US of renal insufficiency in neonates

Diagnostic Value of the Systemic Immune-Inflammation Index in Newborns with Urinary Tract Infection

OBJECTIVE

Aim of this study is to investigate the diagnostic role of the systemic immune-inflammation index (SII; neutrophil × platelet [PLT]/lymphocyte) in the prediction of renal involvement in newborns with urinary tract infection (UTI).

STUDY DESIGN

We conducted a retrospective cohort study among 117 newborns with a gestational age greater than 35 weeks and hospitalized in the NICU. Laboratory values obtained from blood samples taken before the initiation of antibiotics were evaluated for renal function tests, complete blood count, and acute phase reactants. The ratios of platelet-to-lymphocyte (PLR), neutrophil-to-lymphocyte (NLR), and SII were calculated. The patients were divided into two main groups according to the presence of urinary tract pathology in ultrasonography (US): group 1, UTI with renal involvement (n = 43) and group 2, UTI without renal involvement (n = 74). Predictive values of different tests were compared.

RESULTS

The mean white blood cell, PLT, mean PLT volume, and neutrophile counts were higher, while lymphocyte counts were significantly lower in group 1 than those of group 2. Interleukin 6 (IL-6; pg/mL; IL-6), C-reactive protein (CRP; mg/L), NLR, PLR, and SII values were also higher in group 1. Receiver operating characteristics curve showed that SII, CRP, IL-6, PLR, and NLR have a predictive ability to discriminate renal involvement from normal renal findings in newborns with UTI. The SII produced an area under curve of 0.75 (72% sensitivity and 60.8% specificity). To define renal involvement, the cut-off values of SII, CRP, IL-6, PLR, and NLR were 217, 3.06, 23, 65.5, and 0.60, respectively.

CONCLUSION

Our results showed that SII might be used as an additional parameter in the prediction of renal involvement in newborns with UTIs. Further studies are required.

KEY POINTS

· Most UTIs in newborns present with upper UTI rather than simple cystitis.. · Some inflammatory markers can be used for the diagnosis of UTIs.. · SII may be useful in the prediction of urinary tract infections..

Can maternal urinary and serum carbohydrate antigen 19-9 concentrations be utilized in the diagnosis of fetal hydronephrosis?

Objective:

Fetal hydronephrosis (FH) is the most common fetal renal pathology encountered in daily obstetric practice. Urinary and serum carbohydrate antigen 19-9 (CA 19-9) concentrations are elevated in obstructive renal pathologies. Our aim was to assess maternal urinary and serum CA 19-9 concentrations in pregnancies with FH and compare results with controls.

Material and Methods:

Twenty pregnancies with severe FH, 20 pregnancies with mild-moderate FH, and 20 healthy singleton pregnancies were included in this descriptive, case-control study. The diagnosis and classification of FH was based on the anterioposterior diameter of fetal renal pelvis. Maternal urinary and serum CA 19-9 concentrations were measured and compared between groups.

Results:

Severe FH cases had significantly higher maternal urinary CA 19-9 concentrations compared to controls (median: 75 vs 24 U/mL; respectively; p=0.014). Concentrations of CA 19-9 did not differ between the mild-moderate FH group and control group. No statistically significant difference was found between the groups with respect to maternal serum CA 19-9 concentrations.

Conclusion:

Our results show that maternal urinary CA 19-9 concentration is significantly higher in pregnancies with severe FH. However, no difference was detected in serum CA 19-9 concentrations between pregnancies with severe FH, mild-moderate FH and controls. If the mechanisms of transplacental passage and maternal urinary excretion are clarified, maternal urinary CA 19-9 may be a potential marker for indicating fetal kidney damage.

Prenatal ultrasound, genotype, and outcome in a large cohort of prenatally affected patients with autosomal-recessive polycystic kidney disease and other hereditary cystic kidney diseases

PURPOSE

To investigate the sonographic and clinical genotype-phenotype correlations in autosomal recessive polycystic kidney disease (ARPKD) and other cystic kidney diseases (CKD) in a large cohort of prenatally detected fetuses with hereditary CKD.

METHODS

We retrospectively studied the clinical and diagnostic data of 398 patients referred with prenatal ultrasound findings suggestive of CKD between 1994 and 2010. Cases with confirmed hereditary CKD (n = 130) were analyzed as to their prenatal ultrasound findings, genotype, and possible predictors of clinical outcome.

RESULTS

ARPKD was most common in our non-representative sample. Truncating PKHD1 mutations led to a significantly reduced neonatal prognosis, with two such mutations being invariably lethal. Sonographically visible kidney cysts occurred in only 3% of ARPKD cases. Renal abnormalities in Meckel syndrome (MKS) appeared earlier than in ADPKD (19.6 ± 3.7 vs. 29.8 ± 5.1 GW) or ARPKD (19.6 ± 3.7 vs. 30.2 ± 1.2 GW). Additional CNS malformations were not found in ARPKD, but were highly sensitive for MKS. Pulmonary hypoplasia, oligo/anhydramnios (OAH), and kidney enlargement were associated with a significantly worse neonatal prognosis.

CONCLUSION

Genotype, sonographic signs of OAH, enlarged kidney size, and pulmonary hypoplasia can be useful predictors of neonatal survival. We propose sonographic morphological criteria for ARPKD, ADPKD, MKS, and renal cyst and diabetes syndrome (RCAD). We further propose a clinical diagnostic algorithm for differentiating cystic kidney diseases.

Ultrasonography of hydronephrosis in the newborn: a practical review

Widespread use of fetal ultrasonography is accompanied by more frequent detection of antenatal hydronephrosis. Therefore, sonographic evaluation of neonates with a history of antenatal hydronephrosis is becoming more widespread. As an initial postnatal non-invasive imaging modality, ultrasonography is used to screen for persistence of hydronephrosis, determine the level and severity of obstruction, and contribute to appropriate diagnosis and treatment. This review aims to provide a practical overview of the sonographic evaluation of neonatal hydronephrosis and to describe the sonographic findings of conditions associated with hydronephrosis in the newborn.

Revised guidelines on management of antenatal hydronephrosis

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

The influence of EPO and hypothermia on the kidneys of rats after perinatal asphyxia

The aim of this study was to determine the effects of erythropoietin (EPO), moderate hypothermia, and a combination thereof on the kidneys of newborn rats damaged during perinatal asphyxia. An animal model of perinatal asphyxia (Wistar rats) was used in which after birth, newborn rats were divided into four groups of 15 animals each: G1, rats exposed only to asphyxia; G2, rats exposed to asphyxia and hypothermia (rectal temperature 32°C) and which received EPO (darbepoetin alpha) intraperitoneally; G3, rats exposed to asphyxia and hypothermia; G4, rats exposed to asphyxia and which received EPO. The rats were sacrificed on the 7th day of life and histopathological evaluation of kidneys was performed. Damage to the proximal tubules was significantly higher in group G1 rats than in groups G2, G3, and G4 rats (p < 0.01). Damage to the distal tubules was found only in group G1 rats. Histological changes in the proximal tubules were more prominent than in the distal tubules (p < 0.01). The immature glomeruli zone was less expressed in group G4 rats than in groups G1, G2, and G3 rats (p < 0.01). Based on these results, we conclude that EPO and hypothermia, as well as the combination thereof, have a protective effect on rats' kidneys damaged during perinatal asphyxia.

The role of routine post-natal abdominal ultrasound for newborns in a resource-poor setting: a longitudinal study

Background-

Neonatal abdominal ultrasound is usually performed in Nigeria to investigate neonatal symptoms rather than as a follow up to evaluate fetal abnormalities which were detected on prenatal ultrasound. The role of routine obstetric ultrasonography in the monitoring of pregnancy and identification of fetal malformations has partly contributed to lowering of fetal mortality rates. In Nigeria which has a high maternal and fetal mortality rate, many pregnant women do not have ante-natal care and not infrequently, women also deliver their babies at home and only bring the newborns to the clinics for immunization. Even when performed, most routine obstetric scans are not targeted towards the detection of fetal abnormalities.

The aim of the present study is to evaluate the benefit of routinely performing abdominal scans on newborns with a view to detecting possible abnormalities which may have been missed ante-natally.

Methods-

This was a longitudinal study of 202 consecutive, apparently normal newborns. Routine clinical examination and abdominal ultrasound scans were performed on the babies by their mother's bedside, before discharge. Neonates with abnormal initial scans had follow-up scans.

Results-

There were 108 males and 94 females. There were 12 (5.9%) abnormal scans seen in five male and seven female neonates. Eleven of the twelve abnormalities were in the kidneys, six on the left and five on the right. Three of the four major renal anomalies- absent kidney, ectopic/pelvic kidney and two cases of severe hydronephrosis were however on the left side. There was one suprarenal abnormality on the right suspected to be a possible infected adrenal haemorrage. Nine of the abnormal cases reported for follow- up and of these, two cases had persistent severe abnormalities.

Conclusions-

This study demonstrated a 5.9% incidence of genito urinary anomalies on routine neonatal abdominal ultrasound in this small population. Routine obstetric USS is very useful but inadequate availability of skilled personnel and cost implications create great challenges in poor resource settings like Nigeria. However, awareness should be created so that parents who can afford such investigations can make informed decisions.

Renal pyramids: focused sonography of normal and pathologic processes

In neonates and children, sonographic examinations of the renal pyramids may depict a spectrum of unique changes in echogenicity due to the effects of physiologic processes or a wide variety of pathologic processes that may affect the collecting ducts or interstitium of the pyramids. Focused sonographic evaluation of the pyramids with high-frequency transducers produces the most detailed images of the pyramids, revealing some appearances not previously reported, to the authors' knowledge. The authors highlight the clinical settings in which they have documented detailed changes in the echogenicity of the pyramids. The patterns of altered echogenicity alone may reflect a specific cause but in many instances are nonspecific, with clinical and biochemical correlation required to establish a more precise diagnosis. However, there is a lack of histologic data to completely explain the mechanism of many of these changes in echogenicity in all of the processes. As the authors have expanded their use of the focused sonographic technique, they have been able to depict altered echogenicity in the pyramids in greater numbers of children in whom an explanation for the changes is not always immediately apparent; for now, the cause must be considered idiopathic. More work is required to expand the use of this focused technique together with clinical, biochemical, and histologic correlation in an attempt to offer more complete explanations for the changes in echogenicity of the pyramids.

Postmortem MRI of bladder agenesis

We report a 35-week preterm neonate with bladder agenesis and bilateral dysplastic kidneys. A suprapubic catheter was inadvertently inserted into one of the larger inferior cysts of the left dysplastic kidney. A postmortem MRI scan was performed with the findings being confirmed on autopsy. We are unaware of another postmortem MRI study demonstrating bladder agenesis.

Nephrocalcinosis in a preterm infant

Bilateral medullary echogenic foci are not uncommonly seen in renal ultrasounds of sick, preterm neonates. Often, the likely diagnosis is nephrocalcinosis. We present one such case. The long term outcome in this population is unknown, but is generally thought to be essentially good.

[Multicystic dysplastic kidney disease: update and information for parents at the time of prenatal diagnosis]

Multicystic kidney disease (MCKD) is the most common form of Congenital Abnormality of Kidney and Urinary Tract (CAKUT). This anomaly of renal development is characterized by unilateral enlarged cystic formations and fibrous dysplastic parenchyma. The long-term prognosis is usually good; however because of reduced nephron mass, an early prevention of cardiovascular risk and nephrotoxicity is recommended. A lifelong follow-up of blood pressure, serum creatinine and microalbuminuria seems logical as well as in other patients with a single kidney. MCKD is usually diagnosed during pregnancy so that parents often question about long-term prognosis and follow-up. Therefore, we propose an information sheet for parents.

Magnetic resonance urography in the evaluation of prenatally diagnosed hydronephrosis and renal dysgenesis

PURPOSE

We present our experience with dynamic contrast enhanced magnetic resonance urography for evaluation and treatment in infants born with prenatally recognized hydronephrosis. We determined the characteristics of renal dysgenesis in this population.

MATERIALS AND METHODS

We reviewed magnetic resonance urography images done within the first 6 months of life in 67 infants born with prenatally recognized hydronephrosis. High resolution imaging was used to establish a morphological diagnosis. Functional evaluation was used to assess obstruction and individual renal function. Voiding cystourethrography was performed in 62 patients.

RESULTS

Our study included 67 infants (87 renal units). There were 54 boys and 13 girls with a mean age of 2.8 months (range 0.9 to 4.6). Of these 87 renal units 30 (35%) had ureteropelvic junction obstruction, 18 (21%) had primary megaureters, 10 (11%) had nondilating vesicoureteral reflux, 10 (11%) had fetal folds, 8 (9%) had posterior urethral valves, 6 (7%) had ectopic ureters, 4 (5%) had multicystic dysplastic kidneys and 1 (1%) had a normal study. Magnetic resonance urography revealed renal dysgenesis in 24 renal units (28%), consisting of loss of corticomedullary differentiation, renal cystic changes distinct from multicystic dysplastic kidneys, solid renal dysplasia, hypoplasia and dysmorphic calyces.

CONCLUSIONS

Magnetic resonance urography is an excellent addition to our armamentarium for evaluating neonatal hydronephrosis and renal dysgenesis. Due to its comprehensiveness magnetic resonance urography has the potential to become the study of choice for evaluating infants with significant prenatally recognized hydronephrosis. However, further prospective, comparative studies in larger patient populations are needed to justify the cost and the need for sedation in infants.