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Jones K, Keiser AM, Miller JL, Atkinson MA. Bilateral renal agenesis: fetal intervention and outcomes. Pediatr Nephrol 2024:10.1007/s00467-024-06449-8. [PMID: 38997547 DOI: 10.1007/s00467-024-06449-8] [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: 03/27/2024] [Revised: 06/11/2024] [Accepted: 06/11/2024] [Indexed: 07/14/2024]
Abstract
Bilateral renal agenesis (BRA) is a fetal anomaly which leads to anhydramnios and resultant pulmonary hypoplasia. Historically, this anomaly was universally fatal early in the neonatal period due to the severity of the associated lung disease. Over the last 30 years, innovations in fetal therapies-specifically, serial amnioinfusions-have led to instances of infant pulmonary survival and initiation of postnatal dialysis, raising the possibility that early neonatal death may not be inevitable. Amnioinfusions are not without risk, and maternal complications can include prelabor rupture of membranes, preterm labor, infection, and bleeding. The data detailing neonatal outcomes are still limited and actively being collected. Two case series and one non-randomized clinical trial have supplied most of the known outcome data for infants with BRA after prenatal amnioinfusion. Although there are survivors reported in the literature, mortality remains high, with many deaths in infancy due to dialysis-associated sepsis. In addition, previously unknown morbidities have been documented in these infants, including neurologic injury. These challenges, in addition to the mechanical difficulties of providing dialysis to extremely small infants, can result in significant burdens for patients and their caregivers and moral distress for the health care team. The present review aims to explain the pathophysiology of BRA, detail the historical context and rationale for serial amnioinfusions to treat the pulmonary insufficiency associated with BRA, describe the available data regarding outcomes of infants born following prenatal amnioinfusions, discuss ethical issues surrounding this fetal intervention, and describe critical aspects of prenatal counseling for patients considering the intervention.
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Affiliation(s)
- Katherine Jones
- Department of Pediatrics, F. Edward Hébert School of Medicine, Uniformed Services University, Tripler Army Medical Center, 1 Jarrett White Rd., Honolulu, HI, 96859, USA.
| | - Amaris M Keiser
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jena L Miller
- Center for Fetal Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meredith A Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Nishi K, Ozawa K, Kamei K, Sato M, Ogura M, Muromoto J, Sugibayashi R, Isayama T, Ito Y, Wada S, Yokoo T, Ishikura K. Long-Term Outcomes, Including Fetal and Neonatal Prognosis, of Renal Oligohydramnios: A Retrospective Study over 22 Years. J Pediatr 2024; 273:114151. [PMID: 38880380 DOI: 10.1016/j.jpeds.2024.114151] [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: 03/13/2024] [Revised: 05/02/2024] [Accepted: 06/11/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE To assess the long-term outcome of renal oligohydramnios and risk factors for fetal, neonatal, and postneonatal death. STUDY DESIGN This retrospective cohort study included fetuses with prenatally detected renal oligohydramnios between 2002 and 2023. Patients who were lost to follow-up were excluded. Fetal, neonatal, and long-term outcomes were evaluated, and their risk factors were analyzed. RESULTS Of 131 fetuses with renal oligohydramnios, 46 (35%) underwent a termination of pregnancy, 11 (8%) had an intrauterine fetal death, 26 (20%) had a neonatal death, nine (7%) had a postneonatal death, and 39 (30%) survived. Logistic regression analyses showed that an earlier gestational age at onset (OR 1.16, 95% CI 1.01-1.37) was significantly associated with intrauterine fetal death; anhydramnios (OR 12.7, 95% CI 1.52-106.7) was significantly associated with neonatal death as a prenatal factor. Although neonatal survival rates for bilateral renal agenesis, bilateral multicystic dysplastic kidney (MCDK), and unilateral MCDK with contralateral renal agenesis were lower than for other kidney diseases, 1 case of bilateral renal agenesis and two of bilateral MCDK survived with fetal intervention. Kaplan-Meier overall survival rates were 57%, 55%, and 51% for 1, 3, and 5 years, respectively. In the Cox proportional hazards model, birth weight <2000 g (hazard ratio 7.33, 95% CI 1.48-36.1) and gastrointestinal comorbidity (hazard ratio 4.37, 95% CI 1.03-18.5) were significant risk factors for postneonatal death. CONCLUSION Long-term survival following renal oligohydramnios is a feasible goal and its appropriate risk assessment is important.
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Affiliation(s)
- Kentaro Nishi
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Jin Muromoto
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan.
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Claes D, Markham KB, Cortezzo DE. An Ethical Analysis of Therapy for Severe Congenital Kidney and Urinary Tract Anomalies. Pediatrics 2024; 153:e2023064720. [PMID: 38784992 DOI: 10.1542/peds.2023-064720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 05/25/2024] Open
Abstract
Technological advancements before and after delivery have greatly altered the counseling of pregnant patients facing a fetal diagnosis of severe oligohydramnios or anhydramnios secondary to congenital anomalies of the kidneys and urinary tract. Once considered a nearly uniformly lethal abnormality, long-term survival may now be possible secondary to prenatal innovations aimed at restoring the amniotic fluid volume and the availability of more advanced neonatal dialysis techniques. However, these available therapies are far from perfect. The procedures are onerous for pregnant patients without a guarantee of success, and families must prepare themselves for the complex life-long medical care that will be necessary for surviving individuals. Multidisciplinary counseling is imperative to help pregnant individuals understand the complexity of these conditions and assist them in exercising their right to informed decision-making. Moreover, as with any developing field of medicine, providers must contend with ethical questions related to the treatment options, including questions regarding patient-hood, distributive justice, and the blurred lines between research, innovation, and standard care. These ethical questions are best addressed in a multidisciplinary fashion with consideration of multiple points of view from various subspecialties. Only by seeing the entirety of the picture can we hope to best counsel patients about these highly complex situations and help navigate the most appropriate care path.
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Affiliation(s)
- Donna Claes
- Divisions of Nephrology
- Departments of Pediatrics
| | - Kara B Markham
- Cincinnati Children's Fetal Care Center
- Obstetrics and Gynecology and Division of Maternal Fetal Medicine
| | - DonnaMaria E Cortezzo
- Cincinnati Children's Fetal Care Center
- Neonatal and Pulmonary Biology
- Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Departments of Pediatrics
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Divisions of Neonatology
- Pain and Palliative Care
- Fetal Care Program, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
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4
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Glover J, Bock M, Reynolds R, Zaretsky M, Vemulakonda V. Prenatally-diagnosed renal failure: an ethical framework for decision-making. J Perinatol 2024; 44:333-338. [PMID: 37735209 DOI: 10.1038/s41372-023-01779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 08/31/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
The Children's Hospital Working Group has developed an ethical framework to guide patient care and research for prenatally diagnosed severe renal anomalies. It identifies ethical challenges in communication, timing of decisions and scarce resources. Key elements include shared decision-making, establishing a trusting relationship, and managing disagreement. The ethical framework will be used to develop a clinical pathway that operationalizes the key values of trust, honesty, transparency, beneficence, nonmaleficence, respecting parental authority, professional integrity, and justice.
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Affiliation(s)
- Jacqueline Glover
- Pediatrics, Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA.
| | - Margret Bock
- Pediatrics, Nephrology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Regina Reynolds
- Pediatrics, Neonatology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael Zaretsky
- OB, GYN, Maternal-Fetal Medicine, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Vijaya Vemulakonda
- Surgery, Pediatric Urology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
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Affiliation(s)
- Cynthia Gyamfi-Bannerman
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla
| | - Krishelle Marc-Aurele
- Neonatal-Perinatal Medicine Fellowship Program, Divisions of Neonatology and Palliative Medicine, Department of Pediatrics, University of California, San Diego/Rady Children's Hospital of San Diego, San Diego
| | - Karen Mestan
- Division of Neonatology, Department of Pediatrics, University of California, San Diego/Rady Children's Hospital of San Diego, San Diego
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Abstract
OBJECTIVE Perinatal palliative care (PPC) is an option for patients who discover that their infant has a life-limiting fetal condition, which decreases the burden of the condition using a multidisciplinary approach. STUDY DESIGN This review discusses the landmark literature in the past two decades, which have seen significant growth and development in the concept of PPC. RESULTS The literature describes the background, quality, and benefits of offering PPC, as well as the ethical principles that support its being offered in every discussion of fetal life-limiting diagnoses. CONCLUSION PPC shares a similar risk profile to other options after life-limiting diagnosis, including satisfaction with choice of continuation of pregnancy. The present clinical opinion closes by noting common barriers to establishing PPC programs and offers a response to overcome each one. KEY POINTS · Perinatal palliative care serves patients who continue pregnancies with life-limiting fetal anomaly.. · Perinatal palliative care has a risk profile similar to other options such as termination.. · Health care providers can serve as champions to extend PPC to patients in their region..
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Affiliation(s)
- Cara Buskmiller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Byron C Calhoun
- Perinatal Diagnostic Center, Charleston Area Medical Center, Charleston, West Virginia
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Abstract
The most severe forms of congenital anomalies of the kidney and urinary tract present in fetal life with early pregnancy renal anhydramnios and are considered lethal due to pulmonary hypoplasia without fetal therapy. Due to the high rate of additional structural anomalies, genetic abnormalities, and associated syndromes, detailed anatomic survey and genetic testing are imperative when stratifying which pregnancies are appropriate for fetal intervention. Restoring amniotic fluid around the fetus is the principal goal of prenatal treatment. The ongoing multi-center Renal Anhydramnios Fetal Therapy (RAFT) trial is assessing the safety and efficacy of serial amnioinfusions to prevent pulmonary hypoplasia so that the underlying renal disease can be addressed.
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Atkinson MA, Jelin EB, Baschat A, Blumenfeld Y, Chmait R, O’Hare E, Moldenhauer J, Zaretsky M, Miller R, Ruano R, Gonzalez J, Johnson A, Mould A, Davis J, Hanley D, Keiser A, Rosner M, Miller JL. Design and Protocol of the Renal Anhydramnios Fetal Therapy (RAFT) Trial. Clin Ther 2022; 44:1161-1171. [PMID: 35918190 PMCID: PMC9847373 DOI: 10.1016/j.clinthera.2022.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/08/2022] [Accepted: 07/05/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE Anhydramnios secondary to anuria before 22 weeks of gestational age and congenital bilateral renal agenesis before 26 weeks of gestational age are collectively referred to as early-pregnancy renal anhydramnios. Early-pregnancy renal anhydramnios occurs in at least 1 in 2000 pregnancies and is considered universally fatal when left untreated because of severe pulmonary hypoplasia precluding ex utero survival The Renal Anhydramnios Fetal Therapy (RAFT) trial is a nonrandomized, nonblinded, multicenter clinical trial designed to assess the efficacy, safety, and feasibility of amnioinfusions for patients with pregnancies complicated by early-pregnancy renal anhydramnios. The primary objective of this study is to determine the proportion of neonates surviving to successful dialysis, defined as use of a dialysis catheter for ≥14 days. METHODS A consortium of 9 North American Fetal Therapy Network (NAFTNet) centers was formed, and the RAFT protocol was refined in collaboration with the NAFTNet Scientific Committee. Enrollment in the trial began in April 2020. Participants may elect to receive amnioinfusions or to join the nonintervention observational expectant management group. Eligible pregnant women must be at least 18 years of age with a fetal diagnosis of isolated early-pregnancy renal anhydramnios. FINDINGS In addition to the primary study objective stated above, secondary objectives include (1) to assess maternal safety and feasibility of the serial amnioinfusion intervention (2) to perform an exploratory study of the natural history of untreated early pregnancy renal anhydramnios (3) to examine correlations between prenatal imaging and lung specific factors in amniotic fluid as predictive of the efficacy of serial percutaneous amnioinfusions and (4) to determine short- and long-term outcomes and quality of life in surviving neonates and families enrolled in RAFT IMPLICATIONS: The RAFT trial is the first clinical trial to investigate the efficacy, safety, and feasibility of amnioinfusions to treat the survival-limiting pulmonary hypoplasia associated with anhydramnios. Although the intervention offers an opportunity to treat a condition known to be almost universally fatal in affected neonates, the potential burdens associated with end-stage kidney disease from birth must be acknowledged. CLINICALTRIALS gov identifier: NCT03101891.
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Affiliation(s)
- Meredith A. Atkinson
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University, Baltimore, MD
| | - Eric B. Jelin
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University, Baltimore, MD
| | - Ahmet Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
| | - Yair Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, CA
| | - Ramen Chmait
- Department of Fetal Surgery, Children’s Hospital Los Angeles-USC Fetal-Maternal Center, Los Angeles, CA
| | - Elizabeth O’Hare
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University, Baltimore, MD
| | - Julie Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Russell Miller
- Department of Obstetrics and Gynecology, Columbia University, New York, NY
| | - Rodrigo Ruano
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami Medical School, Miami, FL
| | - Juan Gonzalez
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, University of Texas Health Center, Houston, TX
| | - Andrew Mould
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD
| | - Jonathan Davis
- Department of Pediatrics, Tufts Children’s Hospital, Boston, MA
| | - Daniel Hanley
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD
| | - Amaris Keiser
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University, Baltimore, MD
| | - Mara Rosner
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
| | - Jena L. Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
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Han DS, Bock ME, Glover JJ, Vemulakonda VM. Outcomes of dialysis in neonates with anuric end-stage renal disease at birth: ethical considerations. J Perinatol 2022; 42:920-924. [PMID: 35121797 DOI: 10.1038/s41372-022-01328-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 12/29/2021] [Accepted: 01/25/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION We present a case series of neonates with anuric ESRD undergoing renal replacement therapy (RRT) and discuss the associated ethical implications of RRT in this population. METHODS We reviewed patients who initiated RRT within 1 week of life due to anuric ESRD from 2009-2019 at a single tertiary center. Primary outcomes were receipt of renal transplant (RT), one-year survival, and overall survival. RESULTS Five patients met the inclusion criteria. Two patients received an RT. One-year survival was 80%, while overall survival was 60% with a median follow-up of 18 months. In the 2 still-living patients who have not undergone RT, they are ineligible, one due to recent malignancy and the other from acquired cardiovascular comorbidities. CONCLUSION Patients with anuric ESRD requiring RRT undergo multiple treatment challenges with low RT and survival rates. These findings should be shared with families considering intervention for cases of severe renal disease diagnosed prenatally.
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Affiliation(s)
- Daniel S Han
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Margret E Bock
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, USA
| | - Jacqueline J Glover
- Department of Pediatrics and the Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Abstract
OBJECTIVE We describe the essential elements of professional ethics in perinatology and explain how professional ethics in perinatology should guide decision making with pregnant patients and with parents. FINDINGS Professional ethics in perinatology draws on two ethical principles, beneficence and respect for patient autonomy, the ethical concept of the fetus as a patient, and the best interests of the child standard and the concept of parental permission. Counseling about intrapartum management should be based on the ethical concept of the fetus as a patient and on the role of the pregnant patient as the ultimate decision maker. Counseling about setting ethically justified limits on perinatal clinical management should be based on four specified concepts of futility, but not on quality-of-life futility. Counseling about innovation and research should emphasize that investigation clinical management is an experiment. CONCLUSION Professional ethics in perinatology is an essential component of perinatal practice, innovation, and research.
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Affiliation(s)
- Frank A Chervenak
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, 10075, USA
| | - Laurence B McCullough
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York, USA.
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Irfan A, O'Hare E, Jelin E. Fetal interventions for congenital renal anomalies. Transl Pediatr 2021; 10:1506-1517. [PMID: 34189109 PMCID: PMC8192995 DOI: 10.21037/tp-2020-fs-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Congenital abnormalities of the kidney and urinary tract (CAKUT) represent 20% of prenatally diagnosed congenital abnormalities. Although the majority of these abnormalities do not require intervention either pre or postnatally, there is a subset of patients whose disease is so severe that it may warrant intervention prior to delivery to prevent morbidity and mortality. These cases consist of patients with moderate lower urinary tract obstruction (LUTO) in which vesicocentesis, shunting or cystoscopy are options and patients with early pregnancy renal anhydramnios (EPRA) in whom amnioinfusion therapy may be an option. The main causes of EPRA are congenital bilateral renal agenesis (CoBRA), cystic kidney disease (CKD) and severe LUTO. Untreated, EPRA is universally fatal secondary to anhydramnios induced pulmonary hypoplasia. The evidence regarding therapy for LUTO is limited and the stopped early PLUTO (Percutaneous Shunting in Lower Urinary Tract Obstruction) trial was unable to provide definitive answers about patient selection. Evidence for EPRA therapy is also scant. Serial amnioinfusions have shown promise in cases of EPRA due to CoBRA or renal failure and this treatment modality forms the basis of the ongoing NIH funded RAFT (Renal Anhydramnios Fetal Therapy) trial. At present, there is consensus that treatment for EPRA should only occur in the setting of a clinical trial.
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Affiliation(s)
- Ahmer Irfan
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth O'Hare
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Eric Jelin
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Martins PH, Duarte IPL, Leite CRVS, Cavalli RC, Marcolin AC, Duarte G. Influence of Religiosity on Situational Coping Scores in Women with Malformed Fetuses. JOURNAL OF RELIGION AND HEALTH 2020; 59:3071-3083. [PMID: 31664656 DOI: 10.1007/s10943-019-00934-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In clinical care settings, religiosity may serve as an important source of support for coping with the prenatal diagnosis of fetal abnormalities. This study evaluated the influence of religiosity on the situational coping of 28 pregnant women with fetal abnormalities. The study was approved by the institutional research ethics committee, and the informed consent document was obtained from all participants included in this study. Validated measures of religiosity and situational coping were used to evaluate data collected. Practical religiosity but not intrinsic religiosity correlated positively and significantly with coping scores. However, the severity of the fetal malformations did not correlate significantly with the scores of maternal coping. The results showed that religious practices were associated with improved coping in women diagnosed with fetal abnormalities and should be encouraged in care settings.
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Affiliation(s)
- Paulo Henrique Martins
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School of University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Ilmara Pereira Leão Duarte
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School of University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Ricardo Carvalho Cavalli
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School of University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Alessandra Cristina Marcolin
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School of University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Geraldo Duarte
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School of University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
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Abstract
Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.
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Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Discordance for Potter's Syndrome in a Dichorionic Diamniotic Twin Pregnancy-An Unusual Case Report. ACTA ACUST UNITED AC 2020; 56:medicina56030109. [PMID: 32143317 PMCID: PMC7143793 DOI: 10.3390/medicina56030109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/29/2020] [Accepted: 02/24/2020] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Potter's syndrome, also known as Potter's sequence, is an uncommon and fatal disorder. Potter's sequence in a multiple pregnancy is uncommon, and its frequency remains unknown. Worldwide in a diamniotic twin pregnancy, there are only a few cases described. CASE REPORT We present an unusual case discordance for Potter's syndrome in a dichorionic diamniotic twin pregnancy. Twin A had the typical physical and histological Potter's findings. Twin B had normal respiratory function and normal physical examination findings. There are many controversies about this condition in diamniotic twin pregnancy. One case report concluded that that the presence of a normal co-twin in diamniotic pregnancy prevented the cutaneous features seen in Potter's syndrome and ameliorated the pulmonary complications, whereas two other case studies reported that the affected twin had extrarenal features typical of the syndrome. CONCLUSION We performed an autopsy and calculated lung weight/body weight ratio to diagnose pulmonary hypoplasia. Histopathologic examination of lungs and kidneys was performed. We concluded that the appearance of extrarenal features in the affected twin depends on the amniocity.
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End-stage kidney disease in infancy: an educational review. Pediatr Nephrol 2020; 35:229-240. [PMID: 30465082 PMCID: PMC6529305 DOI: 10.1007/s00467-018-4151-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 12/15/2022]
Abstract
An increasing number of infants with end-stage kidney disease (ESKD) are surviving and receiving renal replacement therapy (RRT). Unique clinical issues specific to this age group of patients influence their short- and long-term outcomes. This review summarizes current epidemiology, clinical characteristics, ethical dilemmas, management concerns, and outcomes of infants requiring chronic dialysis therapy. Optimal care during infancy requires a multidisciplinary team working closely with the patient's family. Nutritional management, infection prevention, and attention to cardiovascular status are important treatment targets. Although mortality rates remain higher among infants on dialysis compared to older pediatric dialysis patients, outcomes have improved over time. Most importantly, infants who subsequently receive a kidney transplant are now experiencing graft survival rates that are comparable to older pediatric patients.
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Talati AN, Webster CM, Vora NL. Prenatal genetic considerations of congenital anomalies of the kidney and urinary tract (CAKUT). Prenat Diagn 2019; 39:679-692. [PMID: 31343747 DOI: 10.1002/pd.5536] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 07/16/2019] [Accepted: 07/20/2019] [Indexed: 12/20/2022]
Abstract
Congenital anomalies of the kidney and urinary tract (CAKUT) constitute 20% of all congenital malformations occurring in one in 500 live births. Worldwide, CAKUT are responsible for 40% to 50% of pediatric and 7% of adult end-stage renal disease. Pathogenic variants in genes causing CAKUT include monogenic diseases such as polycystic kidney disease and ciliopathies, as well as syndromes that include isolated kidney disease in conjunction with other abnormalities. Prenatal diagnosis most often occurs using ultrasonography; however, further genetic diagnosis may be made using a variety of testing strategies. Family history and pathologic examination can also provide information to improve the ability to make a prenatal diagnosis of CAKUT. Here, we provide a comprehensive overview of genetic considerations in the prenatal diagnosis of CAKUT disorders. Specifically, we discuss monogenic causes of CAKUT, associated ultrasound characteristics, and considerations for genetic diagnosis, antenatal care, and postnatal care.
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Affiliation(s)
- Asha N Talati
- Department of Obstetrics and Gynecology, DRAFT, Division of Maternal Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Carolyn M Webster
- Department of Obstetrics and Gynecology, DRAFT, Division of Maternal Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Neeta L Vora
- Department of Obstetrics and Gynecology, DRAFT, Division of Maternal Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Riddle SL, Polzin W, Kingma P. Uncovering new physiology in bilateral renal agenesis following amnioinfusion. CASE REPORTS IN PERINATAL MEDICINE 2019. [DOI: 10.1515/crpm-2018-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Bilateral renal agenesis has uniformly been a lethal diagnosis in the perinatal or neonatal period. With the advent of more advanced renal replacement therapy as a bridge to renal transplantation, amnioinfusion has been explored at our center as a way to prevent lethal pulmonary hypoplasia secondary to oligohydramnios.
Case presentation
We describe two cases of bilateral renal agenesis with serial amnioinfusion during pregnancy. The families opted for full neonatal intervention and post-natal renal support. While lethal pulmonary hypoplasia was avoided, early and refractory hypotension limited the ability to perform dialysis in these neonates.
Conclusions
Our limited experience shows that barriers to care such as lethal respiratory failure and technical limitations of early dialysis are not the only barriers prohibiting care for this population.
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Affiliation(s)
- Stefanie L. Riddle
- Division of Neonatology and Pulmonary Biology , Cincinnati Children’s Hospital Medical Center , 3333 Burnet Ave, MLC 7009 , Cincinnati, OH 45229 , USA , Tel.: +513-517-0089, Fax: +513-803-0968
- Perinatal Institute , Cincinnati Children’s Hospital Medical Center , Cincinnati, OH , USA
- Cincinnati Fetal Center , Cincinnati, OH , USA
- Department of Pediatrics , University of Cincinnati, College of Medicine , Cincinnati, OH , USA
| | - William Polzin
- Cincinnati Fetal Center , Cincinnati, OH , USA
- Good Samaritan Hospital , Cincinnati, OH , USA
| | - Paul Kingma
- Perinatal Institute , Cincinnati Children’s Hospital Medical Center , Cincinnati, OH , USA
- Cincinnati Fetal Center , Cincinnati, OH , USA
- Department of Pediatrics , University of Cincinnati, College of Medicine , Cincinnati, OH , USA
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center , Cincinnati, OH 45229 , USA
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Ethical Considerations Concerning Amnioinfusions for Treating Fetal Bilateral Renal Agenesis. Obstet Gynecol 2018; 131:130-134. [PMID: 29215523 DOI: 10.1097/aog.0000000000002416] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Congenital bilateral renal agenesis has been considered a uniformly fatal condition. However, the report of using serial amnioinfusions followed by the live birth in 2012 and ongoing survival of a child with bilateral renal agenesis has generated hope, but also considerable controversy over an array of complex clinical and ethical concerns. To assess the ethical concerns associated with using serial amnioinfusions for bilateral renal agenesis, we assembled a multidisciplinary group to map the ethical issues relevant to this novel intervention. The key ethical issues identified were related to 1) potential risks and benefits, 2) clinical care compared with innovation compared with research, 3) counseling of expectant parents, 4) consent, 5) outcome measures, 6) access and justice, 7) conflicts of interest, 8) effects on clinicians, 9) effects on institutions, and 10) long-term societal implications. These ethical issues should be addressed in conjunction with systematic efforts to examine whether this intervention is safe and effective. Future work should capture the experiences of expectant parents, women who undergo serial amnioinfusions, those born with bilateral renal agenesis and their families as well as clinicians confronted with making difficult choices related to it.
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Abstract
Since first performed in 1954, kidney transplantation has evolved as the preferred long-term treatment of children with end stage renal disease (ESRD). The etiology of chronic kidney disease (CKD) and ESRD in children is broad and can be quite complicated, necessitating a multidisciplinary team to adequately care for these patients and their myriad needs. Precise surgical techniques and modern protocols for immunosuppression provide excellent long-term patient and graft survival. This article reviews the many etiologies of renal failure in the pediatric population focusing on those most commonly leading to the need for kidney transplantation. The processes of evaluation, kidney transplantation, short-term and long-term complications, as well as long-term outcomes are also reviewed.
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Affiliation(s)
- Jonathan P Roach
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 3123 East 16th Ave, Aurora, Colorado 80045.
| | - Margret E Bock
- Section of Nephrology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jens Goebel
- Section of Nephrology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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