Congenital urinary tract obstruction: the long view

Adv Chronic Kidney Dis. 2015 Jul;22(4):312-9. doi: 10.1053/j.ackd.2015.01.012.

Abstract

Maldevelopment of the collecting system resulting in urinary tract obstruction (UTO) is the leading identifiable cause of CKD in children. Specific etiologies are unknown; most cases are suspected by discovering hydronephrosis on prenatal ultrasonography. Congenital UTO can reduce nephron number and cause bladder dysfunction, which contribute to ongoing injury. Severe UTO can impair kidney growth in utero, and animal models of unilateral ureteral obstruction show that ischemia and oxidative stress cause proximal tubular cell death, with later development of interstitial fibrosis. Congenital obstructive nephropathy, therefore, results from combined developmental and obstructive kidney injury. Because of inadequacy of available biomarkers, criteria for surgical correction of upper tract obstruction are poorly established. Lower tract obstruction requires fetal or immediate postnatal intervention, and the rate of progression of CKD is highly variable. New biomarkers based on proteomics and determination of glomerular number by magnetic resonance imaging should improve future care. Angiotensin inhibitors have not been effective in slowing progression, although avoidance of nephrotoxins and timely treatment of hypertension are important. Because congenital UTO begins in fetal life, smooth transfer of care from perinatologist to pediatric and adult urology and nephrology teams should optimize quality of life and ultimate outcomes for these patients.

Keywords: Biomarkers; Child; Chronic kidney disease; Progression; Urinary tract obstruction.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Continuity of Patient Care
  • Disease Progression
  • Fetal Therapies
  • Hydronephrosis / congenital
  • Hydronephrosis / etiology
  • Hydronephrosis / surgery*
  • Kidney Glomerulus
  • Nephrology
  • Pediatrics
  • Perinatology
  • Renal Insufficiency, Chronic / etiology
  • Renal Insufficiency, Chronic / prevention & control*
  • Transition to Adult Care
  • Ureteral Obstruction / complications
  • Ureteral Obstruction / congenital
  • Ureteral Obstruction / surgery*
  • Urethral Obstruction / complications
  • Urethral Obstruction / congenital
  • Urethral Obstruction / surgery*
  • Urogenital Abnormalities
  • Urology