肾盂前后径与胎儿肾积水预后的相关性研究
刘慧丽,刘 鑫,殷晓鸣,赵 琦,杨 屹

中国医科大学附属盛京医院小儿外科(辽宁省沈阳市,110004)

胎儿; 肾积水; 肾盂/畸形; 输尿管梗阻; 转归

Correlation between anteroposterior renal pelvic diameter and outcomes of fetal hydronephrosis.
Liu Huili,Liu Xin,Yin Xiaoming,Zhao Qi,Yang Yi.

Department of Pediatric Surgery,Affiliated Shengjing Hospital,China Medical University,Shenyang 110004,China.Corresponding author:Yang Yi,Email:yangy2sj-hospital.org.

Fetus; Hydronephrosis; Kidney Pelvis/AB; Ureteral Obstruction; Prognosis

DOI: 10.3969/j.issn.1671— 6353.2018.06.004

备注

目的 评估孕晚期和生后1周APP值对胎儿肾积水患儿产后自愈及行肾盂成形术的诊断价值,进一步探讨在术前不同DRF水平UPJO的患儿术后患肾功能的改善情况。方法 回顾性分析了2015年1月至2017年1月由本院门诊诊断的单侧胎儿肾积水患儿的临床资料。通过ROC曲线来评估孕晚期和生后1周APD值对其转归的敏感度和特异度。分析手术前后分肾功能的变化,以增加5%作为分肾功能好转的标准。结果 本研究共纳入245例单侧胎儿肾积水患儿。多因素Logistic回归分析发现孕晚期APD值(OR=0.17,95%CI:0.09～0.40)和生后1周APD值(OR=0.21,95%CI:0.10～0.42)为肾积水患儿产后自愈的保护因素; 孕晚期APD值(OR=1.53,95%CI:1.32～1.77)和生后1周APD值(OR=1.60,95%CI:1.601.36～1.88)为肾积水患儿产后行肾盂成形术的危险因素。孕晚期、生后1周APD值分辨肾积水患儿产后自愈的最佳临界点分别为8.3 mm 和12 mm,两个指标对应的敏感度分别为83%和93%,特异度分别为71%和76%,AUC分别为0.79和0.86,二者联合对预测患儿是否自愈的AUC为0.87,灵敏度、特异度、约登指数分别为96%、38%、0.69; 二者分辨肾积水患儿对产后行肾盂成形术的最佳临界点分别为19 mm 和19 mm,敏感度分别为68%和78%,特异度分别为71%和69%,AUC分别为0.71和0.78,二者联合对预测患儿是否行肾盂成形术的AUC为0.84,灵敏度、特异度、约登指数分别为89%、34%、0.59。术前DRF<40%和DRF≥40%患儿术后肾功能均可得到改善,DRF<40%组患儿术后肾功能的改善较DRF≥40%组明显(t=3.14,P<0.001),但术后患肾功能仍未达到术前DRF≥40%组的术后患肾功能。结论 孕晚期APD值联合生后1周APD值能够提高预测单侧胎儿肾积水患儿生后转归的准确性; 小儿肾积水手术解除梗阻后,患肾的分肾功能是可以得到提高的。
Objective To evaluate the diagnostic accuracy of renal pelvic dilatation and explore whether postoperative differential renal function(DRF)may be improved in infants with ureteropelvic junction obstruction(UPJO). Methods Between 2015 and 2017, 245 newborns diagnosed with isolated prenatal hydronephrosis were retrospectively reviewed. Diagnostic sensitivity, specificity and area under the curve(AUC)of anterioposterior diameter(APD)in late stage of pregnancy and 1 week after birth were evaluated. The preoperative and postoperative changes of DRF were analyzed. Primary outcome measures were >5% improvement in baseline DRF. Results A total of 245 patients were recruited. Multivariate Logistic regression analysis indicated that APD in late stage of pregnancy(OR=0.17, 95%CI:0.09-0.40)and 1 week after birth(OR=0.21, 95%CI:0.10-0.42)were protective factors for postpartum self-healing in children with hydronephrosis and risk factors for pyeloplasty in postpartum children with hydronephrosis(OR=1.53,95%CI:1.32-1.77; OR=1.60, 95%CI:1.601.36-1.88). The optimal critical points for postpartum self-healing of APD in late pregnancy and 1 week after birth were 8.3 mm and 12 mm. The sensitivity were 83% and 93%, specificity 71% and 76% and AUC 0.79 and 0.86 respectively. The AUC of combination with two indicators to predict whether postpartum self-healing was 0.87 and sensitivity, specificity and Jordan index were 96%, 38% and 0.69 respectively. The optimal critical points for postpartum pyeloplasty in children with hydronephrosis were 19 mm and 19 mm with sensitivity of 68% and 78%, specificity of 71% and 69%, and AUC of 0.71 and 0.78 respectively. The AUC of combination with two indicators to predict whether pyeloplasty was 0.84 and sensitivity, specificity and Jordan index were 89%, 34% and 0.59 respectively.Postoperative renal functions improved in childrens with preoperative DRF<40% and DRF≥40%. The effects were more pronounced in the former group(t=3.14,P<0.001). However, postoperative renal functions of the former group failed to reach the levels of those of the latter group. Conclusion The combination of APD in the late stage of pregnancy and 1 week after birth may increase the accuracy of prognosis. And DRF improves after pyeloplasty in children with hydronephrosis.