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Antenatally detected renal pelvis dilatation

Antenatally detected renal pelvis dilatation

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Antenatally detected renal pelvis dilatation

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  1. Antenatally detected renal pelvis dilatation Anil Chacko Chris Lilley Neonatal unit PRM Glasgow

  2. Background • Renal Pelvis dilatation (RPD) • incidence of between 0.5 and 1% • may be associated with significant renal disease in a small number of babies1 • PRM population- up to 60 babies year • Detailed USS in 20-25% currently • majority of babies the condition is benign • isolated renal pelvis dilatation • Dudley et al Clinical relevance and implications of antenatal hydronephrosis Arch. Dis. Child. Fetal Neonatal Ed. 1997; 76: F31-F3

  3. Challenge • 2006 • Not doing either very well • System choked • No clear end points • All babies >10mm • Trimethoprim • Delayed Investigation • Identify babies with significant renal problems • requiring surgical intervention • long term renal damage • avoid unnecessary treatment and investigation of normal babies

  4. Background • Opportunistic USS • Roughly 25- 30% mums receive detailed USS currently • Universal imminent • Assessment during detailed scan: size, morphology, AP diameter, presence of other features • Paediatric communication and parental information

  5. What is normal? • RPD cut-off of 5-7mm has been accepted in the second trimester • with wide ranging reports of 5mm to 20mm1-5 • Led to Ix of all RPD>7mm • PRM Audit 1998 • No significant problems identified under 10mm • Ismaili et al  European Urology Volume 48, Issue 2 pp 207-214 • Ismaili et al Journal of Pediatrics, Volume 144, Issue 6, June 2004, pp 759-765 • Ismaili et al journal of paediatrics, volume 141(1),pp 21-24 • Ulman et al J Urol Volume 164(3) Part 2 of 2, September 2000, pp 1101-1105 • Stocks et Pediatric Urology Volume 155(3) • Findlay et al 1998 unpblished

  6. Cumulative evidence • isolated RP dilatation < 12mm not associated with significant morbidity and resolved in all cases studied Dhillon, Prenatally diagnosed hydronephrosis: the Great Ormond Street experience BJU Int, Vol81, Issue s2, pp39-44

  7. Evidence • above 12 mm too varied to allow for meaningful analysis • No evidence for routine use of prophylactic AB • clear that an RPD above 15mm confers a higher risk for significant obstruction to urinary flow 1-3 • J A Dudley Clinical relevance and implications of antenatal hydronephrosis ADC. Fetal Neonatal Ed. 1997; 76: F31-F3 • Wollenberg A. Neuhaus TJ. Willi UV. Wisser J. Outcome of fetal renal pelvic dilatation diagnosed during the third trimester. Ultrasound in Obstetrics & Gynecology. 25(5):483-8, 2005 May. • N D Plant, R J Hornung, M G Coulthard, M J Keir, J N S Matthews and S C Robson Does antenatal pelvic dilation predict renal scarring? Arch. Dis. Child. Fetal 2005;90;339-340

  8. High risk features • any parenchymal abnormality • calyceal dilatation • ureterocoele • bladder wall thickening • bilateral findings • ureteral dilatation • Oligohydramnios • lack of urine in bladder

  9. Aims of audit 2008 • Monitor adherence to guidelines • Are infants with isolated RPD <12mm ‘safe’ • Are the low risk cases (<15mm) progressing to develop significant renal morbidity • Are we picking up the babies at high risk of renal damage or requiring surgery • RPD >15mm • Additional risk factors

  10. Methods • Retrospective study • July 2007 to Oct 2008 • Data from antenatal USS dept, paediatric case notes, audit folder, PACS system and HISS

  11. Numbers RPD

  12. Numbers - others

  13. Isolated RPD <15mm

  14. Outcomes isolated RPD 10-15mm

  15. Isolated RPD >15mm

  16. Isolated RPD >15 (Cases 3 to 7)

  17. Outcomes isolated RPD>15mm

  18. Outcomes

  19. Outcomes

  20. Outcomes: others

  21. Results • Adherence to guidelines good • Variable second line Ix • Low risk progressing to significant renal morbidity • One case and picked up by 3 months • Management of isolated RPD>15mm • Early referral

  22. Limitations • Small number of cases • Early days • Number of children one year old or above was 8 out of 20 from the group • Need to explore longer term outcomes

  23. Recommendations • Further Audit • Rpt for 2008 • Pan Glasgow • Follow up longer term • National audit

  24. Thank you