先天性肾脏和尿路畸形超声筛查三级转诊体系的高危儿肾盂扩张筛查和随访研究

The significance of establishing a general management of urinary ultrasound screening,referral and follow-up for congenital anomalies of the kidney and urinary tract in high-risk renal pelvis dilation infants

目的对0~3月龄高危儿肾盂扩张(RPD)筛查和随访,探讨先天性肾脏和尿路畸形泌尿系统超声筛查三级(社区卫生服务中心-妇幼保健院-儿童专科医院)转诊体系(简称三级转诊体系)实施的可行性。方法在三级转诊体系中,社区卫生服务中心甄别高危儿并转诊至妇幼保健院,妇幼保健院泌尿系统超声筛查RPD、随访和转诊,儿童专科医院对转诊RPD患儿确诊和制定干预措施。结果①筛查结果:2010年6月至2012年5月,3 743名0~3月龄高危儿泌尿系统超声筛查RPD阳性率9.0%(338例),男婴在总的RPD以及轻、中和重度RPD的筛查阳性率均明显高于女婴,但男女婴轻、中、重度RPD构成比差异无统计学意义;②随访结果:285例在1岁时统计随访结果,诊断肾盂输尿管连接处梗阻3例,巨输管症2例,重复肾、重复上肾积水伴输尿管异位开口1例,其中手术3例;余279例RPD患儿经(5.4±4.5)个月随访,241例RPD恢复正常,其中轻、中和重度比例分别为91.9%、76.3%和22.2%;RPD好转16例,持续17例,加重5例。③三级转诊体系:第2年度较第1年度自愿接受泌尿系统超声筛查高危儿的比例增加(83.0%vs 64.1%),RPD筛查阳性率未见明显差异(9.5%vs 7.8%);第1年度较第2年度转诊率及随访率差异均无统计学意义。结论基于三级转诊体系的高危儿RPD筛查、随访和转诊运行实施效果良好,儿童专科医院需进一步完善培训和转诊机制,妇幼保健院在三级转诊体系中的作用关键,特别是随访和转诊是三级转诊体系的最重要环节。

Objective To identify a new screening and transferring system based on the current high-risk infants health system by urinary ultrasound screening and follow-up of renal pelvis dilation（RPD） in 0-3 months old high-risk infants. Methods In the three-level transferring system, high-risk infants were identified in community health service（CHS） and then transferred to maternal and child health hospital （MCH） for screening of CAKUT. Cases with RPD were followed-up in MCH and/or transferred to academic pediatric hospital according to designed criteria and path. Cases transferred were examined for further investigations for confirmative disgnosis. Results Between Jun. 1st, 2010 and May. 31th, 2012, screening of 3 743 0 -3 month-old infants yielded 338 （9.0%） positive cases of RPD. Overall RPD positive rate and proportion of different RPD grading significantly differed between males and females. A subgroup of 285 in 338 infants with postnatally detected RPD was followed up, further investigation yielded a specific diagnosis in 6 cases, 3 cases were with ureteropelvic junction obstruction（ PUJO）, 2 with megaloureter and 1 with duplexkidney combined with ectopic ureter. 3 cases of them underwent surgeL＇y. During follow-up for （5.4 ＋ 4.5 ） mouths, averagely 86.4% （241 out of 279 cases） t^covered, the rate were 91.9% , 76.3% and 22.2% for mihl, moderate and severe RPD patients, respectively. RPD pesisted in only 17 cases and deteriorated in 5 cases. The absolute quantity and relative percentage of high-risk infants screened in the second yem of study was obviously higher than that of the first year（ 83.0% vs 64. 1% ） , the positive rate of RPD was 7.8% and 9.46% for I st year and 2nd year. The rate of RPD transferred alld loss of follow-up were not significantly different I）etween the two yeaz,＇s. Conclusion Our data suggest that the screening and three-level transfen＇ing system of CAKUT by adding urinary ultrasound screening to the current high-risk infants heahh system in CHS and MCH shouhl he i~＇asible. The academic pediatric hospital is supposed to set up training and scientific research, higher professional quality requirements are proposed to doctors in maternal and child heahh hospital.