肾盂前后径与胎儿肾积水预后的相关性研究

Correlation between anteroposterior renal pelvic diameter and outcomes of fetal hydronephrosis

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 obstruc-tion （UPJO） . Methods Between 2015 and 2017 , 245 newborns diagnosed with isolated prenatal hydrone-phrosis 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 preoper-ative 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 indi-cated that APD in late stage of pregnancy （OR =0. 17, 95%CI： 0 .0 9 - 0 .4 0 ） and 1 week after birth （OR = 0. 21, 95% Cl ： 0. 10 - 0 .4 2 ） 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% Cl： 1. 32 - 1. 77; OR = 1.60, 95% Cl ： 1.601. 36 - 1. 8 8 ） . 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 AUG 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 .0 0 1 ） . 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.