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VOL. 97, No. i ANGIOGRAPHIC EVALUATION OF ANURIA IN THE NEWBORN* By MELVIN P. JUDKINS, M.D., and CHARLES T. DOTFER, M.D. PORTLAND, OREGON NURIA in the newborn is common dun- plete absence of kidneys, renal arteries, ureters, ing the first 24 hours of life, being urinary bladder and urethra. present in about 30 per cent of the infants.3 COMMENT When persistent for a longer period of time, it is usually due to such severe renal The reported incidence of bilateral renal dysplasias as renal agenesis and polycystic agenesis is about i :,ooo births; 70 per disease or complete obstruction of the cent are males.4 Most often these infants urinary tract. It is important to diagnose are premature. If carried to term, little definitively the presence or absence of the weight is gained after the 32nd week. The occasional surgically correctable lesion. majority dies of respiratory failure within Suprapubic puncture of the bladder, when a few hours. One infant has reportedly positive, is an aid in making a diagnosis. lived for 3 days.7 Retrograde femoral aortography, how- EMBRYOLOGY ever, is a relatively simple and precise method of determining the presence of A normal kidney is formed only when a renal parenchyma. Recently, such a pro- ureteral bud originates from the meso- cedure performed on an anunic infant nephric duct and penetrates metanephro- quickly established a definite diagnosis of genic mesoderm. The stimulus of the bilateral renal agenesis. branching uneteral bud is essential for the differentiation of this nephrogenic cap’ REPORT OF A CASE (Fig. 2). Apart from rare hereditary ab- I.H. (No. 33-83-90), a 3 day old, 1,785 gm. nonmalities, the primary cause of dys- premature female of about o weeks’ gestation, plasia is developmental inhibition or ar- was transferred to University of Oregon Med- rest.’ The fetal kidney forms between the ical School Hospital for evaluation. The infant th and 7th weeks. It is during this period became tachypneic 2 hours after delivery, but was not cyanotic; a chest roentgenogram was that the developing kidney is vulnerable to negative. Failure to void was soon noted; the environmental influences such as nutni- blood urea nitrogen was 6 mg. per cent. The tional deficiencies and endocrine disturb- suprapubic tap failed to recover urine. On ad- ances, on to infectious, chemical (drugs) and mission, the infant’s respirations were labored. physical agents. Abortogenic drugs such as The ears were deformed and low-set; there was the protoplasmic poison quinine may be a edema about the eyes, and the left hip was dis- significant cause. located. A urethral dimple was present, but the If the uretenic buds do not form, the urethra was not patent. The provisional differ- metanephros (kidney) will not develop. ential diagnosis was bilateral ureteropelvic ob- The absence of fetal urine results in oligo- struction, urethral atresia or congenital renal hydramnios, which in turn leads to posi- agenesis. Emergency abdominal aortography was performed (Fig. i, ii and B), and a diag- tional abnormalities of the extremities and nosis of congenital bilateral renal agenesis was pulmonary hypoplasia. A characteristic established. The infant expired of respiratory facial appearance is said to accompany the failure at 6 days of age. The blood urea nitro- absence of renal function. “The face is gen was 98 mg. per cent. Autopsy revealed corn- characterized by a prominent epicanthic a From the University ofOregon Minthorn Memorial Laboratory for Cardiovascular Research through Radiology. Aided by grants from the U. S. Public Health Service (H-3275 and H-6336 and 6F HD 23, 838), the Oregon Heart Association, and Mallinckrodt Pharmaceuticals. 239 240 Melvin P. Judkins and Charles T. Dotter MAY, 1966 ‘, 0 oY per cent conrav through a PE I 20 catheter inserted via the right superficial femoral artery. (4) Arterial phase. All of the usually recognized branches of the abdominal aorta except the renal arteries can be identi- tied. (B) Nephrographic j)hase. A nephrogram is not observed. fold, a flattelle(1 nose, large, imperfectly sence of kidney function rather than to a formed ears set low 011 tIle ilead and often specific malformation. An’ infant with a less upright than normal, afld an un- severe urinary tract dsplasia or anomaly, pleasant, senile expression” (Potter’s s\n- therefore, ma present a similar appear- drorne).4 a nce. At least 8 per cent of infants with bi- 1)1 S C U S S I 0 N lateral renal agenesis Ilave typical facial characteristics.2 Ihis is related to tile ab- lile difterential diagnosis of an anunic --Nephrogenic cord---. --Mesonephric duct fl.- . Cloacal loaca Cloacal membrane Rectum tissue 5 WEEKS 6 WEEKS FIG. 2. Diagram showing the early stages of the embryonic development of the urinary tract (after Arey’). VOL. 97, No. i Angiographic Evaluation of Anunia 241 state in a newborn includes such severe diagnosis of bilateral renal agenesis in a dvsplasias and anomalies as renal agenesis, 1,785 gm. infant is reported. polycystic disease, urethral atresia, and Melvin P. Judkins, M.D. u netenovesi cal or u neteropelvic obstnu c- Department of Radiology tion. The case reported did not present University of Oregon Medical School entirely typical Potter’s facies. Because the 3 I 8 1 S.W. Sam Jackson Park Road urethra was not patent, it was possible Portland, Oregon 97201 that an obstructive unopathy was present. REFERENCES When there is a possibility that a surgically I. AREY, L. B. Anatomy. Developmental Sixth correctable lesion is present, aontography edition. W. B. Saunders Company, Phila- can be used to determine quickly the delphia, 3954, pp. 68o. presence of renal arteries on panenchyma. 2. BAIN, A. D., and SCOTT, J. S. Renal agenesis and Even if the diagnosis is bilateral renal severe urinary tract dysplasia: review of 5o agenesis, the clinician will be able to ad- cases, with particular reference to associated anomalies.Brit. M. 7., 1960, i, 841-846. vise the parents of the prognosis and can 3. CAMPBELL, M. F. Principles of Urology. W. B. follow a conservative treatment plan. Saunders Company, Philadelphia, i 957. 4. POTTER, E. L. Facial characteristics of infants SUMMARY with bilateral renal agenesis. Am. 7. Obst. & The differential diagnosis of anuria in Gynec., 1946, 51, 88-888. 5. POTTER, E. L. Bilateral absence of ureters and the newborn over 24 hours of age includes kidneys. Obst. & Gynec., 3965, 25, 3-12. severe renal dysplasia and complete un- 6. SYLVESTER, P. E., and HUGHES, D. R. Con- nary obstruction. The latter is rare, but may genital absence of both kidneys; report of be correctable. When it is reasonable to cases. Brit. M. 7., 1954, I, 77-79. expect that significant information can be 7. WOOLF, R. B., and ALLEN, W. M. Concomitant malformations ; frequent, simultaneous occur- gained, aortography is indicated and feas- rence of congenital malformations of reproduc- ible even in a premature infant. tive and urinary tracts. Obst. & Gynec., 1953, The use of angiography to establish the 2, 236-265.
"IN THE NEWBORN"