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Predictors of Early Chronic Kidney Disease Progression in Children with Posterior Urethral Valves
Corey Weinstein, MD, MSPH1, John Weaver, MD2, Mandy Rickard, MN-NP3, Neeta D'Souza, BS1, Bernarda Viteri, MD2, Karl Godlewski, MD2, Katherine Fischer, MD2, Christopher Long, MD2, Armando Lorenzo, MD, MSc3, Gregory Tasian, MD, MSc, MSCE2, Dana Weiss, MD2.
1SUNY Downstate Health Sciences University, Brooklyn, NY, USA, 2Children's Hospital of Philadelphia, Philadelphia, PA, USA, 3The Hospital for Sick Children, Toronto, ON, Canada.

BACKGROUND: Posterior urethral valves (PUVs) leads to early chronic kidney disease (CKD) and renal failure in some children, while others may maintain preserved kidney function even into adulthood. Currently, prediction of risk of CKD progression relies on nadir creatinine during the first year of life. We hypothesized that there are additional clinical features available in the first 3 months of life that would be associated with risk of CKD progression.
METHODS: Following individual institutional research board approvals, we performed a retrospective cohort study at two institutions. Electronic medical records were queried to identify all patients with a history of PUVs treated between 1990 and 2021. Children who presented in the first year of life and had their initial renal bladder ultrasound (RBUS) and voiding cystourethrogram (VCUG) and performed within the first 90 days of life were included. The primary outcome, CKD progression, was defined as development of ESRD requiring dialysis or renal transplant or a decline in eGFR of greater than 50%. Demographic data was obtained for all patients. Clinical information abstracted included: findings on initial RBUS (perinephric urinoma, cystic dysplasia, atrophic kidney), vesicoureteral reflux (VUR) on initial postnatal VCUG (degree and laterality), split function on nuclear medicine scan, history of vesicostomy creation, and nadir creatinine. Solitary kidney was defined as having an atrophic kidney on initial postnatal RBUS or nuclear medicine scan reporting less than 20% split function.
RESULTS: Out of 537 patients with PUV's, 274 met our inclusion criteria. Table 1 shows the baseline characteristics of the cohort. Median follow up was 5.84 years (IQR 1-19.5), and 55 patients (20%) reached our primary outcome. On multivariable analysis, presence of any vesicoureteral reflux, OR 3.2 (95% CI 1.37-7.5) and nadir creatinine, OR 22.71 (95% CI 8.34-61.84) had significantly higher odds of CKD progression (Table 2). When nadir creatinine within the first year of life is used as a sole predictor of CKD progression, the area under the receiver-operator curve is 0.872 (Figure 1).
CONCLUSIONS: This study confirms nadir creatinine as a strong predictor for CKD progression and ESRD in patients with posterior urethral valves. In our cohort, the presence of any degree or laterality of vesicoureteral reflux, was also a significant predictor for CKD progression.



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