The Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
The Department of Radiology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
J Pediatr Urol. 2022 Dec;18(6):801.e1-801.e9. doi: 10.1016/j.jpurol.2022.08.002. Epub 2022 Aug 17.
The management of bilateral ureteropelvic junction obstruction (UPJO) is greatly debated. We aim to identify the risk of early postoperative acute kidney injury (AKI) in relation to the sequence of intervention in children with bilateral UPJO managed in a sequential manner.
A single center database was retrospectively reviewed for children ≤2 years who underwent bilateral pyeloplasty. According to the differential renal function on the preoperative renograms, patients were categorized into group A: pyeloplasty on the poorer functioning kidney first and group B: pyeloplasty on the better functioning side first. Serum creatinine and eGFR, using the modified Schwartz formula, were evaluated at four time points (I): before the first intervention (II): within 48 h of the first intervention (III): before the second intervention and (IV): within 48 h of the second intervention. Preoperative and postoperative values were compared. The incidence of early postoperative AKI in both groups was defined according to the Acute Kidney Injury Network (AKIN) criteria.
The study comprised 46 children treated by staged pyeloplasty, 28 of them underwent pyeloplasty on the poorer functioning side first. Baseline serum creatinine and eGFR were not significantly different between both groups. Patients who underwent pyeloplasty on the poorer functioning side first, had a significant decline of eGFR after the first intervention (p = 0.006). Conversely, no significant eGFR changes were observed after the first or second interventions in the other group (figure). Overall, 64.3% and 33.3% of patients developed some degrees of AKI when intervention was started on the poorer and better functioning renal units, respectively (p = 0.04).
Bilaterality is seen in approximately ¼ of patients with UPJO. Oftentimes, both renal units are asymmetrically affected with little data to guide surgeons on the optimal sequence of intervention. Following pyeloplasty, 52.2% of the evaluated children with bilateral UPJO had early postoperative AKI, mostly of low stage. Our data suggest that intervening first on the better functioning side allows for better recovery of the renal functional reserve and lowers the risk of postoperative AKI.
In children with bilateral UPJO, starting intervention on the poorer functioning kidney is associated with increased risk of postoperative AKI. Long-term prospective studies are needed to confirm our findings.
双侧肾盂输尿管连接部梗阻（UPJO）的治疗存在很大争议。我们旨在确定与双侧 UPJO 患儿的序贯治疗相关的早期术后急性肾损伤（AKI）风险，这些患儿接受了序贯肾盂成形术。
回顾性分析了在单中心数据库中接受双侧肾盂成形术的≤2 岁儿童。根据术前肾图的分肾功能，患者分为 A 组：先对功能较差的肾脏进行肾盂成形术，B 组：先对功能较好的肾脏进行肾盂成形术。使用改良 Schwartz 公式评估血清肌酐和 eGFR，在四个时间点（I）：第一次干预前；（II）：第一次干预后 48 小时内；（III）：第二次干预前；和（IV）：第二次干预后 48 小时内。比较术前和术后的值。根据急性肾损伤网络（AKIN）标准定义两组患儿的早期术后 AKI 发生率。
本研究纳入了 46 例行分期肾盂成形术的患儿，其中 28 例行功能较差侧的肾盂成形术。两组患者的基线血清肌酐和 eGFR 无显著差异。先对功能较差的肾脏进行肾盂成形术的患者，第一次干预后 eGFR 显著下降（p=0.006）。相反，另一组患者在第一次或第二次干预后，eGFR 无明显变化（图）。总体而言，当在功能较差和较好的肾脏单位开始干预时，分别有 64.3%和 33.3%的患者出现不同程度的 AKI（p=0.04）。
约有 1/4的 UPJO 患者存在双侧病变。通常，两个肾脏单位均存在不对称性病变，但很少有数据可以指导外科医生选择最佳的干预顺序。行肾盂成形术后，24 例双侧 UPJO 患儿中有 52.2%发生早期术后 AKI，主要为低分期。我们的数据表明，先对功能较好的肾脏进行干预可以更好地恢复肾功能储备，降低术后 AKI 的风险。
在双侧 UPJO 患儿中，先对功能较差的肾脏进行干预与术后 AKI 风险增加相关。需要进行长期前瞻性研究来证实我们的发现。
