背景:在巯基乙酰三甘氨酸(MAG-3)利尿剂肾图(肾脏扫描)上,高度肾积水(HN)和非阻塞性引流的患者可能会给临床医生带来困境。一些患者可能会进展,需要肾盂成形术;然而,这些患者的结局需要更加明确.
目的:我们的主要目的是预测哪些患者的高度HN和非阻塞性肾扫描,(定义为T1/2时间<20分钟)将经历HN的分辨率。我们的次要目标是确定手术干预的预测因素。
方法:从2007年至2022年,从7个中心前瞻性招募了产前检测到HN的患者。纳入的患者在肾脏扫描前进行了T½<20分钟的肾脏扫描,并且在最后一次超声检查(RBUS)时进行了胎儿泌尿外科学会(SFU)3或4级。主要结果是HN的分辨率定义为SFU1级和肾盂前后直径(APD)<10mm随访RBUS。次要结果是肾盂成形术,将接受肾盂成形术的患者与接受无分辨率连续成像的患者进行比较.采用多变量logistic回归进行分析。
结果:在总共2228名患者中,1311分离了HN,338例患者进行了肾脏扫描,129例符合纳入标准。肾脏扫描的中位年龄为3.1个月,77%为男性,中位随访时间为35个月(IQR20-49)。我们发现22%(29/129)解决了,42%的患者进行了肾盂成形术(54/129),而36%的患者持续需要随访的HN(46/129)。分辨率的单变量预测因子为肾脏扫描时年龄≥3个月(p=0.05),T½时间≤5分钟(p=0.09),SFU3级(p=0.0009),和APD<20mm(p=0.005)。经过多变量分析,SFU3级(OR=4.14,95%CI:1.30-13.4,p=0.02)和APD<20mm(OR=6.62,95%CI:1.41-31.0,p=0.02)是显着的预测因素。在肾盂成形术的决策分析中,SFU4级(OR=2.40,95%CI:1.01-5.71,p=0.04)和随后肾脏扫描≥20分钟的T1/2时间(OR=5.14,95%CI:1.54-17.1,p=0.008)是显着的预测因素。
结论:患有高度HN和令人放心的肾脏扫描的患者可能对临床管理构成重大挑战。我们的结果有助于确定一个具体的候选人,以观察几乎没有进展的风险:患者SFU3级,APD在20毫米,在肾脏扫描时3个月或更大的5分钟或更短的T½。然而,许多患者可能进展到手术或不能完全消退,需要继续随访.
BACKGROUND: Patients with high grade hydronephrosis (HN) and non-obstructive drainage on mercaptoacetyltriglycine (MAG-3) diuretic renography (renal scans) can pose a dilemma for clinicians. Some patients may progress and require pyeloplasty; however, more clarity is needed on outcomes among these patients.
OBJECTIVE: Our primary objective was to predict which patients with high-grade HN and non-obstructive renal scan, (defined as T ½ time <20 min) would experience resolution of HN. Our secondary objective was to determine predictors for surgical intervention.
METHODS: Patients with prenatally detected HN were prospectively enrolled from 7 centers from 2007 to 2022. Included patients had a renal scan with T ½<20 min and Society for Fetal Urology (SFU) grade 3 or 4 at last ultrasound (RBUS) prior to renal scan. Primary outcome was resolution of HN defined as SFU grade 1 and anterior posterior diameter of the renal pelvis (APD) < 10 mm on follow-up RBUS. Secondary outcome was pyeloplasty, comparing patients undergoing pyeloplasty with patients followed with serial imaging without resolution. Multivariable logistic regression was used for analysis.
RESULTS: Of the total 2228 patients, 1311 had isolated HN, 338 patients had a renal scan and 129 met inclusion criteria. Median age at renal scan was 3.1 months, 77% were male and median follow-up was 35 months (IQR 20-49). We found that 22% (29/129) resolved, 42% of patients had pyeloplasty (54/129) and 36% had persistent HN that required follow-up (46/129). Univariate predictors of resolution were age≥3 months at time of renal scan (p = 0.05), T ½ time≤5 min (p = 0.09), SFU grade 3 (p = 0.0009), and APD<20 mm (p = 0.005). Upon multivariable analysis, SFU grade 3 (OR = 4.14, 95% CI: 1.30-13.4, p = 0.02) and APD<20 mm (OR = 6.62, 95% CI: 1.41-31.0, p = 0.02) were significant predictors of resolution. In the analysis of decision for pyeloplasty, SFU grade 4 (OR = 2.40, 95% CI: 1.01-5.71, p = 0.04) and T ½ time on subsequent renal scan of ≥20 min (OR = 5.14, 95% CI: 1.54-17.1, p = 0.008) were the significant predictors.
CONCLUSIONS: Patients with high grade HN and reassuring renal scan can pose a significant challenge to clinical management. Our results help identify a specific candidate for observation with little risk for progression: the patient with SFU grade 3, APD under 20 mm, T ½ of 5 min or less who was 3 months or older at the time of renal scan. However, many patients may progress to surgery or do not fully resolve and require continued follow-up.