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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 21-25

Sonographic evaluation of hydronephrosis in pediatric patients and correlation with intravenous urography


1 Department of Radiology and Imaging, NICVD, Dhaka, Bangladesh
2 Department of Radiology and Imaging, Dhaka, Community Medical College and Hospital, Dhaka, Bangladesh
3 Mugda Medical College Dhaka, Dhaka, Bangladesh
4 Department of Orthopaedic Surgery, Central Police Hospital, Dhaka, Bangladesh
5 Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Date of Submission04-Sep-2021
Date of Acceptance23-Sep-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Kanij Fatema
Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, 1000
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pnjb.pnjb_4_21

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  Abstract 

Introduction: This cross sectional study was carried out with an aim to evaluate the accuracy of ultrasonography (USG) in the evaluation of hydronephrosis (HDN) in pediatric age group. Methodology: The study was carried out from January 2017 to November 2017 in the Department of Radiology and Imaging, Sir Salimullah Medical Collage and Mitford Hospital, Dhaka. Eighty two patients aged from 1-18 years, admitted as suspected HDN were included as study subject. Result: In this study, the mean age of the patients was 6.31 (±3.34) years and 46.3% belonged to 5 years age group. Male and female ratio was approximately 2:1, 55 (67.1%) were male. Regarding the presenting complains, loin pain was most common (81.7%) feature. Recurrent urinary tract infection (URI) was observed in 52.4%, hematuria in 29.3%, flank mass in 18.3%, vomiting in 2.4% of the study patients. In every patient, with proper clinical evaluation, renal function test was done. After admission, in every patient USG and IVU was done in every patient. In IVU, it was found that 25.6% of cases had left sided HDN , 24.4% right sided HDN and 31.7% both sided HDN. In USG, out of 93 HDN cases in IVU, 85 were correctly diagnosed. The sensitivity was 91.4%. Out of 71 non-obstructed kidneys on USG, 68 were correctly assigned as non HDN, the specificity was 95.8%. Conclusion: This study findings showed USG to be a sensitive screening technique for excluding urinary tract obstruction.

Keywords: Hydronephrosis (HDN), Ultrasonography (USG), Intravenous urography (IVU)


How to cite this article:
Shomee DA, Sultana M, Reza MS, Rahman SM, Leema EA, Fatema K. Sonographic evaluation of hydronephrosis in pediatric patients and correlation with intravenous urography. Paediatr Nephrol J Bangladesh 2021;6:21-5

How to cite this URL:
Shomee DA, Sultana M, Reza MS, Rahman SM, Leema EA, Fatema K. Sonographic evaluation of hydronephrosis in pediatric patients and correlation with intravenous urography. Paediatr Nephrol J Bangladesh [serial online] 2021 [cited 2022 Dec 1];6:21-5. Available from: http://www.pnjb-online.org/text.asp?2021/6/1/21/334117




  Introduction Top


Hydronephrosis is an anatomical entity that is defined as an enlargement of the capacity of the collecting system of kidneys, calices, and pelvis. Hydroureteronephrosis includes the dilatations of the ureter. Currently, obstruction is defined clinically as a restriction to urinary flow that, left untreated, will cause progressive renal deterioration.[1]

Hydronephrosis is a fairly common problem in pediatric patients. It is frequently, but not always, associated with obstruction; ultrasound is particularly sensitive for its detection.[2] Dilatation of renal calices is abnormal and suggests significant pathology. In order to make a more precise diagnosis and estimate severity, information concerning the degree of dilatation, whether unilateral or bilateral, if ureters are dilated, and the status of the renal parenchyma should be obtained with sonography. Dilatation may be because of obstruction, reflux, or abnormal muscle development.[3]

Intravenous urography (IVU) has been used as the primary imaging technique for the diagnostic evaluation of the urinary tract for several years. With the development of more competitive imaging modalities and apprehension about the adverse effects of contrast media and radiation, it is going to be replaced by a renogram.[4]

With the advent of antenatal sonography, hydronephrosis is being detected with increasing frequency, in as many as 1.4% of fetuses, persisting postnatally in half of these cases.[5] These patients thus report to the urologist or nephrologist immediately after birth, with a presumptive diagnosis rather than a symptom.[6],[7]

Although IVU is still the best imaging study for evaluating the anatomy of the urinary tract, it has hazards of radiation.[8] In the pediatric population, thus the use of IVU has been decreased as ultrasonography can initially reveal most of the anatomic detail necessary for management decisions, without the use of radiation or the risk of intravenous contrast. Thus, sonography now has replaced other imaging procedures mostly and is used as a screening method for the evaluation of possible hydronephrosis in many clinical situations.[9] In previous studies regarding the detection of hydronephrosis by sonography as a screening method showed high sensitivity and specificity.[10],[11],[12],[13],[14],[15]

On the above basis, this study has been designed to detect the accuracy of ultrasonography in the detection of hydronephrosis in the pediatric population considering IVU as a test of reference.


  Methodology Top


This cross-sectional study was carried out with the aim to evaluate the accuracy of ultrasonography in the evaluation of hydronephrosis in the pediatric age group. The study was carried out from January 2017 to November 2017 in the Department of Radiology and Imaging, Sir Salimullah Medical College, and Mitford Hospital, on 82 patients of age from 1 to 18 years. Indoor patients already admitted in the pediatric nephrology department who were suspected of having hydronephrosis with serum creatinine less than 1 mg/dL were included in the study. To detect urinary tract infection, a urine routine test and culture were done.

A pre-designed questionnaire was used for the data collection. All the ultrasonography examinations were performed on Hitachi Aloka F37 and Toshiba Xario 100 US Scanners. The grading system of the Society of Fetal Urology was used to assess. Ultrasonographic hydronephrosis ranged from detectable renal pelvic dilatation (grade I) to pelvic dilatation greater than 1 cm (grade II) to three degrees of progressive caliectasis (grades III–V).

In each patient, IVU was done. Before IVU, renal function tests and ultrasonography were done in every patient. Laxative was administered to each patient the day before IVU. For that intravenous contrast material was injected into the patient and subsequent excretion of the contrast media allowed the visualization of the urinary system. The contrast agent used in the evaluation of the kidneys and urinary tract was triodinated benzoic acid compound in solution.

Data were collected and analyzed using Statistical Package for the Social Sciences (SPSS) Version 20. For the validity of study outcome, sensitivity, specificity, positive predictive value, and negative predictive value of ultrasonography in the diagnosis of hydronephrosis were calculated after the confirmation of the diagnosis by IVU. Intra-rater reliabilities between ultrasonography and IVU were measured by Kappa statistics. Kappa statistics were interpreted as proposed by Byrt (1996). 0.93–1.00: Excellent agreement, 0.81–0.92: Very good agreement, 0.61–0.80: Good agreement, 0.41–0.60: Fair agreement, 0.21–0.40: Slight agreement, 0.01–0.20: Poor agreement, ≤0.00: No agreement.


  Results Top


Of 82 patients, maximum of 46.3% patients belonged up to 5 years age range followed by 43.9% within 6–10 years and 9.8% more than 10 years [Figure 1]. The mean (±SD) age of the patient was 6.31 (±3.34), 67.1% were male and 32.9% were female. Male and female ratio was 2.04:1 [Figure 2].
Figure 1: Bar diagram shows the age distribution of the patients

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Figure 2: Pie chart shows the sex distribution of the patients

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Regarding presenting complaints, loin pain was the most common presenting complaint of the patients. About 81.7% had complaints of loin pain, 52.4% had recurrent urinary tract infection (UTI), 29.3% had hematuria, 18.3% had flank mass, 2.4% had vomiting and 9.8% had some non-specific symptoms [Figure 3].
Figure 3: Bar diagram shows the clinical presentations of the patients

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In the sonography, 25.6% had left-sided hydronephrosis, 23.2% had right-sided hydronephrosis, 29.3% had both-sided hydronephrosis and only 22% of patients had normal kidneys. Although in IVU, 25.6% had left-sided hydronephrosis, 24.4% had only right-sided hydronephrosis, 31.7.3% had both-sided hydronephrosis and only 18.3% of patients have diagnosed features other than hydronephrosis [Figure 4].
Figure 4: Bar diagram shows the ultrasonography and IVU evaluation of the location of hydronephrosis

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The sensitivity of ultrasonography to diagnose hydronephrosis was 91.4%, specificity 95.8%, positive predictive value 96.6%, negative predictive value 89.5%, and accuracy 93.3% [Figure 5].
Figure 5: Bar diagram of different types of validity test results in the diagnosis of hydronephrosis

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  Discussion Top


The current study was designed to evaluate the accuracy of ultrasonography in the diagnosis of hydronephrosis in pediatric age group. The study subject was 82, mean (±SD) age of the patients was 6.31 (±3.34) years and a maximum of 46.3% of patients belonged up to 5 years age group. Age range of all patients was 2–14 years. Male and female ratio was approximately 2:1, 55 (67.1%) were male. In previous studies, male predominance was also observed in pediatric patients with UTI.[16] In a study by Hafez et al. out of 45 study patients, 28 were boys and 17 were girls.[12] This finding was also supported by a study by Pourissa et al., where 77% were male and 23% were female and the ratio was 3:11.[17]

Regarding the clinical features, loin pain was a common presenting feature of the patients of this study. About 81.7% had complaints of loin pain here. Other presenting complaints were 52.4% recurrent UTI, 29.3% hematuria, 18.3% flank mass, 2.4% vomiting, and 9.8% had some nonspecific symptoms. This study had similarities with other related studies. Frokiaer and Zeidel reported flank pain, abdominal mass, nausea, vomiting, and urinary tract infection, fever, painful urination, increased urinary frequency, and increased urinary urgency as presenting symptoms in patients with hydronephrosis.[18]

In every patient here, a renal function test followed by ultrasonography and IVU was done. After confirmation by IVU in this study, it was found that 25.6% of the study subject had left-sided hydronephrosis, 24.4% had right-sided hydronephrosis and 31.7.3% had bilateral hydronephrosis. In a related study done by Lim et al., the left kidney involvement was also predominant (left 256, right 171).[19]

In this study, sonographic and IVU diagnosis was compared. Of the 93 patients with hydronephrosis, which were diagnosed with IVU, 85 were correctly diagnosed by ultrasound. The sensitivity was 91.4%. The remaining eight were missed in ultrasonography. Again, of the 71 nonobstructed kidneys on urography, 68 were correctly assigned as non- hydronephrosis on ultrasonography, the specificity here was 95.8%. The remaining three were misinterpreted as hydronephrosis. In a related study done by, Ellenbogen et al., sonographic findings were compared with IVU. In their study, of 47 obstructed kidneys on urography, 46 were correctly diagnosed by ultrasonography, thus the sensitivity was 98%.[11] Diament et al. also assessed hydronephrosis by ultrasonography and compared it with IVU in pediatric patients. In their study, the sensitivity of ultrasonography was 89% and the specificity was 95%.[9] In another study done by Dalla-Palma et al., 125 patients were evaluated with ultrasonography and IVU. The overall diagnostic accuracy of ultrasonography in detecting hydronephrosis was 85.2%, with a specificity of 84.4% and a sensitivity of 89.9%.[10]

In this study, both ultrasonography and IVU were done. It is here to mention that, although ultrasonography is safe, less costly, and easy to perform with minimal radiation hazard, it may miss the accurate diagnosis in some cases. However, for screening purposes, it is an excellent tool to diagnose hydronephrosis in the pediatric population. On the other hand, the diagnostic accuracy obstruction is much superior in the case of IVU. Yet, it has some disadvantages such as hypersensitivity reaction may occur here. Moreover, it can not be performed if renal function is impaired as it requires contrast.[20]


  Conclusion Top


Ultrasound may be considered as the screening test of choice for the diagnosis of hydronephrosis. The findings of this study showed ultrasound to be a sensitive screening technique for excluding urinary tract obstruction. As a result, many patients with kidney disorders may be spared to perform excretory urography.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Homsy YL, Koff SA Problems in the diagnosis of obstruction in neonate. In: King LR, editor. Urologic Surgery in Neonates and Young Infants. Philadelphia: Saunders; 1988. p. 77-94.  Back to cited text no. 1
    
2.
Onen A Grading of hydronephrosis: An ongoing challenge. Front Pediatr 2020;8:458.  Back to cited text no. 2
    
3.
Babcock DS, Patriquin HB The pediatric kidney and adrenal glands. In: Rumack Carol M, Wilson Stephanie R, Charboneau J. William, Johnson Jo – Ann M, editors. Diagnostic Ultrasound. 3rd ed. China: Elservier Mosby; 2005. p. 1910.  Back to cited text no. 3
    
4.
Hung AJ, Lee VS, Rusinek H MR imaging in renal function. Radiol Clin N Am 2003;41:1001-17.  Back to cited text no. 4
    
5.
Grignon A, Filion R, Filiatrault D, Robitaille P, Homsy Y, Boutin H, et al. Urinary tract dilatation in utero: Classification and clinical applications. Radiology 1986;160:645-7.  Back to cited text no. 5
    
6.
Nguyen HT, Benson CB, Bromley B, Campbell JB, Chow J, Coleman B, et al. Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). J Pediatr Urol 2014;10:982-98.  Back to cited text no. 6
    
7.
Passerotti CC, Kalish LA, Chow J, Passerotti AM, Recabal P, Cendron M, et al. The predictive value of the first postnatal ultrasound in children with antenatal hydronephrosis. J Pediatr Urol 2011;7:128-36.  Back to cited text no. 7
    
8.
Homsy YL, Saad F, Laberge I, Williot P, Pison C Transitional hydronephrosis of the newborn and infant. J Urol 1990;144:579-83; discussion 593-4.  Back to cited text no. 8
    
9.
Wu HY, Bellah R, Snyder HM Radiographic Evaluation of the Pediatric Urinary Tract. Avialable from: www. Emedicine. Com. 2010 [Access: 01.09.2010].  Back to cited text no. 9
    
10.
Diament MJ, Takasugi J, Kangarloo H Hydronephrosis in childhood–Reliability of ultrasound screening. Pediatric Radiology 1984;14:31-6.  Back to cited text no. 10
    
11.
Dalla – Palma L, Bazzocchi M, Pozzi- Mucelli RS, Stacul F, Rossi M, Agostini R, Ultrasonography in the diagnosis of hydronephrosis in patients with normal renal function. Urologic Radiology 1983;5:221-6.  Back to cited text no. 11
    
12.
Ellenbogen PH, Scheible FW, Talner LB, Leopold GR Sensitivity of gray scale ultrasound in detecting urinary tract obstruction. AJR Am J Roentgenol 1978;130:731-3.  Back to cited text no. 12
    
13.
Hasch E Ultrasound in the diagnosis of hydronephrosis in infants and children. J Clin Ultrasound 1974;2:21-5.  Back to cited text no. 13
    
14.
Malave SR, Neiman HL, Spies SM, Cisternino SJ, Adamo G Diagnosis of hydronephrosis: Comparison of radionuclide scanning and sonography. AJR Am J Roentgenol 1980;135:1179-85.  Back to cited text no. 14
    
15.
Eze CU, Agwu KK, Ezeasor DN, Agwuna KK, Aronu AE, Mba EI Sonographic biometry of normal kidney dimensions among school-age children in Nsukka, southeast Nigeria. West Indian Med J 2014;63:46-53.  Back to cited text no. 15
    
16.
Hafez AT, McLorie G, Bagli D, Khoury A Analysis of trends on serial ultrasound for high grade neonatal hydronephrosis. J Urol 2002;168:1518-21.  Back to cited text no. 16
    
17.
Pourissa M, Refahi S, Nazari H Evaluation of the incidence and outcome of fetal hydro nephrosis prenatally diagnosed by ultrasound. Acta Medica Iranica 2005;43:336-38.  Back to cited text no. 17
    
18.
Frokiaer J, Zeidel ML Urinary tract obstruction. In: Brenner BM, editor. Brenner and Rector’s The Kidney. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2007. p. 35.  Back to cited text no. 18
    
19.
Lim DJ, Park JY, Kim JH, Paick SH, Oh SJ, Choi H Clinical characteristics and outcome of hydronephrosis detected by prenatal ultrasonography. J Korean Med Sci 2003;18:859-62.  Back to cited text no. 19
    
20.
Ucar AK, Kurugoglu S Urinary ultrasound and other imaging for ureteropelvic junction type hydronephrosis (UPJHN). Front Pediatr 2020;8:546.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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