Medical Professional Publications

Uroepithelial Thickening (UET) Helps Predict High-grade VUR in Infants With Prenatal Hydronephrosis

Columbus, OH — January 2017

Infants diagnosed with prenatal hydronephrosis are typically evaluated with postnatal renal bladder ultrasonography (RBUS); when that RBUS shows moderate to severe hydronephrosis or hydroureter, both the Society for Fetal Urology and the American Urological Association recommend infants undergo a voiding cystourethrogram (VCUG) to assess vesicoureteral reflux (VUR).

But those costly, uncomfortable VCUGs often are negative for VUR. Is there a better criteria for deciding which infants should undergo those tests? A recent study from physician-researchers at Nationwide Children’s Hospital has found that a criteria including uroepithelial thickening is more specific and selective than the common criteria.

“Although they are very helpful in some situations, voiding cystourethrograms are expensive, they expose patients to radiation and they can cause parents a great deal of anxiety,” says Seth A. Alpert, MD, attending pediatric urologist at Nationwide Children’s and senior author of the paper. “We do not want to order them if they are they not going to change patient management. The presence of uroepithelial thickening on ultrasound can help us decide when VCUG is more likely to show high-grade VUR.”

The research, published in the Journal of Pediatric Urology, builds on a previous study from Dr. Alpert and his colleagues demonstrating that uroepithelial thickening is strongly associated with high-grade VUR in young children after a first urinary tract infection. The authors wanted to find if the association also existed in infants diagnosed with prenatal hydronephrosis.

The records of 135 infants younger than 30 days who underwent RBUS for prenatal hydronephrosis were examined. A total of 23 had low-grade VUR and 16 had high-grade VUR. On multivariable analysis, uroepithelial thickening, hydroureter, duplication and renal dysmorphia were all significant independent predictors of high-grade VUR.

The authors created new criteria based on those findings: RBUS was considered abnormal (and the infant potentially in need of a VCUG) if two of those predictors were present. That criteria had 100 percent sensitivity and 82 percent specificity for predicting high-grade VUR. The commonly used criteria, in contrast, had 88 percent sensitivity and 44 percent specificity.

In fact, the presence of uroepithelial thickening alone is both more sensitive and specific than the common criteria.

The criteria created by the authors would have resulted in 43 fewer VCUGs in the studied cohort than the common criteria and would have missed zero cases of high-grade VUR. The common criteria would have missed two children with high-grade VUR.

“Our findings tell us, first, that presence or absence of uroepithelial thickening on RBUS should be reported by radiologists,” says Dr. Alpert, who is also a Clinical Associate Professor of Urology at The Ohio State University College of Medicine. “And second, any criteria used to determine whether an infant with a diagnosis of prenatal hydronephrosis should undergo a VCUG should include the presence of uroepithelial thickening as an element.”   

References:

Gordon ZN, McLeod DJ, Ching CB, Herz DB, Bates DG, Becknell B, Alpert SA.  Uroepithelial thickening improves detection of vesicoureteral reflux in infants with prenatal hydronephrosis. Journal of Pediatric Urology.  2016 Aug; 12(4):257.e1-7.

Gordon ZN, McLeod DJ, Becknell B, Bates DG, Alpert SA. Uroepithelial thickening on sonography improves detection of vesicoureteral reflux in children with first febrile urinary tract infection. The Journal of Urology. 2015 Oct; 194(4):1074-9. 

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