Evaluation of Differential Renal Function and Renographic Patterns in Patients with Dietl Crisis

Hydronephrotic lower moiety of duplex systems: Observations using diuresis renography

PURPOSE

The purpose of this study is to characterize the prevalence and behavior of hydronephrosis of non-refluxing lower moiety of duplex kidneys using MAG-3 diuresis renography. We compare our data to previous case series and ureteropelvic junction obstruction of single systems.

MATERIALS AND METHODS

An IRB-approved database of over 5000 diuresis renograms performed in 2025 patients was queried to identify cases of hydronephrosis of lower moiety of duplex kidneys suspicious for ureteropelvic obstruction, excluding those with hydroureter or reflux. Kidney function and post-furosemide drainage parameters on initial and follow-up diuresis renograms were recorded. Medical records and patient outcomes were reviewed.

RESULTS

In total, 19 renal units were identified in 18 patients (11 male, 7 female), age range 0.5 months to 17.8 years, including one patient with bilateral lower moiety hydronephrosis. Initial diuresis renograms in 12 asymptomatic patients (13 renal units) with antenatal hydronephrosis demonstrated varying drainage patterns from normal to obstructed. Follow-up studies showed worsening drainage in 3 patients, who all underwent surgery. Drainage improved in 4 patients and remained unchanged in 5 patients (6 renal units). Of the 6 patients presenting with Dietl's crisis, 5 showed obstructive drainage on initial diuresis renogram, 2/5 with decreased function. All 5 obstructed patients underwent surgery.

CONCLUSION

Hydronephrosis of the lower moiety of a duplex system is rare and behaves similarly to single systems. The majority are diagnosed antenatally, display a dynamic nature, and may present with acute obstruction. Diuresis renography is a valuable tool in its evaluation and management.

Dietl crisis: Presentation and imaging findings in a 7-year-old boy

Intermittent ureteropelvic junction obstruction, or Dietl crisis, is a rare entity with sparse reports in published literature. Establishing the diagnosis is challenging given its intermittent nature. We report a case of Dietl crisis, focusing on ultrasound (US) and magnetic resonance urography (MRU) findings in a 7-year-old boy with recurrent episodes of colicky abdominal pain prompting multiple visits to the emergency department. Severe left hydronephrosis was visualized on US during one episode with complete resolution on follow-up US. MRU demonstrated severe left hydronephrosis with delayed calyceal transit time, time-to-peak enhancement, and excretion. There was no aberrant blood vessel. Surgical pyeloplasty provided complete symptomatic resolution. MRU can be a valuable tool in eliciting and dynamically confirming the diagnosis of Dietl crisis.

The clinical manifestations of intermittent hydronephrosis and their relationship with renal function in pediatric patients

BACKGROUND AND OBJECTIVE

Most patients with intermittent hydronephrosis have preserved differential renal function (DRF), while others already have impaired DRF at diagnosis. We summarized the clinical manifestations of intermittent hydronephrosis to elucidate what may be related to DRF loss.

STUDY DESIGN

We retrospectively reviewed patients presenting to our department with unilateral Dietl's Crisis between January 2014 and December 2017. Clinical characteristics were collected, including age of first onset, time of onset, duration of the longest single episodes and whether the patient had prenatally detected hydronephrosis. Ultrasonographic (US) parameters included anteroposterior diameter (APD) during the symptomatic and asymptomatic period. Dynamic renograms (DR) were reviewed to obtain preoperative DRF.

RESULTS

A total of 150 patients met the selective criteria. Of the 128 patients whose mother had regular obstetric ultrasounds during pregnancy, 50 (39.06%) had prenatally detected pelvic dilation. The mean age of the first attack was earlier in the prenatally detected hydronephrosis group than in the postnatally detected group (4.58 vs 5.87, p = 0.002). The mean preoperative DRF was 41.03% in all of the patients. The patients whose DRFs were below 40% had longer durations of single attacks than those over 40%. The former group also had larger APD during the symptomatic periods than the latter group. The risk of DRF < 40% was higher in the patients whose APD at attack was greater than 35 mm (OR=5.111, χ²=12.899, p < 0.001). The attack times, waiting time before the surgery and age of the first onset had no association with preoperative DRF.

DISCUSSION

Our study first found that in patients with Dietl's Crisis, the APD during the symptomatic periods and the longest duration of the attack were associated with DRF loss. But the retrospective nature of our study limited us to understand the relationship between DRF and total duration of all attacks.

CONCLUSION

This study revealed that children with prenatal hydronephrosis could develop Dietl's Crisis at early ages. A longer duration of attack and larger APD during the attack were associated with impaired DRF.

Diuresis renography in the evaluation and management of pediatric hydronephrosis: What have we learned?

Diuresis renography (DR) is widely used in the evaluation of hydronephrosis and hydroureter in infants and children. The goal of this provocative nuclear imaging examination should be to detect the hydronephrotic kidneys at risk for loss of function and development of pain, hematuria, and urinary tract infection. The reliability of DR is dependent on the acquisition and processing of the data as well as interpretation and utilization of the results. In this review, the key concepts of standardized DR and pitfalls to avoid are highlighted.

Holding Water: Congenital Anomalies of the Kidney and Urinary Tract, CKD, and the Ongoing Role of Excellence in Plumbing

Congenital anomalies of the kidneys and urinary tracts can result in diminished natal kidney function, possibly through common embryologic pathway disruption or as a result of development taking place in the face of disordered 'post-renal' drainage. Impaired conduit and reservoir function present potential for an ongoing assault leading to further deterioration and progression of chronic kidney disease, a risk that extends to adults with these conditions, even after "correction". The drainage and storage aspects of the urinary system that can impact kidney function are reviewed with attention to correctable or manageable problems including: Bladder dysfunction wherein the low pressure storage of urine is compromised requiring the kidney to work against a pressure gradient, the classic post renal failure problem. The kidney in the aftermath of obstruction which may have lost concentrating capacity leading to a tendency to dehydration ('pre-renal' failure) and through polyuria which exacerbates bladder pressure problems. Further there is an added challenge in evaluation for ongoing or reemergent obstruction in a significantly dilated system where the capacious system leads to slow turnover of urine often requiring a ureteral stent or nephrostomy to clearly establish clinical significance of delayed drainage. Stasis where slow urine flow leads to buildup of debris (stone) or potentiates infection. Vessicoureteral reflux which allows for introduction of lower urinary tract bacteria to the kidney and can lead to pyelonephritis. Conditions which combine problems such as posterior urethral valves where the bladder outlet obstruction compromises kidney function potentially impairing concentrating ability, creates bladder compromise often reducing emptying efficiency or elevating bladder storage pressures, as well as dilating the system potentially promoting stasis. Cognizance of the potential for plumbing problems to further kidney deterioration as patients with congenital urinary tract anomalies, even after they have been repaired is incumbent on those caring for these patients as they age. Thoughtful evaluation of those patients in whom kidney compromise maybe aggravated by drainage and storage disorder will optimize native renal function.

[Intermittent hydronephrosis in childhood]

INTRODUCTION

Intermittent pelviureteric junction obstruction, and its consequence,intermittent hydronephrosis is a difficult condition to identify. The renal collecting system is not dilated between the episodes of abdominal pain attacks and a prompt investigation is hard to carry out during the time of painful crisis. Therefore, most of the patients are initially misdiagnosed.

AIM

The aim of the study was to assess the occurrence and the clinical characteristics of this phenomenon in children operated in the Department of Urological Surgery, Heim Pál Children Hospital, Budapest, Hungary.

PATIENTS AND METHODS

Medical records of children operated for hydronephrosis between 2008 and 2012 were reviewed. The occurrence rate and clinical features of intermittent hydronephrosis were analyzed.

RESULTS

76 children were operated for pelviureteric junction obstruction, of which 10 met the criteria of intermittent hydronephrosis. The average interval between the onset of symptoms and the final diagnosis was 2 years and 4 months. In 7 patients pyeloplasty, and in 3 patients nephrectomy were performed.

CONCLUSIONS

Intermittent hydronephrosis represents a well-defined proportion among cases operated for hydronephrosis. The delay in diagnosis led to the loss of the kidney in one third of the patients, and this finding urges for the awareness of health professionals for this phenomenon. In case of recurrent abdominal pain of unknown etiology one must suspect a urological origin, even if a previous abdominal ultrasound showed normal kidneys.