MANAGEMENT OF ANTENATAL

HYDRONEPHROSIS

Fatoş Yalçınkaya M.D.

Ankara University Faculty of Medicine
Department of Pediatric Nephrology
Ankara-TURKEY
 ANTENATAL HYDRONEPHROSIS

DEFINITION: dilation of the fetal renal collecting system that is

detected on prenatal ultrasonography

PREVALENCE: 0.5-4% (Bilateral in 17-54% )

OUTCOME: depends on the underlying etiology

 ANTENATAL HYDRONEPHROSIS

DIFFERENTIAL DIAGNOSIS

Transient hydronephrosis (resolves prenatally)

Nonobstructive hydronephrosis
Ureteropelvic junction obstruction (UPJO)
Vesicoureteric reflux (VUR)
Ureterovesical junction obstruction (UVJO), megaureter
Multicystic dysplastic kidney
Duplex kidneys (±ureterocele)
Posterior urethral valves (PUV)
Others: Ectopic ureter, megaureter, urethral atresia,
urogenital sinus malformation, prune belly syndrome,
tumors
 ANTENATAL HYDRONEPHROSIS

PRENATAL EVALUATION AND MONITORING

AHN can be diagnosed and graded based on the transfers plane measurement
of anteroposterior diameter (APD) of the fetal renal pelvis

Nguyen HT. J. Pediatr.Urol.2010

 ANTENATAL HYDRONEPHROSIS

DESCRIPTIVE DEFINITIONS of AHN by APD for PRENATAL EVALUATION

APD ≥4 mm in second trimester

Antenatal hydronephrosis is present if
APD ≥7 mm in the third trimester

Classificaton of Second Trimester Third Trimester

AHN APD (mm) APD(mm)
Mild 4-7 7-9
Moderate 7-10 9-15
Severe >10 >15

Nguyen HT. J. Pediatr.Urol.2010

 ANTENATAL HYDRONEPHROSIS

ADDITIONAL PRENATAL EVALUATION & MONITORING

US at 16-20 weeks gestation should include evaluation for lower urinary tract obstruction
renal dysplasia and extrarenal structural malformations
 ANTENATAL HYDRONEPHROSIS

ADDITIONAL PARAMETERS FOR PRENATAL EVALUATION

 Loss of renal parenchyma

Cortical thinning
Decreased corticomedullary differentiation
Cortical thinning
Parenchmal cysts
 Caliceal dilatation
 Ureteral dilatation
 Thick walled bladder
 Key-hole sign
 Oligohydramnios

Timbirlake MD. Nat Rev Urol. 2013

 ANTENATAL HYDRONEPHROSIS

COURSE

88% of patients with mild ANH resolved in utero or neonatal period

30% of patients with moderate or severe ANH persisting in the third trimester
require postnatal surgery

In fetuses with unilateral AHN repeat US in the third trimester is valuable

The risk in utero worsening is higher for bilateral than for unilateral disease

For fetuses with AHN imaging should be repeated every 4-6 weeks or more frequently
depending on the severity of HN, or the presence of findings suggestive of lower urinary
tract obstruction such as dilated bladder and ureters and/or oligohydramnos

Sairam S. Ultrasound Obstet Gynecol 2001

Alconcher LF. Pediatr Nephrol 2006
 BILATERAL AHN

POSTERIOR URETRAL VALVE

27th week
 BILATERAL AHN

POSTERIOR URETRAL VALVE

35th week
 POSTERIOR URETRAL VALVE

Postnatal VCUG (first day)

Antenatal MR Urography (35th week)

 ANTENATAL HYDRONEPHROSIS

COURSE from PRENATAL to POSTNATAL PERIOD

 The degree of AHN predicts the severity of postnatal HN

 98% of patients with APD<10 mm had mild or resolved dilation on postnatal evaluation

 APD 10–20 mm corresponded to improvement in 80% or persistent moderate HN postnatally in 20% of patients

 The rate of postnatal pathology increased with the degree of pelvic dilatation ranging from 12% for mild, 45% for moderate
to 88% for severe HN. This relation was evident for patients with PUV or UPJO but not VUR or UVJO

Herndon CD. Scientific World Journal 2006

Lee RS. Pediatrics. 2006
Barbosa J. Prenat Diagn 2012
 ANTENATAL HYDRONEPHROSIS

UPJO

 Degree of postnatal HN is predictive for the presence of UPJO

 UPJO is typically represented by severe HN on postnatal imaging
 UPJO is under represented in patients with mild (8%) or moderate (23%) postnatal HN

Herndon CD. Scientific World Journal 2006

Lee RS. Pediatrics. 2006
Barbosa J. Prenat Diagn 2012
 ANTENATAL HYDRONEPHROSIS

VUR

 Degree of postnatal HN is not predictive for the presence or severity of VUR

 VUR was present in 19% of the patients with mild and 26% with moderate HN
 VUR was demonstrated in 1/4rd of patients in which HN resolves completely on postnatal imaging

Chertin B. Eur Urol. 2006

Herndon CD. Scientific World Journal 2006
 ANTENATAL HYDRONEPHROSIS

PUV

 PUV demonstrates bilateral hydroureteronephrosis with a thick walled bladder and keyhole sign in the bladder
neck of males on the second trimester US

 Degree of bilateral postnatal HN is predictive for the presence of PUV

Hodges SJ. Scientific World Journal 2009

 ANTENATAL HYDRONEPHROSIS

POSTNATAL EVALUATION

 No universal guidelines for the clinical management of patients with mild to moderate AHN are
currently available

 Antero-posterior diameter (APD) measurements of the renal pelvis and Society for Fetal
Urology (SFU) grades are the two most-commonly used grading systems for AHN

 Postnatal US should include evaluation for calyceal or ureteric dilation, cortical cysts and
enhanced renal echogenicity, ureterocel and bladder wall abnormalities and bladder emptying
 ANTENATAL HYDRONEPHROSIS

POSTNATAL EVALUATION    ANTEROPOSTERIOR PELVIC DIAMETER

Severity of HN (in patients with UPJO or PUV) correlates

positively with postnatal HN negatively with spontaneous resolution

need for surgery and risk of UTI

Lee RS. Pediatrics 2006

Sharma, G. J Urol 2012
Dias CS. J urol 2013
 ANTENATAL HYDRONEPHROSIS

POSTNATAL EVALUATION ANTEROPOSTERIOR PELVIC DIAMETER

 Measurement of pelvic APD was shown to be predicted retained renal function

 Stable or decreased APD on serial imaging is predictive for retained or

improved renal function

 The risk of postnatal pathology increased with the degree of antenatal pelvic
dilatation (12% for mild, 45% for moderate and 88% for severe HN)

 ANH resolved or stabilized in 98% patients with APD<12 mm as compared

to 51% with larger APD

 Surgical intervention was needed in all patients with APD>40mm

Lee RS. Pediatrics 2006

Sharma, G. J Urol 2012
Dias CS. J urol 2013
 ANTENATAL HYDRONEPHROSIS

POSTNATAL EVALUATION SOCIETY FOR FETAL UROLOGY CLASSIFICATION

The grading system of Society for Fetal Urology for postnatal HN is based on US findings
of the degree of renal-pelvic & calyceal dilation and takes into account the integrity of the parenchyma.
Grade 0 is normal and not represented in the figure

Fernbach S. Pediatr Radiol 1993

Nguyen HT. J PediatrUrol 2010
 ANTENATAL HYDRONEPHROSIS

POSTNATAL EVALUATION SOCIETY FOR FETAL UROLOGY CLASSIFICATION

SFU Grade 0 SFU Grade 1

SFU Grade 2

SFU Grade 3
SFU Grade 4
 ANTENATAL HYDRONEPHROSIS

POSTNATAL EVALUATION SFU GRADE & APD

 The risk of postnatal pathology increased with the degree of antenatal pelvic dilatation
(12% for mild, 45% for moderate and 88% for severe HN)

 Patients with SFU grade 1 or 2 hydronephrosis or postnatal APDs <20mm are at low risk
for significant pathology, renal deterioration and a subsequent need for surgery

 Prophylactic antibiotics and complete evaluation are needed for patients with SFU grade
4 hydronephrosis or APDs >30 mm

 Progression to renal deterioration and need for surgery in patients with SFU grade 3 or
bilateral grade 2 hydronephrosis (or APDs 20–30 mm) is unclear with APD>40mm

Lee RS. Pediatrics 2006

Sharma, G. J Urol 2012
Dias CS. J urol 2013
 ANTENATAL HYDRONEPHROSIS

POSTNATAL EVALUATION    RİSK GROUPS

LOW RISK: Patients with SFU grade 1 or 2 HN

or postnatal APDs <20 mm

INTERMEDIATE RISK: Patients with SFU grade 3 or bilateral HN

or postnatal APDs 20-30 mm

HIGH RISK: Patients with SFU grade 4 HN

or postnatal APDs >30 mm

Timbirlake MD. Nat Rev Urol. 2013

 ANTENATAL HYDRONEPHROSIS

POSTNATAL INITIAL EVALUATION

All newborns with history of AHN (including those in whom it had resolved prenatally) should have
postnatal US examination at the end of the first week of life (3-7days )
before the hospital discharge

US should be performed within 24-48 hr of birth in neonates with suspected

lower urinary tract obstruction (PUV), oligohydramnios or severe AHN
 ANTENATAL HYDRONEPHROSIS

POSTNATAL FOLLOW UP WITH ULTRASOUND

Neonates with normal ultrasound examination in the first week of life should
undergo a repeat US examination at 4-6 weeks

The presence of two normal postnatal renal ultrasounds excludes presence of

significant renal disease including dilating VUR

Infants with isolated mild unilateral or bilateral HN (APD <10 mm or SFU grade 1-2) should be
followed by sequential ultrasound alone, for resolution or progression of findings

The presence of two normal postnatal renal ultrasounds excludes presence of

significant renal disease including dilating VUR

Corteville JE. Am. J. Obstet. Gynecol.1991

Sinha A. Indian Pediatrics 2013
 ANTENATAL HYDRONEPHROSIS

VESICOURETERAL REFLUX

VUR is present in 8-38% patients with AHN, as compared to <1% in the general population

Although there is increased risk of UTI, there is lack of evidence that antibiotic prophylaxis in
patients with mild VUR confers clinical benefit

Severity of ANH does not correlate with the grade of reflux and patients with VUR may have
normal postnatal ultrasound

Zerin JM. Radiology 1993

Garin EH. Pediatrics. 2006
Hodson EM. Cochrane Database Syst Rev 2007
 ANTENATAL HYDRONEPHROSIS

VOIDING CYSTOURETHROGRAPHY

VCUG be restricted to patients with moderate to severe AHN (APD >10mm ; SFU grade 3-4) or ureteric
dilatation at 4-6 weeks of age

VCUG should be performed early within 24-72 hours of life, to the patients with suspected lower urinary
tract obstruction

VCUG should be performed to the patients with AHN who developed UTI

VCUG is also required in patients with history of milder grades of ANH who show worsening HN, progressive
parenchymal thinning

VCUG is associated with risks of UTI & and exposure to radiation !

Ismaili K. J Pediatr. 2002

Ward VL. Pediatr Radiol. 2006
Abdulnour HA. Eur J Pediatr. 2012
 ANTENATAL HYDRONEPHROSIS

URETEROPELVIC JUNCTION OBSTRUCTION (UPJO)

UPJO should be considered in infants with AHN when dilating VUR is excluded

Diuretic renography preferably with MAG3 should be performed to the infants with moderate to severe HN (SFU
grade 3-4, APD >10 mm) who do not have VUR at 6-8 weeks of age

Infants with HN s who do not have VUR should also undergo diuretic renography

Patients with VUR who had worsening HN should be evaluated for UPJO because both may coexist

Detection of obstruction is higher in patients with SFU grade 4 or APD>20-30mm

Lee RS. Pediatrics. 2006

Sidhu G. Pediatr Nephrol. 2006
Gordon I. Eur J Nucl Med Mol Imaging. 2011
 ANTENATAL HYDRONEPHROSIS

DIURETIC RENOGRAPHY

Diuretic renography allows differentiation between

non-obstructive and obstructive HN and estimates differential renal function
ANTENATAL HYDRONEPHROSIS

DIURETIC RENOGRAPHY

Normal
An early peak (2-5 min.), rapidly descending phase and
almost complete renal emptying by 20 min.

Non-obstructive HN
Satisfactory drainage spontaneously,
or following IV frusemide and micturition

Obstructive HN
An ascending or plateau phase over 20 minutes,
that fails to empty following IV frusemide and
on post-micturition views
 ANTENATAL HYDRONEPHROSIS

DIURETIC RENOGRAPHY

DIFFERENTIAL RENAL FUNCTION

NORMAL : between 45%-55%
IMPAIRED: below 30-40 % in obstructed kidney
ANTENATAL HYDRONEPHROSIS

DIURETIC RENOGRAPHY - UVJO

 ANTENATAL HYDRONEPHROSIS

Urinary Tract Infection (UTI) & Antibiotic Prophylaxis

 The risk of UTI increases with degree of HN (8% with mild HN vs 20% of moderate or severe HN)

 No uniform guidelines exist about the usage of prophylactic antibiotics

 Literature included limited data to support the proposed protective effect of antibiotic prophylaxis

 A significant benefit was demonstrated in infants with high-grade HN who were given prophylaxis
as compared with those who were not

CoelhoG. Pediatr Nephrol 2007

Passerotti CC. J Pediatr Urol 2011
Szymanski KM. J Urol2012
 ANTENATAL HYDRONEPHROSIS

Urinary Tract Infection (UTI) & Antibiotic Prophylaxis

 Parents should be informed about the risk of UTI and need for prompt management

 Infants with moderate or severe HN (SFU 3-4; renal APD >10 mm) or dilated ureter should receive antibiotic
prophylaxis during evaluation

 All patients with VUR were recommended to receive antibiotic prophylaxis through the first year of life

Tombesi MM. J Pediatr Urol 2012

Braga LH. Pediatrics 2013
 ANTENATAL HYDRONEPHROSIS

INDICATIONS FOR SURGERY

 Infants with lower urinary tract obstruction should be immediately referred to a surgeon for appropriate
intervention

 Surgery should be considered in patients with obstructed HN and either reduced differential renal
function or its worsening on repeat evaluation

 Surgery be considered in patients with bilateral HN or HN in solitary kidney showing worsening

dilatation and deterioration of function

Sarhan O. J Urol 2008

Heinlen JE. Urology 2009
Heinlen JE. J Urol. 2009
 ANTENATAL HYDRONEPHROSIS
Postnatal US
at the first week & repeat at 4-6 weeks

Moderate & Severe HN

No HN Mild HN SFU Grade 3-4; APD>10mm
SFU Grade 0 (without ureteric dilatation) Mild HN with ureteric dilatation
APD<7mm SFU Grade 1-2; APD 7-10mm

Voiding Cystouretrography
No intervention

VUR Lower Urinary Tract

No VUR Obstruction

Diuretic Renography Antibiotic Prophylaxis

Refer for Surgery

Not Obstructed Obstructed

US 3-6months for two years

then annually until resolution
Consider surgery if differential function
<40% or declines on follow up
Monitor by US until resolution