Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA.
Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA.
J Pediatr Urol. 2024;20 Suppl 1:S11-S17. doi: 10.1016/j.jpurol.2024.05.017. Epub 2024 May 31.
Patients with high grade hydronephrosis (HN) and non-obstructive drainage on mercaptoacetyltriglycine (MAG-3) diuretic renography (renal scans) can pose a dilemma for clinicians. Some patients may progress and require pyeloplasty; however, more clarity is needed on outcomes among these patients.
Our primary objective was to predict which patients with high-grade HN and non-obstructive renal scan, (defined as T ½ time <20 min) would experience resolution of HN. Our secondary objective was to determine predictors for surgical intervention.
Patients with prenatally detected HN were prospectively enrolled from 7 centers from 2007 to 2022. Included patients had a renal scan with T ½<20 min and Society for Fetal Urology (SFU) grade 3 or 4 at last ultrasound (RBUS) prior to renal scan. Primary outcome was resolution of HN defined as SFU grade 1 and anterior posterior diameter of the renal pelvis (APD) < 10 mm on follow-up RBUS. Secondary outcome was pyeloplasty, comparing patients undergoing pyeloplasty with patients followed with serial imaging without resolution. Multivariable logistic regression was used for analysis.
Of the total 2228 patients, 1311 had isolated HN, 338 patients had a renal scan and 129 met inclusion criteria. Median age at renal scan was 3.1 months, 77% were male and median follow-up was 35 months (IQR 20-49). We found that 22% (29/129) resolved, 42% of patients had pyeloplasty (54/129) and 36% had persistent HN that required follow-up (46/129). Univariate predictors of resolution were age≥3 months at time of renal scan (p = 0.05), T ½ time≤5 min (p = 0.09), SFU grade 3 (p = 0.0009), and APD<20 mm (p = 0.005). Upon multivariable analysis, SFU grade 3 (OR = 4.14, 95% CI: 1.30-13.4, p = 0.02) and APD<20 mm (OR = 6.62, 95% CI: 1.41-31.0, p = 0.02) were significant predictors of resolution. In the analysis of decision for pyeloplasty, SFU grade 4 (OR = 2.40, 95% CI: 1.01-5.71, p = 0.04) and T ½ time on subsequent renal scan of ≥20 min (OR = 5.14, 95% CI: 1.54-17.1, p = 0.008) were the significant predictors.
Patients with high grade HN and reassuring renal scan can pose a significant challenge to clinical management. Our results help identify a specific candidate for observation with little risk for progression: the patient with SFU grade 3, APD under 20 mm, T ½ of 5 min or less who was 3 months or older at the time of renal scan. However, many patients may progress to surgery or do not fully resolve and require continued follow-up.
患有高级别肾积水（HN）且巯基乙酰三甘氨酸（MAG-3）利尿剂肾扫描显示非梗阻性引流的患者可能会给临床医生带来困境。一些患者可能会进展并需要肾盂成形术；然而，我们需要更多关于这些患者结局的信息。
我们的主要目的是预测哪些患有高级别 HN 和非梗阻性肾扫描（定义为 T1/2 时间<20 分钟）的患者会经历 HN 的缓解。我们的次要目的是确定手术干预的预测因素。
从 2007 年至 2022 年，我们在 7 个中心前瞻性招募了患有产前检测到的 HN 的患者。纳入的患者在进行肾扫描前最后一次超声（RBUS）上有 T1/2<20 分钟和胎儿泌尿科协会（SFU）3 级或 4 级的患者。主要结局是定义为 SFU 分级 1 和肾盂前后径（APD）<10 毫米的 HN 缓解，通过后续 RBUS 进行评估。次要结局是肾盂成形术，比较行肾盂成形术的患者与未缓解行连续影像学检查的患者。使用多变量逻辑回归进行分析。
在总共 2228 名患者中，1311 名患者有孤立性 HN，338 名患者进行了肾扫描，129 名患者符合纳入标准。肾扫描时的中位年龄为 3.1 个月，77%为男性，中位随访时间为 35 个月（IQR 20-49）。我们发现 22%（29/129）缓解，42%的患者行肾盂成形术（54/129），36%的患者 HN 持续存在需要随访（46/129）。缓解的单变量预测因素包括肾扫描时年龄≥3 个月（p=0.05）、T1/2 时间≤5 分钟（p=0.09）、SFU 分级 3（p=0.0009）和 APD<20 毫米（p=0.005）。多变量分析显示，SFU 分级 3（OR=4.14，95%CI：1.30-13.4，p=0.02）和 APD<20 毫米（OR=6.62，95%CI：1.41-31.0，p=0.02）是缓解的显著预测因素。在分析肾盂成形术的决策时，SFU 分级 4（OR=2.40，95%CI：1.01-5.71，p=0.04）和后续肾扫描 T1/2 时间≥20 分钟（OR=5.14，95%CI：1.54-17.1，p=0.008）是显著的预测因素。
患有高级别 HN 和令人放心的肾扫描的患者可能会对临床管理构成重大挑战。我们的结果有助于确定具有最小进展风险的特定观察候选者：SFU 分级 3、APD 低于 20 毫米、T1/2 为 5 分钟或更短且在肾扫描时年龄为 3 个月或以上的患者。然而，许多患者可能会进展为手术或未完全缓解并需要继续随访。
