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Hamdani G, Yaniv N, Shoham S, Borovitz Y, Levi S, Landau D, Dagan A. Isolated Hydronephrosis and Urinary Tract Infection by Two Years of Age: A Population-Based Study. J Pediatr 2024; 271:114055. [PMID: 38614256 DOI: 10.1016/j.jpeds.2024.114055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 03/12/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE To evaluate the risk for urinary tract infection (UTI) in infants with isolated hydronephrosis (IH). STUDY DESIGN A retrospective, population-based study including all infants insured by Clalit Health Services and followed from birth to age 2 years in 3 regions of central Israel. Infants were divided into 3 groups based on electronic medical record diagnoses by age 6 months: (1) control: no urological diagnosis; (2) IH; and (3) complicated urological diagnosis (CUD): any additional nephrological/urological diagnosis with/without HN. The primary outcome was a diagnosis of UTI in the first 2 years of life. RESULTS The cohort included 340 619 infants (52% male): 333 920 controls, 4369 with IH, and 2331 with CUD. Infants with IH were associated with a greater risk for UTI than control patients (17% vs 4%, P < .001). UTI risk for a male infant with IH was greater than for a female infant in the control group (12.6% vs 6.5%, P < .001). In a multivariable logistic regression analysis, both IH (OR 7.04; 95% CI 6.46-7.66) and CUD (OR 14.9; 95% CI 13.6-16.4) were independently associated with UTI. CONCLUSION Infants with IH are at a greater risk for UTI in the first 2 years of life, supporting the recommendation for a high index of suspicion for UTI in this population.
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Affiliation(s)
- Gilad Hamdani
- Nephrology Institute, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.
| | - Noga Yaniv
- Research Institute, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Shoval Shoham
- Research Institute, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Yael Borovitz
- Nephrology Institute, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Shelly Levi
- Nephrology Institute, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Daniel Landau
- Nephrology Institute, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Dagan
- Nephrology Institute, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hodhod A, Eid H, Fermin-Risso C, Farhad M, Aburezq J, Cook A, Weber B. Significant improvement in hydronephrosis with pyeloplasty prior to 3 months of age in patients with antenatal severe hydronephrosis. Int Urol Nephrol 2024; 56:2467-2473. [PMID: 38507157 DOI: 10.1007/s11255-024-04002-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/22/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Pyeloplasty is the definitive management of ureteropelvic junction obstruction (UPJO). One of the challenging questions is when to perform pyeloplasty. We studied if improvement post-pyeloplasty in the first 3 months of life could show greater improvement in hydronephrosis than surgery at an older age. PATIENTS AND METHODS Patients with postnatally diagnosed UPJO and underwent pyeloplasty in the first year of life were retrospectively reviewed. We excluded patients with concomitant vesicoureteral reflux, and patients who had pyeloplasty because of UTI or missed follow-up. Patients were divided into two groups, according to the age at pyeloplasty, before and after the age of 3 months. We collected patients' demographics, anteroposterior diameter of the renal pelvis (APD), SFU grade, renogram data, perioperative data (surgery duration, hospital stay, and ureteral stent duration) and postoperative ultrasound changes. The percentage of change of APD (Δ%APD) was calculatedusing the formula: Δ%APD = [ (initial APD-last APD)/initial APD] *100. RESULTS We included 90 patients (93 renal units). 36 patients had pyeloplasty during the first 3 months of life and 57 patients at 3 -12 months. Patients' characteristics were similar in both groups except APD which was higher when pyeloplasty was done < 3 months of age (p = 0.02). Both groups had comparable perioperative parameters. After almost similar follow-up period of both groups. The Δ%APD was 58% when pyeloplasty was done < 3 months compared to 33% when was performed > 3 months (p = 0.009). Using Kaplan-Meier analysis, APD significantly improved when pyeloplasty was performed before the age of 3 months (p = 0.001). CONCLUSION Early pyeloplasty, in the first 3 months of life, showed a significant improvement of APD postoperatively than those had surgery later. It is unclear if this will relate to less loss of renal function yet certainly this would be suspected and feel this finding provides some evidence for early intervention.
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Affiliation(s)
- Amr Hodhod
- Pediatric Urology Division, King Abdullah Specialized Children's Hospital, Riyadh, Saudi Arabia.
| | - Hadeel Eid
- Pediatric Radiology Subdivision, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- Radiology Department, Menoufia Faculty of medicine, Menoufia University, Shebin Elkom, Menoufia, Egypt
| | - Carolina Fermin-Risso
- Pediatric Urology Division, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Mutaz Farhad
- Pediatric Urology Division, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Jarah Aburezq
- Pediatric Urology Division, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Anthony Cook
- Pediatric Urology Division, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Bryce Weber
- Pediatric Urology Division, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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Zeybek SG, Selvi İ, Oktar T, Dönmez Mİ, Ziylan O, Seçkin Ş, Küçükgergin C. Can urinary caspase-3 and cytochrome c levels be used as predictive biomarkers in the management of unilateral antenatal hydronephrosis? Int Urol Nephrol 2024; 56:2459-2466. [PMID: 38494584 DOI: 10.1007/s11255-024-04008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 02/26/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE We aimed to investigate the urinary caspase-3 and cytochrome c levels in patients with unilateral antenatal hydronephrosis and to determine whether changes in urinary biomarker levels could be useful for both predicting the need for surgical intervention due to ureteropelvic junction obstruction (UPJO) and postoperative surgical success. METHODS Sixty-five children with a history of unilateral antenatal hydronephrosis and postnatal anteroposterior diameter ≥ 10 mm were included in this prospective case-control study between January 2013 and December 2021. The obstruction group consisted of 33 patients (28 boys, 84.8%) who underwent open dismembered pyeloplasty due to UPJO. The non-obstructive dilatation (NOD) group consisted of 32 patients (27 boys, 84.4%) with stable or improving hydronephrosis and no significant reduction in ipsilateral split renal function during follow-up, whereas 34 healthy children were enrolled in the study as a control group. Urinary urinary caspase-3 and cytochrome c levels using ELISA were measured. RESULTS The median preoperative urinary caspase-3 level was significantly higher in the obstruction group when compared to the NOD group (4.82 ng/mgCr vs. 2.61 ng/mgCr, p = 0.013) as well as the control group (4.82 ng/mgCr vs. 1.72 ng/mgCr, p = 0.002). In the postoperative period, urinary caspase-3 levels significantly decreased compared to preoperative measurements (4.82 ng/mgCr vs. 2.51 ng/mgCr, p = 0.006) and became similar to the control group (2.51 ng/mgCr vs. 1.72 ng/mgCr, p = 0.422). On the other hand, no significant differences were observed in urinary cytochrome c levels between the groups. All patients who underwent pyeloplasty achieved postoperative resolution in hydronephrosis and improved drainage on MAG-3, so none of the patients required re-do pyeloplasty. Postoperative decrease in caspase-3 level was found to be compatible with adequate urine drainage on MAG-3 scan. The cut-off value of urinary caspase-3 to predict patients requiring pyeloplasty was found to be 3.31 ng/mg creatinine with 63.6% sensitivity, 62.5% specificity (AUC = 0.679). In the multivariable analysis, urinary caspase-3 level (OR: 1.653, p = 0.019), anteroposterior pelvic diameter (OR: 1.401, p = 0.001), and split renal function on MAG-3 (OR: 1.277, p = 0.011) were found to be independent factors in determining patients who require surgery. CONCLUSION Based on our preliminary findings, urinary caspase-3 levels could be a useful biomarker not only for predicting the need for surgical intervention but also for determining the postoperative surgical success in children with UPJO.
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Affiliation(s)
- Seyide Görkem Zeybek
- Department of Biochemistry, Institute of Health Sciences, Istanbul University, Istanbul, Turkey
| | - İsmail Selvi
- Department of Urology, Division of Pediatric Urology, Istanbul Faculty of Medicine, Istanbul University, Çapa-Fatih, 34093, Istanbul, Turkey.
| | - Tayfun Oktar
- Department of Urology, Division of Pediatric Urology, Istanbul Faculty of Medicine, Istanbul University, Çapa-Fatih, 34093, Istanbul, Turkey
| | - M İrfan Dönmez
- Department of Urology, Division of Pediatric Urology, Istanbul Faculty of Medicine, Istanbul University, Çapa-Fatih, 34093, Istanbul, Turkey
| | - Orhan Ziylan
- Department of Urology, Division of Pediatric Urology, Istanbul Faculty of Medicine, Istanbul University, Çapa-Fatih, 34093, Istanbul, Turkey
| | - Şule Seçkin
- Department of Biochemistry, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Canan Küçükgergin
- Department of Biochemistry, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Yılmaz S, Özçakar ZB, Cakar N, Biral Coşkun B, Burgu B, Yalcinkaya F. Long Term Follow-Up Of Patients With Nonrefluxing Hydronephrosis. KLINISCHE PADIATRIE 2024; 236:247-251. [PMID: 37989212 DOI: 10.1055/a-2183-8351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
BACKGOUND The aim of this study is to examine the long-term prognosis of children with ureteropelvic junction obstruction-like hydronephrosis (UPJO-like HN). PATIENTS AND METHODS The files of children with hydronephrosis (HN) were analyzed retrospectively. Patients with vesicoureteral reflux (VUR) and other genitourinary anomalies were excluded. The final status of the HN, the need for surgery, and urinary tract infection (UTI) frequency were evaluated. RESULTS The study included 219 patients with 302 renal units (RU) with HN. Surgery rate was higher in RUs with larger kidney size and parenchymal thinning (p:<0.001 for both). Hydronephrosis resolved in 113 (40.2%) RUs, improved in 66 (23.3%), unchanged in 100 (35.5%) and worsened in 4 (1.4%). The frequency of recovery and improvement was found to be less in RUs with severe HN, large kidney size, and thin parenchyma. The UTI frequency was higher in severe HN group (12.2% vs 30.6% p:<0.001). CONCLUSIONS Children with mild HN had an excellent prognosis. Although the majority of the patients with high-grade HN had also a good prognosis, it seems important to closely follow up patients with severe HN, increased kidney size, and accompanying parenchymal thinning. Clinicians should be aware of the increased frequency of UTIs in children with severe HN.
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Affiliation(s)
- Songül Yılmaz
- Pediatric Nephrology, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Nilgun Cakar
- Pediatric Nephrology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Burcu Biral Coşkun
- Pediatric Nephrology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Berk Burgu
- Pediatric Urology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Fatoş Yalcinkaya
- Pediatric Nephrology, Ankara University Faculty of Medicine, Ankara, Turkey
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Chen J, Gao X, Yang M, Li Y, Chai S, Zhou Y, Xiao X, Lei Z, Xing Y, Li B. The Whitaker test: a predictive tool for evaluating the surgical efficacy of upper urinary tract reconstruction in patients carrying a nephrostomy tube after surgery. Int Urol Nephrol 2024; 56:1817-1824. [PMID: 38285099 DOI: 10.1007/s11255-023-03927-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/17/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE To explore the role of the Whitaker test in evaluating the postoperative outcome of upper urinary tract reconstruction surgery in patients carrying a nephrostomy tube after surgery. PATIENTS AND METHODS This was a prospective observational study performed in 42 patients with nephrostomy tube undergoing the Whitaker test after upper urinary tract reconstruction surgery between January 2020 and December 2021. Data on clinical information, the Whitaker test and surgical procedure were collected prospectively, and the long-term follow-up results were analysed retrospectively. RESULTS The 46 ureters of 42 patients (right 16, left 22, bilateral 4) underwent six common upper urinary tract surgical reconstruction procedures and one combined procedure, including pyeloplasty, ureteroureterostomy, lingual mucosal onlay graft, appendiceal onlay flap, ureteral reimplantation, Boari flap, and ipsilateral lingual mucosal onlay graft combined ureteral reimplantation. All patients underwent the Whitaker test successfully without any discomfort after examination. The postoperative Whitaker test showed 43 kidneys without obstruction and 3 kidneys with obstruction. At a median follow-up of 18 months (range 13-31), the follow-up results showed that the overall success rate of the surgery was 100% (46/46). Concerning the concordance Whitaker test and follow-up results, the observed proportion of agreement was 93.5% (43/46). CONCLUSION The Whitaker test can achieve similar consistency with the long-term follow-up results after upper urinary tract reconstruction surgery and can be used as a tool to evaluate the surgical efficacy of upper urinary tract reconstruction surgery, which can provide a prognostic efficacy evaluation for patients carrying a nephrostomy tube after surgery.
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Affiliation(s)
- Jiawei Chen
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xincheng Gao
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ming Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ying Li
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shuaishuai Chai
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuancheng Zhou
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xingyuan Xiao
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ziqiao Lei
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China.
| | - Yifei Xing
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Bing Li
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China.
- Institute of Urology, Wuhan University, Wuhan, China.
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Xie Q, Wang C, Su C, Shi B, Li Y, Huang J, Chen C. Feasibility and Effectiveness of Repeat Laparoscopic Pyeloplasty for Recurrent Ureteropelvic Junction Obstruction in Pediatric Patients. J Endourol 2024; 38:584-589. [PMID: 38545757 DOI: 10.1089/end.2023.0577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Objective: To assess the outcomes of redo laparoscopic pyeloplasty (RLP) in pediatric patients with recurrent ureteropelvic junction obstruction (UPJO) in contrast to redo open pyeloplasty (ROP). In addition, evaluate the feasibility and efficacy of RLP as a treatment modality for recurrent UPJO in children. Materials and Methods: The data of 44 patients from March 2012 to March 2022, who underwent redo pyeloplasty, were retrospectively reviewed. In Group RLP, the children underwent RLP, whereas ROP was attempted in Group ROP. Demographics, clinical manifestations, surgical duration, hospitalization duration, complication rates, and treatment success were examined within the respective groups. Moreover, preoperative and postoperative measurements of anterior-posterior diameter of the renal pelvis (APD), preoperative assessment of differential renal function (DRF), and the percentage of improvement in DRF (PI-DRF) were subject to analysis. Results: The study included 28 patients who underwent RLP (Group RLP), and 16 patients who underwent ROP (Group ROP). In all cases, the Anderson-Hynes technique was employed. There was no significant difference between the two groups regarding age, body mass index, gender distribution, affected side, preoperative APD, postoperative APD, and preoperative DRF. In comparison to Group ROP, Group RLP exhibited a shorter hospitalization duration, a longer surgical procedure duration, and a higher percentage improvement in PI-DRF. The median follow-up period for Group RLP was 25 months, whereas it was 25.5 months for Group ROP. Notably, the success rates were similar between the two groups, with a success rate of 89.2% in RLP and 87.5% in ROP (p = 0.634). Conclusion: RLP has a comparable success rate to ROP and is a safe, effective, and feasible procedure for the treatment of failed pyeloplasty in children.
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Affiliation(s)
- Qike Xie
- Department of Pediatric Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Congjun Wang
- Department of Pediatric Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Cheng Su
- Department of Pediatric Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Bo Shi
- Department of Pediatric Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong Li
- Department of Pediatric Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Junqiang Huang
- Department of Pediatric Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chao Chen
- Department of Pediatric Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Cajigas-Loyola SC, Chow JS, Hayatghaibi S, Iyer RS, Kwon J, Rubesova E, Sánchez-Jacob R, Wyers M, Otero HJ. Imaging of Vesicoureteral Reflux: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2024; 222:e2329741. [PMID: 37672329 DOI: 10.2214/ajr.23.29741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Vesicoureteral reflux (VUR) is a common congenital anomaly of the urinary tract that can present with collecting system dilation or as a febrile infection. VUR can lead to permanent renal sequelae requiring surgery but can also spontaneously resolve without complication. Therefore, recognizing patient populations who warrant imaging for screening, confirmation, or ongoing surveillance for VUR is important, as is avoiding overdiagnosis. In the appropriate patient populations, an accurate diagnosis of VUR allows early treatment and prevention of pyelonephritis and scarring. Various imaging modalities are available to diagnose and grade VUR, including voiding cystourethrography, radionucleotide cystography, and contrast-enhanced voiding urosonography (ceVUS). The objective of this article is to summarize the current understanding of VUR diagnosis and management and to discuss these imaging modalities' strengths and pitfalls. Considerations include indications for VUR imaging, patient preparation, conduct of the examination, issues related to radiologic reporting, and cost-effectiveness. An emphasis is placed on ceVUS, which is the most recently introduced of the three imaging modalities and is receiving growing support among pediatric radiologists.
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Affiliation(s)
- Stephanie C Cajigas-Loyola
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Jeanne S Chow
- Department of Radiology, Boston Children's Hospital, Boston, MA
| | | | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, Seattle, WA
| | - Jeannie Kwon
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Erika Rubesova
- Department of Radiology, Stanford Medicine Children's Health, Palo Alto, CA
| | | | - Mary Wyers
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
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Mao C, Tao C, Yang C, Cao Y. Laparoscopic pyeloplasty for the treatment of bilateral hydronephrosis with stones in a 6-week-old infant. Asian J Surg 2024; 47:2768-2769. [PMID: 38521756 DOI: 10.1016/j.asjsur.2024.03.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/10/2024] [Indexed: 03/25/2024] Open
Affiliation(s)
- Changkun Mao
- Department of Urology, Anhui Provincial Children's Hospital, Hefei, Anhui, China.
| | - Chengpin Tao
- Department of Urology, Anhui Provincial Children's Hospital, Hefei, Anhui, China
| | - Chao Yang
- Department of Urology, Anhui Provincial Children's Hospital, Hefei, Anhui, China
| | - Yongsheng Cao
- Department of Urology, Anhui Provincial Children's Hospital, Hefei, Anhui, China
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Park K, Kim K, Im YJ. Role of urinary N-acetyl-beta-D-glucosaminidase in predicting the prognosis of antenatal hydronephrosis. Investig Clin Urol 2024; 65:293-299. [PMID: 38714520 PMCID: PMC11076795 DOI: 10.4111/icu.20240091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 05/10/2024] Open
Abstract
PURPOSE Urinary biomarkers are known to be able to diagnose renal damage caused by obstruction at an early stage. We evaluated the usefulness of urine N-acetyl-beta-D-glucosaminidase (NAG) to determine the prognosis of antenatal hydronephrosis. MATERIALS AND METHODS From January 2019 to December 2021, a retrospective study was performed on patients with grade 3 or 4 hydronephrosis. We analyzed the ultrasonographic findings and the urinary NAG/Cr ratio between the laparoscopic pyeloplasty (LP) group and active surveillance (AS) group. RESULTS A total of 21 children underwent LP for ureteropelvic junction (UPJ) obstruction and 14 children underwent AS. The mean age at the time of examination was 3.7 months (1.7-7.5 months) in the LP and 5.2 months (0.5-21.5 months) in the AS (p=0.564). The mean anteroposterior pelvic diameter was 30.0 mm (15.0-49.0 mm) in the LP and 16.7 mm (9.0-31.3 mm) in the AS (p=0.003). The mean renal parenchymal thickness was 2.6 mm (1.2-3.7 mm) in the LP and 3.8 mm (2.9-5.5 mm) in the AS (p=0.017). The urinary NAG/Cr ratio was 26.1 IU/g (9.8-47.4 IU/g) in the LP and 11.1 IU/g (2.6-18.1 IU/g) in the AS (p=0.003). After LP, the urinary NAG/Cr ratio was significantly reduced to 10.4 IU/g (3.4-14.2 IU/g) (p=0.023). CONCLUSIONS The urinary NAG/Cr ratio, one of the biomarkers of acute renal injury, is closely related to the degree of hydronephrosis. Therefore, it may be useful to determine whether to perform surgery on the UPJ obstruction and to predict the prognosis.
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Affiliation(s)
- Kwanjin Park
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyeong Kim
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Young Jae Im
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea.
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Kim HW, Hwang J, Pai KS, Suh YA. Urinary tract dilation classification system for predicting surgical management and urinary tract infection in neonates and young infants: a systematic review and meta-analysis. Pediatr Radiol 2024; 54:795-804. [PMID: 38282063 DOI: 10.1007/s00247-024-05854-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 01/07/2024] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND The urinary tract dilation classification system has recently been developed to ensure a unified approach to describe urinary tract dilation in neonates and young infants. However, the predictive value of this system for surgical intervention or urinary tract infection (UTI) has not yet been evaluated in a meta-analysis. OBJECTIVE This systematic review and meta-analysis aimed to evaluate the utility of a postnatal urinary tract dilation classification system for predicting surgical management or a UTI occurrence. MATERIALS AND METHODS As the urinary tract dilation classification system was introduced in 2014, we searched Embase and PubMed databases for studies published between January 2014 and December 2022. Original articles that reported surgical interventions or UTI episodes according to postnatal urinary tract dilation grades were included. The pooled odds ratio (OR) was calculated, using either the fixed-effects or random-effects model, given the lower urinary tract dilation grades as the base category. The quality of the included studies was evaluated using the Newcastle-Ottawa scale. RESULTS Of the 285 articles reviewed, eight (comprising 2,165 children) were included in the analysis. The studies were of medium-to-high quality. Pooled analysis demonstrated that urinary tract dilation P3 (combined OR, 21.41; 95% confidence interval [CI], 15.72-29.17) and urinary tract dilation P2-P3 (combined OR, 65.17; 95% CI, 33.08-128.38) were associated with surgical intervention. The urinary tract dilation P3 (combined OR, 2.11; 95% CI, 1.56-2.85) and urinary tract dilation P2-P3 (combined OR, 3.36; 95% CI, 2.43-4.63) were associated with UTI episodes. CONCLUSION The postnatal urinary tract dilation classification system is useful for predicting the need for surgical management and UTI episodes in infants with hydronephrosis.
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Affiliation(s)
- Hae Won Kim
- Department of Healthcare, Kakao Brain Co., Seongnam, Republic of Korea
| | - Jisun Hwang
- Department of Radiology, Ajou University Hospital, Ajou University School of Medicine, 164 World Cup-Ro, Yeongtong-Gu, Suwon, 16499, Republic of Korea.
| | - Ki Soo Pai
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Yoong-A Suh
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea
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Morizawa Y, Aoki K, Fukui S, Tomizawa M, Shimizu T, Onishi K, Hori S, Gotoh D, Nakai Y, Miyake M, Torimoto K, Fujimoto K, Otani T, Fujimoto K. Long-term follow-up of congenital hydronephrosis in a single-center study. Int J Urol 2024; 31:507-511. [PMID: 38205874 DOI: 10.1111/iju.15391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVES Many congenital hydronephroses spontaneously resolve. This study evaluated a long-term follow-up of more than 4 years of patients with congenital hydronephrosis at a single center. METHODS In total, 215 patients (286 kidneys) with congenital hydronephrosis were included. Hydronephrosis outcomes (resolution, improvement, and persistence) and time-to-outcome were evaluated. RESULTS Fourteen patients underwent early surgical intervention until the age of 2 years. A total of 189 congenital hydronephrosis cases (66%) showed resolution at a median of 16 months (interquartile range: 7-21 months) and 169 (80%) of 210 kidneys with grade I to II hydronephrosis showed resolution at a median of 14 months (interquartile range: 6-23 months). Of 76 kidneys with grade III to IV hydronephrosis, 24 (32%) showed resolution at a median of 29 months (interquartile range: 24-41 months), and 56 (74%) showed improvement to grade II or less at a median of 12 months (interquartile range: 5-23 months). Of the 76 kidneys with grade III to IV hydronephrosis, five required delayed pyeloplasty at a median of 66 months (interquartile range: 42-89 months). One patient was asymptomatic, with a marked worsening of hydronephrosis and decreased renal function 6 years after the resolution of hydronephrosis. CONCLUSIONS None of the patients with grade I to II hydronephrosis required surgical treatment, and a shorter follow-up may be sufficient. Grade III to IV severe hydronephrosis should be considered for a longer and more careful follow-up, given the possibility of asymptomatic exacerbation of hydronephrosis.
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Affiliation(s)
- Yosuke Morizawa
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
- Department of Pediatric Urology, Nara Prefecture General Medical Center, Nara, Nara, Japan
- Department of Urology, Okanami General Hospital, Iga, Mie, Japan
- Department of Urology, Matsusaka Chuo General Hospital, Matsusaka, Mie, Japan
| | - Katsuya Aoki
- Department of Pediatric Urology, Nara Prefecture General Medical Center, Nara, Nara, Japan
| | - Shinji Fukui
- Department of Urology, Yamato Takada Municipal Hospital, Yamato Takada, Nara, Japan
| | - Mitsuru Tomizawa
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Takuto Shimizu
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Kenta Onishi
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Shunta Hori
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Daisuke Gotoh
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Kazumasa Torimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Ken Fujimoto
- Department of Urology, Okanami General Hospital, Iga, Mie, Japan
| | - Takeshi Otani
- Department of Urology, Matsusaka Chuo General Hospital, Matsusaka, Mie, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
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12
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Lu W, Guo Y, Liu H, Zhang T, Zhang M, Li X, Li Z, Shi M, Jiang Z, Zhao Z, Yang S, Li Z. The Inhibition of Fibrosis and Inflammation in Obstructive Kidney Injury via the miR-122-5p/SOX2 Axis Using USC-Exos. Biomater Res 2024; 28:0013. [PMID: 38617751 PMCID: PMC11014086 DOI: 10.34133/bmr.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/14/2024] [Indexed: 04/16/2024] Open
Abstract
Background: Fibrosis and inflammation due to ureteropelvic junction obstruction substantially contributes to poor renal function. Urine-derived stem-cell-derived exosomes (USC-Exos) have therapeutic effects through paracrine. Methods: In vitro, the effects of USC-Exos on the biological functions of HK-2 and human umbilical vein endothelial cells were tested. Cell inflammation and fibrosis were induced by transforming growth factor-β1 and interleukin-1β, and their anti-inflammatory and antifibrotic effects were observed after exogenous addition of USC-Exos. Through high-throughput sequencing of microRNA in USC-Exos, the pathways and key microRNAs were selected. Then, the antifibrotic and anti-inflammatory effects of exosomal miR-122-5p and target genes were verified. The role of the miR-122-5p/SOX2 axis in anti-inflammatory and antifibrotic effects was verified. In vivo, a rabbit model of partial unilateral ureteral obstruction (PUUO) was established. Magnetic resonance imaging recorded the volume of the renal pelvis after modeling, and renal tissue was pathologically analyzed. Results: We examined the role of USC-Exos and their miR-122-5p content in obstructive kidney injury. These Exos exhibit antifibrotic and anti-inflammatory activities. SOX2 is the hub gene in PUUO and negatively related to renal function. We confirmed the binding relationship between miR-122-5p and SOX2. The anti-inflammatory and antifibrotic effects of miR-122-5p were inhibited, indicating that miR-122-5p has anti-inflammatory and antifibrotic effects by inhibiting SOX2 expression. In vivo, the PUUO group showed typical obstructive kidney injury after modeling. After USC-Exo treatment, the shape of the renal pelvis shown a remarkable improvement, and inflammation and fibrosis decreased. Conclusions: We confirmed that miR-122-5p from USC-Exos targeting SOX2 is a new molecular target for postoperative recovery treatment of obstructive kidney injury.
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Affiliation(s)
- Wenjun Lu
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
- Key Laboratory of Growth Regulation and Translational Research of Zhejiang Province,
School of Life Sciences, Westlake University,Hangzhou 310024, Zhejiang, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou 310024, Zhejiang, China
- Laboratory of Systems Immunology,
Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Hangzhou 310024, Zhejiang, China
| | - Yujun Guo
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
| | - Hengchen Liu
- Department of General Surgery,
The Second Hospital Affiliated to Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou 310022, Zhejiang, China
| | - Tingting Zhang
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
| | - Mingzhao Zhang
- Department of General Surgery,
The Second Hospital Affiliated to Anhui Medical University, No. 678 Furong Road, Hefei 230031, Anhui, China
| | - Xiangqi Li
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
| | - Zhou Li
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
| | - Manyu Shi
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
| | - Zhitao Jiang
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
| | - Zheng Zhao
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
| | - Shulong Yang
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
| | - Zhaozhu Li
- Department of Pediatric Surgery,
The Sixth Hospital Affiliated to Harbin Medical University, Harbin Medical University, No.998 Aiying Street, Harbin 150027, Heilongjiang, China
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13
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Damasio MB, Donati F, Bruno C, Darge K, Mentzel HJ, Ključevšek D, Napolitano M, Ozcan HN, Riccabona M, Smets AM, Sofia C, Stafrace S, Petit P, Ording Müller LS. Update on imaging recommendations in paediatric uroradiology: the European Society of Paediatric Radiology workgroup session on voiding cystourethrography. Pediatr Radiol 2024; 54:606-619. [PMID: 38467874 DOI: 10.1007/s00247-024-05883-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 03/13/2024]
Abstract
Voiding cystourethrography (VCUG) is a fluoroscopic technique that allows the assessment of the urinary tract, including the urethra, bladder, and-if vesicoureteral reflux (VUR) is present-the ureters and the pelvicalyceal systems. The technique also allows for the assessment of bladder filling and emptying, providing information on anatomical and functional aspects. VCUG is, together with contrast-enhanced voiding urosonography (VUS), still the gold standard test to diagnose VUR and it is one of the most performed fluoroscopic examinations in pediatric radiology departments. VCUG is also considered a follow-up examination after urinary tract surgery, and one of the most sensitive techniques for studying anatomy of the lower genitourinary tract in suspected anatomical malformations. The international reflux study in 1985 published the first reflux-protocol and graded VUR into five classes; over the following years, other papers have been published on this topic. In 2008, the European Society of Paediatric Radiology (ESPR) Uroradiology Task Force published the first proposed VCUG Guidelines with internal scientific society agreement. The purpose of our work is to create a detailed overview of VCUG indications, procedural recommendations, and to provide a structured final report, with the aim of updating the 2008 VCUG paper proposed by the European Society of Paediatric Radiology (ESPR). We have also compared VCUG with contrast-enhanced VUS as an emergent alternative. As a result of this work, the ESPR Urogenital Task Force strongly recommends the use of contrast-enhanced VUS as a non-radiating imaging technique whenever indicated and possible.
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Affiliation(s)
- Maria Beatrice Damasio
- Pediatric Radiology Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy.
| | - Francesco Donati
- Pediatric Surgery Department, University of Genova, Genoa, Italy
| | - Costanza Bruno
- Radiology Department, AOUI Verona (Azienda Ospedaliera Universitaria Integrata), Verona, Italy
| | - Kassa Darge
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Department of Radiology, Universitätsklinikum Jena, Jena, Germany
| | - Damjana Ključevšek
- Department of Radiology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Marcello Napolitano
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital, Milan, Italy
| | - H Nursun Ozcan
- Department of Radiology/Division of Pediatric Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Anne M Smets
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Carmelo Sofia
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Samuel Stafrace
- McMaster University and McMaster Children's Hospital, Hamilton, ON, Canada
| | - Philippe Petit
- Department of Pediatric Radiology, Hopital Timone Enfants, Aix Marseille-Université, Marseille, France
| | - Lil-Sofie Ording Müller
- Division of Radiology and Nuclear Medicine, Department of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
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14
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Roy C, Godse A, Lall A, Peace R, Gopal M. Utility of F-15 diuretic MAG3 renography in assessment of paediatric hydronephrosis. J Pediatr Urol 2024:S1477-5131(24)00182-7. [PMID: 38614952 DOI: 10.1016/j.jpurol.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/15/2024]
Abstract
INTRODUCTION Diuretic renography is crucial in evaluation of paediatric hydronephrosis. Furosemide is conventionally given 15-20 min after radiolabelled tracer (F+15/F+20 protocol), however this is equivocal in around 15% of patients. Giving furosemide 15 min prior to tracer (F-15 MAG3 protocol) has been suggested as an additional tool in the investigation of patients with suspected upper urinary tract obstruction. However, the role of this method in assessment and management of paediatric hydronephrosis is not widely reported. OBJECTIVE To investigate utility of F-15 renograms in children with hydronephrosis being assessed for Pelvi-Ureteric Junction Obstruction (PUJO). STUDY DESIGN Retrospective review of patients <16 years old undergoing F-15 MAG3 renogram between 2018 and 2021 in our tertiary paediatric surgical centre. Data collected included patient demographics, mode of presentation, investigations, management and outcomes. RESULTS Eighteen patients were included. Median age at F-15 renogram was 7.3 years. Eleven patients presented with antenatal hydronephrosis, 5 with symptoms in childhood and 2 with incidental hydronephrosis on trauma imaging. Fourteen patients were symptomatic. Ten had a prior non-obstructed F+20 renogram but persisting symptoms suggestive of PUJO. Seven had previous equivocal F+20 renograms. One symptomatic patient directly underwent an F-15 renogram. A conclusive result was obtained in 16/18 (89%); 11 patients had obstructed curves and 5 non-obstructed. Two asymptomatic patients' scans were inconclusive. All symptomatic patients had conclusive scans. Of 11 patients with an obstructed F-15, 9 have undergone pyeloplasty to date. All have had post-operative resolution in symptoms and static or improved post-operative ultrasound. One patient with an inconclusive scan underwent pyeloplasty due to persisting hydronephrosis and parent preference. Three patients with non-obstructed F-15 renograms have been discharged. One symptomatic patient with a non-obstructive F-15 had a ureteric stent inserted due to persistent flank pain; 1 continues under surveillance. DISCUSSION It is known that conventional F+20 MAG3 renograms can give equivocal results. Published experience suggests that F-15 renograms are conclusive in the majority of patients. Routine primary use is, however, discouraged as they can 'over diagnose' obstruction and limit the study of tracer transit under physiological flow rates. This study indicates that the F-15 renogram is a useful adjunct in the assessment of patients with symptoms suggestive of PUJO who have previously had an equivocal or a non-obstructed F+20 renogram. CONCLUSION F-15 renogram was conclusive in 89% of patients. We recommend using F-15 renograms to aid surgical decision-making in children with equivocal F+20 renograms, especially in the presence of symptoms.
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Affiliation(s)
- Chloe Roy
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle upon Tyne, England.
| | - Alok Godse
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle upon Tyne, England.
| | - Anupam Lall
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle upon Tyne, England.
| | - Richard Peace
- Department of Nuclear Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, England.
| | - Milan Gopal
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle upon Tyne, England.
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15
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Shi T, Lao W, Ouyang K, Chen Y, Zhang Y, Luo J, Chen S. Laparoscopic pyeloplasty for newborns with severe hydronephrosis. Front Pediatr 2024; 12:1343211. [PMID: 38560400 PMCID: PMC10979644 DOI: 10.3389/fped.2024.1343211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Aim We aimed to investigate the short-term efficacy and safety of laparoscopic pyeloplasty for treating newborns with severe hydronephrosis due to ureteropelvic junction obstruction (UPJO). Methods A retrospective analysis was performed on 16 newborn patients with severe neonatal hydronephrosis who underwent laparoscopic pyeloplasty at our hospital from January 2021 to November 2022. All patients were regularly followed up. Laparoscopic pyeloplasty with double J stent placement was performed after the presence of severe hydronephrosis was confirmed. Results Among the 16 pediatric patients (13 males, 3 females), the left side was affected in 13 cases and the right side in 3. The average age at surgery was 9.50 (8.50-12.00) days, with an average weight of 3.30 ± 0.95 kg. Laparoscopic pyeloplasty was performed in all cases without the need for open conversion. The mean surgery duration was 292.06 ± 73.60 min, with minimal blood loss (2.50, 2.00-5.00 ml). Postoperative hospital stays averaged 13.44 ± 4.70 days. No anastomotic leakage occurred, and follow-ups at 1, 3, 6, and 12 months showed no stent displacement, except for one case where the stent was removed at 1 month, and the others at 3 months. There were no cases of worsened hydronephrosis, except for one with renal atrophy at the 6-month follow-up. Changes in renal pelvis anteroposterior diameter exhibited a time effect (F = 49.281, P < 0.001), with significant differences at 1, 3, 6, and 12 months postoperatively compared to preoperative values (P < 0.05). Notably, differences were observed between 6 and 3 months, as well as between 12 and 3 months postoperatively (P < 0.05). Similarly, renal parenchymal thickness changes showed a time effect Pediatric urology, Guangdong Women and Children Hospital, Guangzhou, China (F = 49.281, P < 0.001), with significant differences at 1, 3, 6, and 12 months postoperatively compared to preoperative values (P < 0.05). Significant differences were also noted between 6 and 1 month, as well as between 12 and 1 month postoperatively (P < 0.05). There was one case of urinary tract infection after surgery, and no case of recurrence was observed. Conclusion Severe neonatal hydronephrosis must be treated promptly. Laparoscopic pyeloplasty is a safe and feasible treatment with minimal complications for newborn patients with severe hydronephrosis due to UPJO.
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Affiliation(s)
| | - Weihua Lao
- Pediatric Urology, Guangdong Women and Children Hospital, Guangzhou, China
| | | | - Yueqing Chen
- Pediatric Urology, Guangdong Women and Children Hospital, Guangzhou, China
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16
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Santos AI, Ferreira RT. Nuclear medicine and pediatric nephro-urology: a long-lasting successful partnership. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2024; 68:3-22. [PMID: 38445832 DOI: 10.23736/s1824-4785.24.03557-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Congenital anomalies of the kidney and urinary tract, as well as urinary infections, are very frequent in children. After the clinical and laboratory evaluation, the first imaging procedure to be done is a renal and bladder ultrasound, but afterwards, a main contribution comes from nuclear medicine. Through minimally invasive and sedation-free procedures, nuclear medicine allows the evaluation of the functional anatomy of the urinary tract, and the quantification of renal function and drainage. If pediatric dosage cards provided by scientific societies are used, radiation exposure can also be low. In the pediatric conditions previously mentioned, nuclear medicine is used both for initial diagnosis and follow-up, mostly in cases of suspicion of ureteropelvic or ureterovesical junction syndromes, as well as vesicoureteral reflux or renal scars of febrile infectious episodes. Pediatric nephro-urology constitutes a significant workload of pediatric nuclear medicine departments. The following paragraphs are a revision of the renal radiopharmaceuticals, as well as the nuclear nephro-urology procedures - dynamic and static renal scintigraphy, and direct and indirect radionuclide cystography. A summary of the techniques, main indications, interpretation criteria and pitfalls will be provided. Some future directions for the field are also pointed out, among which the most relevant is the need for nuclear medicine professionals to use standardized protocols and integrate multidisciplinary teams with other pediatric and adult health professionals that manage these life-long pediatric pathologies, which are recognized as an important cause of adult chronic kidney disease.
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Affiliation(s)
- Ana I Santos
- Service of Nuclear Medicine, Hospital Garcia de Orta, Almada, Portugal -
- Nova Medical School, NOVA University, Lisbon, Portugal -
| | - Rita T Ferreira
- Service of Nuclear Medicine, Hospital Garcia de Orta, Almada, Portugal
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17
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Geminiganesan S, Kumar AR, Kumaravel S, Priya CDM, Arunaa S, Babu R. Comparison of Urinary Biomarkers in Diagnosis of Ureteropelvic Junction Obstruction and Differentiation from Nonobstructive Dilatation. J Indian Assoc Pediatr Surg 2024; 29:104-109. [PMID: 38616828 PMCID: PMC11014170 DOI: 10.4103/jiaps.jiaps_204_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/05/2023] [Accepted: 10/28/2023] [Indexed: 04/16/2024] Open
Abstract
Background and Aims Differentiation of nonobstructive dilatation (NOD) from ureteropelvic junction obstruction (UPJO) is a challenge in children with antenatally detected hydronephrosis. The aim of this study is to compare the utility of urinary biomarkers: carbohydrate antigen (CA 19-9), neutrophil gelatinase-associated lipocalin (NGAL), and kidney injury molecule (KIM) in diagnosing UPJO. Methods A prospective study was conducted after obtaining ethical clearance between 2021 and 2022. Group 1 - control group (n = 30): children with normal antenatal ultrasound with no urinary symptoms. Group 2 - study group (n = 48): children with unilateral hydronephrosis: Group 2a - NOD (n = 24): children stable on ultrasound and diuretic renogram and Group 2b - UPJO (n = 24): children who worsened to Grade 4 hydronephrosis on ultrasound/worsening of differential renal function (10% drop) on renogram who underwent pyeloplasty. Urinary biomarkers NGAL, KIM-1, and CA 19-9 were measured using the enzyme-linked immune absorbent assay method. Results The urine CA 19-9 level was 128.05 ± 4.08 U/mL in the UPJO group, and this was significantly higher (P = 0.001) than NOD, 70.29 ± 4.41, and controls, 1.91 ± 1.57. The urine NGAL level was 21.41 ± 4.44 pg/mL in UPJO, and this was significantly higher than controls, 2.669 ± 0.513, but not NOD, 24.55 ± 2.67. The urine KIM level was 817 ± 15.84 pg/mL in the UPJO group, and this was significantly higher than controls, 285 ± 8.10, but not NOD, 768.23 ± 15.12. Receiver operating characteristic analysis of CA 19-9 revealed a urine biomarker cutoff of 95 U/mL for diagnosing UPJO (sensitivity 95%; specificity 96%; and area under the curve 0.99). Conclusions CA 19-9 is a superior marker compared to NGAL and KIM in differentiating UPJO from NOD. Further studies with larger numbers are warranted.
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Affiliation(s)
- Sangeetha Geminiganesan
- Department of Paediatric Nephrology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Ashwin Raj Kumar
- Department of Paediatric Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - S. Kumaravel
- Department of Department of Paediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - C. D. Mohana Priya
- Department of Human Genetics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Sathyamurthy Arunaa
- Department of Paediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Ramesh Babu
- Department of Paediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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18
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Pakkasjärvi N, Belov S, Jahnukainen T, Kivisaari R, Taskinen S. Stratifying Antenatal Hydronephrosis: Predicting High-Grade VUR Using Ultrasound and Scintigraphy. Diagnostics (Basel) 2024; 14:384. [PMID: 38396423 PMCID: PMC10888138 DOI: 10.3390/diagnostics14040384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Antenatal hydronephrosis (AHN), detected in approximately one percent of prenatal ultrasounds, is caused by vesicoureteral reflux (VUR) in 15-21% of cases, a condition with significant risks such as urinary tract infections and renal scarring. Our study addresses the diagnostic challenges of VUR in AHN. Utilizing renal ultrasonography and scintigraphy, we developed a novel scoring system that accurately predicts high-grade VUR, optimizing diagnostic precision while minimizing the need for more invasive methods like voiding cystourethrogram (VCUG); (2) Methods: This retrospective study re-analyzed renal ultrasonography, scintigraphy, and VCUG images from infants admitted between 2003 and 2013, excluding cases with complex urinary anomalies; (3) Results: Our analysis included 124 patients (75% male), of whom 11% had high-grade VUR. The multivariate analysis identified visible ureter, reduced renal length, and decreased differential renal function (DRF) as primary predictors. Consequently, we established a three-tier risk score, classifying patients into low, intermediate, and high-risk groups for high-grade VUR, with corresponding prevalences of 2.3%, 22.2%, and 75.0%. The scoring system demonstrated 86% sensitivity and 79% specificity; (4) Conclusions: Our scoring system, focusing on objective parameters of the visible ureter, renal length, and DRF, effectively identifies high-grade VUR in AHN patients. This method enhances diagnostics in ANH by reducing reliance on VCUG and facilitating more tailored and less invasive patient care.
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Affiliation(s)
- Niklas Pakkasjärvi
- Department of Pediatric Surgery, Helsinki University Hospital, 000290 Helsinki, Finland; (S.B.); (S.T.)
| | - Sofia Belov
- Department of Pediatric Surgery, Helsinki University Hospital, 000290 Helsinki, Finland; (S.B.); (S.T.)
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Helsinki University Hospital, University of Helsinki, 000290 Helsinki, Finland;
| | - Reetta Kivisaari
- Department of Pediatric Radiology, Helsinki University Hospital, 000290 Helsinki, Finland;
| | - Seppo Taskinen
- Department of Pediatric Surgery, Helsinki University Hospital, 000290 Helsinki, Finland; (S.B.); (S.T.)
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19
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Mahmoud TA, Morsy EEDS, Morsy HAEA, Abouzeid AM, Elmoghazy HM. Predictors of surgical intervention for antenatally detected ureteropelvic junction obstruction (UPJO): A prospective multivariate analysis. Urologia 2024; 91:220-225. [PMID: 37232448 DOI: 10.1177/03915603231173009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE We aimed to identify clinical and radiological predictors of the need for surgical intervention in infants with antenatally detected UPJO. MATERIAL AND METHODS We prospectively followed infants born with antenatally diagnosed ureteropelvic junction obstruction (UPJO) presented at our outpatient clinics for evidence of obstructive injury with a standard protocol with ultrasonography and renal scintigraphy. Indications for surgery included progression of hydronephrosis on serial examinations, initial differential renal function (DFR) ⩽35% or >5% loss in sequential studies, and febrile urinary tract infection (UTI). Univariate and multivariate analyses were utilized to define the predictors for surgical intervention, while the appropriate cut-off value of the initial Anteroposterior diameter (APD) was determined using the receiver operator curve analysis. RESULTS Univariate analysis revealed a significant association between surgery, the initial APD, cortical thickness, Society for Fetal Urology grade, UTD risk group, initial DRF, and febrile UTI (p-value < 0.05). No significant association between surgery and sex or side of the affected kidney (p-value 0.91 and 0.38, respectively). On multivariate analysis, the initial APD, initial DRF, obstructed renographic curve, and febrile UTI (p-value < 0.05) were the only independent predictors for surgical intervention. An initial APD of 23 mm can predict surgical requirement, with a specificity of 95% and sensitivity of 70%. CONCLUSION For antenatally diagnosed UPJO, the APD value (at the age of 1 week), DFR value (at the age of 6-8 weeks), and febrile UTI during follow-up are significant and independent predictors of the need for surgical intervention. APD, when used with a cut-off value of 23 mm, is associated with high specificity and sensitivity for predicting surgical need.
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Nulens K, Lorenzo AJ, Dos Santos J, Ellul K, Rickard M. Fetal urinary tract dilation: What to tell the parents. Prenat Diagn 2024; 44:148-157. [PMID: 38117007 DOI: 10.1002/pd.6497] [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: 08/29/2023] [Revised: 11/04/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023]
Abstract
Urinary tract dilation (UTD), which refers to the abnormal dilation of the urinary collection system, is the most common finding on prenatal ultrasound and presents with varying severity, presentation, etiology, and prognosis. Prenatal classification and risk stratification aim to prevent postnatal complications, such as urinary tract infections and further kidney dysfunction. Parents expecting a child with UTD should be counseled by a multidisciplinary team consisting of maternal-fetal medicine specialists, and pediatric urology and nephrology providers. This review summarizes the key points in the diagnostic evaluation and management during the prenatal and initial postnatal period, focusing on the information that should be provided to future parents. We address frequently asked parental questions and concerns that our multidisciplinary clinical practice faces.
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Affiliation(s)
- Katrien Nulens
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Joana Dos Santos
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Katie Ellul
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mandy Rickard
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Selvi I, Dönmez Mİ, Değirmenci E, Zoroğlu H, Ziylan O, Oktar T. Voiding Cystourethrogram Before Pyeloplasty: To Do or Not To Do? Urology 2024; 184:182-188. [PMID: 37866651 DOI: 10.1016/j.urology.2023.10.003] [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: 08/20/2023] [Revised: 10/01/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE To assess the incidence of concomitant vesicoureteral reflux (VUR) in unilateral cases of ureteropelvic junction obstruction (UPJO) and to identify factors that predict VUR. METHODS Files of 381 pediatric patients who underwent unilateral pyeloplasty between 2000 and 2017 were retrospectively reviewed. A total of 270 patients with available data and ≥5 years of follow-up were eligible for this study. Demographic parameters, preoperative hydronephrosis grade, renal pelvis anteroposterior diameter (APD), renal parenchymal thickness (PT), split renal functions on MAG-3 scan and VUR status were noted. The patients were divided into two groups: those with concomitant VUR (group I, n: 24, 8.9%) and those without VUR (group II, n: 246, 91.1%). RESULTS Among 270 patients (205 boys, 75.9%) with a median age of 4 months (2-98), 197 (72.9%) had antenatal hydronephrosis. Median follow-up was 11 years (5-22). Among 24 patients with concurrent VUR, 6 (25%) had grade II VUR, whereas grade III-V VUR was detected in 18 (75%). Of these, 12 (50%) had ipsilateral VUR, 3 (12.5%) had contralateral, and 9 (37.5%) had bilateral VUR. In a median 137-month follow-up, spontaneous VUR resolution was observed in 6 (25%) patients, whereas 15 (62.5%) patients underwent endoscopic subureteral injection and 3 (12.5%) patients ureteroneocystostomy, respectively. Preoperative APD [35.5, (Inter Quantile Range) IQR (27.6-36.0) vs 26.5 IQR (25.0-35.0), P = .004] were significantly higher in group I, whereas group I had significantly lower PT [3.7, IQR (3.4-6.4) vs 5.8 IQR (4.4-6.1), P = .026]. Predictive factors for concomitant VUR were presentation with febrile UTI (odds ratio (OR): 2.769, P = .048), PT <3.95 mm (OR: 1.367, P = .043), and APD >28.8 mm (OR: 1.035, P = .001). CONCLUSION Our results indicated that concomitant VUR and UPJO might be detected in 1 out of every 11 patients undergoing pyeloplasty, while some type of surgical intervention for VUR was required in 75% of these patients. Thus, voiding cystourethrogram prior to pyeloplasty may be limited in those presenting with febrile urinary tract infection, having higher APD and lower PT on preoperative urinary ultrasonography.
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Affiliation(s)
- Ismail Selvi
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Istanbul, Turkey
| | - M İrfan Dönmez
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Istanbul, Turkey.
| | - Enes Değirmenci
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Istanbul, Turkey
| | - Hatice Zoroğlu
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Istanbul, Turkey
| | - Orhan Ziylan
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Istanbul, Turkey
| | - Tayfun Oktar
- İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, Istanbul, Turkey; Koç University, School of Medicine, Department of Urology, Istanbul, Turkey
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Shalash B, Ernst M, Stout M, Asti L, McLeod DJ. Clearance While Upright on Initial Diuretic Renography Predicts the Need for Surgery in Children With Congenital Hydronephrosis. Urology 2024; 184:212-216. [PMID: 38040296 DOI: 10.1016/j.urology.2023.11.004] [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: 07/26/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE To improve the predictive ability of diuretic renography (DR) for surgical intervention in children with congenital hydronephrosis (CH) and concern for ureteropelvic junction obstruction. METHODS Children with CH born between 2007 and 2021 who underwent initial DR prior to 6months of life, had both clearance while upright (CUP) and T ½ reported, and did not have immediate surgical intervention after the first DR were retrospectively evaluated for surgical intervention during the period of clinical observation. Once the optimal cut-points were identified for CUP and T ½, they were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS In total 65 patients were included in the final analysis with 33 (50.8%) undergoing surgical intervention (pyeloplasty) and 32 (49.2%) still on observation at last follow-up. The optimal cut-points for predicting surgical intervention were 28.1 minutes for T ½ and 22.4% for CUP. Applying the CUP cut-point of 22.4% we achieved a sensitivity of 60.6% (95% CI: 43.9-77.3), specificity of 96.9% (95% CI: 90.1-100.0), positive predictive value of 95.2% (95% CI: 86.1-100.0), and negative predictive value of 70.5% (95% CI: 57.0-83.9). CONCLUSION A low CUP accurately predicts surgical intervention in children with CH who are initially observed. Although there is no singular measure on DR that can with absolute certainty predict future clinical course, our data do suggest there is utility in incorporating CUP (if <22.4%) into the decision process. Further research is necessary to help guide the management of children with intermediate CUP values.
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Affiliation(s)
- Bayan Shalash
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | - Michael Ernst
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH
| | - Megan Stout
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH; The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lindsey Asti
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | - Daryl J McLeod
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH; The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, OH; The Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH.
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Fwu CW, Barthold JS, Mendley SR, Bennett K, Chan K, Wilkins KJ, Parsa A, Norton JM, Eggers PW, Kimmel PL, Schulman IH, Kirkali Z. Epidemiology of Infantile Ureteropelvic Junction Obstruction in the US. Urology 2024; 183:185-191. [PMID: 37802192 PMCID: PMC10843281 DOI: 10.1016/j.urology.2023.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE To describe sex- and diagnosis-specific comorbidities, outcomes, and secular trends associated with ureteropelvic junction obstruction (UPJO) in a large, real-world population diagnosed with hydronephrosis in infancy. MATERIALS AND METHODS We identified all infants ≤1 year old with ≥1 claim in the Optum Clinformatics 2007-2020 nationwide population database and used univariable and multivariable Cox regression analyses to estimate associations of demographic and clinical characteristics of infants with a UPJO diagnosis with surgical status. RESULTS Of 22,349 infants with hydronephrosis (1.1% of infants; males-1.4%, females-0.7%), 1722 (7.7%; 7.9%-males, 7.2%-females) had UPJO. Follow-up was ≥1 year in 1198 (70%) and ≥3 years in 555 (32%) cases, and UPJO repair was performed in 542 children (31.5%; 32.3%-males, 29.5%-females); 77.7% within 1 year and 97.3% within 3 years. UPJO repair was associated with prior urinary tract infection (UTI) (hazard ratio (HR) 1.41, 95% confidence interval (CI) 1.12-1.76) and South (HR 1.42, 95% CI 1.14-1.78) or Midwest (HR 1.60, 95% CI 1.26-2.04) geographic region but did not change over time. CONCLUSION This population-based study provides a real-world view of postnatally diagnosed hydronephrosis, focusing on UPJO, for which 522 cases (∼1/3) had ≥3 years continuous coverage. UPJO-associated comorbidities were more common in females, and the frequencies of UPJO-associated surgery and comorbidities were higher than in other studies. Other than UTI, no other associated kidney or urinary tract diagnoses were associated with UPJO repair. We identified unique sex- and diagnosis-specific differences in associated comorbidities and interventions in children diagnosed with UPJO in the first year of life.
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Affiliation(s)
- Chyng-Wen Fwu
- Division of Public Health Research, Social & Scientific Systems, Inc., a DLH Holdings Corp Company, Atlanta, GA.
| | - Julia S Barthold
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Susan R Mendley
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Kara Bennett
- Division of Public Health Research, Social & Scientific Systems, Inc., a DLH Holdings Corp Company, Atlanta, GA.
| | - Kevin Chan
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Kenneth J Wilkins
- Biostatistics Program, Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Afshin Parsa
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Jenna M Norton
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Paul W Eggers
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Paul L Kimmel
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Ivonne H Schulman
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
| | - Ziya Kirkali
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
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Xu B, Zhang JE, Ye L, Yuan CW. The progression of obstructive renal fibrosis in rats is regulated by ADAMTS18 gene methylation in the embryonic kidney through the AKT/Notch pathway. J Biochem Mol Toxicol 2024; 38:e23628. [PMID: 38229317 DOI: 10.1002/jbt.23628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/20/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024]
Abstract
This study aimed to explore the mechanism by which postembryonic renal ADAMTS18 methylation influences obstructive renal fibrosis in rats. After exposure to transforming growth factor (TGF)-β1 during the embryonic period, analysis of postembryonic renal ADAMTS18 methylation and expression levels was conducted. Histological analysis was performed to assess embryonic kidney lesions and damage. Western blot analysis was used to determine the expression of renal fibrosis markers. Rats with ureteral obstruction and a healthy control group were selected. The methylation levels of ADAMTS18 in the different groups were analyzed. Western blot analysis and immunohistochemistry were performed to analyze the expression of renal fibrosis markers, and kidney-related indicators were measured. Treatment with TGF-β1 resulted in abnormal development of the postembryonic kidney, which was characterized by rough kidney surfaces with mild depressions and irregularities on the outer surface. TGF-β1 treatment significantly promoted ADAMTS18 methylation and activated the protein kinase B (AKT)/Notch pathway. Ureteral obstruction was induced to establish a renal hydronephrosis model, which led to renal fibrotic injury in newborn rats. Overexpression of the ADAMTS18 gene alleviated renal fibrosis. The western blot results showed that compared to that in the control group, the expression of renal fibrosis markers was significantly decreased after ADAMTS18 overexpression, and there was a thicker renal parenchymal tissue layer and significantly reduced p-AKT/AKT and Notch1 levels. TGF-β1 can induce ADAMTS18 gene methylation in the postembryonic kidney, and the resulting downregulation of ADAMTS18 expression has long-term effects on kidney development, potentially leading to increased susceptibility to obstructive renal fibrosis. This mechanism may involve activation of the AKT/Notch pathway. Reversing ADAMTS18 gene methylation may reverse this process.
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Affiliation(s)
- Ben Xu
- Department of Urology, Peking University First Hospital and Institute of Urology, Peking University, Beijing, China
| | - Jia-En Zhang
- Department of Urology, Peking University First Hospital and Institute of Urology, Peking University, Beijing, China
| | - Lin Ye
- Department of Urology, Peking University First Hospital and Institute of Urology, Peking University, Beijing, China
| | - Chang-Wei Yuan
- Department of Urology, Peking University First Hospital and Institute of Urology, Peking University, Beijing, China
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Chan JY, Khondker A, Lee MJ, Kim JK, Chancy M, Chua ME, Santos JD, Brownrigg N, Richter J, Lorenzo AJ, Rickard M. The role of circumcision in preventing urinary tract infections in children with antenatal hydronephrosis: Systematic review and meta-analysis. J Pediatr Urol 2023; 19:766-777. [PMID: 37563014 DOI: 10.1016/j.jpurol.2023.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Circumcision has been reported to reduce the risk of urinary tract infections (UTIs) in boys with antenatal hydronephrosis (HN). Our aim was to compare the incidence of UTIs in circumcised vs. uncircumcised boys with antenatal HN by conducting a systematic review and meta-analysis. STUDY DESIGN A comprehensive search was performed until December 2022. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included: UTIs, continuous antibiotic prophylaxis (CAP) use, renal outcomes, and circumcision complications. Odds ratios (OR) and mean difference with 95% confidence interval (CI) were extrapolated from available data. Random-effects meta-analysis were performed. RESULTS Twenty-three studies describing 9093 boys with antenatal HN were identified, including 4677 uncircumcised and 4416 circumcised boys. Overall effect estimates demonstrate that circumcised boys have significantly reduced odds of developing any UTI [OR 0.26, 95%CI 0.21, 0.32; p < 0.001]]. In addition, there a significantly reduced odds of developing UTI when circumcised and on CAP [OR 0.19, 95% CI 0.13, 0.30; p < 0.001]. When stratifying by etiology, circumcision reduced the odds of UTI in boys with isolated HN [OR 0.33, 95% CI 0.16, 0.68; p = 0.003], vesicoureteral reflux [OR 0.23, 95% CI 0.13, 0.42; P < 0.00001], or with posterior urethral valves [OR 0.29, 95% CI 0.13, 0.64; p = 0.002]. DISCUSSION Circumcision reduces the incidence of UTIs in boys with antenatal HN. This review is limited by the varied definitions of UTIs and inconsistent reporting on HN etiology, renal outcomes, and circumcision complications. CONCLUSIONS Circumcision should be considered in boys with antenatal HN to prevent the risk of developing UTI. Further research is warranted to individualize the prophylactic role of circumcision for patients with HN.
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Affiliation(s)
- Justin Yh Chan
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Adree Khondker
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada
| | - Min Joon Lee
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Jin Kyu Kim
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Margarita Chancy
- Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Michael E Chua
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Joana Dos Santos
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Natasha Brownrigg
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Juliane Richter
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Mandy Rickard
- Division of Urology, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada; Division of Urology, Department of Surgery, University of Toronto, ON, Canada.
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Luithle T, Obermayr F, Dittmann H, Engel C, Etzler A, Kosch F, Menke IT, Schäfer M, Schuster T, Younsi N, Fuchs J. Determination of tissue tracer transit of Technetium-99m-mercaptoacetyltriglycine diuretic renography in infants with suspected ureteropelvic junction obstruction - A multicenter prospective observational study. J Pediatr Urol 2023; 19:780.e1-780.e7. [PMID: 37718234 DOI: 10.1016/j.jpurol.2023.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION There is an ongoing controversy regarding management of ureteropelvic junction obstruction in infants, with a shift towards a non-operative approach. However, precise predictors of outcome are lacking. Recent studies postulated a high prognostic value of Technetium-99m-mercaptoacetyltriglycine tissue tracer transit with regard to the development of an impaired differential renal function and its potential improvement following pyeloplasty. OBJECTIVE To evaluate the prognostic value of Technetium-99m-mercaptoacetyltriglycine tissue tracer transit for the occurrence of changes in differential renal function in infants with suspected unilateral ureteropelvic junction obstruction in a prospective observational multicenter study. STUDY DESIGN Infants below 3 months of age with a unilateral isolated hydronephrosis ≥ grade 3 received ultrasound and Technetium-99m-mercaptoacetyltriglycine diuretic renography at two different time points (timepoint 1 and timepoint 2). Data were analyzed at local centers and at the study center and were collected in an internet-based database system. Tissue tracer transit was determined for each diuretic renography, inter-observer variation for tissue tracer transit and standard parameters for judgement of differential renal function development were assessed. RESULTS Thirty-seven patients were analyzed. Median age was 11 weeks (7-15) at timepoint 1 and 26 weeks (19-33) at timepoint 2. A delayed tissue tracer transit at timepoint 1 was not associated with deterioration of differential renal function at timepoint 2 in both, locally (10/37 cases) and centrally (4/37) analyzed cases. However, sensitivity and specificity were poor. The intraclass correlation coefficient comparing local and central findings of tissue tracer transit and renal drainage demonstrated poor or fair agreement. Analysis of standard parameters for differential renal function development revealed a prognostic value only for the dichotomized anteroposterior renal pelvic diameter (APD, p = 0.03, 95%-CI 1.2-22.2). DISCUSSION Regarding the primary endpoint of our study, we could not confirm the hypothesis that delayed tissue tracer transit reliably predicts a subsequent decline in differential renal function in the cohort of patients studied. Whether the low age of the patients, technical problems in the correct assessment of tissue tracer transit by the investigator in early infancy, the study design, or the parameter itself played a role is debated. CONCLUSION In the presented setting tissue tracer transit was not useful as a predictive parameter for deterioration of differential renal function in infants with suspected unilateral ureteropelvic junction obstruction. Sensitivity and specificity of tissue tracer transit were not sufficient for risk stratification. Improved utility of tissue tracer transit as a marker might be achieved using a different study setting.
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Affiliation(s)
- Tobias Luithle
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany.
| | - Florian Obermayr
- Faculty of Medicine, University of Marburg, Baldingertrasse, 35043 Marburg, Germany.
| | - Helmut Dittmann
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Otfried-Müller-Str.14, 72076 Tuebingen, Germany.
| | - Corinna Engel
- Center for Pediatric Clinical Studies (CPCS), University Children's Hospital Tuebingen, Frondsbergstr. 23, 72070 Tuebingen, Germany.
| | - Andrea Etzler
- Department of Pediatric Surgery and Pediatric Urology, Klinikum Bremen-Mitte, St.-Jürgen-Str. 1, 28205 Bremen, Germany.
| | - Ferdinand Kosch
- Department of Pediatric Surgery, Städtisches Klinikum Karlsruhe, Moltkestr. 90, 76131 Karlsruhe, Germany.
| | - Ines Theresa Menke
- Department of Pediatric Surgery and Pediatric Urology, Medical Center Dortmund, Beurhausstr. 40, 44137 Dortmund, Germany.
| | - Mattias Schäfer
- Department of Pediatric Surgery and Pediatric Urology, Cnopf'sche Kinderklinik, St. Johannis-Mühlgasse 19, 90419 Nuremberg, Germany.
| | - Tobias Schuster
- Department of Pediatric Surgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany.
| | - Nina Younsi
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Joerg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany.
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Buchanan CL, Morris MA, Matlock D, Kempe A, Vemulakonda VM. Parental experience and understanding of parent-provider discussions of treatment for infants with ureteropelvic junction obstruction. PEC INNOVATION 2023; 2:100142. [PMID: 37588298 PMCID: PMC10426279 DOI: 10.1016/j.pecinn.2023.100142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 08/18/2023]
Abstract
Objective The purpose of the current study was to understand what families identify as necessary information to guide decision-making in the treatment of their child with UPJO. Methods We conducted semi-structured interviews with parents of children with UPJO using phenomenological methodology. Data were systematically analyzed according to principles of thematic analysis, using a team-based inductive approach. Results 32 parents were interviewed. Findings are organized by three major themes including barriers to meaningful participation in decision making, logistical aspects of the decision, and psychosocial aspects of the decision. Conclusion These findings suggest the need to increase parent education and understanding around medical and surgical decision-making, and the need to enhance psychosocial support for more meaningful parental engagement in the surgical decision-making process. Practice implications The findings from the interviews highlight the importance of caregivers needing clear and accurate information in order to engage in meaningful discussions related to surgical decision-making for decisions around surgery for UPJO treatment.
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Affiliation(s)
- Cindy L. Buchanan
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, USA
| | - Megan A. Morris
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Daniel Matlock
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Allison Kempe
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Vijaya M. Vemulakonda
- Department of Pediatric Urology, University of Colorado School of Medicine, Aurora, USA
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Guo K, Zhao D. The correlation between GFR and unit renal volume in infants with hydronephrosis measured by two imaging methods. Sci Rep 2023; 13:19556. [PMID: 37945690 PMCID: PMC10636024 DOI: 10.1038/s41598-023-46996-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 11/07/2023] [Indexed: 11/12/2023] Open
Abstract
The purpose of this study was to investigate the correlation between GFR and unit renal volume in infants with congenital hydronephrosis measured by 99mTc-DMSA static renal imaging and ultrasonography. According to the classification of hydronephrosis, 38 infants aged 0-12 months with congenital hydronephrosis were divided into six groups: healthy kidney groups, mild hydronephrosis groups, and severe hydronephrosis groups. Within one week, all patients underwent ultrasound, diuretic dynamic renal imaging, static renal imaging and lateral imagings of both kidneys after static renal imaging respectively. Pediatric renal volume was calculated using the improved formula length × width × thickness × 0.674, and then the renal function in per unit volume (GFR/unit volume, ml/cm3) was obtained. All statistical analysis was done with SPSS Statistics version 24.0. The renal function in per unit volume was a minimum of 1.62 ml/cm3 in left healthy kidney in static renal imaging, but the renal function in per unit volume was a maximum value of 2.20 ml/cm3 in right healthy kidney in ultrasonography. There was a strong positive correlation observed between GFR and renal volume in left healthy kidney group and left and right kidneys with mild hydronephrosis groups (r = 0.865, r = 0.872, r = 0.822). A moderate positive correlation was found between GFR and renal volume in right healthy kidney group and left and right kidneys wih severe hydronephrosis groups (r = 0.783, r = 0.542, r = 0.798). GFR in per unit volume ranged from 1.62 to 2.20 ml/cm3 in healthy kidney, and was significantly higher in right kidney as compared to in left kidney, and also decreased with the progression of hydronephrosis.
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Affiliation(s)
- Ke Guo
- Department of Nuclear Medicine, The Second Hospital of Shanxi Medical University, No.382 Wuyi Road, Taiyuan, 030001, Shanxi Province, China
| | - Deshan Zhao
- Department of Nuclear Medicine, The Second Hospital of Shanxi Medical University, No.382 Wuyi Road, Taiyuan, 030001, Shanxi Province, China.
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Sloan M, Li H, Lescay HA, Judge C, Lan L, Hajiyev P, Giger ML, Gundeti MS. Pilot study of machine learning in the task of distinguishing high and low-grade pediatric hydronephrosis on ultrasound. Investig Clin Urol 2023; 64:588-596. [PMID: 37932570 PMCID: PMC10630684 DOI: 10.4111/icu.20230170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE Hydronephrosis is a common pediatric urological condition, characterized by dilation of the renal collecting system. Accurate identification of the severity of hydronephrosis is crucial in clinical management, as high-grade hydronephrosis can cause significant damage to the kidney. In this pilot study, we demonstrate the feasibility of machine learning in differentiating between high and low-grade hydronephrosis in pediatric patients. MATERIALS AND METHODS We retrospectively reviewed 592 images from 90 unique patients ages 0-8 years diagnosed with hydronephrosis at the University of Chicago's Pediatric Urology Clinic. The study included 74 high-grade hydronephrosis (145 images) and 227 low-grade hydronephrosis (447 images). Patients were excluded if they had less than 2 studies prior to surgical intervention or had structural abnormalities. We developed a radiomic-based artificial intelligence algorithm incorporating computerized texture analysis and machine learning (support-vector machine) to yield a predictor of hydronephrosis grade. RESULTS Receiver operating characteristic analysis of the classifier output yielded an area under the curve value of 0.86 (95% CI 0.81-0.92) in the task of distinguishing between low and high-grade hydronephrosis using a five-fold cross-validation by kidney. In addition, a Mann-Kendall trend test between computer output and clinical hydronephrosis grade yielded a statistically significant upward trend (p<0.001). CONCLUSIONS Our findings demonstrate the potential of machine learning in the differentiation between low and high-grade hydronephrosis. Further studies are warranted to validate our findings and their generalizability for use in clinical practice as a means to predict clinical outcomes and the resolution of hydronephrosis.
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Affiliation(s)
- Matthew Sloan
- Department of Surgery, Section of Urology, University of Chicago, Chicago, IL, USA
| | - Hui Li
- Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Hernan A Lescay
- Department of Surgery, Section of Urology, University of Chicago, Chicago, IL, USA
| | - Clark Judge
- Department of Surgery, Section of Urology, University of Chicago, Chicago, IL, USA
| | - Li Lan
- Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Parviz Hajiyev
- Department of Surgery, Section of Urology, University of Chicago, Chicago, IL, USA
| | | | - Mohan S Gundeti
- Department of Surgery, Section of Urology, University of Chicago, Chicago, IL, USA.
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Taghavi K, Van Haltren K, Woods J, Tai D, Teoh M, Pacilli M, Nataraja RM, Kimber C. Influence of foetal position on the degree of isolated antenatal hydronephrosis. ANZ J Surg 2023; 93:2706-2709. [PMID: 37461270 DOI: 10.1111/ans.18611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/12/2023] [Accepted: 07/06/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUNDS The effect of foetal position on the degree of antenatal hydronephrosis (ANH) is unknown. We hypothesized that foetal position is an important contextual factor in ANH, with consequences on prenatal counselling and postnatal management. The current study aimed to investigate the effect of foetal position on the degree of ANH. METHODS A retrospective study was carried out on consecutive pregnancies with isolated ANH over a 10-year period. Gestational age, foetal presentation (cephalic vs. breech), and degree of ANH (as measured by the AP diameter) were retrieved. Foetuses with other ultrasound findings of the renal tract (renal parenchymal abnormality, ureteric dilatation, or bladder abnormalities) were excluded. Logistic regression analysis was conducted to examine the relationship between the anterior-posterior diameter (APD) and the mode of presentation (cephalic or breech). A P-value of <0.05 was considered significant. RESULTS Initially 745 scans were identified, with 436 included in the final analysis. Overall, there was an association between foetal presentation and APD regardless of trimester, with cephalic presentations having a greater APD (OR 1.07, 95% CI 1.02-1.11, P = 0.04). CONCLUSION Cephalic presentations are associated with a significantly greater APD indicating that foetal position should be considered when stratifying ANH. Furthermore, foetal position may be a contributing factor in the mechanism of 'physiological' hydronephrosis.
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Affiliation(s)
- Kiarash Taghavi
- Department of Paediatric Urology, Monash Children's Hospital, Monash Health, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Keith Van Haltren
- Monash Health Imaging, Monash Children's Hospital, Monash Health, Melbourne, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, Australia
| | - Jessica Woods
- Monash Health Imaging, Monash Children's Hospital, Monash Health, Melbourne, Australia
| | - Davina Tai
- Fetal Diagnostic Unit, Monash Health, Melbourne, Australia
| | - Mark Teoh
- Fetal Diagnostic Unit, Monash Health, Melbourne, Australia
| | - Maurizio Pacilli
- Department of Paediatrics, Monash University, Melbourne, Australia
- Department of Paediatric Surgery, Monash Children's Hospital, Monash Health, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Ramesh M Nataraja
- Department of Paediatrics, Monash University, Melbourne, Australia
- Department of Paediatric Surgery, Monash Children's Hospital, Monash Health, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Chris Kimber
- Department of Paediatric Urology, Monash Children's Hospital, Monash Health, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
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Herthelius M. Antenatally detected urinary tract dilatation: long-term outcome. Pediatr Nephrol 2023; 38:3221-3227. [PMID: 36920569 PMCID: PMC10465645 DOI: 10.1007/s00467-023-05907-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/26/2023] [Accepted: 02/06/2023] [Indexed: 03/16/2023]
Abstract
This review provides updated knowledge on the long-term outcomes among children with antenatally diagnosed urinary tract dilatation (UTD), previously often referred to as antenatal hydronephrosis. Different definitions of UTD exist, which makes comparison between studies and generalized conclusions difficult. Roughly, one-third of antenatally diagnosed UTD, defined as a renal pelvis anterior posterior diameter (APD) of ≥ 4 mm in the second trimester and/or ≥ 7 mm in the third trimester, will resolve before birth, another third will resolve within the first years of life, and in the remaining cases, UTD will persist or a congenital abnormality (CAKUT) will be diagnosed postnatally. The risk of a postnatal CAKUT diagnosis increases with the degree of prenatal and postnatal dilatation, except for vesicoureteral reflux (VUR), which cannot be predicted from the degree of UTD. Urinary tract infections (UTIs) occur in 7-14% of children with UTD during the first years of life. The risk of UTI is higher in children with traditional risk factors for UTI, such as dilated VUR, hydroureteronephrosis, female gender, and intact foreskin. Continuous antibiotic prophylaxis may be considered in selected patients during the first years of life. In long-term follow-ups, permanent kidney damage is diagnosed in approximately 40% of children with moderate or severe UTD, but hypertension, proteinuria, and/or reduced eGFR are uncommon (0-5%). In children with mild UTD, the long-term outcome is excellent, and these children should not be subjected to unnecessary examinations and/or follow-up.
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Affiliation(s)
- Maria Herthelius
- Astrid Lindgren Children's Hospital, K88, Karolinska University Hospital, 141 86, Stockholm, Sweden.
- Division of Paediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden.
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Ostrowski DA, Logan JR, Antony M, Broms R, Weiss DA, Van Batavia J, Long CJ, Smith AL, Zderic SA, Edwins RC, Pominville RJ, Hannick JH, Woo LL, Fan Y, Tasian GE, Weaver JK. Automated Society of Fetal Urology (SFU) grading of hydronephrosis on ultrasound imaging using a convolutional neural network. J Pediatr Urol 2023; 19:566.e1-566.e8. [PMID: 37286464 DOI: 10.1016/j.jpurol.2023.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/14/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Grading of hydronephrosis severity on postnatal renal ultrasound guides management decisions in antenatal hydronephrosis (ANH). Multiple systems exist to help standardize hydronephrosis grading, yet poor inter-observer reliability persists. Machine learning methods may provide tools to improve the efficiency and accuracy of hydronephrosis grading. OBJECTIVE To develop an automated convolutional neural network (CNN) model to classify hydronephrosis on renal ultrasound imaging according to the Society of Fetal Urology (SFU) system as potential clinical adjunct. STUDY DESIGN A cross-sectional, single-institution cohort of postnatal renal ultrasounds with radiologist SFU grading from pediatric patients with and without hydronephrosis of stable severity was obtained. Imaging labels were used to automatedly select sagittal and transverse grey-scale renal images from all available studies from each patient. A VGG16 pre-trained ImageNet CNN model analyzed these preprocessed images. Three-fold stratified cross-validation was used to build and evaluate the model that was used to classify renal ultrasounds on a per patient basis into five classes based on the SFU system (normal, SFU I, SFU II, SFU III, or SFU IV). These predictions were compared to radiologist grading. Confusion matrices evaluated model performance. Gradient class activation mapping demonstrated imaging features driving model predictions. RESULTS We identified 710 patients with 4659 postnatal renal ultrasound series. Per radiologist grading, 183 were normal, 157 were SFU I, 132 were SFU II, 100 were SFU III, and 138 were SFU IV. The machine learning model predicted hydronephrosis grade with 82.0% (95% CI: 75-83%) overall accuracy and classified 97.6% (95% CI: 95-98%) of the patients correctly or within one grade of the radiologist grade. The model classified 92.3% (95% CI: 86-95%) normal, 73.2% (95% CI: 69-76%) SFU I, 73.5% (95% CI: 67-75%) SFU II, 79.0% (95% CI: 73-82%) SFU III, and 88.4% (95% CI: 85-92%) SFU IV patients accurately. Gradient class activation mapping demonstrated that the ultrasound appearance of the renal collecting system drove the model's predictions. DISCUSSION The CNN-based model classified hydronephrosis on renal ultrasounds automatically and accurately based on the expected imaging features in the SFU system. Compared to prior studies, the model functioned more automatically with greater accuracy. Limitations include the retrospective, relatively small cohort, and averaging across multiple imaging studies per patient. CONCLUSIONS An automated CNN-based system classified hydronephrosis on renal ultrasounds according to the SFU system with promising accuracy based on appropriate imaging features. These findings suggest a possible adjunctive role for machine learning systems in the grading of ANH.
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Affiliation(s)
- David A Ostrowski
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Joseph R Logan
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Translational Research Informatics Group, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maria Antony
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Reilly Broms
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dana A Weiss
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jason Van Batavia
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher J Long
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ariana L Smith
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Stephen A Zderic
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca C Edwins
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Raymond J Pominville
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jessica H Hannick
- Division of Pediatric Urology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Lynn L Woo
- Division of Pediatric Urology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Yong Fan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory E Tasian
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John K Weaver
- Division of Pediatric Urology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
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Gulyuz A, Tekin M. The Diagnostic Efficacy of and Requirement for Postnatal Ultrasonography Screening for Congenital Anomalies of the Kidney and Urinary Tract. Diagnostics (Basel) 2023; 13:3106. [PMID: 37835849 PMCID: PMC10572234 DOI: 10.3390/diagnostics13193106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND We aimed to investigate the efficacy of postnatal ultrasonography in detecting congenital anomalies of the kidneys and urinary tract in term infants without prenatal history of congenital anomalies of the kidneys and urinary tract. METHODS In this retrospective cohort study, we reviewed the records of term infants between six weeks and three months of age who underwent urinary tract ultrasonography during routine pediatric care. RESULTS Congenital anomalies of the kidneys and urinary tract were detected on prenatal ultrasonography in 75 of the 2620 patients included in the study. Congenital anomalies of the kidneys and urinary tract were detected via postnatal USG in 46 (1.8%) of 2554 patients without anomalies on prenatal USG screening. The most common anomaly was hydronephrosis (69.6%). Thirty-two cases of hydronephrosis, three cases of renal agenesis, four cases of horseshoe kidney, one case of MCDK, and two cases of duplex systems which were not detected on prenatal USG were detected on postnatal USG. On the other hand, 29 (1.1%) cases with mild or moderate hydronephrosis on prenatal ultrasonography did not have hydronephrosis on postnatal ultrasonography. CONCLUSIONS In our study, approximately one-third of the cases of hydronephrosis, unilateral renal agenesis, duplex systems, horseshoe kidney, and ectopic kidney were not detected in prenatal ultrasonography screening. Therefore, we believe that in addition to prenatal ultrasonography screening, postnatal ultrasonography screening of all children for urinary tract anomalies would be beneficial.
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Affiliation(s)
- Abdulgani Gulyuz
- Department of Pediatrics, School of Medicine, Turgut Ozal University, 06560 Malatya, Turkey;
| | - Mehmet Tekin
- Department of Pediatrics, School of Medicine, Inonu University, 44280 Malatya, Turkey
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Högberg L, Värelä S, Anderberg M, Salö M. Sex differences in children operated with pyeloplasty for pelvoureteric junction obstruction. Pediatr Surg Int 2023; 39:270. [PMID: 37682361 PMCID: PMC10491548 DOI: 10.1007/s00383-023-05543-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE Pelvoureteric junction obstruction (UPJO) is a common cause of hydronephrosis in children but no previous studies have evaluated differences between boys and girls operated with pyeloplasty. This study aimed to evaluate potential differences between sexes in children operated with pyeloplasty for PUJO in terms of presentation, surgery, and long-term results. METHODS Data was retrospectively collected from all children operated on with pyeloplasty between January 2002 and December 2020. Data contained several variables covering presentation, surgery, and long-term results. RESULTS In total, 194 patients were included of which 126 (64.9%) were boys. There were no significant differences in prenatal findings, pelvic dilation on ultrasound, function of the affected kidney, surgical method, obstruction type, resolution of hydronephrosis, or improvement of function. Boys presented with pain more often than girls (47.4 vs 25.0%, p < 0.01) while girls were more prone to infections preoperatively (17.2 vs 7.0%, p = 0.04). All nine patients requiring reoperation were boys (p = 0.03). CONCLUSION Girls with UPJO seem to experience infections as presenting symptoms more often than boys, while boys significantly more often present with pain. There is also a higher percentage of boys needing reoperation.
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Affiliation(s)
- Linnea Högberg
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Sanni Värelä
- Department of Clinical Sciences, Pediatrics, Lund University, Lasarettsgatan 48, 221 85, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Magnus Anderberg
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Pediatrics, Lund University, Lasarettsgatan 48, 221 85, Lund, Sweden
| | - Martin Salö
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden.
- Department of Clinical Sciences, Pediatrics, Lund University, Lasarettsgatan 48, 221 85, Lund, Sweden.
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Ajiki J, Naitoh Y, Kanazawa M, Fujihara A, Ukimura O. Assessment of lower urinary tract function in pediatrics using ultrasonography. J Med Ultrason (2001) 2023:10.1007/s10396-023-01358-z. [PMID: 37656379 DOI: 10.1007/s10396-023-01358-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023]
Abstract
Ultrasound imaging is a less invasive imaging modality without radiation exposure and is available for repeated tests. It is the gold standard examination for diagnosing and managing disorders of the urinary tract, including lower urinary tract dysfunction (LUTD) in pediatric urology. Ultrasound imaging is effective for screening underlying diseases and determining treatment strategies. Ultrasound examination at the bedside should focus on post-voided residual urine (PVR), bladder wall thickening, renal morphology, and rectal diameter. Since PVR must be tested immediately after voiding, examining infants who cannot complain of the urge to void is difficult. PVR measurement combined with a 4-h voiding observation or alarm system activated by urine is recommended for these infants. Early diagnosis is important because LUTD is associated with the risk of morbid residual urine and high voiding pressure, which can result in renal deterioration, urinary leakage, and febrile urinary tract infection.
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Affiliation(s)
- Jun Ajiki
- Kyoto-Chubu Medical Center, Yagicho-Yagiueno 25, Nantan City, Kyoto, 629-0197, Japan.
- Department of Urology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji 465, Kyoto City, Kyoto, 602-8566, Japan.
| | - Yasuyuki Naitoh
- Department of Urology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji 465, Kyoto City, Kyoto, 602-8566, Japan
| | - Motohiro Kanazawa
- Kyoto-Chubu Medical Center, Yagicho-Yagiueno 25, Nantan City, Kyoto, 629-0197, Japan
| | - Atsuko Fujihara
- Department of Urology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji 465, Kyoto City, Kyoto, 602-8566, Japan
| | - Osamu Ukimura
- Department of Urology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji 465, Kyoto City, Kyoto, 602-8566, Japan
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Bortnick EM, Nelson CP. Vesicoureteral Reflux: Current Care Trends and Future Possibilities. Urol Clin North Am 2023; 50:391-402. [PMID: 37385702 DOI: 10.1016/j.ucl.2023.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Although investigations over the past 2 decades have improved our understanding of the natural history of vesicoureteral reflux (VUR) and helped identify those at higher risk of both VUR itself as well as its potential severe sequelae, debate exists regarding key aspects of care, including when to perform diagnostic imaging and which patients benefit from continuous antibiotic prophylaxis. Artificial intelligence and machine learning have the potential to distill large volumes of granular data into practical tools that clinicians can use to guide diagnosis and management decisions. Surgical treatment, when indicated, remains highly effective and is associated with low morbidity.
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Affiliation(s)
- Eric M Bortnick
- Department of Pediatric Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Caleb P Nelson
- Department of Pediatric Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Li J, Fu Y, Liu Q, Shen K, Yao R, Fu Y, Lu Y, Xie M, Jian W, Guo M, Dai L, Zhang W. Multiomics-based study of amniotic fluid small extracellular vesicles identified Moesin as a biomarker for antenatal hydronephrosis. Clin Transl Med 2023; 13:e1360. [PMID: 37531302 PMCID: PMC10395771 DOI: 10.1002/ctm2.1360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/22/2023] [Accepted: 07/28/2023] [Indexed: 08/04/2023] Open
Affiliation(s)
- Jingzhi Li
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
- Hunan Engineering Research Center of Early Life Development and Disease PreventionChangshaChina
| | - Ying Fu
- Department of Oncology, NHC Key Laboratory of Cancer Proteomics and State Local Joint Engineering Laboratroy for Anticancer DrugsXiangya Hospital, Central South UniversityChangshaChina
| | - Qiaoshu Liu
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
| | - Kuifang Shen
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
| | - Ruojin Yao
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
| | - Yimei Fu
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
| | - Yang Lu
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
- Hunan Engineering Research Center of Early Life Development and Disease PreventionChangshaChina
| | - Mingkun Xie
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
- Hunan Engineering Research Center of Early Life Development and Disease PreventionChangshaChina
| | - Wenyan Jian
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
| | - Ming Guo
- Department of Oncology, NHC Key Laboratory of Cancer Proteomics and State Local Joint Engineering Laboratroy for Anticancer DrugsXiangya Hospital, Central South UniversityChangshaChina
| | - Lei Dai
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
- Hunan Engineering Research Center of Early Life Development and Disease PreventionChangshaChina
| | - Weishe Zhang
- Department of ObstetricsXiangya Hospital Central South UniversityChangshaChina
- Hunan Engineering Research Center of Early Life Development and Disease PreventionChangshaChina
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Li B, Ramesh S, McGrath M, Braga LH. Association of the Hydronephrosis Severity Score With Likelihood of Pyeloplasty: A Large Prospective Database Analysis. Urology 2023; 177:162-168. [PMID: 37088315 DOI: 10.1016/j.urology.2023.04.011] [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: 01/19/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To apply and reproduce this scoring system in our prenatal hydronephrosis population with ureteropelvic junction obstruction (UPJO)-like hydronephrosis (HN), specifically looking at determining better HHS cutoffs that would allow for stratification into three risk categories: spontaneous HN resolution, observation, and surgery. METHODS A prospectively collected prenatal hydronephrosis database was reviewed to extract UPJO-like HN patients. Children with vesicoureteral reflux, primary megaureter, bilateral HN, and other associated anomalies were excluded. Only patients who had an ultrasound and mercaptoacetyltriglycine renal scan at a minimum of 2-time points were included. Hydronephrosis Severity Score was calculated at the initial, interim, and last follow-up clinic visits. Scores were analyzed regarding its usefulness to determine which patients would have been more likely to undergo pyeloplasty. RESULTS Of 167 patients, 131 (78%) were male, 119 (71%) had left UPJO-like, and 113 (67%) had a pyeloplasty. The median age at baseline was 2months (interquartile range 1-4). According to initial (first clinic visit) Hydronephrosis Severity Score, 5/36 (14%) patients with a 0-4 score, 93/116 (80%) with a 5-8 score, and 15/15 (100%) with a 9-12 score underwent pyeloplasty, respectively (P < .01). CONCLUSION The proposed HHS system for UPJO-like HN patients is reproducible, however, cut-off values need to be reassessed to accurately reflect true risk categories, as the purpose of this system is to differentiate those who have HN severe enough to require intervention from those who can be managed nonsurgically. Changing risk groups to mild (0-3), moderate (4-6), and severe (7-12) allowed for better discrimination between patients who underwent surgical intervention from those who did not in our dataset.
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Affiliation(s)
- Bruce Li
- Division of Urology, Department of Surgery, Western University, London, Ontario, Canada
| | - Smruthi Ramesh
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Melissa McGrath
- McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, Ontario, Canada
| | - Luis H Braga
- McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Urology, McMaster University, Hamilton, Ontario, Canada.
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Vazouras K, Jackson C, Folgori L, Anastasiou-Katsiardani A, Hsia Y, Basmaci R. Quality indicators for appropriate antibiotic prescribing in urinary tract infections in children. BMC Infect Dis 2023; 23:400. [PMID: 37308821 DOI: 10.1186/s12879-023-08356-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 05/29/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The aim of this study was to define a set of urinary tract infections (UTIs)-specific quality indicators for appropriate prescribing in children and evaluate clinical practices in a district general hospital in Greece. METHODS The UTIs-specific quality indicators were informed by a review of the existing literature. Quality indicators were selected to describe the overall antibiotics use, prescribing patterns and UTIs clinical management regarding treatment and prophylaxis in a cohort of children admitted with a UTI. Microbiological, clinical and prescribing data about dosing, duration and route of administration were collected from the patients' electronic health records. RESULTS Twelve quality indicators were adapted or developed for prescribing in childhood UTIs. A broad variety of antibiotics were prescribed for UTIs, with a drug utilization (DU) 90% rate of 6 and 9 different antibiotics for febrile and afebrile UTIs, respectively. Despite the low incidence of multi-drug resistant UTIs in the study period (9/261, 3.4%), broad-spectrum antibiotics were prescribed in 33.5% (164/490) of prescriptions. A total of 62.8% (164/261) of patients were started on empiric combined therapies, while opportunities to de-escalate were missed in 37.8% (62/164) of them. One quarter (67/261, 25.7%) of patients did not fulfil the criteria for receiving treatment, while nearly half of those prescribed prophylaxis (82/175, 46.9%) could have avoided having a prophylaxis prescription. CONCLUSIONS Our study identified substantial gaps for improvement in antimicrobial prescribing for UTIs in children. The application of the proposed quality indicators could help to limit unnecessary antibiotics use in children with UTI.
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Affiliation(s)
- Konstantinos Vazouras
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte Jackson
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0QT, England
| | - Laura Folgori
- Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | | | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, Cranmer Terrace, London, SW17 0QT, England.
- Queen's University Belfast, School of Pharmacy, 97 Lisburn Road, Belfast, BT9 7BL, UK.
| | - Romain Basmaci
- Service de Pédiatrie-Urgences, Hôpital Louis-Mourier, Assistance Publique - Hôpitaux de Paris, 92700, Colombes, France
- Université de Paris, Infection, Antimicrobiens, Modélisation, Evolution, Unité Mixte de Recherche 1137, Institut National de La Santé Et de La Recherche Médicale, 75006, Paris, France
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Meng X, He Z, Guo L, Lin H, Feng L. OSCA-finder: Redefining the assay of kidney disease diagnostic through metabolomics and deep learning. Talanta 2023; 264:124745. [PMID: 37290332 DOI: 10.1016/j.talanta.2023.124745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/12/2023] [Accepted: 05/25/2023] [Indexed: 06/10/2023]
Abstract
Liquid chromatography-mass spectrometry (LC-MS) is a platform for urine and blood sample analysis. However, the high variability in the urine sample reduced the confidence of metabolite identification. Therefore, pre and post-calibration operations are inevitable to ensure an accurate urine biomarker analysis. In this study, the phenomenon of a higher creatinine concentration variable in ureteropelvic junction obstruction (UPJO) patient urine samples than in healthy people was revealed, indicating the urine biomarker discovery of UPJO patients is not adapted to the creatinine calibrate strategy. Therefore, we proposed a pipeline "OSCA-Finder" to reshape the urine biomarker analysis. First, to ensure a more stable peak shape and total ion chromatography, we applied the product of osmotic pressure and injection volume as a calibration principle and integrated it with an online mixer dilution. Therefore, we obtained the most peaks and identified more metabolites in a urine sample with peak area group CV<30%. A data-enhanced strategy was applied to reduce the overfit while training a neural network binary classifier with an accuracy of 99.9%. Finally, seven accurate urine biomarkers combined with a binary classifier were applied to distinguish UPJO patients from healthy people. The results show that the UPJO diagnostic strategy based on urine osmotic pressure calibration has more potential than ordinary strategies.
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Affiliation(s)
- Xuanlin Meng
- Instrumental Analysis Center, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Zhian He
- Instrumental Analysis Center, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Lizhen Guo
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Houwei Lin
- Department of Pediatric Urology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China; Department of Pediatric Surgery, Jiaxing Women and Children Hospital Affiliated to Wenzhou Medical University, Jiaxing, 314050, China.
| | - Lei Feng
- Instrumental Analysis Center, Shanghai Jiao Tong University, Shanghai, 200240, China.
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Reed F, Recabal X, Echeverría P, Braga LH, Cherian A, Gatti JM, Garcia-Aparicio L, Perez-Bertolez S, de Badiola F, Bujons A, Moldes JM, Mushtaq I, López PJ. Are weight or age limits for pediatric laparoscopic pyeloplasty? Results of a multicentric study. World J Urol 2023; 41:1675-1679. [PMID: 36947174 DOI: 10.1007/s00345-023-04359-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/21/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Anderson-Hynes pyeloplasty is the technique of choice for the treatment of pyeloureteral junction obstruction (PUJO) with an excellent success rate. Minimally invasive surgery has become the standard of care for the management of PUJO in children. Although it has been comparable to the open approach at all levels, its diffusion or employment in younger children has not been widely adopted. Our aim is to evaluate laparoscopic pyeloplasty outcomes from international academic centers in children under 1 year of age, focusing on feasibility and outcomes including possible complications. MATERIALS AND METHODS This is review of consecutive infants under 1 year of age who underwent laparoscopic pyeloplasty between 2009 and 2018 with more than 12 months of follow-up. Seven different training centers with different backgrounds participated in this study. Evaluation was carried out with ultrasound and renogram before and after surgery. Demographic data, perioperative characteristics, complications, and results are described and analyzed. RESULTS Over 9 years, 124 transperitoneal laparoscopic Anderson-Hynes pyeloplasties were performed on 123 children under 1 year of age; 88 males and 35 females, with 1 case of bilateral PUJO. Of the 124 renal units, 86 were left-sided. Mean age at surgery was 6.6 months (1 week-12 months), with 56% (n = 70) done before 6 months of age. Mean weight at surgery was 6.8 kg (3-12 kg), with 59% (n = 73) weighing less than 8 kg. Mean operative time (skin-to-skin) was 150 min (75-330 min). After a mean follow-up of 46 months (12-84 months), 12 (9%) patients developed complications, with only 1 needing a redo pyeloplasty also done laparoscopically. One child, with deterioration in renal function, underwent nephrectomy. CONCLUSION Laparoscopic pyeloplasty under 1 year of age and/or less than 12 kilos is feasible with lower complication rate. Furthermore, age younger than 6 months and weight less than 8 kg are no longer limiting factors for a successful pyeloplasty as shown by this multicentre study.
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Affiliation(s)
- Francisco Reed
- Hospital Exequiel González Cortés and Clínica Alemana, Santiago, Chile.
- Pediatric Urology Service, Hospital Dr. Exequiel González Cortés and Clínica Alemana, Universidad de Chile, Av Gran Avenida 3300, San Miguel, Santiago, Chile.
| | | | | | | | | | | | | | | | | | | | | | | | - Pedro-José López
- Hospital Exequiel González Cortés and Clínica Alemana, Santiago, Chile
- McMaster University, Hamilton, Canada
- Great Ormond Street Hospital, London, England
- Children's Mercy Hospital, Kansa City, MO, USA
- Hospital Saint Joan de Deu, Barcelona, Spain
- Hospital Italiano, Buenos Aires, Argentina
- Fundación Puigvert, Barcelona, Spain
- Facultad Medicina, Servicio Pediatria y Cirugia Infantil, Universidad de Chile, Santiago, Chile
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Ahram DF, Lim TY, Ke J, Jin G, Verbitsky M, Bodria M, Kil BH, Chatterjee D, Piva SE, Marasa M, Zhang JY, Cocchi E, Caridi G, Gucev Z, Lozanovski VJ, Pisani I, Izzi C, Savoldi G, Gnutti B, Capone VP, Morello W, Guarino S, Esposito P, Lambert S, Radhakrishnan J, Appel GB, Uy NS, Rao MK, Canetta PA, Bomback AS, Nestor JG, Hays T, Cohen DJ, Finale C, van Wijk JA, La Scola C, Baraldi O, Tondolo F, Di Renzo D, Jamry-Dziurla A, Pezzutto A, Manca V, Mitrotti A, Santoro D, Conti G, Martino M, Giordano M, Gesualdo L, Zibar L, Masnata G, Bonomini M, Alberti D, La Manna G, Caliskan Y, Ranghino A, Marzuillo P, Kiryluk K, Krzemień G, Miklaszewska M, Lin F, Montini G, Scolari F, Fiaccadori E, Arapović A, Saraga M, McKiernan J, Alam S, Zaniew M, Szczepańska M, Szmigielska A, Sikora P, Drożdż D, Mizerska-Wasiak M, Mane S, Lifton RP, Tasic V, Latos-Bielenska A, Gharavi AG, Ghiggeri GM, Materna-Kiryluk A, Westland R, Sanna-Cherchi S. Rare Single Nucleotide and Copy Number Variants and the Etiology of Congenital Obstructive Uropathy: Implications for Genetic Diagnosis. J Am Soc Nephrol 2023; 34:1105-1119. [PMID: 36995132 PMCID: PMC10278788 DOI: 10.1681/asn.0000000000000132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/18/2023] [Indexed: 03/31/2023] Open
Abstract
SIGNIFICANCE STATEMENT Congenital obstructive uropathy (COU) is a prevalent human developmental defect with highly heterogeneous clinical presentations and outcomes. Genetics may refine diagnosis, prognosis, and treatment, but the genomic architecture of COU is largely unknown. Comprehensive genomic screening study of 733 cases with three distinct COU subphenotypes revealed disease etiology in 10.0% of them. We detected no significant differences in the overall diagnostic yield among COU subphenotypes, with characteristic variable expressivity of several mutant genes. Our findings therefore may legitimize a genetic first diagnostic approach for COU, especially when burdening clinical and imaging characterization is not complete or available. BACKGROUND Congenital obstructive uropathy (COU) is a common cause of developmental defects of the urinary tract, with heterogeneous clinical presentation and outcome. Genetic analysis has the potential to elucidate the underlying diagnosis and help risk stratification. METHODS We performed a comprehensive genomic screen of 733 independent COU cases, which consisted of individuals with ureteropelvic junction obstruction ( n =321), ureterovesical junction obstruction/congenital megaureter ( n =178), and COU not otherwise specified (COU-NOS; n =234). RESULTS We identified pathogenic single nucleotide variants (SNVs) in 53 (7.2%) cases and genomic disorders (GDs) in 23 (3.1%) cases. We detected no significant differences in the overall diagnostic yield between COU sub-phenotypes, and pathogenic SNVs in several genes were associated to any of the three categories. Hence, although COU may appear phenotypically heterogeneous, COU phenotypes are likely to share common molecular bases. On the other hand, mutations in TNXB were more often identified in COU-NOS cases, demonstrating the diagnostic challenge in discriminating COU from hydronephrosis secondary to vesicoureteral reflux, particularly when diagnostic imaging is incomplete. Pathogenic SNVs in only six genes were found in more than one individual, supporting high genetic heterogeneity. Finally, convergence between data on SNVs and GDs suggest MYH11 as a dosage-sensitive gene possibly correlating with severity of COU. CONCLUSIONS We established a genomic diagnosis in 10.0% of COU individuals. The findings underscore the urgent need to identify novel genetic susceptibility factors to COU to better define the natural history of the remaining 90% of cases without a molecular diagnosis.
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Affiliation(s)
- Dina F. Ahram
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Tze Y. Lim
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Juntao Ke
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Gina Jin
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Miguel Verbitsky
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Monica Bodria
- Division of Nephrology and Renal Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Byum Hee Kil
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Debanjana Chatterjee
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Stacy E. Piva
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Maddalena Marasa
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Jun Y. Zhang
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Enrico Cocchi
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Gianluca Caridi
- Division of Nephrology and Renal Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Laboratory on Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Zoran Gucev
- Medical Faculty of Skopje, University Children's Hospital, Skopje, Macedonia
| | - Vladimir J. Lozanovski
- Medical Faculty of Skopje, University Children's Hospital, Skopje, Macedonia
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Isabella Pisani
- Unità Operativa Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Claudia Izzi
- Division of Nephrology, Department of Obstetrics and Gynecology, ASST Spedali Civili of Brescia, Brescia, Italy
| | | | - Barbara Gnutti
- Medical Genetics Laboratory, ASST-Spedali Civili, Brescia, Italy
| | - Valentina P. Capone
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Guarino
- Department of Woman and Child and of General and Specialized Surgery, Università degli Studi della Campania “Luigi Vanvitelli,” Naples, Italy
| | - Pasquale Esposito
- Department of Internal Medicine, University of Genoa, Genova, Italy
- Unit of Nephrology, IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Sarah Lambert
- Yale School of Medicine/Yale New Haven Health System, New Haven, Connecticut
| | - Jai Radhakrishnan
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Gerald B. Appel
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Natalie S. Uy
- Division of Pediatric Nephrology, Department of Pediatric, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Maya K. Rao
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Pietro A. Canetta
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Andrew S. Bomback
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Jordan G. Nestor
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Thomas Hays
- Department of Pediatrics, Division of Neonatology, Columbia University, New York, New York
| | - David J. Cohen
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Carolina Finale
- Nephrology, Dialysis and Renal Transplantation Unit, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I, Lancisi, Salesi of Ancona, Ancona, Italy
| | - Joanna A.E. van Wijk
- Department of Pediatric Nephrology, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Claudio La Scola
- Nephrology and Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - Olga Baraldi
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Dacia Di Renzo
- “Spirito Santo” Hospital of Pescara, Pediatric Surgery of “G. d'Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Anna Jamry-Dziurla
- Polish Registry of Congenital Malformations, Chair and Department of Medical Genetics, University of Medical Sciences, Poznan, Poland
| | - Alessandro Pezzutto
- Nephrology and Dialysis Unit, Department of Medicine, SS Annunziata Hospital, “G. d'Annunzio” University, Chieti, Italy
| | - Valeria Manca
- Department of Pediatric Urology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Adele Mitrotti
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
- Section of Nephrology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giovanni Conti
- Department of Pediatric Nephrology, Azienda Ospedaliera Universitaria “G. Martino,” Messina, Italy
| | - Marida Martino
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital “Giovanni XXIII,” Bari, Italy
| | - Mario Giordano
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital “Giovanni XXIII,” Bari, Italy
| | - Loreto Gesualdo
- Section of Nephrology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Lada Zibar
- Department of Nephrology, University Hospital Merkur, Zagreb, Croatia
- Faculty of Medicine, University Josip Juraj Strossmayer in Osijek, Osijek, Croatia
| | - Giuseppe Masnata
- Department of Pediatric Urology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Mario Bonomini
- Nephrology and Dialysis Unit, Department of Medicine, SS Annunziata Hospital, “G. d'Annunzio” University, Chieti, Italy
| | | | - Gaetano La Manna
- IRCCS Azienda Ospedaliera di Bologna, Nephrology, Dialysis and Kidney Transplant Unit, St. Orsola University Hospital, Bologna, Italy
| | - Yasar Caliskan
- Division of Nephrology, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Andrea Ranghino
- Nephrology, Dialysis and Renal Transplantation Unit, Azienda Ospedaliera Universitaria Ospedali Riuniti Umberto I, Lancisi, Salesi of Ancona, Ancona, Italy
| | - Pierluigi Marzuillo
- Department of Woman and Child and of General and Specialized Surgery, Università degli Studi della Campania “Luigi Vanvitelli,” Naples, Italy
| | - Krzysztof Kiryluk
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Grażyna Krzemień
- Department of Pediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland
| | - Monika Miklaszewska
- Department of Pediatric Nephrology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Fangming Lin
- Division of Pediatric Nephrology, Department of Pediatric, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Giuliana and Bernardo Caprotti Chair of Pediatrics, University of Milano, Milano, Italy
| | - Francesco Scolari
- Division of Nephrology and Dialysis, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia and ASST Spedali Civili of Brescia, Brescia, Italy
| | - Enrico Fiaccadori
- Unità Operativa Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Adela Arapović
- Department of Pediatrics, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Marijan Saraga
- Department of Pediatrics, University Hospital of Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - James McKiernan
- Department of Urology, Columbia University Irving Medical Center, New York, New York
| | - Shumyle Alam
- Department of Urology, Columbia University Irving Medical Center, New York, New York
- Division of Pediatric Urology, MUSC Health-University Medical Center, Charleston, South Carolina
| | - Marcin Zaniew
- Department of Pediatrics, University of Zielona Góra, Zielona Góra, Poland
| | - Maria Szczepańska
- Department of Pediatrics, FMS in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Agnieszka Szmigielska
- Department of Pediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Sikora
- Department of Pediatric Nephrology, Medical University of Lublin, Lublin, Poland
| | - Dorota Drożdż
- Department of Pediatric Nephrology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | | | - Shrikant Mane
- Yale Center for Mendelian Genomics (YCMG), New Haven, Connecticut
| | | | - Velibor Tasic
- Medical Faculty of Skopje, University Children's Hospital, Skopje, Macedonia
| | - Anna Latos-Bielenska
- Polish Registry of Congenital Malformations, Chair and Department of Medical Genetics, University of Medical Sciences, Poznan, Poland
| | - Ali G. Gharavi
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Gian Marco Ghiggeri
- Division of Nephrology and Renal Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Laboratory on Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Anna Materna-Kiryluk
- Polish Registry of Congenital Malformations, Chair and Department of Medical Genetics, University of Medical Sciences, Poznan, Poland
| | - Rik Westland
- Department of Pediatric Nephrology, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Simone Sanna-Cherchi
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
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Hodhod A, Fermin-Risso C, Farhad M, Cook AJ, Aburezq J, Eid H, Weber BA. Can we improve the usefulness of the diuretic renogram in the diagnosis of ureteropelvic junction obstruction (UPJO) in children? Introduction of mercaptoacetyltriglycine-suspected obstruction scoring system (MAG-SOS). J Pediatr Urol 2023; 19:311.e1-311.e8. [PMID: 36922332 DOI: 10.1016/j.jpurol.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Mercaptoacetyltriglycine (MAG-3) renogram is one of the gold standard diagnostic tools of ureteropelvic junction obstruction (UPJO); however, there is no widely agreed indications of pyeloplasty based on MAG-3 findings. In this study, we introduce a renogram scoring system that can help improve the prognostic value of MAG-3 renogram and in the decision making of pyeloplasty. PATIENTS AND METHODS We retrospectively reviewed consecutive pyeloplasties for antenatal hydronephrosis from 2010 to 2020. A control group was included of non-operatively managed SFU grade 3 and 4. The initial renal ultrasound and preoperative MAG-3 Lasix renogram were reviewed for differential renal function (DRF), type of renogram curve and tracer washout half-time (T1/2). A ROC curve was used to evaluate the cut-off points that can be associated with obstruction. A multivariate linear regression model was used to assess the best renogram parameter that can predict surgical intervention. RESULTS We included 188 patients with 209 renal units. The median age for pyeloplasty was 5.4 months. The mercaptoacetyltriglycine-Suspected Obstruction Scoring System (MAG-SOS) was associated with pyeloplasty (AUC = 0.97, P < 0.001) (Figure A). A score of 5 is 100% specific for obstruction. 78% of units required surgical intervention had a MAG-SOS score of≥5 while all units of the control group had a range of score 0-4. Using the multivariate analysis, the MAG-SOS system showed to the only independent predictor for pyeloplasty (HR = 0.03, p < 0.001). DISCUSSION This study has some limitations. Firstly, the retrospective nature of the cohort; however, all patients were reviewed by one investigator who was blinded to the line of management. This is a single institutional study; therefor, this MAG-SOS should be evaluated by other centers to ensure its efficiency. Lastly, the pyeloplasty decision was taken by 3 different urologists; nevertheless, all of them adopt the same indications which are similar to those of the Society for Pediatric Urology and the Canadian Urological Association guidelines. CONCLUSION The MAG-SOS system showed to be a useful tool that can predict pyeloplasty. A score of 5 has 100% specificity for patients having a pyeloplasty performed. Prospective studies are required to confirm the usefulness of this novel tool.
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Affiliation(s)
- Amr Hodhod
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada.
| | | | - Mutaz Farhad
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Anthony J Cook
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Jarrah Aburezq
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Hadeel Eid
- Pediatric Radiology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Bryce A Weber
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada
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Wang J, Zhao Y, Chen Z, Geng H, Fang X. Ureterocele with duplex collecting systems and febrile urinary tract infection risk. Pediatr Surg Int 2023; 39:200. [PMID: 37191737 DOI: 10.1007/s00383-023-05442-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Ureterocele has been hypothesized to be the risk factor for febrile urinary tract infections (F-UTIs) in patients with duplex collecting systems, but this has not been proved, and our goal was to assess the relation between ureterocele with duplex collecting systems and F-UTIs. METHODS We included individual-participant data from patients seen for complicated duplex collecting systems from 2010 to 2020 retrospectively followed. Those with using continuous low-dose antibiotic prophylaxis and incompletely duplicated systems were removed from the study. The participants were divided into two cohorts according to patients with or without ureterocele. The primary endpoint of this study was recurrent F-UTIs. RESULTS We analyzed medical reports of 300 patients, of which 75% were female. Among the 300 patients, F-UTIs developed in 111/159 (69.8%) patients in the ureterocele group and in 69/141 (48.9%) patients in the no-ureterocele group. Univariate analysis found no discernible difference except in grade of hydronephrosis between ureterocele group and no-ureterocele group. Moreover, Cox proportional regression analysis revealed that patients of duplex system ureterocele might be intrinsically more prone to develop F-UTIs (adjusted hazard ratio 1.894; 95% CI 1.412-2.542; p < 0.001). CONCLUSION Among participants with duplex systems, the risk of recurrent F-UTIs in patients with ureterocele was higher than patients without it, and mini-invasive surgical correction should be considered at young age to reduce F-UTIs.
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Affiliation(s)
- Jinbin Wang
- Department of Pediatric Urology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Department of Pediatric Urology, Women and Children's Hospital, Qingdao University, Qingdao, People's Republic of China
| | - Yining Zhao
- Department of Pediatric Urology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, People's Republic of China
| | - Zhoutong Chen
- Department of Pediatric Urology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Hongquan Geng
- Department of Pediatric Urology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaoliang Fang
- Department of Pediatric Urology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.
- Department of Pediatric Urology, Shanghai Xinhua Hospital, No. 1665 Kongjiang Road, Shanghai, People's Republic of China.
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45
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Arlen AM, Leong T, Kirsch AJ, Cooper CS. Spontaneous vesicoureteral reflux resolution curves based on ureteral diameter ratio. J Pediatr Urol 2023:S1477-5131(23)00157-2. [PMID: 37188603 DOI: 10.1016/j.jpurol.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 04/16/2023] [Accepted: 04/23/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Various factors influence the clinical course of vesicoureteral reflux (VUR) in the pediatric population. Distal ureteral diameter ratio (UDR) is an objective measure reflective of ureterovesical junction anatomy that has been shown to independently predict both spontaneous resolution and breakthrough febrile urinary tract infection (UTI) in children with primary reflux. UDR resolution curves were created, hypothesizing that a UDR value existed at which spontaneous resolution was unlikely to occur. MATERIALS AND METHODS UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1-L3 vertebral bodies. Recursive partitioning with 10-fold cross validation methodology for time to event data, utilizing martingale residuals was used to create high and low risk groups based on UDR, and stratified by age at diagnosis and laterality. RESULTS Three hundred and four patients (226 female, 78 male) were analyzed with a mean age at diagnosis of 1.55 ± 1.98 years. Unilateral reflux (p = 0.02), VUR grades 1-3 (p < 0.001), and lower UDR (p < 0.001) were associated with spontaneous resolution on univariate analysis. UDR values were categorized into risk groups based on recursive partitioning. Low risk patients (those with UDR <0.30) achieved VUR resolution faster and with a continuing rate compared to the high-risk group (≥0.30), which had persistent reflux after 3 years [Summary Figure]. When the 0.30 cutoff was applied randomly to patients in test group, the cutoff significantly discriminated between low and high-risk patients (log rank test p = 0.02). DISCUSSION Primary VUR is often a self-limiting diagnosis, with conservative management favored in low-risk children, UDR may be used to help distinguish those children who may benefit from intervention. Unlike traditional VUR grading where children with any grade of reflux may spontaneously resolve, there appears to be a consistent UDR cutoff whereby patients are very unlikely to spontaneously resolve, regardless of length of follow-up. Therefore, parents of children with a UDR above the 0.3 cutoff, regardless of VUR grade, may be counselled that VUR is very unlikely to resolve over time - thereby reducing the number of VCUGs and length of time these patients are on prophylactic antibiotic prior to surgical intervention. CONCLUSIONS Children with primary VUR and a UDR of greater than 0.30 are significantly less likely to spontaneously resolve regardless of length of follow-up, and resolution after 3 years was rare. UDR provides objective prognostic information facilitating individualized patient management.
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Affiliation(s)
- Angela M Arlen
- From the Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Traci Leong
- Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Andrew J Kirsch
- Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Christopher S Cooper
- Departments of Urology and Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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Huang R, Fu F, Zhou H, Zhang L, Lei T, Cheng K, Yan S, Guo F, Wang Y, Ma C, Li R, Yu Q, Deng Q, Li L, Yang X, Han J, Li D, Liao C. Prenatal diagnosis in the fetal hyperechogenic kidneys: assessment using chromosomal microarray analysis and exome sequencing. Hum Genet 2023; 142:835-847. [PMID: 37095353 DOI: 10.1007/s00439-023-02545-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/13/2023] [Indexed: 04/26/2023]
Abstract
Fetal hyperechogenic kidneys (HEK) is etiologically a heterogeneous disorder. The aim of this study was to identify the genetic causes of HEK using prenatal chromosomal microarray analysis (CMA) and exome sequencing (ES). From June 2014 to September 2022, we identified 92 HEK fetuses detected by ultrasound. We reviewed and documented other ultrasound anomalies, microscopic and submicroscopic chromosomal abnormalities, and single gene disorders. We also analyzed the diagnostic yield of CMA and ES and the clinical impact the diagnosis had on pregnancy management. In our cohort, CMA detected 27 pathogenic copy number variations (CNVs) in 25 (25/92, 27.2%) fetuses, with the most common CNV being 17q12 microdeletion syndrome. Among the 26 fetuses who underwent further ES testing, we identified 7 pathogenic/likely pathogenic variants and 8 variants of uncertain significance in 9 genes in 12 fetuses. Four novel variants were first reported herein, expanding the mutational spectra for HEK-related genes. Following counseling, 52 families chose to continue the pregnancy, and in 23 of them, postnatal ultrasound showed no detectable renal abnormalities. Of these 23 cases, 15 had isolated HEK on prenatal ultrasound. Taken together, our study showed a high rate of detectable genetic etiologies in cases with fetal HEK at the levels of chromosomal (aneuploidy), sub-chromosomal (microdeletions/microduplications), and single gene (point mutations). Therefore, we speculate that combined CMA and ES testing for fetal HEK is feasible and has good clinical utility. When no genetic abnormalities are identified, the findings can be transient, especially in the isolated HEK group.
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Affiliation(s)
- Ruibin Huang
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Fang Fu
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Hang Zhou
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Lu Zhang
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Tingying Lei
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Ken Cheng
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, 510641, Guangdong, China
| | - Shujuan Yan
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Fei Guo
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - You Wang
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
- The First Clinical Medical College, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Chunling Ma
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
- The First Clinical Medical College, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Ru Li
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Qiuxia Yu
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Qiong Deng
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Lushan Li
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Xin Yang
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Jin Han
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Dongzhi Li
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China
| | - Can Liao
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510620, Guangdong, China.
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Neilson M, Lombardo P, Goodyear M, McLean G, Taghavi K. Medullary pyramid thickness: The optimal cut-off value associated with the need for pyeloplasty in infants. J Pediatr Urol 2023:S1477-5131(23)00132-8. [PMID: 37120366 DOI: 10.1016/j.jpurol.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/14/2023] [Accepted: 04/05/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION The medullary pyramid compresses during the early phases of severe hydronephrosis and represents a promising ultrasound metric for the diagnosis and surveillance of PUJ obstruction. The aim of this study was to define the optimal cut-off value and utility of medullary pyramid thickness (MPT) associated with the need for pyeloplasty in infants being followed up for hydronephrosis. METHODS A retrospective review was performed over a five-year period to identify patients that were under surveillance for hydronephrosis during infancy and underwent a MAG3 to monitor the possible need for pyeloplasty. Ultrasound images were retrospectively reviewed to measure the MPT of the affected kidney in a blinded fashion. The primary outcome measure was subsequent requirement for pyeloplasty before three years of age. The Mann-Whitney U Test was used to determine statistically significant differences in the minimum MPT between the infant group requiring pyeloplasty and the non-operative group. Receiver operating characteristic analysis was performed to determine the optimal cut-off value associated with the requirement for pyeloplasty. RESULTS A total of 63 patient cases were included, of which 45 underwent pyeloplasty (70%). A significant difference was found in the median MPT measurement between the pyeloplasty and non-operative groups (1.7 mm vs. 3.8 mm, p < 0.001). The optimal cut-off value of MPT associated with pyeloplasty was 3.4 mm. An MPT threshold of ≤3.4 mm conferred a sensitivity of 98%, specificity of 63%, positive predictive value of 86%, and negative predictive value of 92%. CONCLUSION Thinning of the medullary pyramid is an important ultrasound sign of parenchymal deterioration in high-grade hydronephrosis. An optimal MPT cut-off value of ≤3.4 mm is associated with subsequent pyeloplasty in infants. MPT should be considered in future studies addressing the diagnosis and surveillance of PUJ obstruction.
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Affiliation(s)
- Mikaelah Neilson
- Department of Medical Imaging, Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia; Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
| | - Paul Lombardo
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
| | | | - Glenda McLean
- Department of Medical Imaging, Monash Children's Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Kiarash Taghavi
- Department of Paediatric Urology, Monash Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.
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Staub E. Current and potential methods to assess kidney structure and morphology in term and preterm neonates. Anat Rec (Hoboken) 2023. [PMID: 36883787 DOI: 10.1002/ar.25195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/25/2023] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
After birth, the kidney structure in neonates adapt to the functional demands of extrauterine life. Nephrogenesis is complete in the third trimester, but glomeruli, tubuli, and vasculature mature with the rapidly increasing renal blood flow and glomerular filtration. In preterm infants, nephrogenesis remains incomplete and maturation is slower and may be aberrant. This structural and functional deficit has life-long consequences: preterm born individuals are at higher risk for chronic kidney disease and arterial hypertension later in life. This review assembles the literature on existing and potential methods to visualize neonatal kidney structure and morphology and explore their potential to longitudinally document the developmental deviation after preterm birth. X-rays with and without contrast, fluoroscopy and computed tomography (CT) involve relevant ionizing radiation exposure and, apart from CT, do not provide sufficient structural details. Ultrasound has evolved into a safe and noninvasive high-resolution imaging method which is excellent for longitudinal observations. Doppler ultrasound modes can characterize and quantify blood flow to and through the kidneys. Microvascular flow imaging has opened new possibilities of visualizing previously unseen vascular structures. Recent advances in magnetic resonance imaging display renal structure and function in unprecedented detail, but are offset by the logistical challenges of the imaging procedure and limited experience with the new techniques in neonates. Kidney biopsies visualize structure histologically, but are too invasive and remain anecdotal in newborns. All the explored methods have predominantly been examined in term newborns and require further research on longitudinal structural observation in the kidneys of preterm infants.
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Affiliation(s)
- Eveline Staub
- Department of Neonatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- University of Sydney Northern Clinical School, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Meshaka R, Biassoni L, Leung G, Mushtaq I, Hiorns MP. Radiological and surgical correlation of pelviureteric junction obstruction in positional anomalies of the kidney in children. Pediatr Radiol 2023; 53:544-557. [PMID: 36538085 DOI: 10.1007/s00247-022-05557-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/10/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022]
Abstract
Pelviureteric junction obstruction, also known as ureteropelvic junction obstruction, is a congenital narrowing of the urinary excretory tract at the junction between the renal pelvis and the ureter and is a common cause of congenital pelvicalyceal dilatation. The outcome is variable, from spontaneous resolution to renal parenchymal function loss in cases of untreated high-grade obstruction. Abnormalities in renal ascent, rotation and vascularity can be associated with pelviureteric junction obstruction and easily overlooked radiologically. In this pictorial review, we explore the anatomical, radiological and surgical correlations of pelviureteric junction obstruction in the context of a normal kidney and a spectrum of renal abnormalities, including hyper-rotation (also known as renal malrotation), failed renal ascent, fusion anomalies and accessory crossing renal vessels. For each scenario, we provide technical tips on how to identify the altered anatomy at the first ultrasound assessment and correlation with scintigraphic, cross-sectional and postoperative imaging where appropriate. A detailed ultrasound protocol specifically to assess and characterise pelviureteric junction obstruction in paediatric patients is also offered.
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Affiliation(s)
- Riwa Meshaka
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, WC1H 3JH, UK. .,Department of Clinical Radiology, The Royal London Hospital, Barts Health NHS Trust, London, UK.
| | - Lorenzo Biassoni
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, WC1H 3JH, UK
| | - Gorsey Leung
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, WC1H 3JH, UK
| | - Imran Mushtaq
- Department of Urology, Great Ormond Street Hospital for Children, London, UK
| | - Melanie P Hiorns
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, WC1H 3JH, UK
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Lien WC, Chang YC, Chou HH, Lin LC, Liu YP, Liu L, Chan YT, Kuan FS. Detecting Hydronephrosis Through Ultrasound Images Using State-of-the-Art Deep Learning Models. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:723-733. [PMID: 36509616 DOI: 10.1016/j.ultrasmedbio.2022.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 09/12/2022] [Accepted: 10/04/2022] [Indexed: 06/17/2023]
Abstract
The goal of this study was to assess the feasibility of three models for detecting hydronephrosis through ultrasound images using state-of-the-art deep learning algorithms. The diagnosis of hydronephrosis is challenging because of varying and non-specific presentations. With the characteristics of ready accessibility, no radiation exposure and repeated assessments, point-of-care ultrasound becomes a complementary diagnostic tool for hydronephrosis; however, inter-observer variability still exists after time-consuming training. Artificial intelligence has the potential to overcome the human limitations. A total of 3462 ultrasound frames for 97 patients with hydronephrosis confirmed by the expert nephrologists were included. One thousand six hundred twenty-eight ultrasound frames were also extracted from the 265 controls who had normal renal ultrasonography. We built three deep learning models based on U-Net, Res-UNet and UNet++ and compared their performance. We applied pre-processing techniques including wiping the background to lessen interference by YOLOv4 and standardizing image sizes. Also, post-processing techniques such as adding filter for filtering the small effusion areas were used. The Res-UNet algorithm had the best performance with an accuracy of 94.6% for moderate/severe hydronephrosis with substantial recall rate, specificity, precision, F1 measure and intersection over union. The Res-UNet algorithm has the best performance in detection of moderate/severe hydronephrosis. It would decrease variability among sonographers and improve efficiency under clinical conditions.
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Affiliation(s)
- Wan-Ching Lien
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Chung Chang
- Department of Computer Science and Engineering, National Chi Nan University, Nantou, Taiwan
| | - Hsin-Hung Chou
- Department of Computer Science and Engineering, National Chi Nan University, Nantou, Taiwan.
| | - Lung-Chun Lin
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yueh-Ping Liu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Affairs Ministry of Health and Welfare, Taipei, Taiwan
| | - Li Liu
- Show Chwan Health Care System, Taipei, Taiwan
| | - Yen-Ting Chan
- Department of Research Planning of Omni Health Group Inc., Taipei, Taiwan
| | - Feng-Sen Kuan
- Department of Business Development, Huasin H. T. Limited, Taipei, Taiwan
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