Antenatal ultrasound to predict postnatal renal function in congenital lower urinary tract obstruction: Systematic review of test accuracy

The School of Clinical and Experimental Medicine (Reproduction, Genes and Development), College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.
BJOG An International Journal of Obstetrics & Gynaecology (Impact Factor: 3.45). 06/2009; 116(10):1290-9. DOI: 10.1111/j.1471-0528.2009.02194.x
Source: PubMed


Congenital urinary tract obstruction can lead to perinatal mortality and morbidity. Assessing antenatal ultrasound features may help identify fetuses likely to suffer complications.
To evaluate the accuracy of antenatal ultrasound in the prediction of postnatal renal function in cases of congenital lower urinary tract obstruction (LUTO).
We conducted electronic searches in MEDLINE, EMBASE, the Cochrane Library, MEDION, SIGLE, SCISEARCH Index of scientific and technical proceedings, National Research Register (database inception - 2008) and Medical Conferences register and searched reference lists.
Two reviewers independently selected articles in which the accuracy of fetal ultrasound features were evaluated to predict postnatal renal function with no language restrictions.
Data were extracted on study characteristics, quality and results to construct 2 x 2 tables. Likelihood ratios for positive (LR+) and negative (LR-) test results, sensitivity and specificity were generated for the different ultrasound parameters and reference standards.
Thirteen articles that met the selection criteria, including 215 women and 33 2 x 2 tables. Meta-analysis was performed using clinically similar subgroups to minimise clinical heterogeneity. The ultrasound parameter that showed the best predictive value for postnatal renal function in survivors was renal cortical appearance, sensitivity 0.57 (95% CI 0.37-0.76) and specificity 0.84 (95% CI 0.71-0.94), area under the curve 0.78.
Measurement of amniotic fluid volume and the appearance of the renal cortex at diagnosis of LUTO show promising predictive accuracy for poor postnatal renal function.

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    • "In the diagnosis of lower urinary tract obstruction (such as from PUVs), oligohydramnios, renal cortical abnormalities , and early gestational age at diagnosis (e.g. <24 weeks) were found to be independent predictors of poor postnatal renal function [27]. "
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    ABSTRACT: Objective: Urinary tract (UT) dilation is sonographically identified in 1-2% of fetuses and reflects a spectrum of possible uropathies. There is significant variability in the clinical management of individuals with prenatal UT dilation that stems from a paucity of evidence-based information correlating the severity of prenatal UT dilation to postnatal urological pathologies. The lack of correlation between prenatal and postnatal US findings and final urologic diagnosis has been problematic, in large measure because of a lack of consensus and uniformity in defining and classifying UT dilation. Consequently, there is a need for a unified classification system with an accepted standard terminology for the diagnosis and management of prenatal and postnatal UT dilation. Methods: A consensus meeting was convened on March 14-15, 2014, in Linthicum, Maryland, USA to propose: 1) a unified description of UT dilation that could be applied both prenatally and postnatally; and 2) a standardized scheme for the perinatal evaluation of these patients based on sonographic criteria (i.e. the classification system). The participating societies included American College of Radiology, the American Institute of Ultrasound in Medicine, the American Society of Pediatric Nephrology, the Society for Fetal Urology, the Society for Maternal-Fetal Medicine, the Society for Pediatric Urology, the Society for Pediatric Radiology and the Society of Radiologists in Ultrasounds. Results: The recommendations proposed in this consensus statement are based on a detailed analysis of the current literature and expert opinion representing common clinical practice. The proposed UTD Classification System (and hence the severity of the UT dilation) is based on six categories in US findings: 1) anterior-posterior renal pelvic diameter (APRPD); 2) calyceal dilation; 3) renal parenchymal thickness; 4) renal parenchymal appearance; 5) bladder abnormalities; and 6) ureteral abnormalities. The classification system is stratified based on gestational age and whether the UT dilation is detected prenatally or postnatally. The panel also proposed a follow-up scheme based on the UTD classification. Conclusion: The proposed grading classification system will require extensive evaluation to assess its utility in predicting clinical outcomes. Currently, the grading system is correlated with the risk of postnatal uropathies. Future research will help to further refine the classification system to one that correlates with other clinical outcomes such as the need for surgical intervention or renal function.
    Journal of Pediatric Urology 11/2014; 10(6). DOI:10.1016/j.jpurol.2014.10.002 · 0.90 Impact Factor
    • "We did not attempt prenatal bladder drainage but the recent review on effectiveness of antenatal intervention for treatment of congenital lower urinary tract obstruction done by Morris et al., concluded that although bladder drainage improves survival but it may confer a high residual risk of poor postnatal renal function.[11] In group IV, the cases were mild, renal function was preserved, as shown by appearance of normal liquor and normal bladder. "
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    ABSTRACT: To determine the prognosis of antenatally detected renal anomalies by sonographic evaluation. This was a follow-up study of all antenatally detected renal anomalies from January 2008 to Dec 2009 referred to fetal medicine clinic. Prenatal evaluation was done and cases were divided into four groups depending upon their prenatal sonographic findings. Post natal follow-up was done up to one year in cases of live babies. Autopsy was carried out in still born fetus after consent. The renal anomaly was detected in 55 cases, which were fully followed. The prognosis was said to be poor for group I cases with gross extra renal anomaly along with the renal anomaly, and for group II in which there was organic renal pathology with loss of renal function suggested by non-visualization of bladder and almost absent liquor. Prognosis was guarded and depended upon the gestational age of presentation in group III, which had obstructive uropathy; prognosis was good in group IV cases, which were mild, unilateral or which presented late. Prenatal sonographic evaluation gives reasonably accurate picture of the prognosis and can be very helpful in counseling the parents regarding prognosis and help in deciding the timing and route of delivery.
    Indian Journal of Human Genetics 03/2012; 18(1):75-82. DOI:10.4103/0971-6866.96656
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    ABSTRACT: To report the experience with fetal cystoscopy and laser fulguration of posterior urethral values (PUV) for severe lower urinary tract obstruction (LUTO). Between July 2006 and December 2008, fetal cystoscopy was offered to 23 patients whose fetuses presented with severe LUTO, favorable urinary analysis and gestational age <26 weeks. Fetal urinary biochemistry was evaluated before and after cystoscopy. All infants were followed 6-12 months after birth. Abnormal renal function was defined when serum creatinine higher than 50 micromol/L (2 Standard Deviation) or the necessity of dialysis or renal transplantation. Autopsy was always performed whenever fetal or neonatal deaths occurred. Eleven patients decided to undergo fetal therapy and 12 elected to continue with expectant observation. There was no difference between both groups in gestation age at diagnosis and referral examinations. Urethral atresia was diagnosed in 4/11 (36.4%) fetuses by fetal cystoscopy. At 26 weeks, fetuses that were managed expectantly presented with worse urinary biochemistry results (p < 0.05). Survival rates and percentage of infants with normal renal function were significantly higher in the cystoscopic group than in the expectant group (p < 0.05). Percutaneous fetal cystoscopy is feasible using a thinner special cannula for prenatal diagnosis and therapy of LUTO. Prenatal laser ablation of the PUV under cystoscopy may prevent renal function deterioration improving postnatal outcome.
    Prenatal Diagnosis 11/2009; 30(1):30-9. DOI:10.1002/pd.2418 · 3.27 Impact Factor
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