Predictive Factors for Surgery and Urinary Tract Infections for Upper Pole Pathologies in Duplex Kidneys: A Retrospective Review from the Mid-Atlantic Pediatric Consortium
Clinton Yeaman, MD MS1, Kathryn Morgan, NP1, Sherry S. Ross, MD2, Jaime Michael, BA2, Rebecca S. Zee, MD3, Hans G. Pohl, MD4, Daniel P. Casella, MD4, Bruce M. Sprague, BS4, C.D. Anthony Herndon, MD3, Nora G. Kern, MD1.
1University of Virginia, Charlottesville, VA, USA, 2University of North Carolina, Chapel Hill, NC, USA, 3Virginia Commonwealth University, Richmond, VA, USA, 4Children's National Hospital, Washington, DC, USA.
BACKGROUND: Duplex kidneys account for 5-7% of antenatal hydronephrosis cases. Management of upper pole pathologies can be quite variable based on provider preference. Therefore, we aimed to describe practice patterns from various institutions, and more specifically, aimed to identify clinical predictors of surgical intervention and urinary tract infection (UTI).
METHODS: We conducted a retrospective review of patients between 2015-2020 treated at 4 institutions in the Mid-Atlantic. Inclusion criteria included patients with a duplex kidney. Demographic and clinical information were obtained. The primary outcome was surgical intervention. Secondary outcome included UTI. Multivariate logistic regression was used to identify predictors of surgical intervention and UTI based upon demographic and clinical characteristics. Linear regression was used to identify clinical predictors for UTI events. Descriptive statistics and regression modeling analyses were performed using SAS.
RESULTS: 223 patients were included with a total of 250 duplex renal units (Table 1). 165 (74.0%) were female and 58 (26.0%) were male. Of the males, 40 (69.0%) were circumcised. The most common upper pole pathology was ureterocele, affecting 45.2% of renal units. 39.6% were found to have lower pole vesicoureteral reflux. 78.0% of patients were on antibiotic prophylaxis in the first year of life and decreased to 54.2% after 1 year. 67 (30%) patients had a total of 120 confirmed UTI events. Of those who had at least one UTI, patients had an average of 1.8 UTI events. Demographic and clinical characteristics are displayed in Table 1. 140 (62.7%) patients required surgical intervention and underwent a total of 206 surgeries, with incision of ureterocele being the most common intervention. Obstruction was the most common indication for surgical intervention. Complications in this cohort were uncommon. Table 2 shows the results of clinical predictive factors for surgical intervention and UTI events on multivariate logistic regression. Hydronephrosis grade (both SFU and UTD) and number of prior UTI events were statistically significant predictors for surgical intervention (p=0.018/0.001 and p=0.01 respectively). Circumcision was significantly associated with decreased UTI risk (p=0.03); grade of hydronephrosis did not change the UTI risk. On linear regression modelling, treatment with antibiotic prophylaxis after the first year of life was associated with decreased risk of further UTI events (p=0.03); however antibiotic prophylaxis within the first year of life did not decrease UTI risk (p=0.12).
CONCLUSIONS: Management of upper pole pathologies in duplex renal systems are heterogeneous, driven by an array of clinical features. Hydronephrosis grade and UTI events are significant predictors for surgical intervention. Circumcision and antibiotic prophylaxis after one year of life are protective against UTI events. Identification of these risk factors associated with duplex pathologic states aids in standardization of care practices to reduce long-term UTI risk. 
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