Prenatally detected hydroureteronephrosis is associated with vesicoureteral reflux and urinary tract infection: A report from the Society for Fetal Urology (SFU) Hydronephrosis Registry
Anne G. Dudley, MD1, Melissa McGrath, BASc2, C. D. Anthony Herndon, MD3, Gina M. Lockwood, MD4, Nora G. Kern, MD5, Antoine E. Khoury, MD6, Walid Farhat, MD7, Patricio C. Gargollo, MD8, Joshua Chamberlin, MD9, Rebecca S. Zee, MD3, Luis H. Braga, MD10.
1Connecticut Children's Medical Center, Hartford, Hartford, CT, USA, 2McMaster University, Faculty of Health Sciences, Hamilton, ON, Canada, 3Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA, 4University of Iowa, Iowa City, IA, USA, 5University of Virginia, Charlottesville, VA, USA, 6CHOC Children's, Orange, CA, USA, 7University of Wisconsin American Family Children's Hospital, Madison, WI, USA, 8Mayo Clinic, Rochester, MN, USA, 9Loma Linda University, Loma Linda, CA, USA, 10McMaster University, Faculty of Health Science, Hamilton, ON, Canada.
Background:Prenatally detected hydronephrosis (PNH) is a common entity that presents diagnostic and therapeutic questions in the neonate. Initial postnatal ultrasound is critical to guide further testing, counseling and provide prognostic value. The UTD consensus statement recommends voiding cystourethrogram (VCUG) in children with PNH and ureteral dilation (UD), however practice variability has been reported. We sought to determine the implication of UD detection on the rates of urinary tract infection (UTI) and vesicoureteral reflux (VUR) in a cohort of infants with PNH.
Methods:Patients with history of PNH were prospectively enrolled into the Society for Fetal Urology (SFU) Hydronephrosis Registry (n=1848). Patients with ureteral dilation (UD)>7mm, who had undergone VCUG and did not have preceding UTI or additional anomalies were included in the analysis (n=148). The following variables were collected: SFU grade, degree of UD (7-10mm, >10mm) presence and grade of VUR, history of UTI, sex and circumcision status. UTI was defined as positive pyuria on midstream or catheterized specimen with single organism >50,000 CFU on urine culture. Studentís t test, Fisher exact test, and stratified analyses were used to adjust for confounding.
Results:Study population consisted of 143 infants: 76% (108) were male, of which 44% (48) were circumcised. Distribution of hydronephrosis grade according to VUR severity is demonstrated in Figure 1a. Overall, VUR was noted in 31% (44) of patients, with 84% of these having high grade VUR. The UTI rate for the whole cohort was 25.8% (27). When stratified by circumcision status and sex, uncircumcised males had a higher UTI rate (10% vs 39%; p=0.01) than females and circumcised males, only in the non VUR group, (Figure 1d)In children with high grade hydronephrosis (SFU 3-4) and UD, 2.5 VCUG studies would be needed to diagnose 1 patient with high grade VUR
Conclusions:Almost 30% of infants with PNH and UD developed UTI. The degree of PNH in patients with UD at first postnatal ultrasound does not correlate with VUR severity. In patients with high grade PNH and UD, 2.5 VCUG studies would need be completed to detect one patient with high grade reflux. Of all VUR patients, 84% had grades 3-5 reflux, with a 30% UTI rate. Identifying those with VUR may be beneficial, to guide initiation of prophylaxis when considering sex and circumcision status.
Figure 1 Legend:
A: VUR Grades High (3-5) vs Low (1-2) by SFU Grades High (III-IV) vs Low (I-II)B: UTI Rate by VUR Grade High (3-5) vs Low (1-2)C: UTI Rate by Gender with VURD: UTI Rate by Gender without VUR
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