Nephro-urological outcomes of a proactive management of children with spina bifida in their first 5 Years of life

Published:December 09, 2021DOI:https://doi.org/10.1016/j.jpurol.2021.12.002

      Summary

      Introduction

      The proactive management of spina bifida (SB), especially of its severe form, myelomeningocele (MMC), has contributed to decreasing chronic kidney disease (CKD). The objective of this study is to present the evolution of 5-year-old patient with MMC followed from birth with a proactive approach.

      Material and methods

      This retrospective study included 55 cases with MMC of up to 5 years of age. All of them were admitted at birth and followed by a multidisciplinary group, with a proactive approach: CIC and anticholinergics. In the same group, the variables were compared within the first year and the within the fifth year of life. Chronic kidney disease (CKD) was defined by: alterations on renal DMSA scintigraphy; alterations in microalbuminuria/creatininuria ratio, proteinuria 24 hs and decrease in glomerular filtration rate (GFR) calculated with Schwartz bedside equation.

      Results

      Although overactivity, UTI and VUR decreased throughout the first 5 years (49, 9 and 12%), reduced cystometric capacity, DLPP >40 cm of water and end-filling pressure (Pdet) >20 cm of water increased (41, 27 and 61%). All patients at 5 years of age required CIC. Reduced cystometric capacity and VUR were more significant with abnormal DMSA (36%) at 5 years old ( p: 0.03). Proteinuria and CKD increased to 25% and 49%. Similarly, the need for enalapril increased from 10% to 27%. The microalbuminuria/creatininuria ratio was pathological in 27.3%. 48 patients (87%) remained unchanged on DMSA scan and the other 7 underwent modifications (4 new cases with altered DMSA) over time. Of the 32 normal DMSA cases without changes, 81% did not present proteinuria and 88% continued to respond favorably to oxybutynin. GFR <90 ml/min/1.72m 2 was found in only 3 cases with abnormal DMSA. There was a RR 1.91 (IC95% 1.15-3.16) greater of renal compromise in cases that were anticholinergic-resistant compared to non-refractory cases.

      Discussion

      Over time, some patients suffered loss of bladder wall compliance, despite the proactive approach. There is an association between abnormal renal DMSA, reduced bladder capacity, and VUR at 5 years of age. Although proteinuria, CKD and enalapril requirement increased over 5 years, almost 90% did not show changes in renal DMSA status.

      Conclusions

      Summary TableNephro-urological variables of patients with spina bifida (SB) at one year and at 5 years of age. Ref: UTI: Symptomatic urinary tract infections. DMSA: dimercaptosuccinic acid.
      8 months of age 60 months of age
      n % n %
      Patients with SB 60 55
      Mean age (months) 8 60
      Males 32 53.3 28 50.9
      UTIs 21 35.0 5 9
      Urinary Tract Dilation P1 (UTD P1) 22 36.6 24 43.6
      Vesicoureteral reflux (VUR) 12 20.0 7 12.7
      Abnormal renal scintigraphy-DMSA 18 30.0 20 36.0
      Excluded patients 5 8.3

      Keywords

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