IN THE NEWBORN by alicejenny

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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.

								
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