Obstructive uropathies in children at UNTH Enugu DR. H.U. OKAFOR CONSULTANT PAEDIATRICIAN UNTH ENUGU

OUTLINE INTRODUCTION STUDY OBJECTIVES METHODOLOGY FINDINGS DISCUSSION

Introduction Posterior Urethral valves has been severally reported as the commonest cause of obstructive uropathy in Nigerian children. (Anochie,2004;OkoroB.A et al,1999). At the UNTH Enugu ,a total of 51 cases of obstructive uropathy in children were seen between 2008 -2011. & Of these 41 (80.4%) were cases of PUV Reports from developing countries indicate that diagnostic and therapeutic difficulties in addition to patient factors contribute to the high morbidity and mortality rates in these cases of PUV. In order to optimize outcome, we felt there is need to identify these factors. We set out to evaluate the determinants of outcome in patients seen in our centre as it is a major referral centre in SE Nigeria.

Study objectives To evaluate profile of PUV To ascertain determinants of outcome To identify challenges of management

Methodology A prospective cohort study whereby all cases with a diagnosis of PUV from January 2008 were recruited and followed up. Data collected included age, mode of presentation ,anthropometric measurements, results of blood &radiological investigations. Treatment given & post intervention results, challenges encountered and outcome were also documented. Radiological investigations were repeated 3 months post intervention. Renal function tests were done monthly.

Results 31 children were seen between Jan.2008 –Dec 2009. Median age at presentation was 2.5yrs with a range of 2weeks-15years. 22 (71%)children had prenatal ultrasonograhy;5 had oligohydramnios, and only 2 were diagnosed prenatally. 18 had onset of symptoms before 1mth while 13 became symptomatic about 2years.

Results Clinical feature Number Percentage Poor urinary stream 30 96.8 Straining on micturition Dribbling of urine 21 67.7 hematuria 6 19.4 Failure to thrive 17 54.8 Recurrent fever 10 32.3 Anemia 20 64.5 Facial puffiness 5 16.1 Urinary ascites 2 6.5 Enlarged kidneys 27(16pts) 51.6 Palpable bladder 26 83.9

Clinical Features contd. Parameter Values Mean eGFR at presentation 39.5ml/min/1.73m2 Range 4.4-116 Pyuria 23pts(74.2%) Positive urine culture 12pts(38.7%) Thickened bladder on sonogram 29(94%) Bilateral hydronephrosis 24(77.4%) VUR 14(45.2%)

Treatment Prior to treatment,4pts required dialysis 8pts required upper tract diversion in form of cutaneous ureterostomy. Catheter balloon avulsion was done on 28pts Post avulsion undiversion was done in all 8 cases with cutaneous ureterostomy.

outcome Mean eGFR after 3months was 64.8ml/min/1.73m2+_ 11.6 In those with ureterostomy mean GFR increased from 31.6ml/min/1.73m2 to 72.9ml/min/1.73m2. Overall ,18 cases had clinical ,biochemical and radiological improvement. 9 still had poor renal function 4 died,2 of which were neonates and the others were 13 and 15 yrs respectively. Causes of death were acute renal failure and pulmonary hypoplasia in neonates and ESRD in the older patients. Average duration of follow-up was 12.6months During this period 8 of the surviving cases with VUR have resolution while 2 are awaiting reflux surgery.

Discussion PUV is the commonest form of obstructive uropathy seen at UNTH Enugu. Pre-natal diagnosis is low probably due to lack of expertise. Onset of symptoms occur early but presentation to the hospital is usually late due to lack of awareness amongst both health workers and caregivers. Mortality was significantly affected by bilateral VUR and eGFR. Infections and renal failure apparently contribute immensely to morbidity and mortality. Poor access to adequate RRT is a major problem.

Conclusion Most of our PUV cases present late. Management is challenged by poverty, lack of facilities for RRT etc. Overall outcome is adversely affected by extremes of age, low eGFR at presentation, associated bilateral VUR.

Recommendations To create awwareness amongst mothers and primary health workers To emphasize the need to observe urinary stream in male infants To encourage early refferals

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