Poorly functioning kidneys
CAN WE SAVE POORLY FUNCTIONING HYDRONEPHROTIC KIDNEYS SECONDARY TO PELVIURETERIC JUNCTION OBSTRUCTIONS BY SURGERY ? THE ANSWER IS YES
Kidneys which are located in the abdomen are special organs which work as filtering organs removing all the harmful waste products and extra fluids from body with additional function of regulation of blood pressure, production of red blood cells, keep our bones strong & healthy and have many other functions. We have two kidneys and it imperative to maintain both of them in optimal function for good health. However in children these kidneys can suffer from various diseases of which most diseases are inborn, are called CAKUT( Congenital anomalies of Kidney & urinary tract) & such babies can be detected to this problem antenatally by ultrasonography. One such common occurrence is hydronephrosis. The common cause of hydronephrosis is secondary to block at junction at renal pelvis(collecting system with kidney) and ureter(drainage pipe from kidney to bladder) called PUJO(Pelviureteric junction obstruction). As we have two kidneys for the function diagnosis of the kidney disease if affecting only single kidney the diagnosis will be delayed leading to severe loss of function and even if attended and treated which then would be less rewarding, hence leading to removal of that poorly or non functioning kidneys called nephrectomy. But this needed to change as Dr Santosh B Kurbet, Professor, Senior Consultant Paediatric surgeon working since last 15 years at KLEs Dr Prabhakar Kore Hospital & MRC, designed a rescuing strategy where he planned a design a saviour method to salvage the kidneys with severe loss of functional i.e, poorly functioning kidneys and even zero functioning kidneys. The strategy was to operate all patients with severe hydronephrosis with less or no function under various schemes or at a lesser financial burden and do that by rescue pyeloplasty, help this smaller kids have last shot of saving/retaining the kidneys by improvement in function of kidneys and this worked in more than 95 % of kidneys with no pt requiring removal of kidneys called nephrectomy in these children.
The study was done, which involved Children of either sex of age 1 day to 6 years with proved poorly functioning hydronephrotic kidneys (<30%) secondary to PUJ obstruction were prospectively studied over last 12 years. Of these children 12 underwent directly Pyeloplasty which is removal of excess renal pelvis, ureter tapering and anastomosis of pelvis with ureter allowing free uninterrupted drainage of urine from kidneys into ureter and beyond. Two neonates who had massive hydronephrosis & one infant who had infected hydronephrosis, underwent nephrostomy(drainage of urine directly from kidney to exterior) and later pyeloplasty. The children were followed up for a minimum of 6 months and assessed for improvement in symptoms, cortical thickness & renal function after minimum of 3-6 months by urine analysis, ultrasonography and diuretic renal scans. In our series of 15 children with poorly functioning kidneys of age ranging from 1 month to 6 years, 8 males & 7 females, were studied with function ranging from 0% to 29 %. 12 of 15 children showed improvement in the renal function proved by statistical analysis. One pt showed no improvement and required nephrectomy & two pts were lost to follow up.(Figures) In a prospective study between 2000-2008 by Rajesh Bansal, et.al. which studied hydronephroisis due to PUJO in 39 patients with poor function of less than 30 % of age group of 4 mth to 13 yrs the following were noted. The children underwent pyeloplasty and were assessed for improvement in renal function and only considered significant as the criteria used was improved symptoms or better drainage after DTPA after 3 months. Of these 2 required redosurgeries and noted a rate of 90 % success in these children treated by pyeloplasty. In another study of a total of 126 patients over 8 years by Haraz AM et.al., in those with poorly functioning kidneys secondary to PUJO who underwent pyeloplasty 5 % improvement considered significant in differential function & cortical thickness change as points of consideration for improvement in the renal function. The study showed considerable patients improved with pyeloplasty in these children with poor function. Similarly our cases with severe hydronephrosis also showed improvement after meticulously done reconstructive pyeloplasty in most children. To summarize the poorly functioning hydronephrotic kidneys secondary to PUJ obstruction in children if dealt with corrective pyeloplasty will have improved function. The poorly functioning hydronephrotic, even zero (0 %) functioning kidneys secondary to pelviureteric junction obstruction should be given a chance by surgery i.e pyeloplasty, which will save the native kidney, reduce long term sequalae on another kidney and give better life to the children.
Figures showing photos of investigations & follow up of Poorly functioning kidneys operated by pyeloplasty.
Dr. Santosh B Kurbet
M.S., M.Ch., DNB
Professor & Head
Dept of Paed Surgery