Maria Candida F. Bouzada

Clinical course of 822 children with prenatally detected nephrouropathies.

BACKGROUND AND OBJECTIVES With the advent of fetal screening ultrasonography, the detection of congenital anomalies of the kidney and urinary tract (CAKUT) in utero has permitted early management of these conditions. This study aims to describe the clinical course of a large cohort of patients with prenatally detected nephrouropathies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this retrospective cohort study, 822 patients were prenatally diagnosed with CAKUT and systematically followed up at a tertiary Renal Unit for a median time of 43 months. Variables included in the analysis were sex, laterality, fetal ultrasonography (isolated versus associated hydronephrosis), and presence/absence of nephrouropathies. The events of interest were urinary tract infection, surgical interventions, hypertension, CKD, and death. Survival analyses were performed to evaluate time until occurrence of the events of interest. RESULTS Urinary tract infection occurred in 245 (29.8%) children, with higher risk in females (hazard ratio=1.30, 95% confidence interval=1.02-1.70, P=0.05); 22 patients (2.7%) had hypertension, and 49 (6%) patients developed CKD. The risk of CKD was greater in patients with associated hydronephrosis (hazard ratio=5.20, 95% confidence interval=2.90-9.30, P<0.001). Twelve patients (1.5%) died during follow-up. Death was significantly associated with being born during the first period of the study (hazard ratio=6.00, 95% confidence interval=1.60-22.50, P<0.001), associated hydronephrosis (hazard ratio=9.30, 95% confidence interval=2.90-29.30, P<0.001), and CKD (hazard ratio=170.00, 95% confidence interval=41.00-228.00, P<0.001). CONCLUSIONS In our series, the clinical course of prenatally detected CAKUT was heterogeneous, and those infants with associated hydronephrosis at baseline were identified as a high-risk subgroup.

Early risk factors for neonatal mortality in CAKUT: analysis of 524 affected newborns

BackgroundCongenital abnormalities of the kidney and urinary tract (CAKUT) are significant causes of morbidity. The aim of the study was to determine predictive factors of mortality in newborns with CAKUT.MethodsAll 29,653 consecutive newborns hospitalized in a tertiary neonatal unit between 1996 and 2006 were evaluated. The main outcome was neonatal mortality. The variables analyzed as risk factors were maternal age, first pregnancy, low birth weight (LBW), prematurity, oligohydramnios, and CAKUT associated with other malformations (Associated CAKUT).ResultsCAKUT was detected in 524 newborns, with an overall prevalence of 17.7 per 1,000 live births. A total of 325 (62%) cases were classified as urinary tract dilatation, 79 (15.1%) as renal cystic disease, and 120 (22.9%) as other subgroups. In the urinary tract dilatation subgroup, independent risk factors for early mortality were Associated CAKUT [odds ratio (OR) 20.7], prematurity (OR 4.5) LBW (OR 3.8), oligohydramnios (OR 3.0), and renal involvement (OR 3.0). In the renal cystic disease subgroup, two variables remained associated with neonatal mortality: LBW (OR 12.3) and Associated CAKUT (OR 21.4).ConclusionThe presence of extrarenal anomalies was a strong predictor of poor outcome in a larger series of infants with CAKUT.

Predictive Factors for Vesicoureteral Reflux and Prenatally Diagnosed Renal Pelvic Dilatation

PURPOSE We sought to identify predictive factors for primary vesicoureteral reflux among infants with prenatally detected renal pelvic dilatation. MATERIALS AND METHODS A total of 250 neonates were diagnosed with isolated renal pelvic dilatation between 1999 and 2008, and followed prospectively. The main event of interest was presence of moderate to severe reflux (grade III to V). Diagnostic odds ratio, sensitivity, specificity, and diagnostic accuracy (assessed by AUC) of fetal and postnatal renal pelvic dilatation were determined. Severity of dilatation was classified by Society for Fetal Urology grade. Binary logistic regression was performed to identify variables significantly associated with vesicoureteral reflux. RESULTS A total of 23 patients (9.2%) had primary vesicoureteral reflux, of whom 16 had grade III to V disease. Diagnostic accuracy was 0.70 (95% CI 0.63 to 0.75) for fetal and 0.65 (95% CI 0.59 to 0.71) for postnatal renal pelvic dilatation. Combined results of fetal and postnatal renal pelvic dilatation were also assessed. When both tests less than 10 mm were considered negative indicators of moderate to severe vesicoureteral reflux sensitivity increased to 97% and diagnostic odds ratio to 19.1. After adjustment by logistic regression only Society for Fetal Urology grade greater than I and ureteral dilatation were variables independently associated with grade III to V reflux. CONCLUSIONS Fetal and postnatal renal pelvic dilatation was a poor predictor of vesicoureteral reflux. Nevertheless, diagnostic accuracy regarding clinically significant vesicoureteral reflux improved when fetal and postnatal renal pelvic dilatation less than 10 mm was considered a negative indicator of reflux.

Urinary levels of TGF β-1 and of cytokines in patients with prenatally detected nephrouropathies

This study aimed to identify noninvasive biomarkers of clinically significant nephrouropathies in patients with antenatal renal and/or urinary tract alterations. Spot-urine levels of interleukin-6 (IL-6), transforming growth factor-β1 (TGF-β1) and tumor necrosis factor-α (TNF-α) were measured in 100 patients with antenatal detected nephrouropathies. Patients were divided in idiopathic hydronephrosis (n = 47), urinary tract malformations (n = 35), and dysplastic kidneys (n = 18). Urinary concentrations of TGF-β1, IL-6, and TNF-α were compared between groups according to clinical and image findings. Receiver-operating characteristic (ROC) curves were analyzed for the overall diagnostic accuracy of TGF-β1, IL-6, and TNF-α levels in discriminating infants with nephrouropathies. No significant differences in urinary TGF- β1, IL-6, and TNF-α levels were found in the comparison between the groups. TGF-β1 levels tended to be higher in patients with renal hypodysplasia compared to idiopathic hydronephrosis (p = 0.07). Twenty-nine patients had reduced DMSA uptake. In these cases, absolute urinary concentration of TGF-β1 and levels standardized for creatinine were significantly higher than in patients with normal DMSA uptake, while IL6 and TNF-α did not differ between groups. Urinary cytokine measurements were not useful as a screening test for clinically significant nephrouropathies. Conversely, increased concentrations of TGF-β1 pointed out to renal damage as indicated by reduced DMSA uptake.

Evaluation of national health‐care related infection criteria for epidemiological surveillance in neonatology

OBJECTIVE to assess the use of the Brazilian criteria for reporting of hospital-acquired infections (HAIs) in the neonatal unit and compare them with the criteria proposed by the National Healthcare Safety Network (NHSN). METHODS this was a cross-sectional study conducted from 2009 to 2011. It included neonates with HAI reporting by at least one of the criteria. Statistical analysis included calculation of incidence density of HAIs, distribution by weight, and by reporting criterion. Analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the national criteria was performed considering the NHSN as the gold standard, with agreement assessed by kappa. RESULTS a total of 882 newborns were followed, and 330 had at least one infection notified by at least one of the criteria. A total of 522 HAIs were reported, regardless of the criteria. An incidence density of 27.28 infections per 1,000 patient-days was observed, and the main topographies were sepsis (58.3%), candidiasis (15.1%), and conjunctivitis (6.5%). A total of 489 (93.7%) were notified by both criteria, eight infections were notified only by the national criteria (six cases of necrotizing enterocolitis and two cases of conjunctivitis), and 25 cases of clinical sepsis were reported by NHSN criteria only. The sensitivity, specificity, PPV, and NPV were 95.1%, 98.6%, 98.4%, and 95.7%, respectively, for all topographies, and were 91.8%, 100%, 100%, and 96.3% for the analysis of sepsis. Kappa analysis showed an agreement of 96.9%. CONCLUSION there was a high rate of agreement between the criteria. The use of the national criteria facilitates the reporting of sepsis in newborns, and can help to improve the specificity and PPV.

Risk factors for central venous catheter-related infections in a neonatal population - systematic review,

OBJECTIVE This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population. DATA SOURCE The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified. DATA SYNTHESIS A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs. CONCLUSION Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

Exames de imagem na avaliação de anomalias urológicas em lactentes com hidronefrose fetal: avanços e controvérsias

Recent advances in prenatal diagnosis resulted in an improvement of detection and management of urinary tract abnormalities. Prenatal ultrasonography allows to identify urological abnormalities that otherwise would not be seen until later in life, when complications occur. The voiding cystourethrogram can be reserved for selected patients. Nuclear medicine exams should be performed in cases of moderate and severe hydronephrosis. A review of the current literature on postnatal approach of prenatal hydronephrosis was performed. Data obtained were compared with the records of the Pediatric Nephrology Unit HC/UFMG regarding management and follow-up of children with uropathies detected while investigating for fetal hydronephrosis.Recent advances in prenatal diagnosis resulted in an improvement of detection and management of urinary tract abnormalities. Prenatal ultrasonography allows to identify urological abnormalities that otherwise would not be seen until later in life, when complications occur. The voiding cystourethrogram can be reserved for selected patients. Nuclear medicine exams should be performed in cases of moderate and severe hydronephrosis. A review of the current literature on postnatal approach of prenatal hydronephrosis was performed. Data obtained were compared with the records of the Pediatric Nephrology Unit HC/UFMG regarding management and follow-up of children with uropathies detected while investigating for fetal hydronephrosis.