1
|
Nassr AA, Fisher JE, Belfort MA. Selection of candidates for foetal intervention in congenital lower urinary tract obstruction. Curr Opin Obstet Gynecol 2021; 33:123-8. [PMID: 33620890 DOI: 10.1097/GCO.0000000000000693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Congenital lower urinary tract obstruction (LUTO) is a rare group of conditions characterized by high perinatal morbidity and mortality if associated with oligohydramnios or anhydramnios in early pregnancy. Although foetal intervention has the potential to improve perinatal survival in a select group of foetuses with LUTO, the actual selection of those candidates most likely to benefit from intervention remains challenging. RECENT FINDINGS Foetuses with LUTO who are potential candidates for prenatal intervention should undergo detailed multidisciplinary evaluation to ensure proper assessment and counselling. Using a combination of multiple ultrasound-based renal parameters, including measurement of foetal bladder volumes before and after vesicocentesis and kidney size and morphology, combined with repeated foetal urine biochemistry may allow for better selection than any single test. SUMMARY Foetal intervention should be offered to women carrying a foetus with LUTO only after appropriate evaluation and counselling. A combined approach utilizing ultrasound and biochemical measurements of foetal renal function appears best. Research focusing on the development of more accurate markers is needed.
Collapse
|
2
|
Strizek B, Gottschalk I, Recker F, Weber E, Flöck A, Gembruch U, Geipel A, Berg C. Vesicoamniotic shunting for fetal megacystis in the first trimester with a Somatex ® intrauterine shunt. Arch Gynecol Obstet 2020; 302:133-140. [PMID: 32449061 PMCID: PMC7266802 DOI: 10.1007/s00404-020-05598-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/08/2020] [Indexed: 11/30/2022]
Abstract
Purpose The objective was to evaluate the feasibility of vesicoamniotic shunting (VAS) in the first trimester with the Somatex® intrauterine shunt and report on complications and neonatal outcome. Methods Retrospective cohort study of all VAS before 14 weeks at two tertiary fetal medicine centres from 2015 to 2018 using a Somatex® intrauterine shunt. All patients with a first trimester diagnosis of megacystis in male fetuses with a longitudinal bladder diameter of at least 15 mm were offered VAS. All patients that opted for VAS after counselling by prenatal medicine specialists, neonatologists and pediatric nephrologists were included in the study. Charts were reviewed for complications, obstetric and neonatal outcomes. Results Ten VAS were performed during the study period in male fetuses at a median GA of 13.3 (12.6–13.9) weeks. There were two terminations of pregnancy (TOP) due to additional malformations and one IUFD. Overall there were four shunt dislocations (40%); three of those between 25–30 weeks GA. Seven neonates were born alive at a median GA of 35.1 weeks (31.0–38.9). There was one neonatal death due to pulmonary hypoplasia. Neonatal kidney function was normal in the six neonates surviving the neonatal period. After exclusion of TOP, perinatal survival was 75%, and 85.7% if only live-born children were considered. Conclusion VAS in the first trimester is feasible with the Somatex® Intrauterine shunt with low fetal and maternal complication rates. Neonatal survival rates are high due to a reduction in pulmonary hypoplasia and the rate of renal failure at birth is very low. VAS can be safely offered from the late first trimester using the Somatex® intrauterine shunt.
Collapse
Affiliation(s)
- B Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - I Gottschalk
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Cologne, Cologne, Germany
| | - F Recker
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - E Weber
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - A Flöck
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - U Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - A Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - C Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.,Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Cologne, Cologne, Germany
| |
Collapse
|
3
|
Vinit N, Gueneuc A, Bessières B, Dreux S, Heidet L, Salomon R, Lapillonne A, De Bernardis G, Salomon LJ, Stirnemann JJ, Blanc T, Ville Y. Fetal Cystoscopy and Vesicoamniotic Shunting in Lower Urinary Tract Obstruction: Long-Term Outcome and Current Technical Limitations. Fetal Diagn Ther 2019; 47:74-83. [PMID: 31401627 DOI: 10.1159/000500569] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/23/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND In utero therapeutic approaches for lower urinary tract obstruction (LUTO) have been developed to salvage the fetal kidney function. OBJECTIVE The aim of this work was to report the long-term survival, nephrological, and urological outcome of children treated prenatally for LUTO using operative fetal cystoscopy (FC) and vesicoamniotic shunting (VAS) or both. METHODS A retrospective study of 48 procedures (23 FC, 25 VAS) was performed on 33 patients (between 2008 and 2018). Reviewed data included prenatal management and clinical follow-up by a pediatric nephrologist and a pediatric urologist. Both intention-to-treat and per-protocol analyses were conducted. RESULTS The median follow-up was 3.6 years (0.5-7) for FC and 2.5 years (1.1-5.1) for VAS. There was no difference between FC and VAS in terms of survival (92 vs. 83%, p = 1), complication rate (74 vs. 92%, p = 0.88), or chronic kidney disease (58 vs. 50%, p = 1). The number of procedures was higher in the VAS group: 1.7 (1-3) versus 1.1 (1-2), p = 0.01. With a 30% rate of technical failure, FC added diagnostic value in 3 out of 21 cases. CONCLUSIONS No difference was found between FC and VAS regarding survival, long-term kidney function, or urological outcome. Despite overly optimistic reports on FC, it lacks reproducibility due to posterior-urethra inadequate visualization and inappropriate instrumentation.
Collapse
Affiliation(s)
- Nicolas Vinit
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Alexandra Gueneuc
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Bettina Bessières
- Department of Histology, Embryology and Cytogenetics, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Sophie Dreux
- Department of Biochemistry-Hormonology, Robert Debré Hospital, APHP, Paris, France
| | - Laurence Heidet
- Department of Pediatric Nephrology, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Rémi Salomon
- Department of Pediatric Nephrology, Necker-Enfants Malades Hospital, APHP, Paris, France.,Paris Descartes University, Paris, France
| | - Alexandre Lapillonne
- Department of Neonatology, Necker-Enfants Malades, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Gaston De Bernardis
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Laurent J Salomon
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Julien J Stirnemann
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Thomas Blanc
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France.,INSERM U1151-CNRS UMR 8253, Paris Descartes University, Necker-Enfants Maladies Institute, Necker-Enfants Malades Hospital, Paris, France
| | - Yves Ville
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France, .,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France,
| |
Collapse
|
4
|
Deshpande AV. Current strategies to predict and manage sequelae of posterior urethral valves in children. Pediatr Nephrol 2018; 33:1651-1661. [PMID: 29159472 DOI: 10.1007/s00467-017-3815-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 09/14/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
Posterior urethral valves (PUV) constitute a significant urological cause of chronic kidney disease (CKD) in children. The condition is characterised by the unique pathophysiology of the evolution of bladder dysfunction after relief of obstruction, which contributes to CKD. Improvements in prenatal diagnosis followed by selective foetal intervention have not yet produced improvement in long-term renal outcomes, although better patient selection may alter this in the future. Proactive management with surveillance, pharmacotherapy, timed voiding, double voiding, and/or assisted bladder-emptying, is being increasingly offered to those with severe bladder dysfunction and has the potential of reducing the burden of renal disease. Clinicians are currently able to counsel regarding the prognosis using serum creatinine and other emerging markers. However, much of this work remains to be validated. Satisfactory graft survival rates are now reported with aggressive management of bladder dysfunction in children who are candidates for renal transplantation. Knowledge gaps exist in identifying early markers of renal injury, risk stratification, and in understanding patient and carer perspectives in PUV.
Collapse
Affiliation(s)
- Aniruddh V Deshpande
- Department of Paediatric Urology and Surgery, John Hunter Children's Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia. .,Priority Research Centre GrowupWell, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia.
| |
Collapse
|
5
|
Abstract
Fetal bladder outlet obstruction (BOO), most commonly caused by posterior urethral valves (PUV), remains a challenging and multi-faceted condition. Evolving techniques, and refinement in ultrasound, optics and instrumentation, have increased our rate of prenatal diagnosis, and enabled valve ablation not only in smaller newborns, but also in fetuses. Long-term outcome studies have raised our awareness of the silent damage caused by bladder dysfunction and polyuria and encouraged their proactive management. In spite of our best efforts, the proportion of boys with PUV who progress to chronic and end-stage renal disease (ESRD) has not changed in the last 25 years. Evidence suggests a reduction in perinatal mortality following prenatal intervention, probably resulting from amelioration of oligohydramnios at the crucial time of lung development between 16 and 28 weeks' gestation, but no improvement in postnatal renal outcome. There are no bladder functional outcome studies in patients who have undergone prenatal intervention and hence the long-term effect of in utero defunctionalisation of the bladder is not known. This aim of this review is to revisit the embryopathology of fetal BOO, in particular the renal and bladder structural and functional changes that occur with in utero obstruction. The effect of earlier prenatal diagnosis, and therapy, on postnatal outcome is also explored and compared with outcomes published for traditional postnatal treatment.
Collapse
Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea Children's Hospital at the Chelsea & Westminster Hospital Foundation Trust, London SW10 9NH, UK.
| |
Collapse
|
6
|
Pulido JE, Furth SL, Zderic SA, Canning DA, Tasian GE. Renal parenchymal area and risk of ESRD in boys with posterior urethral valves. Clin J Am Soc Nephrol 2013; 9:499-505. [PMID: 24311709 DOI: 10.2215/cjn.08700813] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Approximately 20% of boys with posterior urethral valves develop ESRD; however, few factors associated with the risk of ESRD have been identified. The objective of this study was to determine if renal parenchymal area, defined as the area of the kidney minus the area of the pelvicaliceal system on first postnatal ultrasound, is associated with the risk of ESRD in infants with posterior urethral valves. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective cohort of boys who were diagnosed with posterior urethral valves at less than 6 months of age between 1988 and 2011 and followed for at least 1 year at a free-standing children's hospital was assembled. Cox proportional hazard regression and Kaplan-Meier analysis were used to estimate the association between renal parenchymal area and time to ESRD. Cox models were adjusted for age at presentation, minimum creatinine 1 month after bladder decompression, and vesicoureteral reflux. RESULTS Sixty patients were followed for 393 person-years. Eight patients developed ESRD. Median renal parenchymal area was 15.9 cm(2) (interquartile range=13.0-21.6 cm(2)). Each 1-cm(2) increase in renal parenchymal area was associated with a lower risk of ESRD (hazard ratio, 0.64; 95% confidence interval, 0.42 to 0.98). The rate of time to ESRD was 10 times higher in boys with renal parenchymal area<12.4 cm(2) than boys with renal parenchymal area≥12.4 cm(2) (P<0.001). Renal parenchymal area could best discriminate children at risk for ESRD when the minimum creatinine in the first 1 month after bladder decompression was between 0.8 and 1.1 mg/dl. CONCLUSION In boys with posterior urethral valves presenting during the first 6 months of life, lower renal parenchymal area is associated with an increased risk of ESRD during childhood. The predictive ability of renal parenchymal area, which is available at time of diagnosis, should be validated in a larger, prospectively-enrolled cohort.
Collapse
Affiliation(s)
- Jose E Pulido
- Perelman School of Medicine, and, ‡Department of Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, †Department of Pediatrics, Division of Nephrology, and, §Department of Surgery, Division of Pediatric Urology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | | |
Collapse
|
7
|
Sammut S, Behr L, Hekmati M, Gubler MC, Laborde K, Lelièvre Pégorier M. Compensatory renal growth after unilateral or subtotal nephrectomy in the ovine fetus. Pediatr Res 2013; 74:624-32. [PMID: 23999074 DOI: 10.1038/pr.2013.149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 04/06/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical and experimental studies show that unilateral (1/2Nx) and subtotal nephrectomy (5/6Nx) in adults result in compensatory renal growth without formation of new nephrons. During nephrogenesis, the response to renal mass reduction has not been fully investigated. METHODS Ovine fetuses underwent 1/2Nx, 5/6Nx, or sham surgery (sham) at 70 d of gestation (term: 150 d), when nephrogenesis is active. At 134 d, renal function was determined, fetuses were killed, and kidneys were further analyzed at the cellular and molecular levels. Additional fetuses subjected to 5/6Nx were killed at 80 and 90 d of gestation to investigate the kinetics of the renal compensatory process. RESULTS At 134 d, in 1/2Nx, a significant increase in kidney weight and estimated glomerular number was observed. In 5/6Nx, the early and marked catch-up in kidney weight and estimated glomerular number was associated with a striking butterfly-like remodeling of the kidney that developed within the first 10 d following nephrectomy. In all groups, in utero glomerular filtration rates were similar. CONCLUSION Compensatory renal growth was observed after parenchymal reduction in both models; however, the resulting compensatory growth was strikingly different. After 5/6Nx, the remnant kidney displayed a butterfly-like remodeling, and glomerular number was restored.
Collapse
|
8
|
Fujita H, Hida M, Kanemoto K, Fukuda K, Nagata M, Awazu M. Cyclic stretch induces proliferation and TGF-β1-mediated apoptosis via p38 and ERK in ureteric bud cells. Am J Physiol Renal Physiol 2010; 299:F648-55. [DOI: 10.1152/ajprenal.00402.2009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We previously reported that p38 mitogen-activated protein kinase (p38) and phosphorylated ERK are upregulated in cyst epithelium of human renal dysplasia and obstructive uropathy in fetal lambs (Omori S, Fukuzawa R, Hida M, Awazu M. Kidney Int 61: 899–906, 2002; Omori S, Kitagawa H, Koike J, Fujita H, Hida M, Pringle KC, Awazu M. Kidney Int 73: 1031–1037, 2008). Dysplastic epithelium is characterized by proliferation, apoptosis, and upregulation of Pax2 and transforming growth factor (TGF)-β1. In the present study, we investigated whether cyclic mechanical stretching of ureteric bud cells, a mimic of the hydrodynamic derangement after fetal urinary tract obstruction, reproduces events seen in vivo. Cyclic stretch activated p38 and ERK and upregulated Pax2 expression in a time-dependent manner in ureteric bud cells. Stretch-stimulated Pax2 expression was suppressed by a p38 inhibitor, SB203580, or a MEK inhibitor, PD98059. 5-Deoxyuridine incorporation was increased by stretch at 24 h, which was also abolished by SB203580 or PD98059. On the other hand, apoptosis was not induced at 24 h by stretch but was significantly increased at 48 h. TGF-β1 secretion was increased by stretch at 24 h, which was inhibited by SB203580 or PD98059. Inhibition of p38 or ERK as well as anti-TGF-β antibody abolished the stretch-induced apoptosis. Finally, exogenous TGF-β1 induced apoptosis of ureteric bud cells, which was inhibited by SB203580 and PD98059. In conclusion, cyclic stretch induces Pax2 upregulation, proliferation, and TGF-β1-mediated apoptosis, features characteristic of dysplastic epithelium, via p38 and ERK in ureteric bud cells.
Collapse
Affiliation(s)
| | | | - Katsuyoshi Kanemoto
- Department of Molecular Pathology, Institute of Basic Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
| | - Keiichi Fukuda
- Regenerative Medicine and Advanced Cardiac Therapeutics, Keio University School of Medicine, Tokyo; and
| | - Michio Nagata
- Department of Molecular Pathology, Institute of Basic Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
| | | |
Collapse
|
9
|
Deng GY, Sun JJ, Wang P, Mo JC. Renal parenchymal thickness and urinary protein levels in patients with ureteropelvic junction obstruction after nephrostomy placement. Int J Urol 2010; 17:250-3. [PMID: 20409217 DOI: 10.1111/j.1442-2042.2010.02448.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess recovery of renal parenchymal thickness and urinary protein levels in patients with severely hydronephrotic kidneys after nephrostomy placement. METHODS Fourteen patients (median age 1 year, range 6 months-7 years) who underwent nephrostomy placement for unilateral ureteropelvic junction obstruction at our hospital between May 2007 and January 2009 were included in a retrospective analysis. All patients had severe hydronephrosis, with a median parenchymal thickness of 1.8 mm (range 1-2.5 mm). Kidney morphology was examined by ultrasound before the procedure and 1, 2, 3, 4, 6 and 8 weeks after. Urinary proteins (including albumin, immunoglobulin [IgG], alpha2-macroglobulin, alpha1-microglobulin, beta2-microglobulin [beta2-MG] and kappa chain) and creatinine levels were also tested during these follow-up visits. Fifteen healthy children were assessed for urinary protein levels as well and made up the control group. RESULTS Parenchymal thickness increased within 4 weeks of nephrostomy placement. Kidney volumes were significantly decreased within 2 weeks. No further changes in morphology were detected after 4 weeks. Urinary alpha1-microglobulin and beta2-MG levels decreased to baseline within 1 and 4 weeks, respectively. Urinary albumin, IgG, alpha2-macroglobulin and kappa chain levels decreased gradually after nephrostomy, but did not return to baseline within 8 weeks. CONCLUSIONS After nephrostomy placement, parenchymal thickness increases within 4 weeks, tubular function returns to normal earlier than glomerular function and glomerular membrane repair is inversely correlated with the severity of damage.
Collapse
Affiliation(s)
- Gao-Yan Deng
- Department of Pediatric Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guang Zhou, China.
| | | | | | | |
Collapse
|
10
|
Chevalier RL, Thornhill BA, Forbes MS, Kiley SC. Mechanisms of renal injury and progression of renal disease in congenital obstructive nephropathy. Pediatr Nephrol 2010; 25:687-97. [PMID: 19844747 DOI: 10.1007/s00467-009-1316-5] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 07/27/2009] [Accepted: 07/28/2009] [Indexed: 12/21/2022]
Abstract
Congenital obstructive nephropathy accounts for the greatest fraction of chronic kidney disease in children. Genetic and nongenetic factors responsible for the lesions are largely unidentified, and attention has been focused on minimizing obstructive renal injury and optimizing long-term outcomes. The cellular and molecular events responsible for obstructive injury to the developing kidney have been elucidated from animal models. These have revealed nephron loss through cellular phenotypic transition and cell death, leading to the formation of atubular glomeruli and tubular atrophy. Altered renal expression of growth factors and cytokines, including angiotensin, transforming growth factor-beta, and adhesion molecules, modulate cell death by apoptosis or phenotypic transition of glomerular, tubular, and vascular cells. Mediators of cellular injury include hypoxia, ischemia, and reactive oxygen species, while fibroblasts undergo myofibroblast transformation with increased deposition of extracellular matrix. Progression of the lesions involves interstitial inflammation and interstitial fibrosis, both of which impair growth of the obstructed kidney and result in compensatory growth of the contralateral kidney. The long-term outcome depends on timing and severity of the obstruction and its relief, minimizing ongoing injury, and enhancing remodeling. Advances will depend on new biomarkers to evaluate the severity of obstruction, to determine therapy, and to follow the evolution of lesions.
Collapse
|
11
|
Fenghua W, Junjie S, Gaoyan D, Jiacong M. Does intervention in utero preserve the obstructed kidneys of fetal lambs? A histological, cytological, and molecular study. Pediatr Res 2009; 66:145-8. [PMID: 19390481 DOI: 10.1203/pdr.0b013e3181aa42f6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ureteropelvic junction obstruction is a common cause of end-stage nephropathy in children. Our aim was to investigate whether relief of obstruction in utero can alleviate the development of nephropathy. A silastic tube was tied around the left superior segment ureter to induce unilateral partial ureteral obstruction in 22 fetal sheep at 75- 85 d of gestation. Three weeks later, the tubes were removed to relieve the obstruction in 10 of the 22 lambs. A sham operation was performed on four fetuses (the control). At birth, the lambs were killed, and their kidneys were removed to study the changes in histology, podocytes, and expression of paired-box 2 (PAX2) and VEGF. In the obstructed kidneys, we observed cysts of various sizes in the cortex, fibrosis in the interstitial tissue, much decreased number of glomeruli, severe podocyte foot process fusion, and markedly increased PAX2 and decreased VEGF expressions. However, relief of obstruction preserved the number of glomeruli, significantly increased VEGF expression, reduced fusion of the podocyte foot processes, andrestored expression of PAX2 to some extent. Thus, relief ofobstruction in utero may prevent or attenuate the development ofnephropathy in lambs.
Collapse
Affiliation(s)
- Wang Fenghua
- Department of Pediatric Surgery, First Affiliated Hospital, University of Sun Yat-Sen, Guangzhou, Guangdong 510080, China
| | | | | | | |
Collapse
|
12
|
Farrugia MK, Woolf AS, Fry CH, Peebles DM, Cuckow PM, Godley ML. Radiotelemetered urodynamics of obstructed ovine fetal bladders: correlations with ex vivo cystometry and renal histopathology. BJU Int 2007; 99:1517-22. [PMID: 17355367 DOI: 10.1111/j.1464-410x.2007.06799.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test the hypothesis that fetal bladder outlet obstruction (BOO) in sheep causes abnormal urodynamics correlating with the initiation of renal pathology, as most boys with posterior urethral valves (PUV) have bladder dysfunction when assessed after birth. MATERIALS AND METHODS Male ovine fetuses at 94 days of gestation were assigned to BOO (four) or sham control (five) groups. In BOO fetuses, radiotelemetry catheters were inserted transurachally and intraperitoneally, and the urethra was partly occluded. In two sham controls catheters were inserted directly through the bladder wall; the remaining three had sham surgery only. Radiotelemetered cystometry was recorded daily where possible. At the end of the experiment (9 days), ex vivo cystometry, bladder contractility studies and renal tract histology were assessed. RESULTS Ultrasonography showed dilated renal tracts only in BOO fetuses; three of four BOO fetuses had renal cortical cysts. The control fetuses with bladder catheters died in utero, so urodynamics were recorded only in fetuses with BOO. The baseline filling/storage detrusor pressures increased slightly (by a mean of 5 mmHg) during the first 4 days of BOO, thereafter returning to those at the outset. There were marked changes in the patterns of bladder activity from 1 to 9 days. The frequency and duration of 'voiding' increased; as such the higher sustained pressures of emptying activity were progressively extended and the periods of low pressure filling/storage accordingly shortened. The patterns among individual fetuses with BOO were not substantially different, except that the one with the non-cystic kidneys had a more moderate frequency and duration of voiding. Ex vivo compliance and contractility showed no consistent differences in detrusor compliance or contractility between BOO and sham bladders. CONCLUSION In this fetal model of PUV, there was a progressive increase in the duration and frequency of sustained elevated 'voiding' pressures, with no change in bladder compliance. Fetal kidneys were sensitive to these altered dynamics, with the formation of cortical cysts by 9 days after initiating BOO.
Collapse
|
13
|
Samnakay N, Orford J, Barker A, Charles A, Terry P, Newnham J, Moss T. Timing of morphologic and apoptotic changes in the sheep fetal kidney in response to bladder outflow obstruction. J Pediatr Urol 2006; 2:216-24. [PMID: 18947615 DOI: 10.1016/j.jpurol.2006.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2005] [Accepted: 05/24/2006] [Indexed: 11/24/2022]
Abstract
PURPOSE Posterior urethral valves are the main cause of bladder outflow obstruction in human fetuses. Thirty per cent of boys with valves develop end-stage renal disease, despite intervention in the postnatal period. The timing and mechanisms of renal damage in bladder outflow obstruction are unknown. We investigated the timing of changes in morphology and apoptosis in the fetal sheep kidney in response to obstruction. MATERIALS AND METHODS Thirty-three fetal lambs at day 70 of gestation underwent surgical creation of bladder outflow obstruction. Twenty-nine fetal lambs had sham surgery. Fetal kidneys were collected 2, 5, 10, 20 and 30 days after surgery. Renal histology was examined. Real-time PCR was used to quantify the renal cortical expression of the pro-apoptotic gene Bax and anti-apoptotic gene Bcl-X. The TUNEL technique was used to assess regional renal apoptosis in response to obstruction. RESULTS Changes in renal morphology were evident as early as 2 days after surgery in fetuses with bladder outflow obstruction, and progressed over 20-30 days to cystic renal dysplasia. Bladder outflow obstruction increased the renal cortical expression of Bax relative to Bcl-X. Tubular apoptosis peaked after 2 days of obstruction. Blastemal apoptosis peaked after 5 days of obstruction. CONCLUSIONS Changes in pro- and anti-apoptotic gene expression in the fetal renal cortex, and alterations in the number of apoptotic cells and renal morphology are evident soon after the onset of bladder outflow obstruction. These findings suggest that damage to the developing fetal kidney begins to occur at the onset of obstruction. Attempts to preserve renal function by antenatal interventions may best be achieved by early treatment.
Collapse
|
14
|
Maruotti GM, Agangi A, Martinelli P, Paladini D. Early prenatal diagnosis of concordant posterior urethral valves in male monochorionic twins. Prenat Diagn 2006; 26:67-70. [PMID: 16378326 DOI: 10.1002/pd.1356] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The association between monozygotic twins and posterior urethral valves (PUV) in postnatal life has been thoroughly described. In the fetus, the prenatal recognition of PUV is feasible. However, it has been repeatedly reported in singletons but never in monochorionic twins. We describe two cases of early prenatal diagnosis of concordant PUVs in monochorionic twins. In one of the sets, the expression of the disease was different for each twin.
Collapse
Affiliation(s)
- G M Maruotti
- Prenatal Diagnosis Unit, Department of Gynecology and Obstetrics, University Federico II of Naples, Naples, Italy
| | | | | | | |
Collapse
|
15
|
Mure PY, Gelas T, Dijoud F, Guerret S, Benchaib M, Hartmann DJ, Mouriquand P. Complete Unilateral Ureteral Obstruction in the Fetal Lamb. Part II: Long-Term Outcomes of Renal Tissue Development. J Urol 2006; 175:1548-58. [PMID: 16516044 DOI: 10.1016/s0022-5347(05)00654-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2005] [Indexed: 11/30/2022]
Abstract
PURPOSE We analyzed the dynamics of the renal tissue response to experimental fetal urinary flow impairment concerning renal morphology, extracellular matrix composition, regulators of connective tissue degradation and PAX2 protein expression. MATERIALS AND METHODS A total of 26 fetal lambs underwent surgical unilateral ureteral obstruction at 90 days of gestation and 14 twin matched animals served as controls. Kidneys were harvested 10, 20 and 40 days after the prior procedure in groups 1 to 3, respectively and in 1-month-old lambs (group 4). Morphological analysis was done using light microscopy. Picrosirius red staining was used to evaluate the area occupied by extracellular matrix components. Collagen I, III and IV, alpha-smooth muscle actin, MMP-1, 2 and 9, TIMP-1 and 2 and PAX2 protein were assessed using immunochemistry. RESULTS All obstructed kidneys were hydronephrotic without dysplasia. Hypoplasia resulting from a decreased NGG was observed. The inflammatory response to obstruction was poor in fetal obstructed kidneys. From 10 days after obstruction interstitial fibrosis was noted and confirmed by an increase in picrosirius red staining. In obstructed kidneys immunochemistry showed an increase in collagen deposition beginning from the papillae and extending through the whole parenchyma. Aberrant interstitial collagen IV deposition was observed. The increase in alpha-smooth muscle actin staining was mainly localized in the blastema and interstitial cells in obstructed kidneys. MMP and TIMP immunostaining was mainly present in tubules throughout the whole nephrogenic period and persisted in mature kidneys. Beginning from 20 days after obstruction a progressive increase in MMP and TIMP expression was noted. This was associated with ectopic expression in the medullary tubules. PAX2 protein was highly expressed in the nephrogenic zone, decreasing progressively to being markedly decreased in control lamb kidneys. No difference was found in PAX2 expression during the fetal period when comparing unobstructed and obstructed kidneys, it but remained strongly expressed in the dilated collecting ducts of obstructed lambs. CONCLUSIONS Complete unilateral ureteral obstruction performed in fetal lambs at 90 days of gestation led to pure hydronephrotic transformation, hypoplasia and a marked increase in connective tissue deposition. Inflammatory infiltrates and PAX2 dysregulation were not seen as having a decisive role in these modifications.
Collapse
Affiliation(s)
- Pierre-Yves Mure
- Department of Pediatric Surgery, Claude Bernard University, Lyon, France.
| | | | | | | | | | | | | |
Collapse
|
16
|
Thiruchelvam N, Nyirady P, Peebles DM, Fry CH, Cuckow PM, Woolf AS. Urinary outflow obstruction increases apoptosis and deregulates Bcl-2 and Bax expression in the fetal ovine bladder. Am J Pathol 2003; 162:1271-82. [PMID: 12651619 PMCID: PMC1851228 DOI: 10.1016/s0002-9440(10)63923-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
During organogenesis, net growth of tissues is determined by a balance between proliferation, hypertrophy, and apoptotic death. Human fetal bladder outflow obstruction is a major cause of end-stage renal failure in children and is associated with complex pathology in the kidney and lower urinary tract. Experimental manipulation of the fetal sheep urinary tract has proved informative in understanding the pathobiology of congenital obstructive uropathy. In this study we used an ovine model of fetal bladder outflow obstruction to examine effects on apoptotic cell death in the developing urinary bladder. While 30 days of obstruction in utero between 75 and 105 days gestation resulted in overall growth of the fetal bladder as assessed by weight, protein, and DNA measurements, we found that apoptosis, as assessed by in situ end-labeling, was up-regulated in fetal bladder detrusor muscle and lamina propria cells and that this was accompanied by a down-regulation of the anti-death protein Bcl-2 and an up-regulation of the pro-death protein Bax. Moreover, activated caspase-3, an effector of apoptotic death, was increased in obstructed bladders. This is the first study to define altered death in an experimental fetal model of bladder dysmorphogenesis. We speculate that enhanced apoptosis in detrusor smooth muscle cells is part of a remodeling response during compensatory hyperplasia and hypertrophy. Conversely, in the lamina propria, an imbalance between death and proliferation leads to a relative depletion of cells.
Collapse
Affiliation(s)
- Nikesh Thiruchelvam
- Nephro-Urology Unit, Institute of Child Health, University College London, London, United Kingdom.
| | | | | | | | | | | |
Collapse
|
17
|
Derbent M, Saygili A, Yilmaz Z, Kervancioğlu M, Balci S, Tokel K. Co-occurrence of chromosome 22q11.2 microdeletion and trisomy 21 mosaicism. Am J Med Genet 2002; 112:99-102. [PMID: 12239730 DOI: 10.1002/ajmg.10545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This report describes a patient who had some phenotypic features of Down syndrome (DS) as well as severe conotruncal cardiac anomalies, including pulmonary atresia with ventricular septal defect (tetralogy of Fallot with pulmonary atresia), confluent pulmonary arteries, a large left-sided ductus arteriosus, left aortic arch, aberrant right subclavian artery, and secundum atrial septal defect. Cytogenetic and fluorescence in situ hybridization (FISH) analysis was carried out on peripheral blood lymphocytes and skin fibroblasts using probes specific for the chromosomal loci 21q22.13 to 21q22.2 and locus 22q11.2. This revealed 47,XX+21/46,XX mosaicism at a rate of 15:85 and the micro-deletion 22q11.2 (del22q11.2). Some patients'congenital cardiac anomalies are atypical for the type of mosaicism or aneuploidy. The case suggests that association of del22q11.2 should be considered in patients with chromosomal mosaicism or aneuploidy who also have particular conotruncal cardiac defects.
Collapse
Affiliation(s)
- Murat Derbent
- Department of Pediatrics, Baskent University Faculty of Medicine, Ankara, Turkey.
| | | | | | | | | | | |
Collapse
|
18
|
Morini F, Ilari M, Casati A, Piserà A, Oriolo L, Cozzi DA. Posterior urethral valves and mirror image anomalies in monozygotic twins. Am J Med Genet 2002; 111:210-2. [PMID: 12210353 DOI: 10.1002/ajmg.10563] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Monozygotic (MZ) twins with both posterior urethral valves (PUV) and additional mirror image malformations are described. This association suggests that an early embryonic event may lead to MZ twinning, PUV, and mirror image anomalies.
Collapse
Affiliation(s)
- Francesco Morini
- Pediatric Surgery Unit, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
| | | | | | | | | | | |
Collapse
|
19
|
Abstract
There are a number of potential biochemical markers that may have some role in predicting renal function postnatally. These include urinary sodium, calcium and beta2-microglobulin. The latter may also be measured in fetal serum. However, the accuracy of these parameters at a point in time is far from perfect as urinary tract obstruction is a progressive disease which may be best defined by repeated observations throughout pregnancy.
Collapse
Affiliation(s)
- U Nicolini
- Department of Obstetrics and Gynaecology, Ospedale V. Buzzi, University of Milan, Via Castelvetro 32, 20147 Milan, Italy
| | | |
Collapse
|