Current Practice Patterns in the Diagnosis and Management of Pediatric Multicystic Dysplastic Kidneys - Results of a Cross-Sectional Physician Survey
Christian A. Rafla, BA1, Zhan Tao Wang, MD, FRCSC2, Ahmed Abdelhalim, MD3, Joshua D. Chamberlin, MD3, Heidi A. Stephany, MD3, Elias J. Wehbi, MD3, Irene M. McAleer, MD3, Antoine E. Khoury, MD3, Kai-wen Chuang, MD3.
1Claremont McKenna College, Claremont, CA, USA, 2London Health Sciences Centre, London, ON, Canada, 3University of California, Irvine, Orange, CA, USA.
Background:
Multicystic Dysplastic Kidney (MCDK) is a developmental anomaly, replacing normal parenchyma with cysts. The natural history of MCDK is benign with expected involution. Previous studies have demonstrated that the contralateral kidney can be associated with other urologic abnormalities, such as vesicoureteral reflux (VUR). However, the majority of VUR diagnosed by screening voiding cystourethrogram (VCUG) are low-grade, self-resolving, and not associated with febrile urinary tract infections (fUTIs), raising a question regarding the utility of such routine tests. Anecdotally, we observed variations in practice locally and sought to assess if discernible patterns exist internationally.
Methods:
We designed a survey querying practice patterns in MCDK management and physician-reported reasons for their practice. Specifically, we asked about how MCDK is most commonly diagnosed, whether the orders for VCUG, prophylactic antibiotic, and renal functional scans are routine or selective, and the frequency and duration of renal ultrasound surveillance. Additionally, we collected respondent demographics regarding years of practice, fellowship training, and location of practice. We hypothesized that practice patterns would differ based on demographics. The survey was then electronically disseminated to members of various professional organizations, including the Societies for Pediatric Urology (SPU), the European Society for Paediatric Urology (ESPU), American Academy of Pediatrics, Section on Urology (AAP), and the Pediatric Urologists of Canada (PUC). Duplicate IP addresses were not allowed.
Results:
263 respondents completed the survey after 280 clicks, yielding a completion rate of 94%. There was good representation across years and location of practice. Overwhelmingly, MCDK is diagnosed incidentally by routine prenatal ultrasound (254 responses, 96.6%). Nearly one quarter of the respondents (62, 23.5%) always order a VCUG, and 10 (3.8%) respondents always start empiric prophylaxis. Out of the 201 (76.5%) respondents who only order VCUG selectively, the most commonly cited clinical indications are fUTIs (95%) and presence of contralateral hydronephrosis (78%). With respect to renal functional scans, 112 (42.5%) respondents always order it to confirm lack of function in a suspected MCDK, and 122 (46.4) sometimes order it to distinguish true MCDK from hydronephrosis. In this cohort, the majority (245 responses, 93%) follows MCDK with serial renal ultrasounds, for the purposes of observing involution of the MCDK (91.4%) and contralateral renal compensatory hypertrophy (78%). Sixteen percent of the respondents quoted concerns for malignant transformation. Regarding when to discontinue ultrasound follow-up, 89 (36%) respondents are satisfied with simply a pattern of involution, 115 (47%) only stop imaging until complete involution occurs, and 41 (16.7%) follow the patients until a certain age is reached. Overall, most respondents (179, 73%) obtain an ultrasound every 6-12 months. Duration of follow-up is variable; however, more European urologists follow MCDK for greater than 10 years when compared to North American urologists.
Conclusion:
Practice patterns in the diagnosis and management of pediatric MCDK is variable. Our survey study found that despite previously demonstrated low rate of high-grade VUR in the contralateral kidney, routine VCUG is still being ordered in almost 25% of MCDK patients. This highlights a potential need for development of clinical guidelines or a best practice statement.
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