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

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

Challenge 2006 Identify babies with significant renal problems 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

Background Opportunistic USS Assessment during detailed scan: 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

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

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

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

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

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

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

Numbers RPD Isolated RPD 10-15mm 4 Isolated RPD >15mm 7 RPD with other risk factors 6 Bilateral findings 3 Total 20

Numbers - others Cystic/dysplastic kidneys 4 Duplex kidneys 2 Renal agenesis/others 7 Total 13

Isolated RPD <15mm

Outcomes isolated RPD 10-15mm

Isolated RPD >15mm

Isolated RPD >15 (Cases 3 to 7)

Outcomes isolated RPD>15mm

Outcomes

Outcomes

Outcomes: others

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

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

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

Thank you