall rare indications are a limitation to sufficient experience on an individual basis. We plead for increased exchange between high volume units and collaborative studies; there may also be a case for self-regulation. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience.
Collapse
Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Azpurua H, Dulay AT, Buhimschi IA, Bahtiyar MO, Funai E, Abdel-Razeq SS, Luo G, Bhandari V, Copel JA, Buhimschi CS. Fetal renal artery impedance as assessed by Doppler ultrasound in pregnancies complicated by intraamniotic inflammation and preterm birth. Am J Obstet Gynecol 2009; 200:203.e1-11. [PMID: 19185102 PMCID: PMC3791328 DOI: 10.1016/j.ajog.2008.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 07/31/2008] [Accepted: 11/05/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the fetal renal artery impedance in the context of inflammation-associated preterm birth. STUDY DESIGN We conducted a prospective Doppler assessment of the fetal renal artery impedance in 70 singleton fetuses. The study group consisted of 56 premature fetuses (median, 28.1 [interquartile range, 25.3-30.6] weeks at enrollment). Gestational age (GA) reference ranges were generated based on fetuses with uncomplicated pregnancies (n = 14). Doppler studies included renal artery pulsatility index (PI), resistance index (RI), systolic/diastolic (S/D) ratio, and presence or absence of end-diastolic blood flow. Proteomic profiling (surface-enhanced laser desorption ionization time-of-flight) was used for assessment of intraamniotic inflammation and biomarker peak corresponding to beta2-microglubin. Data were interpreted in relationship to amniotic fluid index (AFI), cord blood interleukin (IL)-6 and erythropoietin (EPO) levels. The cardiovascular and metabolic profiles of the neonates were investigated in the first 24 hours of life. RESULTS Fetuses delivered by mothers with intraamniotic inflammation had higher cord blood IL-6 but not EPO levels. Fetal inflammation did not affect either renal artery PI, RI, S/D ratio, or end-diastolic blood flow. Neonates delivered in the context of intraamniotic inflammation had higher serum blood urea nitrogen levels, which correlated significantly with AF IL-6 levels. The renal artery RI and SD ratio were inversely correlated with the AFI independent of GA, cord blood IL-6, and status of the membranes. CONCLUSION The fetus is capable of sustaining normal renal artery impedance despite inflammation. Resistance in the renal vascular bed affects urine output independent of inflammation.
Collapse
Affiliation(s)
| | | | | | | | - Edmund Funai
- Department of Obstetrics, Gynecology and Reproductive Sciences
| | | | - Guoyang Luo
- Department of Obstetrics, Gynecology and Reproductive Sciences
| | - Vineet Bhandari
- Department of Department of Pediatrics, Division of Perinatal Medicine Yale University School of Medicine, New Haven, Connecticut 06520
| | - Joshua A. Copel
- Department of Obstetrics, Gynecology and Reproductive Sciences
| | | |
Collapse
|
29
|
Mure PY, Mouriquand P. Upper urinary tract dilatation: prenatal diagnosis, management and outcome. Semin Fetal Neonatal Med 2008; 13:152-63. [PMID: 17988967 DOI: 10.1016/j.siny.2007.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Upper urinary tract dilatation is one of the most common abnormalities detected on prenatal ultrasound scanning. It is commonly due to transient urine flow impairment (UFI) at the level of the pelvi-ureteric and vesico-ureteric junctions, which improves with time in most cases. It is usually in the neonatal period that the diagnosis is confirmed and during the first 18 months of life that the prognosis of the dilatation is defined.
Collapse
Affiliation(s)
- Pierre-Yves Mure
- Department of Paediatric Urology, Claude Bernard University Lyon I, Hôpital Debrousse, 29 Rue Soeur Bouvier, Lyon cedex 05, France.
| | | |
Collapse
|
30
|
Abstract
Congenital urinary tract obstruction is a heterogenous condition with a varying natural history. Accurate diagnosis within the late-first and second trimesters allows for counselling of the parents and planning of multi-disciplinary care for the pregnancy and newborn. Antenatal investigations to predict postnatal renal function are of varying accuracy. However, some factors have been shown to be predictive of poor outcome in terms of renal function at birth and infancy. There is the possibility of in-utero intervention in these fetuses.
Collapse
Affiliation(s)
- R K Morris
- Academic Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, University of Birmingham, Birmingham B15 2TG, UK.
| | | |
Collapse
|
31
|
Craparo FJ, Rustico M, Tassis B, Coviello D, Nicolini U. Fetal Serum β2-Microglobulin Before and After Bladder Shunting: A 2-Step Approach to Evaluate Fetuses With Lower Urinary Tract Obstruction. J Urol 2007; 178:2576-9. [DOI: 10.1016/j.juro.2007.08.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Indexed: 11/30/2022]
Affiliation(s)
- Frank J. Craparo
- Department of Obstetrics and Gynecology, Ospedale V. Buzzi, University of Milan, Milan, Italy
| | - Mariangela Rustico
- Department of Obstetrics and Gynecology, Ospedale V. Buzzi, University of Milan, Milan, Italy
| | - Beatrice Tassis
- Department of Obstetrics and Gynecology, Ospedale V. Buzzi, University of Milan, Milan, Italy
| | - Dario Coviello
- Department of Obstetrics and Gynecology, Ospedale V. Buzzi, University of Milan, Milan, Italy
| | - Umberto Nicolini
- Department of Obstetrics and Gynecology, Ospedale V. Buzzi, University of Milan, Milan, Italy
| |
Collapse
|
32
|
Morris RK, Quinlan-Jones E, Kilby MD, Khan KS. Systematic review of accuracy of fetal urine analysis to predict poor postnatal renal function in cases of congenital urinary tract obstruction. Prenat Diagn 2007; 27:900-11. [PMID: 17610312 DOI: 10.1002/pd.1810] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the clinical usefulness of analysis of fetal urine in the prediction of poor postnatal renal function in cases of congenital urinary tract obstruction. METHODS A systematic review was performed. We conducted extensive electronic searches (database inception-2006). The reference lists of articles obtained were searched for any further articles. Two reviewers independently selected the articles in which the accuracy of fetal urinalysis was evaluated to predict poor postnatal renal function. There were no language restrictions. Data were extracted on study characteristics, quality and results, to construct 2 x 2 tables. Likelihood ratios for positive (LR+) and negative (LR-) test results were generated for the different fetal urinary analytes at various thresholds. RESULTS There were 23 articles that met the selection criteria, including a total of 572 women and 63 2 x 2 tables. The two most accurate tests were calcium > 95th centile for gestation (LR + 6.65, 0.23-190.96; LR - 0.19, 0.05-0.74) and sodium > 95th centile for gestation (LR + 4.46, 1.71-11.6; LR - 0.39, 0.17-0.88). beta(2)-microglobulin was found to be less accurate (LR + 2.92, 1.28-6.69; LR - 0.53, 0.24-1.17). CONCLUSION The current evidence demonstrates that none of the analytes of fetal urine investigated so far can be shown to yield clinically significant accuracy to predict poor postnatal renal function.
Collapse
Affiliation(s)
- R K Morris
- Division of Reproductive and Child Health, Birmingham Women's Hospital, University of Birmingham, Birmingham, UK
| | | | | | | |
Collapse
|
33
|
Maruotti GM, Agangi A, Martinelli P, Paladini D. Early prenatal diagnosis of concordant posterior urethral valves in male monochorionic twins. Prenat Diagn 2006; 26:67-70. [PMID: 16378326 DOI: 10.1002/pd.1356] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The association between monozygotic twins and posterior urethral valves (PUV) in postnatal life has been thoroughly described. In the fetus, the prenatal recognition of PUV is feasible. However, it has been repeatedly reported in singletons but never in monochorionic twins. We describe two cases of early prenatal diagnosis of concordant PUVs in monochorionic twins. In one of the sets, the expression of the disease was different for each twin.
Collapse
Affiliation(s)
- G M Maruotti
- Prenatal Diagnosis Unit, Department of Gynecology and Obstetrics, University Federico II of Naples, Naples, Italy
| | | | | | | |
Collapse
|
34
|
Ismaili K, Hall M, Piepsz A, Alexander M, Schulman C, Avni FE. Insights into the pathogenesis and natural history of fetuses with renal pelvis dilatation. Eur Urol 2005; 48:207-14. [PMID: 16005373 DOI: 10.1016/j.eururo.2005.02.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2004] [Accepted: 02/15/2005] [Indexed: 01/11/2023]
Abstract
Fetal renal pelvis dilatation is a frequent abnormality that has been observed in 4.5% of pregnancies. The majority of these cases have a tendency to resolve during infancy. Nevertheless, fetal renal pelvis dilatation may be due to significant structural abnormalities such as pelvi-ureteric junction stenosis or vesico-ureteral reflux that may adversely affect renal function or cause urinary infection or sepsis. This review article aims to summarize the data regarding fetal renal pelvis dilatation and to analyze controversial attitudes in the light of the various lines of practice, and to present rational antenatal and postnatal investigation strategy.
Collapse
Affiliation(s)
- Khalid Ismaili
- Department of Perinatal and Pediatric Nephrology, Hôpital Universitaire des Enfants - Reine Fabiola, 15, Avenue J.J. CROCQ, 1020-Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
35
|
Jung E, Won HS, Shim JY, Lee PR, Kim A, Kim KS. Successful outcome following prenatal intervention in a female fetus with bladder outlet obstruction. Prenat Diagn 2005; 25:1107-10. [PMID: 16231298 DOI: 10.1002/pd.1285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Bladder outlet obstructions are a diverse and heterogeneous group of developmental abnormalities that generally involve obstruction of the proximal urethra in the male fetus. Indications for prenatal intervention are few and are usually restricted to the male fetus because bladder outlet obstruction in female fetuses is usually caused by complex cloacal development anomalies. We report on a female fetus with an enlarged bladder and a dilated proximal urethra (known as typical keyhole sign). A vesicoamniotic shunt was performed despite non-reassuring prognostic factors, but the procedure resulted in a successful outcome. We propose that in selected cases of bladder outlet obstruction, fetal intervention should be considered even when the fetus is female.
Collapse
Affiliation(s)
- Eui Jung
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | | | | | | | | |
Collapse
|
36
|
Miguelez J, Bunduki V, Yoshizaki CT, Sadek LDSR, Koch V, Peralta CFA, Zugaib M. Fetal obstructive uropathy: is urine sampling useful for prenatal counselling? Prenat Diagn 2005; 26:81-4. [PMID: 16374901 DOI: 10.1002/pd.1360] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate whether fetal urinary sodium and chloride provide clinically useful information in addition to ultrasound in bilateral obstructive uropathy. METHODS Sonographic features and urinary concentrations of sodium and chloride were evaluated in fetuses with bilateral obstructive uropathy. After a minimum of 12 months of postnatal follow-up, cases that developed increased serum creatinine (greater than 50 micromol/L) were compared with those that did not. RESULTS Of the cases studied, 16/35 died perinatally, all showing anamnios and markedly elevated urinary electrolytes. Of the survivors, ten maintained normal postnatal serum creatinine, whereas nine did not. The frequency of reduced amniotic fluid/olygohydramnios was higher in cases that developed increased serum creatinine (four out of nine) than in those that did not (nil). Sodium above the 95th percentile was 100% specific and 44% sensitive to predict an increased serum creatinine during early infancy, while chloride above the 95th percentile was 70% specific and 56% sensitive. All seven cases in which urinary sodium was elevated and/or amniotic fluid volume was reduced developed renal failure. CONCLUSION Urine sampling slightly improved renal function prediction, but this must be balanced against its fetal risks.
Collapse
Affiliation(s)
- Javier Miguelez
- Department of Obstetrics and Gynecology, University of Sao Paulo Medical School Hospital, Sao Paulo, Brazil
| | | | | | | | | | | | | |
Collapse
|
37
|
Eckoldt F, Heling KS, Woderich R, Wolke S. Posterior Urethral Valves: Prenatal Diagnostic Signs and Outcome. Urol Int 2004; 73:296-301. [PMID: 15604570 DOI: 10.1159/000081586] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2003] [Accepted: 05/12/2004] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Urethral valves can be of enormous clinical importance. Both the prognosis for an affected fetus and the indication for a prenatal therapeutic intervention depend to a high degree on the accuracy of the prenatal diagnosis. PATIENTS AND METHODS The sonographic findings and the results of the postnatal diagnostic workup of 24 boys treated for urethral valves in our institute are analyzed in the present paper. RESULTS Out of a group of 900 children, diagnosed prenatally as having urinary tract anomalies, the postnatal diagnostic workup revealed 24 boys suffering from posterior urethral valves. The combination of megacystis, oligohydramnios, and bilateral renal abnormalities was present in 3 boys, and it was only in these cases that urethral valves were correctly identified as the underlying pathology. The largest group (n = 16) of these fetuses presented with bilateral hydronephrosis with and without megaureter. Megacystis in any combination with other findings was detected only in 4 patients. Oligohydramnios as a sign of impaired renal function was observed in four pregnancies. Four children suffered postnatally from beginning renal insufficiency. Eight infants (33%) required some form of respiratory support. This group included the 4 newborns with oligohydramnios during the pregnancy. CONCLUSIONS Posterior urethral valves represent a rare but severe congenital malformation. They can disrupt the development of the entire urinary tract and may be life-limiting to the affected boy. Only rarely, however, are they manifested as the complete pathological picture on prenatal ultrasound. In most cases, bilateral impairment of the fetal renal development suggests severe subvesical obstruction. Thus in cases with bilateral renal impairment on prenatal ultrasonography, posterior urethral valves are to be excluded postnatally. Oligohydramnios is a predictor of a poor outcome of the renal function.
Collapse
Affiliation(s)
- Felicitas Eckoldt
- Klinik und Poliklinik für Kinderchirurgie des Otto-Heubner-Centrums für Kinder- und Jugendmedizin, Berlin, Deutschland.
| | | | | | | |
Collapse
|
38
|
Abstract
Despite the sound experimental basis and initial promise of early animal models, the results of antenatal intervention have been disappointing, with high rates of misdiagnosis of urethral valves, complications from vesicoamniotic shunting, perinatal mortality, and long-term renal impairment and bladder dysfunction in survivors. The recent development of a cystoscopic approach might obviate some of these problems, but to date the procedure been limited by technical difficulty in negotiating the urethrovesical angle. Overcoming these difficulties through equipment modifications might allow definitive testing of whether or not alleviating distal urinary obstruction in utero is beneficial.
Collapse
Affiliation(s)
- Sailesh Kumar
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, London W12 OHS, UK.
| | | |
Collapse
|
39
|
Wilson RD, Johnson MP. Prenatal ultrasound guided percutaneous shunts for obstructive uropathy and thoracic disease. Semin Pediatr Surg 2003; 12:182-9. [PMID: 12961112 DOI: 10.1016/s1055-8586(03)00027-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The authors reviewed the status of closed ultrasound-guided fetal therapy using a pigtail shunt to create vesicoamniotic or thoracoamniotic decompression of the fluid-filled space. This review includes published and textbook reports of in utero therapy for bladder obstruction, pleural effusion, and macrocystic adenomatoid malformation from 1985 through 2002. For fetuses affected by lower urinary tract obstruction, the key component is identifying those fetuses that have retained renal function and are most likely to benefit from in utero shunting. This good prognosis group has been shown to have improved survival rate and a lower incidence of renal failure. Complications of fetal loss are estimated at 5% owing to the shunt procedure, and the risk of shunt displacement varies from 30% to 50%. Hydrops secondary to primary PE has been shown to be associated with low fetal and neonatal survival at 21% to 23%. Treatment by thoracoamniotic shunting increases survival rate to 75%. The fetus with a macrocystic CCAM and secondary hydrops should be considered a candidate for thoracoamniotic shunt to decrease CCAM volume, reverse hydrops, and improve survival rate. Thoracoamniotic shunt and thoracocentesis pregnancy loss risks for pleural effusion (PE) and macrocystic adenomatoid malformation of the lung (CCAM) are 5% and 0.5% to 1.0%, respectively.
Collapse
Affiliation(s)
- R Douglas Wilson
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | |
Collapse
|
40
|
Vanderheyden T, Kumar S, Fisk NM. Fetal renal impairment. ACTA ACUST UNITED AC 2003; 8:279-89. [PMID: 15001131 DOI: 10.1016/s1084-2756(03)00022-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2003] [Accepted: 01/31/2003] [Indexed: 11/22/2022]
Abstract
Renal function in utero deals chiefly with urine production rather than the excretion of metabolites, which are cleared by the placenta. Fetal renal impairment (FRI) in bilateral renal disease thus presents as oligohydramnios or anhydramnios; this can lead to lung hypoplasia and early neonatal death. As in the adult, FRI can be divided into prerenal, renal and postrenal causes. Causes of prerenal FRI include intrauterine growth restriction, unbalanced intertwin transfusion in monochorionic twins and maternal drug ingestion. Bilateral renal agenesis, multicystic dysplasia and both the autosomal dominant and recessive forms of polycystic kidney disease are examples of renal causes, whereas postrenal etiologies are usually caused by lower urinary tract obstruction (LUTO). When both kidneys are affected and there is severe mid-trimester oligohydramnios, the prognosis is poor. Although animal studies have shown that prolonged LUTO leads to lung hypoplasia and renal damage, and that decompression of the fetal kidney in early pregnancy restores fetal pulmonary and renal function, the value of fetal therapy such as vesico-amniotic shunting remains controversial, with a high procedure-related complication rate and a high incidence of end-stage renal failure in childhood. Fetal cystoscopic treatment of posterior urethral valves in utero may obviate some of these difficulties but remains an investigational procedure.
Collapse
Affiliation(s)
- Tina Vanderheyden
- Institute of Reproductive and Developmental Biology, Queen Charlotte's and Chelsea Hospital,Imperial College, Hammersmith Campus, Du Cane Road, London W12OSH, UK.
| | | | | |
Collapse
|