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The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.

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In LUTO, the ultrasound appearance of the fetal kidneys and urinary biochemistry are not correlated. It may be better to take both ultrasound and biochemistry into account when evaluating fetuses with fetal LUTO. © 2016 John Wiley & Sons, Ltd.

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Peritoneal dialysis (PD) is generally considered the preferred extracorporeal therapy for neonates with acute kidney injury (AKI). However, there are situations when PD is not suitable, such as in patients with previous abdominal surgery, hyperammonemia and significant ascites or anasarca. Additionally, with a need to start PD soon after catheter placement, there is increased risk of PD catheter leak and infection. Extracorporeal continuous renal replacement therapy (CRRT) is challenging in severely ill neonates as it requires obtaining adequately sized central venous access to accommodate adequate blood flow rates and also adaptation of a CRRT machine meant for older children and adults. In addition, ultrafiltration often cannot be set in sufficiently small increments to be suitable for neonates. Although CRRT practices can be modified to fit the needs of infants and neonates, there is a need for a device designed specifically for this population. Until that becomes available, providing the highest level of care for neonates with AKI is dependent on the shared experiences of members of the pediatric nephrology community.Keywords Extracorporeal continuous renal replacement therapy . Acute kidney injury . Neonates . nRIFLE . Continuous venovenous hemodiafiltrationIn a recent article in Pediatric Nephrology, Lee and Cho review their continuous renal replacement therapy (CRRT) experience in 34 neonates with acute kidney injury (AKI) [1]. Although single center and retrospective, there are several noteworthy characteristics of this study. The authors standardize neonatal AKI using the neonatal RIFLE (nRIFLE) criteria to define and stratify severity of AKI. Of the 34 neonates included in the study, 44 % were born preterm (25-36 weeks), with 60 % of these preterm infants being either extremely or very low birth weight. All patients had AKI, and 24 patients met the nRIFLE class F (Failure) criterion. Survival was 50 %. Continuous venovenous hemodiafiltration (CVVHDF) with Prisma or Prismaflex (Gambro/Baxter Int., Lund, Sweden) dialysis machines and M10 (50 ml) or HF20 (55 ml) filters was used for all CRRT treatments. Access was via internal jugular 6.5-French (Fr) hemodialysis catheters. Mean filter life was 51.1 h. Similar to other studies in pediatric CRRT patients [2-4, 5], fluid overload (FO), defined by the percentage weight gain over weight at admission to the neonatal intensive care unit (NICU), was independently associated with mortality [6]. Neonatal studies have reported an FO of >15-20 % to be associated with poor outcome defined as need for CRRT, prolonged NICU stay, time to extubation or death within 30 days postcardiothoracic surgery [7,8]. Interestingly, this study by Lee and Cho [1] reports a much higher FO cut-off of 30 % being associated with poor outcomes, including 100 % mortality for patients reaching an FO of >30 %. The authors propose higher body surface area, calorie consumption and insensible water loss in neonates as a possible explanation. They address this issue by using actual weig...

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