Case presentation on antenatal hydroneprosis

Dr Raghavendra Fellow in neonatology.

Patient name: B/o Uma ajay

S/o Ajay Gollaratti(P) Chitradurga

dist

DOB:20/03/2015DOA:24/03/2015DOD:03/04/2015

Single/live/AGA/term male child delivered via naturalis in chitradurga govt hospital on 20/03/2015 at 8 pm.

Baby cried immediately after birth. Bt wt:2.8kg.

C/c Antenatal scan s/o some renal problems need to fallow up in higher centre.

Obstretic history: ANC registered in govt hospital chitradurga. Regular fallow up, taken iron and folic acid tablets. Taken 2 dose of TT inj. Taken three antenatal scan. Antenatal events un eventful.

USG scan at 26 wks s/o fetal bilateral moderate to severe hydroneproureterosis (LT>RT) with moderately distended urinary bladder.?Partial posterior uretral valve. RT kidney 3 x 1.5 cm. LT kidney 3.4cm x 2.2cm.

USG scan at 29 weeks s/o bilateral fetal moderte to severe hydronepro ureterosis ((LT>RT) with thickened urinary mucosa

s/o bladder outlet obstruction. RT kidney 3cm x1.6cm. Lt kidney 3.8cmx 2.6cm.

Antenatal scan at 26 wks

Antenatal scan at 29 wks

Antenatal scan at 36 wks

USG scan at 36 wk s/o fetal bilateral severe hydronephroureterosis (LT>RT) with distended bladder 5 x 2.5cm likely distal obstruction . RT kidney 4cm x 2.5cm. LT kidney 5cm x 2.5cm.

Family history: Married life 6 years. Father studied till 10th std, farmer. Mother studied till 12th ,HW.

1st child male/4years, studing in anganawadi.

GPE:A 4 day old neonate active alert ,well feeding passing adequate stool and urine .

Vitals: HR-148 bpm RR- 38 cpm CFT < 3secs.

Antropometry:HC:32cmLT:34cm

Head to toe examination: within normal limit.

Systemic examination:

CVS- S1 & S2 heard, no murmur

R/S- B/L air entry equal, no added sounds

P/A- soft, BS heard

CNS- tone and reflexes normal

B/o uma ajay admitted in hospital on D4 of life for w/u for antenatal hydroneprosis.

Septic screening was negative,received benefit of prophylactically antibiotic inj ceftriaxone for 7 days.

Physiological hyperbilirubinemia ,Tmax on D4 was 16.4mg/dl received phototherapy for 36hrs.

Workup for renal function test and routine urine and culture sensitivity done.reports are within normal limits.

MCU done on D4 of life s/o bilateral vesicoureteric reflux,grade3 on RT & grade2 on LT.

Baby was discharged on D9 with prophylactic sporidex drops and asked to review after 1 month.

Course in hospital

Reports of 24/03/15

Complete haemogram Hb 17.8 mg /dl Tc 10460 N:39%,L:39% HCT:53.7% PLT:2.58lakh/cumm Crp:18.7mg/dl

S NA:153.3meq/dl S k :5.1meq?dl S cl:115.4 meq/dl

Urea:55.1mg/dl S creatinine:1.3 meq/dl

S bili 16.4mg/dl DB:1.3 mg /dl IB:15.1mg/dl

Investigation

Reports of 29/03/15

S urea :45meq/dl S creatinine:1mg/dl.

S NA :145.8meq/dl S K:5.3meq/dl S cl:108.2meq/dl

21/03/2015 Post natal usg s/o bilateral gross hydrouretronephrosis more on Lt side,?lower urinary tract obstruction.Rt kidney 3.8cmx1.9cm,Lt kidney 4.2cmx2.2cm

Postnatal usg on 21/03/2015

Single/live/term/AGA/male child delivered via naturalis in govt hospital chitradurga on 20/03.regular antenatal checkup done. Antenatal scan s/o B/l hydrouretroneprosis.

Postnatal scan s/o gross hydro ureteroneprosis on Lt side,so refered to our centre for further management.renal function test and urine w/u are within normal limit,received benefit of antibiotics,tmax on d4 16.4mg/dl received photherapy.MCU done on d5 s/o Bilateral vesicouretral reflux grade 3 on Rt and grade2 on Lt.Started prophylactically sporidex drops and dischared on d13.

Discussion

Antenatal hydronephrosis is the dilatation of the collecting system of the fetal kidney.

It is estimated that fetal urinary tract dilatation is identified in 1% of all pregnancies.

In more than 50% cases, the antenatally detected dilatation is transient and resolves spontaneously.

Antenatally detected dilatation, which persists after birth is labeled as neonatal hydronephrosis.

Pelviureteric junction (PUJ) obstruction accounts for 50-60% patients with neonatal hydronephrosis.

Vesicoureteric reflux (VUR) is detected in 20-30% of such cases.

Antenatal hydronephrosis

Common Pelviureteric junction obstruction Vesicoureteric reflux Vesicoureteric junction obstruction Multicystic kidney.

Rare Posterior urethral valves Obstructive and non-obstructive megaureter Ureterocele Neurogenic bladder Prune-belly syndrome Urethral atresia

Causes of Neonatal Hydronephrosis

Fetal hydronephrosis of moderate degree can be detected as early as 15-18 weeks gestation by ultrasonography.

A maximum anteroposterior diameter of renal pelvis of more than 10 mm and the ratio of antero-posterior diameter of renal pelvis to kidney of more than 0.5 after 30 weeks gestation requires postnatal evaluation.

The ultrasound study should be repeated every 6-8 weeks until delivery.

Antenatal Evaluation

Classification of antenatal hydronephrosis, based on renal pelvic anteroposterior diameter

Hydronephrosis . Renal pelvic anteroposterior diameter. Caliectasis. Ureteral dilatation . Renal echogenicity. Contralateral kidney: size, dilatation. Bladder size, thickness. Posterior urethral dilatation. Urinary flow . Amniotic fluid volume

Features Evaluated on Antenatal Ultrasonography

At birth Clinical examination, assess urine stream.

Asymptomatic unilateral hydronephrosis 0–2 weeks Ultrasonography Blood urea, creatinine; urine culture 4–6 weeks Micturating cystourethrogram DTPA scan (with diuretic renography).

Solitary kidney, suspected posterior urethral valves, bilateral hydronephrosis or presence of symptoms

0–2 weeks Ultrasonography Blood urea, creatinine; urine culture Micturating cystourethrogram 4–6 weeks DTPA scan (with diuretic renography)  DMSA renal scan is performed in patients with vesicoureteric reflux

Postnatal Evaluation of Hydronephrosis

Grade 1: Slight separation of the central renal echo complex.

Grade 2: Renal pelvis is further dilated and a single or a few calyces may be visualized.

Grade 3: Renal pelvis is dilated and there are fluid filled calyces throughout the kidney, but renal parenchyma is of normal thickness.

Grade 4: As grade 3, but renal parenchyma over the calyces is thinned

Postnatal grades of hydronephrosis according to the Society of Fetal Urology classification.

Postnatal grades of hydronephrosis according to the Society of Fetal Urology classification.

Postnatal management of antenatally diagnosed hydronephrosis.

Asymptomatic unilateral hydronephrosis is most often a benign condition.

Hydronephrosis due to PUJ obstruction resolves spontaneously with passage of time.

Hydronephrosis & Hydroureteronephrosis due to vesicoureteric junction obstruction improve.

Kidneys with renal pelvic diameter more than 20 mm are likely to show deterioration in renal function, which might require intervention.

Management of Unilateral Hydronephrosis

VUR is seen in 20-25% neonates with antenatally detected hydronephrosis, more commonly in boys.

Forty per cent neonates with VUR show features suggestive of renal scarring on DMSA scan.

Neonates with VUR should be managed on long-term antibiotic prophylaxis (while awaiting spontaneous resolution of the reflux).

The patients are kept on close follow-up for occurrence of break-through urinary infections.

An ultrasound examination, and radionuclide cystogram or MCU should be repeated at 12-15 months.

Vesicoureteric Reflux

Grades of VUR Based on Guidelines of the International Reflux Study CommitteeI Ureter only

II Ureter, pelvis, and calices; no dilatation; normal caliceal fornices

III Mild or moderate dilatation or tortuosity of the ureter and moderate dilatation of the renal pelvis; no or slight blunting of the fornices

IV Moderate dilatation or tortuosity of the ureter and moderate dilatation of the renal pelvis and calices; complete obliteration of the sharp angle of the fornices but maintenance of the papillary impressions in the majority of calices

V Gross dilatation and tortuosity of the ureter; gross dilatation of the renal pelvis and calices; papillary impressions are no longer visible in the majority of the calices

Anatomy and Grading System

                                                  

Conservative Approach

The management of asymptomatic neonatal hydronephrosis is essentially conservative.

severe neonatal hydronephrosis resolve spontaneously and deterioration of renal function, if detected, can be reversed by prompt surgery.

Antibiotic prophylaxis. Cephalexin (10-15 mg/kg/day) should be used for the

initial 3 months, and cotrimoxazole (1-2 mg/kg/day) or nitro-furantoin (1 mg/kg/day).

Urine culture should be promptly obtained if the

patient has symptoms suggestive of urinary tract infection e.g., unexplained fever, turbid or foul smelling urine, poor feeding and lethargy

PUJ obstruction At initial diagnosis Presence of symptoms Solitary kidney with hydronephrosis Bilateral hydronephrosis Differential renal function of obstructed kidney <30% On follow-up Increasing renal pelvic dilatation >10% decline

in differential renal function

Posterior urethral valve, ureterocele Vesicoureteric reflux

Grade IV-V reflux persisting beyond infancy New renal scars or recurrent urinary infections despite

antibiotic prophylaxis

Indications for Surgery in Neonatal Hydronephrosis

Behrman, R.E., Kliegman, R.M., & Jenson, H.B. (2000). Nelson Textbook of Pediatrics (16th ed.). Page1445-1454.

Indian Pediatrics 2001; 38: 1244-1251   Consensus Statement on Management of

Antenatally Detected Hydronephrosis.

Indian J Nephrol. 2013 Mar-Apr; 23(2): 83–97.

. Mallik M, Watson AR. Antenatally detected urinary tract abnormalities: More detection but less action.Pediatr Nephrol. 2008;23:897–904. [PubMed]

2. Dudley JA, Haworth JM, McGraw ME, Frank JD, Tizard EJ. Clinical relevance and implications of antenatal hydronephrosis. Arch Dis Child Fetal Neonatal Ed. 1997;76:F31–4. [PMC free article] [PubMed]

Goole images

References

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