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Antenatal Hydronephrosis. Antenatal Hydronephrosis. Definition: AP diameter renal pelvis > 4mm @ 20 wk EGA AP diameter renal pelvis > 7mm @ 30 wk EGA Incidence: 5% of pregnancies. Antenatal Hydronephrosis. Standard work-up: Postnatal ultrasound Look for AP diameter

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antenatal hydronephrosis1
Antenatal Hydronephrosis
  • Definition:

AP diameter renal pelvis > 4mm @ 20 wk EGA

AP diameter renal pelvis > 7mm @ 30 wk EGA

  • Incidence: 5% of pregnancies
antenatal hydronephrosis2
Antenatal Hydronephrosis
  • Standard work-up:
    • Postnatal ultrasound
      • Look for
        • AP diameter
        • Calyceal/ureteral dilation
        • Renal size
        • Corticomedullary differentiation
        • Thinned/hyperechoic cortex
        • Cortical cysts
        • Ureterocele
        • Ectopic ureteral insertion
      • Best after first 24 hours of life/when not volume depleted
anh work up cont
ANH: Work-up (cont.)
  • VCUG
    • Vesicoureteral reflux
    • Posterior urethral valves
    • Ureterocele
  • Antibiotics (Amoxicillin 10mg/kg/day) until VCUG done (and normal)
is a vcug necessary
Is a VCUG Necessary?
  • Ismaili et al., Journal of Pediatrics, June 2004
    • 258 pts with ANH
    • 81 w/u WNL
    • 49 uncomplicated duplication or dilation resolved
    • 83 with significant findings
      • 27 UPJ
      • 23 primary VUR
      • 15 primary megaureter
      • 10 complicated duplication (ureterocele/ectopic ureter)
      • 3 MCDK
      • 2 posterior urethral valves
      • 2 horseshoe kidney
      • 1 renal dysplasia
ismaili article continued
Ismaili Article Continued
  • Normal postnatal US 3% abnormal VCUG
  • AP diameter 7-10mm -- 64% had significant findings
  • AP diameter >10mm -- 100% had significant findings
  • Recommends no VCUG if US wnl
  • This is in sharp contrast to several earlier studies
phan et al pediatric nephrology october 2003
Phan, et al., Pediatric Nephrology, October 2003
  • 68/111 pts with ANH and AP diameter <10mm (including several wnl)
  • 16 (24%) had VUR
anderson et al pediatric nephrology november 1997
Anderson, et al., Pediatric Nephrology, November 1997
  • Postnatal renal sonogram could not predict presence of VUR in pts with AP diameter >4mm antenatally
  • 9% of pts with nl postnatal US had VUR
farhat et al journal of urology september 2000
Farhat, et al., Journal of Urology, September 2000
  • 27 % of pts with VUR (w/u prompted by ANH) had a normal postnatal RBUS
herndon et al journal of urology september 1999
Herndon, et al., Journal of Urology, September 1999
  • Of pts later dx’d with VUR (as part of ANH w/u) 88% had AP diameter <10mm
  • 25% had nl postnatal RBUS
  • Only 26 ureters (of 112 refluxing units) dilated on RBUS
radiology 1993
Radiology 1993
  • 25% of patients with ANH and nl postnatal RBUS had VUR on VCUG
breakdown of postnatal dx
Breakdown of postnatal dx
  • 60%--normal
  • 25%--UPJ (includes those that require no intervention)
  • 15%--VUR
  • 1-2% other
  • (diagnoses may overlap)
when to get an ivp mag 3
When to get an IVP/Mag 3
  • More reliable results after 8-12 weeks of life
  • Mag 3 nuclear renogram preferred
  • Most algorithms now are based on delayed T ½ on nuclear renogram and changes in differential function
mag 3 nuclear renogram with lasix washout
Mag 3 Nuclear Renogram with Lasix Washout
  • AP diameter >10mm
  • After 12 weeks of life
  • Differential function
  • Drainage (measured as time to drainage of ½ volume of renal pelvis from administration of Lasix [or peak of tracer]), but the actual image may be more revealing, depending on region of interest drawn
when to intervene
When to intervene
  • Differential function < 40%
  • Progressive decrease in differential function on sequential nuclear renograms
onen jayanthi and koff journal of urology september 2002
Onen, Jayanthi, and Koff. Journal of Urology. September 2002
  • Looks at bilateral Initial evaluation: US, nuclear renogram, serum creatinine
  • 13/38 kidneys required pyeloplasty—criteria: worsening hydronephrosis, decrease in relative function >10%
  • Mean time to maximal improvement by US post-op 14 months in operated group
  • 10 months in nonoperative group
other reasons for intervention
Other Reasons for Intervention
  • Symptomatic
    • Failure to thrive
    • UTI
slide18
IVP
  • Megaureter
  • Persistence of AP diameter >10mm, but preserved function at one year
slide19
DMSA
  • Multicystic Dysplastic Kidney
  • Assure that there is no function before abandoning kidney
  • 42% of kidneys dx’d as MCDK kidneys antenatally are actually hydronephrosis/UPJ obstruction
conclusions
Conclusions

Most diagnoses made based on a finding of prenatal hydronephrosis can be handled conservatively.

However, until we have better ways to predict who will require intervention, a complete work-up, including RBUS and VCUG is warranted in all pts with an AP renal diameter >4mm prenatally.

urinary tract infections in children
Urinary Tract Infections in Children

Incidence

  • Neonates: M > F
  • Thereafter: F > M
organisms
Organisms
  • Enterobacteriaciae
    • Escherichia (80%)
    • Klebsiella
    • Enterobacter
    • Citrobacter
    • Proteus
    • Providencia
    • Morganella
    • Serratia
    • Salmonella
other organisms
Other Organisms
  • Pseudamonas
  • Staphylococcus
  • Enterobacter
risk factors
Risk Factors
  • Perineal colonization
  • Family hx
  • Presence of a prepuce
    • 10x risk
    • Periurethral colonization—circ eliminates this
    • Adherence of P fimbriated E. coli to prepuce
  • Urethral length
  • Urine pH (6-7 favors growth)
  • Urine concentration—dilute has less nutrients
  • Dysfunctional elimination
risk factors dysfunctional elimination
Risk Factors—Dysfunctional Elimination
  • Residual urine
  • Increased intravesical pressure
  • Bladder overdistension
  • Constipation
    • 24% day wetters
    • 34% night wetters
  • 90% of pts with UTI and no structural anomalies had dysfunctional elimination
not risk factors
Not Risk Factors
  • Bubble baths
  • Improper wiping
risk factors upper tract infections
Risk FactorsUpper Tract Infections
  • Antigen P1 blood group receptors
  • Vesicoureteral Reflux
    • 25-50% of patients with pyelonephritis have VUR
    • Less virulent strains of E. coli can cause pyelo inpatients with VUR
  • Obstruction
  • Heredity
presentation
Nonverbal Patient

Irritability

Poor feeding

Failure to thrive

Vomiting

Diarrhea

Fever

Verbal Patient

Urgency

Frequency

Enuresis

Dysuria

Fever

Presentation
diagnosis
Diagnosis
  • Urine Culture is ABSOLUTELY NECESSARY
  • Symptoms are not enough
  • History is not enough
  • Of patients with dysuria, urgency, frequency, enuresis 18% had + UCX, 40% had URI (yes, respiratory infection!)
  • Local symptoms could be the same with vulvitis, urethritis, dysfunctional voiding, dehydration
urine cultures
Urine Cultures
  • Bagged specimens are only valuable when negative
  • Voided, midstream catch
  • Catheterized best, and necessary in the pre-potty training age, especially if there is a fever and the diagnosis of UTI is going to lead to further testing
diagnosis1
Diagnosis
  • UA
    • WBC 70% reliable
    • Bacteria on a centrifuged urine
  • UTI if WBC>10/mL & UCx >50k cfu/mL
  • Dipstick LE 52.9%, Nitrite 31.4% sensitive
  • Nitrites require 4hrs of bacterial incubation to be +
  • LE may give false positive after prolonged exposure to air
level of infection
Level of Infection
  • Cystitis
    • Symptoms
      • Dysuria
      • Frequency
      • Urgency
      • 2o enuresis
      • Usually no systemic symptoms
level of infection1
Level of Infection
  • Pyelonephritis
    • Fever
    • Flank pain
    • Pyuria
    • UCx positive
    • Elevated serum WBC, ESR, CRP
asymptomatic bacteruria
Asymptomatic Bacteruria
  • Positive urine culture
  • No urinary symptoms
  • Only 4% later progress to symptomatic infection
  • The organism may be commensal and protective to prevent infection with a more virulent organism
  • In the absence of VUR, no treatment necessary, but look for voiding dysfunction
pyelonephritis continued
Pyelonephritis (continued
  • Diagnosis: UCx and pyuria, but DMSA to be absolutely certain (in the first several days of symptoms)
  • Risks from episodes of pyelo
    • Focal ischemia
    • Inflammatory changes
    • Renal scarring
    • Hypertension
    • Renal insufficiency
treatment
Treatment
  • Lower Tract (no fever)
    • Treat 3-5 days
    • Start with TMP-SMX, nitrofurantoin or cephalosporin
    • Amoxil may change gut flora and lead to future infections with resistant organisms
    • FQ ok if there is no other oral agent to use
treatment1
Treatment
  • Pyelonephritis
    • Treat 10-14 days
    • Start with Bactrim of Cephalosporin until culture is back
    • Hospitalization in severe cases
  • Abscess
    • UCx may be negative
    • Parenteral abx x 10 days then 14d oral therapy
work up after a uti
Work-up after a UTI
  • Who?
    • Fever or documented pyelonephritis
    • <5yo
  • What
    • RBUS (prior to discharge & yes, kidneys & bladder)
    • VCUG once afebrile
    • DMSA
  • Prophylactic antibiotics until work-up
prophylaxis
Prophylaxis
  • Vesicoureteral reflux
  • No Reflux, but <1yo
    • 30-75% recurrence in the first year
  • Frequent symptomatic UTIs