Antenatal hidronefroz tanılı bebeklerin izlemi
Prospective follow up of the patients with antenatal hydronephrosis
Yazar: FİLİZ GÖKASLAN
Danışman: PROF. DR. FATOŞ YALÇINKAYA
Ankara Üniversitesi / Tıp Fakültesi / Çocuk Sağlığı ve Hastalıkları Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2010
Konu: Nefroloji = Nephrology ; Çocuk Sağlığı ve Hastalıkları = Child Health and Diseases
Dizin: Bebekler = Infant ; Böbrek = Kidney ; Böbrek fonksiyon testleri = Kidney function tests ; Böbrek hastalıkları = Kidney diseases ; Hidronefroz = Hydronephrosis ; Ultrasonografi = Ultrasonography ; Üriner sistem enfeksiyonları = Urinary tract infections

Özet:
Renal pelvis ve/veya renal kalikslerin genişlemesi olarak tanımlanan antenatal hidronefroz en sık tespit edilen doğumsal anormalliktir. Bu çalışmanın amacı, antenatal hidronefroz tanılı bebeklerin klinik bulgularının ve uygun izlem planlarının tanımlanmasıdır.Bu çalışma antenatal hidronefroz tanısı konulan 136 hastanın (27K, 109E) 1.5 yıllık ileriye dönük izlem bilgilerini içermektedir. Hidronefroz derecelendirilmesi, Fetal Üroloji Topluluğu (SFU) Derecelendirme Sistemine göre yapılmıştır.Çalışma grubunun %80'inde ÜP bileşke darlığı; %14'ünde VÜR tespit edildi. Hastalar ultrasonografik hidronefroz derecelerine göre iki gruba ayrıldı. Evre I-II hidronefrozu olan hastalar Grup 1 (%64), Evre III ve üzeri hidronefrozu olanlar ise Grup 2 (%36) olarak değerlendirildi. Grup 1'deki hastaların %89'u ve ikinci gruptakilerin %65'inde ÜP bileşke darlığı saptanırken; VSÜG çekilen hastaların %22'sinde (%26'sı grup 1, %74'ü grup 2) VÜR tespit edildi. Birinci gruptaki hastaların %10'u ikinci gruptakilerin %29'u (çalışma grubunun %17'si) İYE geçirdi. Antibiyotik koruması hastaların %43'üne verildi. DMSA böbrek sintigrafisi çekilen hastaların %34'ünde böbrek hasarı tespit edildi. Böbrek hasarı olanların hepsi evre 3 ve üzerinde VÜR tanısı olan hastalardı. Üreteropelvik bileşke darlığı olan hastaların %6'sı, VÜR tanısı alan hastaların %26'sı opere oldu. Bir buçuk yıllık izlem sonunda hastaların %52'sinin USG'si kendiliğinden düzeldi.Düşük dereceli antenatal hidronefrozu olan olgularda cerrahi gereksinimi, İYE geçirme ve VÜR saptanma sıklığı daha azdır. Bu hastalara invaziv tetkiklerin (DMSA, VSÜG, MAG-3) yapılması ve proflaksinin İYE öncesi başlanması gerekli değildir. Buna karşın ileri dereceli hidronefrozu olan hastalara antibiyotik korumasının başlanması ve tanısal tetkiklerin yapılması uygun olacaktır.Anahtar sözcükler: antenatal hidronefroz, ileriye dönük izlem, düşük dereceli hidronefroz, ileri dereceli hidronefroz, VÜR, ÜP bileşke darlığı, idrar yolu enfeksiyonu, US

Abstract:
Antenatal hydronephrosis, defined as dilatation of renal pelvis and calyces is the most frequently detected antenatal abnormality. The aim of this study is to define clinical features and follow-up of the patients with antenatal hydronephrosis.The study consisted of prospective data of 136 infants (109 Male) with antenatal hydronephrosis. The follow-up time was 18 months. Hydronephrosis was graded in accordance with the Society of Fetal Urology study.An ultrasound scan was performed by the same radiologist on days 5-7, weeks 4-8, sixth month and at the first year of life.A voiding cystourethrography (VCUG) was performed in the infants who had bilateral hydronephrosis, dilatation of the ureter, posterior urethral valve (PUV), multicystic dysplastic kidney (MCDK) and who have proven urinary tract infection (UTI).Grading of vesicoureteral reflux (VUR) was made according to the classification of the International Reflux Committee Study.A Technetium-99m (99mTc) dimercaptosuccinic acid (DMSA) scintigraphy was performed in all patients with VUR and ureteropelvic junction obstruction (UPJO) with UTI.A Technetium-99m (99mTc) mercaptoacetyltriglicine-3 (MAG-3) scintigraphy was performed in patients who had stage 3 and above hydronephrosis. Ureteropelvic junction obstruction was defined as prolonged excretion of tracer after administration of furosemide in combination with significant calyceal dilatation and associated renal pelvic dilatation.Indications for surgery were impaired renal function (one-sided <40%), deterioration of relative renal function with >5%, persistence or increase of the hydronephrosis and recurrent UTIs.Ureteropelvic junction obstruction was detected in 80% and VUR in 14% of the study group. Patients were divided into two groups according to their degree of sonographic hydronephrosis. Group 1 included patients who had stage I-II hydronephrosis (n:87, 64%), group 2 included patients who had stage III and above (n:36, 36%). Ureteropelvic junction obstruction was detected in 89% and 65% of the patients in groups 1 and 2, respectively. Voiding cystourethrography was performed in 85 patients. Vesicoureteral reflux was detected in 19 (22%) patients. Twenty six percent of the patients with VUR were in group 1 and 74% of the patients were in group 2. Urinary tract infection (UTI) was observed in 10% and 29% of the patients in groups 1 and 2, respectively. Antimicrobial prophylaxis was given to 58 patients (43%). Renal scarring was observed in 34% of the patients with DMSA scan. All patients who had renal scarring were found to have stage III and above VUR. Surgical treatment was performed in 6% and 26% of the patients with UPJO and VUR, respectively. Ultrasonographies of the 52% of the patients (64.4%) of the patients in group 1, 28.6% of the patients in group 2) were improved spontaneously at the end of 18 months follow-up.Ureteropelvic junction obstruction is the most common abnormality in patients with antenatal hydronephrosis, especially in low grade hydronephrosis. Although, VUR is the second most common abnormality. It?s more frequent in patients with high grade hydronephrosis as compared to low grade. The patients with VUR have higher frequency of surgical requirement and UTI as compared to the patients with UPJO. DMSA scan is valuable investigation for the demonstration for renal scar associated with VUR. However, early performance of DMSA scan to the patients with UPJO is not necessary. Patients with low grade hydronephrosis have less common UTIs, surgical interventions and more common spontaneously resolution as compared to high grade. Therefore non-invasive postnatal follow up without antibiotic prophylaxis is justified for these group of patients.Key words: antenatal hydronephrosis, prospective follow-up, low grade hydronephrosis, high grade hydronephrosis, vesicoureteral reflux, ureteropelvic junction obstruction, urinary tract infection, ultrasonography