McIlroy P J, Abbott G D, Anderson N G, Turner J G, Mogridge N, Wells J E
Department of Paediatrics, Christchurch Hospital, New Zealand.
J Paediatr Child Health. 2000 Dec;36(6):569-73. doi: 10.1046/j.1440-1754.2000.00571.x.
Postnatal investigation of mild degrees of fetal hydronephrosis has allowed subsequent detection of infants with vesicoureteric reflux (VUR). This study was designed to provide short to medium term information on such infants who had primary VUR, the rates of renal damage and progression over time, the risk factors for such damage and to compare the characteristics of those who had mild dilatation of the fetal renal pelvis (4-9 mm) with those who had moderate-severe dilatation (> or = 10 mm).
Since June 1989, infants whose antenatal sonography had identified a fetal renal pelvis with an anteroposterior diameter of > 4 mm were investigated postnatally with renal ultrasonography and micturating cystourethrogram (MCU), and placed on antimicrobial prophylaxis. Those with VUR received 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy. Infants were followed until discharge based on resolution of VUR, surgery, or low grade VUR. A 5.5 year cohort between June 1989 and December 1994 formed the study population. A review of notes and clinical review (if still under follow up) was undertaken. Vesicoureteric reflux on MCU was regraded according to the International Classification, and reflux nephropathy on DMSA scans was regraded according to criteria proposed by Goldraich. Regression analysis was used to assess risk factors for renal damage.
There were 69 infants (37 girls, 32 boys) who were identified with primary VUR, with 37/69 having bilateral reflux. Eight had a urinary tract infection during the follow-up period. There was a broad distribution of grades of reflux detected (Grades I-3, Grades II-23, Grades III-19, Grades IV - 17, Grades V-7). 99m-Tc-dimercaptosuccinic acid scans on 57/69 (83%) demonstrated renal damage in eight infants (14%). This was predominantly global contraction of function. No progression of renal damage was seen over 2-7 years. Regression analysis showed a strong association between Grades IV, V reflux and the presence of renal damage (P < 0.001). Review of the degrees of fetal renal pelvic dilatation showed that 60/69 infants were detected because of mild (4-9 mm) dilatation. The majority (43/60) had lower grades of reflux (Grades I, II, 3), but there was no obvious cut-off between 4 and 9 mm that could predict high grade VUR (Grades IV, V).
The use of 4 mm to define an abnormal fetal renal pelvis allows a much larger group of infants with high grade primary VUR to be detected than if a higher cut-off measurement is used. Although it also detects many more infants with low grade primary VUR, there is no obvious cut-off point at which this effect predominates. Progressive renal damage was not seen in follow up of up to 7 years of age. Renal damage on DMSA scanning in this group is almost exclusively a pattern of global contraction of function. The presence of high-grade VUR appears to be the only important factor in predicting the presence of renal damage.
对轻度胎儿肾积水进行产后调查，已能在后续检测出患有膀胱输尿管反流（VUR）的婴儿。本研究旨在提供有关患有原发性VUR的此类婴儿的短期至中期信息、肾损害发生率及随时间的进展情况、此类损害的危险因素，并比较胎儿肾盂轻度扩张（4 - 9毫米）与中度至重度扩张（≥10毫米）的婴儿的特征。
自1989年6月起，对产前超声检查发现胎儿肾盂前后径＞4毫米的婴儿进行产后肾脏超声检查和排尿性膀胱尿道造影（MCU），并给予抗菌预防。患有VUR的婴儿接受99m锝 - 二巯基丁二酸（DMSA）闪烁扫描。婴儿随访至VUR消退、手术或低度VUR出院。1989年6月至1994年12月的5.5年队列构成研究人群。对病历进行回顾并进行临床复查（如果仍在随访中）。MCU上的膀胱输尿管反流根据国际分类重新分级，DMSA扫描上的反流性肾病根据戈德赖希提出的标准重新分级。采用回归分析评估肾损害的危险因素。
69例婴儿（37例女孩，32例男孩）被确诊为原发性VUR，其中37/69为双侧反流。8例在随访期间发生尿路感染。检测到的反流分级分布广泛（I级 - 3例，II级 - 23例，III级 - 19例，IV级 - 17例，V级 - 7例）。57/69（83%）的婴儿进行了99m锝 - 二巯基丁二酸扫描，其中8例婴儿（14%）显示肾损害。主要为功能的整体收缩。在2至7年的随访中未见肾损害进展。回归分析显示IV级、V级反流与肾损害的存在之间存在强关联（P＜0.001）。对胎儿肾盂扩张程度的回顾显示，60/69例婴儿因轻度（4 - 9毫米）扩张被检测出。大多数（43/60）反流分级较低（I级、II级、III级），但在4至9毫米之间没有明显的界限可以预测高级别VUR（IV级、V级）。
与使用更高的截断测量值相比，使用4毫米来定义异常胎儿肾盂能够检测出更多患有高级别原发性VUR的婴儿。虽然它也检测出更多患有低级别原发性VUR的婴儿，但没有明显的临界点使这种效果占主导。在7岁以下的随访中未见进行性肾损害。该组中DMSA扫描显示的肾损害几乎完全是功能整体收缩的模式。高级别VUR的存在似乎是预测肾损害存在的唯一重要因素。
