Validation of modified diuretic drainage times criteria in congenital hydronephrosis

  • Amr Hodhod
    Affiliations
    Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada

    Division of Pediatric Urology, Department of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
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  • Sophie Turpin
    Affiliations
    Divisions of Nuclear Medicine, Departments of Radiology, Montreal Children's Hospital and CHU Sainte-Justine, McGill University and Université de Montreal, Montreal, Quebec, Canada
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  • Francis Petrella
    Affiliations
    Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
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  • Roman Jednak
    Affiliations
    Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
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  • Mohamed El-Sherbiny
    Affiliations
    Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
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  • John-Paul Capolicchio
    Correspondence
    Correspondence to: John-Paul Capolicchio, The Montreal Children's Hospital, Room B04.2916.4, 1001 Boulevard Décarie, Montréal, QC, H4A 3J1, Canada, Fax: +1514 412 4384
    Affiliations
    Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
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      Summary

      Introduction and objective

      The value of diuretic renography drainage times in congenital hydronephrosis (AHN) decision making is controversial. Recently, a group suggested a modification to the classically described diuretic drainage time cut-off values. They found that a drainage half-time (T1/2) < 5 min was normal whereas a T1/2 exceeding 75 min predicted pyeloplasty. In addition, they reported on the benefit of a delayed drainage image obtained with gravity assistance. We sought to evaluate the ability of these modified T1/2 criteria to predict pyeloplasty, alone or in combination with a delayed drainage image referred to as Global Washout (GWO).

      Methods

      We retrospectively reviewed 113 patients, including consecutive pyeloplasties for AHN from 2004 to 2018. Patients who underwent pyeloplasty due to low differential renal function (DRF) < 30% or infection were excluded. The control group comprised high grade AHN managed non-operatively. The initial renal ultrasound and MAG 3 Lasix renogram were reviewed for grade, differential renal function (DRF), T1/2 and GWO. A ROC curve was used to evaluate the T1/2 and GWO cut-off points that can predict pyeloplasty, using a p-value of less than 0.05.

      Results

      The pyeloplasty group consisted of 62 patients and the control group consisted of 51 patients. Two patients (3%) in the pyeloplasty group had a T1/2 < 5 min whereas 21 (34%) had T 1/2 > 75 min (p < 0.001). In the control group, 25 patients (49%) had T 1/2 < 5 min and none had T1/2 >75 min (P < 0.001). The ROC curve for T1/2 < 5 min demonstrated 94% sensitivity and 51% specificity whereas a T1/2 >75 min demonstrated 100% specificity and 34% sensitivity. Analysis of the GWO using a ROC curve revealed that a cut-off of 50% GWO has 100% specificity and 52% sensitivity for pyeloplasty. Overall, a T1/2 > 75 min or GWO <50% predicted 53% of pyeloplasties (Fig A) and was absent in all conservatively managed cases.

      Discussion

      The limitations of the present study include its retrospective nature. Secondly, the lack of a gold standard diagnostic test for uretero-pelvic junction obstruction hampers objective quantification of diagnostic test utility performance.

      Conclusions

      Summary Figure A
      Graphical AbstractAbility of the modified drainage criteria to predict pyeloplasty.

      Keywords

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      References

        • Kass E.J.
        • Majd M.
        Evaluation and management of upper urinary tract obstruction in infancy and childhood.
        Urol Clin North Am. 1985; 12: 133-141
        • Capolicchio G.
        • Leonard M.P.
        • Wong C.
        • Jednak R.
        • Brzezinski A.
        • Salle J.L.
        Prenatal diagnosis of hydronephrosis: impact on renal function and its recovery after pyeloplasty.
        J Urol. 1999; 162: 1029-1032
        • Dudley J.A.
        • Haworth J.M.
        • McGraw M.E.
        • Frank J.D.
        • Tizard E.J.
        Clinical relevance and implications of antenatal hydronephrosis.
        Arch Dis Child Fetal Neonatal Ed. 1997; 76: F31-F34
        • Ransley P.G.
        • Dhillon H.K.
        • Gordon I.
        • Duffy P.G.
        • Dillon M.J.
        • Barratt T.M.
        The postnatal management of hydronephrosis diagnosed by prenatal ultrasound.
        J Urol. 1990; 144 (discussion 593-4): 584-587
        • Koff S.A.
        • Campbell K.D.
        The nonoperative management of unilateral neonatal hydronephrosis: natural history of poorly functioning kidneys.
        J Urol. 1994; 152: 593-595
        • Babu R.
        • Rathish V.R.
        • Sai V.
        Functional outcomes of early versus delayed pyeloplasty in prenatally diagnosed pelvi-ureteric junction obstruction.
        J Pediatr Urol. 2015; 11: 63 e1-63 e5
        • Peters C.A.
        Urinary tract obstruction in children.
        J Urol. 1995; 154 (discussion 1883-4): 1874-1883
        • Nguyen H.T.
        • Herndon C.D.
        • Cooper C.
        • Gatti J.
        • Kirsch A.
        • Kokorowski P.
        • et al.
        The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis.
        J Pediatr Urol. 2010; 6: 212-231
        • Radmayr C.
        • Bogaert G.
        • Dogan H.S.
        • Kočvara R.
        • Nijman R.
        • Stein R.
        • et al.
        EAU guidelines on paediatric Urology 2018.
        in: European association of Urology guidelines. 2018 edn. European Association of Urology Guidelines Office, Arnhem, The Netherlands2018
        • Capolicchio J.P.
        • Braga L.H.
        • Szymanski K.M.
        Canadian urological association/pediatric urologists of Canada guideline on the investigation and management of antenatally detected hydronephrosis.
        Can Urol Assoc J. 2018; 12: 85-92
        • Sussman R.D.
        • Blum E.S.
        • Sprague B.M.
        • Majd M.
        • Rushton H.G.
        • Pohl H.G.
        Prediction of clinical outcomes in prenatal hydronephrosis: importance of gravity assisted drainage.
        J Urol. 2017; 197: 838-844
        • Rosenthall L.
        • Tyler J.L.
        • Arzoumanian A.
        A crossover study comparing delayed radiohippurate images with furosemide renograms.
        Diagn Imag. 1983; 52: 267-275
        • Wong D.C.
        • Rossleigh M.A.
        • Farnsworth R.H.
        Diuretic renography with the addition of quantitative gravity-assisted drainage in infants and children.
        J Nucl Med. 2000; 41: 1030-1036
        • Nogarede C.
        • Tondeur M.
        • Piepsz A.
        Normalized residual activity and output efficiency in case of early furosemide injection in children.
        Nucl Med Commun. 2010; 31: 355-358
        • Keu K.V.
        • Lambert R.
        • Houle A.-M.
        • Franc-Guimond J.
        • Turpin S.
        • Barrieras D.
        Neonatal hydronephrosis and diuretic renogram: last decade CHU-Ste-Justine experience using new drainage ratio criteria.
        J Nucl Med. 2009; 50: 1376
        • Shulkin B.L.
        • Mandell G.A.
        • Cooper J.A.
        • Leonard J.C.
        • Majd M.
        • Parisi M.T.
        • et al.
        Procedure guideline for diuretic renography in children 3.0.
        J Nucl Med Technol. 2008; 36: 162-168
        • Majd M.
        • Bar-Sever Z.
        • Santos A.I.
        • De Palma D.
        The SNMMI and EANM procedural guidelines for diuresis renography in infants and children.
        J Nucl Med. 2018; 59: 1636-1640
        • Gordon I.
        • Piepsz A.
        • Sixt R.
        • Auspices of Paediatric Committee of European Association of Nuclear M
        Guidelines for standard and diuretic renogram in children.
        Eur J Nucl Med Mol Imag. 2011; 38: 1175-1188
        • Ulman I.
        • Jayanthi V.R.
        • Koff S.A.
        The long-term followup of newborns with severe unilateral hydronephrosis initially treated nonoperatively.
        J Urol. 2000; 164: 1101-1105
        • Connolly L.P.
        • Zurakowski D.
        • Peters C.A.
        • Dicanzio J.
        • Ephraim P.
        • Paltiel H.J.
        • et al.
        Variability of diuresis renography interpretation due to method of post-diuretic renal pelvic clearance half-time determination.
        J Urol. 2000; 164: 467-471
        • Ross S.S.
        • Kardos S.
        • Krill A.
        • Bourland J.
        • Sprague B.
        • Majd M.
        • et al.
        Observation of infants with SFU grades 3-4 hydronephrosis: worsening drainage with serial diuresis renography indicates surgical intervention and helps prevent loss of renal function.
        J Pediatr Urol. 2011; 7: 266-271
        • Subramaniam R.
        • Kouriefs C.
        • Dickson A.P.
        Antenatally detected pelvi-ureteric junction obstruction: concerns about conservative management.
        BJU Int. 1999; 84: 335-338
        • Cordero L.
        • Nankervis C.A.
        • Oshaughnessy R.W.
        • Koff S.A.
        • Giannone P.J.
        Postnatal follow-up of antenatal hydronephrosis: a health-care challenge.
        J Perinatol. 2009; 29: 382-387
        • Conway J.J.
        • Maizels M.
        The "well tempered" diuretic renogram: a standard method to examine the asymptomatic neonate with hydronephrosis or hydroureteronephrosis. A report from combined meetings of the society for fetal urology and members of the pediatric nuclear medicine council--The society of nuclear medicine.
        J Nucl Med. 1992; 33: 2047-2051
        • De Man K.E.
        • Troch M.E.
        • Dobbeleir A.A.
        • Duong H.P.
        • Goethals I.M.
        Comparison of the EANM and SNM guidelines on diuretic renography in children.
        Nucl Med Commun. 2015; 36: 486-488
        • Koff S.A.
        • McDowell G.C.
        • Byard M.
        Diuretic radionuclide assessment of obstruction in the infant: guidelines for successful interpretation.
        J Urol. 1988; 140: 1167-1168
        • Wong J.C.
        • Rossleigh M.A.
        • Farnsworth R.H.
        Utility of technetium-99m-MAG3 diuretic renography in the neonatal period.
        J Nucl Med. 1995; 36: 2214-2219
        • Chaiwatanarat T.
        • Padhy A.K.
        • Bomanji J.B.
        • Nimmon C.C.
        • Sonmezoglu K.
        • Britton K.E.
        Validation of renal output efficiency as an objective quantitative parameter in the evaluation of upper urinary tract obstruction.
        J Nucl Med. 1993; 34: 845-848
        • Saunders C.A.
        • Choong K.K.
        • Larcos G.
        • Farlow D.
        • Gruenewald S.M.
        Assessment of pediatric hydronephrosis using output efficiency.
        J Nucl Med. 1997; 38: 1483-1486