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Role of progressive urethral dilation and primary valve ablation in the long-term renal outcomes of small, preterm infants with posterior urethral valve

  • Charlotte Q. Wu
    Affiliations
    Division of Pediatric Urology, Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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  • Jennifer M. Lovin
    Affiliations
    Division of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA

    Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
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  • Dattatraya Patil
    Affiliations
    Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
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  • Edwin A. Smith
    Correspondence
    Correspondence to: E.A. Smith, MD, Division of Pediatric Urology Children's Healthcare of Atlanta Emory University School of Medicine 5730 Glenridge Dr Ste 200 Atlanta, GA 30328, USA, Tel.: +404 252 5206; Fax.: +404 252 1268
    Affiliations
    Division of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA

    Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
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      Summary

      Introduction

      PUV patients managed with primary vesicostomy instead of primary valve ablation (PVA) historically are preterm, low-birth-weight (LBW) infants with inadequate urethral size. We previously described progressive urethral dilation (PUD) as an effective method of enhancing the likelihood of PVA in these infants, allowing equal access to PVA as an initial management method.

      Objective

      We aim to characterize renal outcomes in patients managed with PUD + PVA and compare this to outcomes with PVA alone. We also re-examine the effect of LBW and gestational age on renal outcomes in PUV with a cohort treated uniformly by PVA.

      Methods

      We performed retrospective review of 78 neonates with PUV treated with PVA prior to 10 weeks of age with >1 year of follow up. Before valve ablation, boys either underwent PUD (serial upsizing of a smaller bore urethral catheter to an 8Fr catheter; PUD + PVA) or non-dilation (smaller bore catheter was maintained; PVA-only). PUD + PVA versus PVA-only was compared using chi-square and t-test. Logistic regression was performed to assess the effect of PUD, preterm (<37 weeks), LBW (<2.5 kg), and other predictors on the final outcomes of CKD3+ and ESRD.

      Results

      31 of 78 patients underwent PUD + PVA. Mean follow up was 5.2 years (SD 3.4), with no significant difference between PUD + PVA and PVA-only. The PUD + PVA group included significantly lower gestational age infants with lower birth weight and ablation weight. There was no significant effect of PUD on final CKD3+ or ESRD outcome on univariable or multivariable analysis. When adjusted for other variables, only Cr nadir >0.5 remained an independent predictor of CKD3+ (OR 41.2; p < 0.001) and ESRD (OR 18.9; p = 0.015).

      Discussion

      We previously demonstrated that PUD is an effective means to achieve PVA in small neonates who might otherwise require vesicostomy. The data herein demonstrates no significant effect of PUD on renal outcomes. In this unique cohort of newborns treated with PVA, only creatinine nadir and not gestational age or an independent predictor of outcomes.

      Conclusion

      Summary Table
      Univariable Multivariable
      CKD3+ OR (95% CI) p OR (95% CI) p
      Prenatal diagnosis 1.909 (0.686–5.310) 0.215
      Preterm 4.222 (1.499–11.892) 0.006 1.955 (0.261–14.653) 0.514
      Low birth weight 5.000 (1.343–18.620) 0.016 2.900 (0.318–26.458) 0.345
      VUR present 3.237 (1.161–9.029) 0.025 3.764 (0.590–24.026) 0.161
      VUR bilateral 3.321 (1.094–10.082) 0.034
      VUR high grade 2.564 (0.939–7.003) 0.066
      PUD 1.548 (0.575–4.164) 0.387 0.518 (0.083–3.242) 0.482
      Catheter duration 1.044 (0.989–1.103) 0.117
      Cr Nadir >0.5 35.700 (8.604–148.120) <0.001 41.196 (6.701–253.258) <0.001
      ESRD OR (95% CI) p OR (95% CI) p
      Prenatal diagnosis 1.344 (0.390–4.629) 0.640
      Preterm 2.231 (0.601–8.282) 0.231
      Low birth weight 4.167 (1.042–16.660) 0.044 1.328 (0.124–14.207) 0.814
      VUR present 4.321 (1.082–17.252) 0.038 9.848 (0.865–112.095) 0.065
      VUR bilateral 2.686 (0.781–9.241) 0.117
      VUR high grade 3.815 (1.055–13.799) 0.041
      Two additional multivariable models each for CKD3+ and ESRD that incorporate the alternate VUR variables can be found in the Supplemental Table.
      PUD 1.016 (0.298–3.466) 0.980 0.425 (0.050–3.596 0.432
      Catheter duration 1.093 (1.023–1.168) 0.009 1.086 (0.947–1.246) 0.328
      Cr Nadir >0.5 28.750 (3.407–242.627) 0.002 18.903 (1.772–201.628) 0.015
      ∗Supplemental Table

      Keywords

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