Renal Replacement Therapy and Intermittent Catheterization Risk in Posterior Urethral Valves

Abstract

on behalf of the Pediatric Urology Midwest Alliance (PUMA) abstract OBJECTIVES: Posterior urethral valves predispose children to renal replacement therapy (RRT) and bladder dysfunction. Researchers of single-institutional series were unable to refine risk stratification because of rarity of the disease. We aimed to identify clinical variables associated with the risk of RRT and clean intermittent catheterization (CIC) in a large multicenter cohort study.METHODS: Children with posterior urethral valves born between 1995 and 2005 who were treated before 90 days of life at 5 children's hospitals were retrospectively reviewed. Outcomes included RRT and recommendation for CIC. Predictors and outcomes were assessed by using survival analysis.RESULTS: A total of 274 patients were managed for a median of 6.3 years, and 42 progressed to RRT. On survival analysis, 16% progressed to RRT by 10 years of age. RRT varied by the serum nadir creatinine level in the first year of life (SNC1) (log-rank P , .001). After stratifying by the SNC1, the estimated risk of progressing to RRT by 10 years of age was 0%, 2%, 27%, and 100% for an SNC1 of ,0.4, an SNC1 of 0.4 to 0.69, an SNC1 of 0.7 to 0.99, and an SNC1 of $1.0 mg/dL, respectively. CIC was recommended in 60 patients, which translated on survival analysis to a risk of 26% by 10 years of age.CONCLUSIONS: Risk of RRT and CIC recommendation increased with age. The SNC1 strongly predicted need for RRT. These results allow for both improved family counseling and the potential for more appropriate screening and intervention strategies for those identified in higher-risk groups.WHAT'S KNOWN ON THIS SUBJECT: A serum nadir creatinine level of ,1 mg/dL is considered a prognostic indicator for need for renal replacement therapy in posterior urethral valves. However, the ability to narrow risk stratification cutoffs to multiple creatinine level ranges has been lacking. WHAT THIS STUDY ADDS:In this multicenter study of children with posterior urethral valves, we identified multiple nadir creatinine level ranges for prediction of renal replacement therapy. These results allow for improved family counseling and more risk-based screening and intervention strategies for higher-risk groups.

Survival and Kidney Outcomes of Children with an Early Diagnosis of Posterior Urethral Valves

“…Of the 59 children (9%) who underwent one or more catheter placements, 69% had them placed during the first year of life, and 83% were placed during the first 5 years of life. This distribution is similar to that observed by McLeod et al (21) in a recent multi-institutional analysis of children with posterior urethral valves. However, our overall rate of dialysis was lower, at 9% in our series versus 15% in theirs.…”

Voiding dysfunction in children causes, management, and prognosis

“…In a previous observational retrospective study from our center in 2015, 1000 children with CKD were enrolled, the incidence of RRT was 7.7% (hemodialysis 3.6%, peritoneal dialysis 2.6%, and kidney transplantation 1.5%), and bladder dysfunction was the most frequent cause of obstructive uropathy (12.1%). 32 McLeod et al, 33 reported in a multicenter study, 274 children with PUV, who were treated before 90 days and were treated for a median of 6.3 years, 16% progressed to ESKD and required RRT by 10 years of age.…”

Chronic Kidney Disease in Boys with Posterior Urethral Valves–Pathogenesis, Prognosis and Management

“…Recent reports from multicenter cohorts from the United States of 274 [ 29 ] and 685 [ 5 ] patients have shed new light on the epidemiology of CKD and ESKD in children with PUV. At the ages of 1, 5 and 15 years, 7%, 12% and 20% of children needed KRT, respectively [ 5 , 29 ]. In a smaller study with 35 infants, after 10 years 50% progressed to CKD stages 2–4, and 15% needed KRT [ 30 ].…”

“…The predictive value of serum creatinine has been identified as a useful parameter in several studies in patients with PUV. Different time points from first month [ 46 ] of life, in the first year of life [ 47 ], days, weeks or years after ablation [ 29 , 48 , 49 , 50 , 51 , 52 , 53 ], have been investigated. Some studies also focused on the creatinine velocity [ 51 , 54 ], which assesses the change in creatinine over time.…”

“…Some studies also focused on the creatinine velocity [ 51 , 54 ], which assesses the change in creatinine over time. In conclusion, there is an abundance of data to support the hypothesis that nadir creatinine after valve ablation is the best independent predictor in infancy for the development of CKD in patients with PUV [ 29 , 48 , 49 , 50 , 51 , 52 , 53 ]. Although nadir creatinine was mostly used to stratify for only ESKD in older studies, recent studies with PUV patients have also proposed using cut-off values to predict different CKD stages.…”