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

2. 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

3. 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

4. Background Opportunistic USS Assessment during detailed scan:
Roughly % mums receive detailed USS currently
Universal imminent
Assessment during detailed scan:
size, morphology, AP diameter, presence of other features
Paediatric communication and parental information

5. 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
Ismaili et al Journal of Pediatrics, Volume 144, Issue 6, June 2004, pp
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
Stocks et Pediatric Urology Volume 155(3)
Findlay et al 1998 unpblished

6. 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

7. 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;

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

10. 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

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

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

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

14. Isolated RPD <15mm

15. Outcomes isolated RPD 10-15mm

16. Isolated RPD >15mm

17. Isolated RPD >15 (Cases 3 to 7)

18. Outcomes isolated RPD>15mm

19. Outcomes

20. Outcomes

21. Outcomes: others

22. 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

23. 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

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

25. Thank you