Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
Ultrasound Obstet Gynecol. 2019 Apr;53(4):520-524. doi: 10.1002/uog.19172.
To propose a staging system for congenital lower urinary tract obstruction (LUTO) capable of predicting the severity of the condition and its prognosis.
This was a national retrospective study carried out at the eight Academic Hospitals in The Netherlands. We collected prenatal and postnatal data of fetuses at high risk of isolated LUTO that were managed conservatively. Postnatal renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the Schwartz formula, considering the length of the infant and the creatinine nadir in the first year after birth. Receiver-operating characteristics (ROC) curve analysis, univariate analysis and multivariate logistic regression analysis with stepwise backward elimination were performed in order to identify the best antenatal predictors of perinatal mortality and postnatal renal function.
In total, 261 fetuses suspected of having LUTO and managed conservatively were included in the study. The pregnancy was terminated in 110 cases and perinatal death occurred in 35 cases. Gestational age at appearance of oligohydramnios showed excellent accuracy in predicting the risk of perinatal mortality with an area under the ROC curve of 0.95 (P < 0.001) and an optimal cut-off at 26 weeks' gestation. Fetuses with normal amniotic fluid (AF) volume at 26 weeks' gestation presented with low risk of poor outcome and were therefore defined as cases with mild LUTO. In fetuses referred before the 26 week of gestation, the urinary bladder volume (BV) was the best unique predictor of perinatal mortality. ROC curve analysis identified a BV of 5.4 cm and appearance of oligohydramnios at 20 weeks as the best threshold for predicting an adverse outcome. LUTO cases with a BV ≥ 5.4 cm or abnormal AF volume before 20 weeks' gestation were defined as severe and those with BV < 5.4 cm and normal AF volume at the 20 weeks' scan were defined as moderate. Risk of perinatal mortality significantly increased according to the stage of severity, from mild to moderate to severe stage, from 9% to 26% to 55%, respectively. Similarly, risk of severely impaired renal function increased from 11% to 31% to 44%, for mild, moderate and severe LUTO, respectively.
Gestational age at appearance of oligo- or anhydramnios and BV at diagnosis can accurately predict mortality and morbidity in fetuses with LUTO. Our proposed staging system can triage reliably fetuses with LUTO and predict the severity of the condition and its prognosis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
提出一种先天性下尿路梗阻（LUTO）的分期系统，该系统能够预测疾病的严重程度及其预后。
这是一项在荷兰 8 所学术医院进行的全国性回顾性研究。我们收集了保守治疗的高危孤立性 LUTO 胎儿的产前和产后数据。通过 Schwartz 公式计算的估计肾小球滤过率（eGFR）评估产后肾功能，考虑婴儿的长度和出生后第一年的肌酐最低点。为了确定围产期死亡率和产后肾功能的最佳产前预测指标，进行了受试者工作特征（ROC）曲线分析、单变量分析和逐步向后消除的多变量逻辑回归分析。
共有 261 例疑似患有 LUTO 并接受保守治疗的胎儿纳入本研究。110 例妊娠终止，35 例围产期死亡。羊水过少出现的孕龄在预测围产期死亡率方面具有出色的准确性，ROC 曲线下面积为 0.95（P<0.001），最佳截断值为 26 周妊娠。26 周妊娠时羊水正常的胎儿发生不良结局的风险较低，因此定义为轻度 LUTO。在 26 周妊娠前转诊的胎儿中，膀胱容积（BV）是围产期死亡率的最佳唯一预测指标。ROC 曲线分析确定 5.4cm 的 BV 和 20 周时出现羊水过少是预测不良结局的最佳阈值。BV≥5.4cm 或 20 周前羊水异常的 LUTO 病例定义为重度，BV<5.4cm 且 20 周扫描时羊水正常的病例定义为中度。根据严重程度的分期，围产期死亡率的风险从轻度到中度到重度分别显著增加，从 9%增加到 26%增加到 55%。同样，轻度、中度和重度 LUTO 的严重肾功能受损风险分别从 11%增加到 31%增加到 44%。
羊水过少或无羊水出现的孕龄和诊断时的 BV 可以准确预测 LUTO 胎儿的死亡率和发病率。我们提出的分期系统可以可靠地对 LUTO 胎儿进行分诊，并预测疾病的严重程度及其预后。版权所有©2018 ISUOG。由 John Wiley & Sons Ltd 出版。
