Fetal Nephrology: A Quaternary Care Center Experience
Kidney360. 2023 Mar 1;4(3):333-340. doi: 10.34067/KID.0004782022
Auda M Plaud Gonzalez, Catherine Joseph, Samantha R Stover, Ahmed Nassr, Chester J Koh, Joseph R Angelo, Michael C Braun
Reviewed by: Antonio M. Fontanella
Fetal Nephrology is a newly developing field focused on the perinatal care of children born with congenital anomalies of the kidney and urinary tract (CAKUTs). The establishment of improved fetal imaging, molecular diagnostics, and genetic testing have allowed for the identification of CAKUTs well before the birth of the child. This early identification has created a new niche where the pediatric nephrologist is able to provide prenatal counseling, anticipatory guidance, and targeted diagnostics to expectant mothers with complex pregnancies. As a growing field, more data is needed to determine the most effective interventions with the aim of optimizing guidelines for pediatric nephrologists.
The objective of this study was to evaluate 8 years worth of fetal nephrology experience at a quarternary pediatric hospital, Texas Children’s Hospital, seeking to establish which modalities of perinatal care had the highest impact on patient outcomes.
This is a single center retrospective study, in which all patients referred to Texas Children’s Hospital with prenatally diagnosed or suspected nephrologic/urologic disorders were included. 4620 patients were referred to the TCH fetal center, while only 217 patients were evaluated by Fetal Nephrology. Of these, only 109 patients had available neonatal information. Data was collected on baseline maternal characteristics, fetal malformations, and pre/postnatal genetic testing. The primary outcomes were perinatal/neonatal survival and requirement of Renal Replacement Therapy at discharge.
Of the 217 patients evaluated by Fetal Nephrology, 35% underwent some form of fetal genetic testing, while 30% opted to only undergo non-invasive prenatal testing (NIPT). Only 5.7% of the prenatal genetic testing group (8/141) had a positive result. Postnatal testing was obtained in 27 neonates, with a positivity rate of 59% (16/27). Neonatal information was only available for 109 patients, of which, 73 patients were discharged from the NICU, and 36 patients died prior to discharge. Of the 36 patients that died, 27 had multiple developmental anomalies (75%), with 11 dying from pulmonary hypoplasia (32%), and another 11 being redirected towards comfort care (32%). Patients who survived had a mean gestational age of 35.7 weeks at the time of delivery with a mean admission length of 43.5 days. Only 5 patients were discharged on chronic dialysis, and 2 patients were discharged to hospice care.
Targeted postnatal genetic testing is more effective in establishing a diagnosis than prenatal testing. Perinatal mortality is high in the CAKUT patient population and more data is needed to determine the most effective diagnostic and therapeutic options in these complex cases.