Signs and symptoms of developmental abnormalities of the genitourinary tract

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He was discharged 72h after delivery in the mother's company, who was instructed to carry on the follow-up with a specialist, as the prenatal ultrasonography had shown the presence of bilateral hydronephrosis with anteroposterior renal pelvis diameter of approximately 12mm. However, after birth, the parents were lost to follow-up with the nephrologist.The consultations with the pediatrician were irregularly attended. At 8 years old, the child was referred for consultation with a hematologist and an endocrinologist due to stunting and anemia unresponsive to treatment with oral iron; these specialists did not find the cause for the alterations.Only at the age of 10 years and 11 months was the child diagnosed with chronic kidney disease (CKD) secondary to bilateral ureteropelvic junction stenosis. At the time of diagnosis, he had already shown signs of chronic nephropathy with bilateral tapering of the renal parenchyma at the ultrasonographic assessment. The parents stated that at the age of 2 years the child already had daytime sphincter control, but they observed polyuria, nocturia, and excessive water consumption. There were no alterations in urinary stream or episodes of urinary tract infection.At 11 years and 3 months, he underwent a pyeloplasty with double J catheter implantation on the right in order to prolong the conservative treatment and delay the onset of renal replacement therapy.At the age of 12 years and 3 months, one year and four months after the diagnosis, he underwent preemptive kidney transplantation from a living donor (his mother).DiscussionThe case described above is factual and common, evidencing the disturbing problem of late diagnosis of CKD in children in Brazil. CKD is defined as the existence of any kidney injury, associated with varying degrees of glomerular filtration rate decrease, as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRef" href="#bib0195">1</a> Stage 5 CKD, requiring renal replacement therapy (RRT; whether dialysis or transplantation), is a public health problem and there is evidence of the increasing incidence and prevalence of this condition.<a class="elsevierStyleCrossRef" href="#bib0200">2</a> In 2010, the number of individuals receiving RRT worldwide was estimated at 2.7 million, but it is also estimated that the similar number of patients who had the indication for RRT did not receive it due to lack of access to the treatment, especially for financial reasons.<a class="elsevierStyleCrossRef" href="#bib0205">3</a> It is further estimated that the proportion of CKD patients in stages 2 to 4 is much higher than that of CKD patients in stage 5.<a class="elsevierStyleCrossRef" href="#bib0210">4</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Fortunately, the proportion of children with CKD is much lower than that of adults, but CKD in children has devastating consequences on growth, weight, height, and intellectual development, resulting in increased morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0210">4</a> The prevalence of pediatric CKD in Brazil is lower than that reported in developed Western countries, probably due to the lack of diagnosis. A study carried out in Brazil in 2012 estimated a total of approximately 1300 pediatric patients on dialysis in the country, resulting in a prevalence of 20 cases per million age-related population (pmarp).<a class="elsevierStyleCrossRef" href="#bib0215">5</a> In Europe, for instance, records show a prevalence rate of 65 pmarp, whereas in the United States, these numbers reach 85 pmarp.<a class="elsevierStyleCrossRef" href="#bib0220">6</a>In developed countries, the main cause of CKD in childhood are inherited diseases, particularly congenital anomalies of the kidneys and urinary tract (CAKUT), which amount to approximately 30% to 60% of children with CKD on RRT.<a class="elsevierStyleCrossRefs" href="#bib0210">4,6</a> In contrast, the main etiological diagnosis that was given to children on dialysis in Brazil was “unknown cause”, comprising 32% of the cases, which is much higher than that reported in Western countries, suggesting that this condition is underdiagnosed in Brazil.<a class="elsevierStyleCrossRef" href="#bib0215">5</a> Another noteworthy aspect is the time between CKD diagnosis and the start of RRT, which in Brazil was 14 months in the Southeast, nine months in the Midwest, and zero months in the Northeast, suggesting a delay in establishing the diagnosis, which also impairs the final prognosis of these children.<a class="elsevierStyleCrossRef" href="#bib0215">5</a>In the aforementioned clinical case, the patient already had anemia and stunting at the time of the diagnosis, which are signs of the late diagnosis. This deserves discussion because, similarly to this case, many others can go undiagnosed, causing harm to the patients. The early diagnosis of CKD is an opportunity for the generalist pediatricians, not for the specialists. It allows for the initiation of medical therapies and indication of surgical procedures when necessary, which can slow the progression of CKD and the need to start RRT.The genetic diagnosis of CAKUT is challenging and not yet accessible, due to the high costs of genetic tests and the complexity of interactions among multiple candidate genes to explain the diseases,<a class="elsevierStyleCrossRef" href="#bib0225">7</a> and will not be discussed here. This study aimed to review the clinical signs and symptoms associated with the most prevalent CAKUT in childhood, in order to provide the generalist pediatrician with elements for the early diagnosis and treatment, aiming to attain a better prognosis of affected children.Classification of congenital abnormalities of the kidneys and urinary tractThe CAKUT are a heterogeneous group of diseases of the kidney and urinary tract development (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In a German study of 30,940 newborns, stillbirths, and miscarriages/abortions, it was estimated that approximately 7% had major malformations. CAKUT were the second most frequent abnormality, with an estimated prevalence of 1.6% of the total.<a class="elsevierStyleCrossRef" href="#bib0230">8</a> In a Brazilian study of 6245 perinatal and pediatric autopsies, the authors observed that CAKUT were present in 2.9% of the cases.<a class="elsevierStyleCrossRef" href="#bib0235">9</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In addition to its role as a main cause of CKD in children, it is understood that CAKUT represent an important CKD etiology also in adults. A recent study of 212,930 adult individuals with CKD showed that patients with CAKUT started RRT at 31 years old, whereas individuals with other etiologies required RRT only at 61 years of age.<a class="elsevierStyleCrossRef" href="#bib0240">10</a> This suggests that adults with kidney failure have CAKUT, which, as during childhood, can be identified and treated early, increasing the importance of this diagnosis.Subsidies for the diagnosis of congenital abnormalities of the kidneys and urinary tractAssociated malformationsCAKUT have very different genetic causes and factors, such as hereditary chromosomal abnormalities and mutations in genes that regulate the development of the urinary tract, which can be the underlying cause of the malformation. Moreover, environmental effects on fetal development are also important, resulting in a complex association between genotype and phenotype in these diseases. As a starting point to try characterizing this complexity, it is important to consider that CAKUT may appear alone or may be associated with other malformations or syndromes.In a recent study with 346,841 abortions/miscarriages, stillbirths, or live births, it was estimated that 34% of the 1678 observed cases of CAKUT had other non-urinary associated malformations. The distribution of these associations is shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>,<a class="elsevierStyleCrossRef" href="#bib0245">11</a> and their importance for the generalist pediatrician is that their presence should be a warning to search for CAKUT cases.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Important past medical history and clinical signs and symptomsPast medical history in the antenatal period that is associated with CAKUT most often includes oligoamnios, prematurity, low birth weight, and intrauterine growth restriction. A study carried out in Japan showed an association between perinatal history and CAKUT, suggesting signs to indicate the screening of children. Of the assessed data (14% of patients with CAKUT were preterm, 18% had low birth weight, 79% showed failure to thrive, 18% had asphyxia, 8% had oligoamnios, and 12% had jaundice), it was found a total of 82% with a history of oligoamnios and failure to thrive, suggesting these two signs are markers to select individuals at higher risk for CAKUT, with a specificity of 95%.<a class="elsevierStyleCrossRef" href="#bib0250">12</a> In a Brazilian study that assessed previous historical data, the latter were a predictor of mortality associated with CAKUT in 29,653 newborns between 1996 and 2006. This study showed 524 cases of CAKUT, corresponding to 17.7 per 1000 live births and the risk factors for mortality were oligoamnios, CAKUT associated with other malformations, low birth weight, and prematurity.<a class="elsevierStyleCrossRef" href="#bib0255">13</a> Another noteworthy past medical history is CAKUT in the family. A recent study showed that 14% of 107 cases of CAKUT had a family history with a confirmed diagnosis in at least one family member.<a class="elsevierStyleCrossRef" href="#bib0260">14</a>In a study involving 1994 patients with CKD (diagnosed before the age of 21) and 20,032 controls, low birth weight and maternal pre-gestational diabetes were significantly associated with the risk of renal dysplasia/aplasia.<a class="elsevierStyleCrossRef" href="#bib0265">15</a>The literature is quite scarce on the description of warning signs and symptoms of urinary system impairment. In the case of CAKUT, the clinical expression of malformations can conceptually be due to: (a) impairment of the upper urinary system leading to renal dysfunction, and can be expressed as polyuria, pollakiuria, nocturia, urinary tract infection, systemic arterial hypertension, and low weight gain<a class="elsevierStyleCrossRefs" href="#bib0260">14,16–18</a> or (b) signs of lower urinary tract impairment with urinary tract obstruction, such as weak urinary stream, difficulty to start urination, distended bladder, non-monosymptomatic enuresis, urinary urge/incontinence, and bowel and bladder dysfunction.<a class="elsevierStyleCrossRef" href="#bib0285">19</a>The controversy on the use of episodes of urinary tract infection as a CAKUT indicator is quite intense, but it appears that some situations represent a higher probability of association with CAKUT. Age younger than 2 years and high fever (higher than 38.3°C) are the factors that can predict urological abnormalities.<a class="elsevierStyleCrossRef" href="#bib0290">20</a>Finally, another evidence that is relevant to allow for the early diagnosis of congenital nephropathy is blood pressure. It is known that hypertension is more common in children with nephropathy and, conversely, that blood pressure control has an effective therapeutic response by slowing CKD progression in children.<a class="elsevierStyleCrossRef" href="#bib0295">21</a> These associations reinforce the importance of the recommendation of blood pressure measurement in children, which should be performed in all pediatric visits, from the age of 3 years onwards, and in children younger than 3 years in the presence of any of the following situations: (a) preterm birth, low birth weight or neonatal complications requiring admission to the neonatal intensive care unit; (b) congenital heart diseases; (c) urinary tract infection, hematuria, or proteinuria; (d) known kidney disease or urologic malformations; (e) family history of congenital kidney disease; (f) solid organ transplantation; (g) malignancies or bone marrow transplantation; (h) systemic diseases associated with hypertension; and (i) evidence of high blood pressure.<a class="elsevierStyleCrossRef" href="#bib0300">22</a>Antenatal ultrasonographic alterationsThe use of ultrasonography in the monitoring of pregnancy and neonates began in the late 1970s. Currently, gestational ultrasonography is part of the medical routine in most countries, with at least two examinations during pregnancy to monitor fetal development and identify possible malformations.<a class="elsevierStyleCrossRef" href="#bib0305">23</a> Gestational ultrasonography greatly improved the diagnosis and prognosis of children with CAKUT, reaching a level of sensitivity for the detection of obstructive uropathies between 80% and 90%. In a European study conducted in 12 countries, the sensitivity to renal malformation detection was 81.2%.<a class="elsevierStyleCrossRef" href="#bib0305">23</a>Hydronephrosis is the ultrasonographic finding most often identified and described. Antenatal hydronephrosis is the presence of one or both kidneys with some degree of pyelocalyceal system dilation in the fetus. The diagnosis is attained through obstetric ultrasonography, using as the main parameter the anteroposterior diameter (APD) of the renal pelvis and the presence of caliectasis. There is hydronephrosis when the pelvis APD is above certain limits, but there is no consensus on the definition of these limits yet. The most frequently cited values, above which there is a greater risk of renal function deterioration or need for surgery, are those proposed by the Society for Fetal Urology (SFU),<a class="elsevierStyleCrossRef" href="#bib0310">24</a> which are summarized in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The highest positive predictive value (PPV) is found in the examination performed in the third trimester of pregnancy. The PPV for APD values >7mm in the third trimester is 69% vs. 49% for APD>4mm in the second trimester.<a class="elsevierStyleCrossRef" href="#bib0210">4</a> The reported incidence of fetal disease varies from 1% to 5% of pregnancies, depending on diagnostic criteria; it is more frequent in boys (3 to 4/1) predominantly unilateral, and only 20% of cases will have postnatal clinical significance.Another ultrasonographic finding that is important for the diagnosis and prognosis of children with CAKUT is the hydronephrosis classification proposed by the SFU, which is based on the degree of pyelocalyceal dilation and also takes parenchyma integrity into account. Grade 0 represents a normal ultrasonography; the other grades are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>This classification system was developed for ultrasonography performed after birth. However, it has been applied to antenatal ultrasonography, and there is evidence that children with grades 3 and 4 of hydronephrosis have increased risk of need for surgery and renal function deterioration.<a class="elsevierStyleCrossRef" href="#bib0315">25</a>Regardless of the classification of hydronephrosis, the postnatal follow-up of children with images of hydronephrosis detected during the gestational period shows resolution in approximately 50% of cases, caliectasis with no obstructive factor including extrarenal pelvis in 15%, ureteropelvic junction stenosis in 11%, vesicoureteral reflux in 9%, megaureter in 4%, multicystic dysplastic kidney in 2%, ureterocele in 2%, renal cysts in 2%, and posterior urethral valve in 1%.<a class="elsevierStyleCrossRefs" href="#bib0315">25–27</a>Other imaging findings obtained at the gestational ultrasonography that help with the diagnosis and prognosis of children with CAKUT and are also associated with renal function deterioration are: (a) the finding of single kidney, in which case 1/3 of the affected individuals has associated CAKUT,<a class="elsevierStyleCrossRefs" href="#bib0330">28,29</a> (b) hydronephrosis associated with other anomalies, when the probability of CKD at 2 years of age is 15% vs. only approximately 2% in children with isolated hydronephrosis<a class="elsevierStyleCrossRef" href="#bib0340">30</a> and (c) bilateral hydronephrosis, which represents a risk of renal function deterioration that is 9.4-fold higher than cases with unilateral alteration.<a class="elsevierStyleCrossRef" href="#bib0345">31</a>In addition to the aspect and degree of hydronephrosis, other ultrasonographic findings should be taken into account, such as: (a) ureteral dilatation, which is present in megaureter; ureterovesical-junction stenosis, posterior urethral valve, and absent in the ureteropelvic junction stenosis; (b) kidney size, which can be affected in renal hypo/dysplasia, or even in hydronephrosis; (c) bladder size and bladder wall thickness, with or without formation of trabeculae, alterations that may be present in the hypertrophic or hypotonic bladder; (d) increased post-voiding residual urinary volume, associated with poor bladder function; and (e) ureterocele, usually present in ureteral duplicity.<a class="elsevierStyleCrossRef" href="#bib0350">32</a>ConclusionsThis study aimed to review the medical literature to list the main clinical data that might be useful in pediatric practice for the early identification of patients with CAKUT. This diagnosis is important, since CAKUT are the most common cause of CKD in children. In the present epidemiological scenario, characterized by a decrease in morbidity and mortality secondary to infectious diseases, chronic diseases in general (and particularly CKD) have become more important in clinical practice, which should become even more prominent with time.<a class="elsevierStyleCrossRef" href="#bib0200">2</a>Current evidence shows that CKD has its origins in intrauterine life, and at present it is known that the number of nephrons in each kidney can vary greatly between individuals, and that a lower number of kidney functional units increases the risk of CKD and cardiovascular disease.<a class="elsevierStyleCrossRefs" href="#bib0355">33,34</a> This consideration is even more important in children with urinary system development abnormalities, in which nephrogenesis is often disturbed, resulting in a lower number of nephrons. These findings anticipate to the pediatric range the moment of greatest interest to attain an early diagnosis of patients at risk for CKD.The time to perform this diagnostic search should be as early as possible, preferably before birth. It is known that even in situations where well-organized follow-up services are available, incomplete adherence of families to the necessary procedures for diagnostic research is a frequent phenomenon.<a class="elsevierStyleCrossRef" href="#bib0365">35</a>Some countries seek the early diagnosis of risk for CKD using compulsory programs of urinary sediment tests or imaging assessment at certain ages,<a class="elsevierStyleCrossRefs" href="#bib0370">36,37</a> but the cost-effectiveness analyses of such programs never conclusively demonstrated that this initiative was advantageous.<a class="elsevierStyleCrossRef" href="#bib0380">38</a> In a situation such as this one, clinical evaluation is an invaluable resource to screen which patients should be studied through more detailed laboratory tests. This strategy appears to be particularly accurate in countries with limited resources in the health care area. In Brazil, with the exception of the Southeast region, the unknown cause is the most common diagnosis of advanced CKD in children,<a class="elsevierStyleCrossRef" href="#bib0215">5</a> suggesting that there is an important gap to be filled in order to better categorize the diagnosis of CKD. It is plausible that many children reach the final stage of the CKD evolution without having access to diagnosis of CAKUT, which is the most important cause of this disease worldwide.A noteworthy observation in this review was that there are no studies with a robust methodology to provide answers based on solid evidence about the subject. Most of the reviewed studies were descriptive and single-centered and, therefore, the findings summarized herein must be considered as preliminary data. Warning signs for the identification of children with CAKUT are summarized in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>The authors believe that, even with the methodological limitations of the reviewed studies, the suggestions can help pediatricians to establish clinical hypotheses for the early diagnosis of abnormalities of the genitourinary tract development, by using clinical data and information from the gestational ultrasonography, without resorting to expensive and invasive methods. As there are no prospective data to evaluate which clinical signs and symptoms listed here are more important to identify the risk, the authors believe that, for the moment, the occurrence of any of them should be an indication to investigate children regarding the possible existence of CAKUT, as early as possible.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres805597" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Data sources" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Data synthesis" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec803716" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres805596" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fontes dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Síntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec803715" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical case" ] 5 => array:3 [ "identificador" => "sec0050" "titulo" => "Discussion" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Classification of congenital abnormalities of the kidneys and urinary tract" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Subsidies for the diagnosis of congenital abnormalities of the kidneys and urinary tract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Associated malformations" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Important past medical history and clinical signs and symptoms" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Antenatal ultrasonographic alterations" ] ] ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-15" "fechaAceptado" => "2016-01-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec803716" "palabras" => array:4 [ 0 => "Urinary tract malformations" 1 => "Chronic kidney disease" 2 => "Early diagnosis" 3 => "Child" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec803715" "palabras" => array:4 [ 0 => "Malformação do trato urinário" 1 => "Doença renal crônica" 2 => "Diagnóstico precoce" 3 => "Criança" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveThe abnormalities of the genitourinary tract development are the leading cause of chronic kidney disease (CKD) in children. The diagnosis of this disease in Brazil is late and incomplete, which results in increased morbidity and mortality in this age group. Early diagnosis of this condition is the prerogative of generalist pediatricians, and the aim of this study was to review the clinical signs and symptoms associated with developmental abnormalities of the genitourinary tract. Data sourcesBased on the description of a symbolic clinical case, the authors conducted a non-systematic review of medical literature. Data synthesisThe results suggest that the following data should be used as a warning for early diagnosis of affected children: (a) combined urinary tract abnormalities (chromosomal abnormalities; sequence of malformations [VACTERLand Prune-Belly]; and musculoskeletal, digestive tract, heart, and nervous system malformations); (b) previous history (congenital anomalies of the kidney and urinary tract [CAKUT] in the family, low birth weight, and oligoamnios); (c) clinical signs (polyuria/nocturia, urinary tract infection, systemic arterial hypertension, failure to thrive, weak urinary stream, difficulty to start urination, distended bladder, non-monosymptomatic enuresis, urinary/urge incontinence, and bowel and bladder dysfunction); and (d) pre- and postnatal ultrasonographic alterations (increased anteroposterior diameter of the renal pelvis, mainly in the third trimester of pregnancy; single kidney; hydronephrosis associated with other abnormalities; and hydronephrosis with parenchymal involvement in the post-neonatal assessment). ConclusionThe suggestions shown here can help the pediatrician to establish clinical hypotheses for the early diagnosis of developmental abnormalities of the genitourinary tract without resorting to expensive and invasive procedures." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Data sources" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Data synthesis" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivoAs anormalidades do desenvolvimento do trato geniturinário são a principal causa de doença renal crônica (DRC) em crianças. O diagnóstico dessa doença no Brasil é formulado de maneira incompleta e tardia, o que resulta em aumento na morbi-mortalidade nessa faixa etária. O diagnóstico precoce dessa condição é prerrogativa dos pediatras generalistas e o objetivo desse trabalho foi revisar os sinais e sintomas clínicos associados às anormalidades do desenvolvimento do trato geniturinário. Fontes dos dadosA partir da descrição de um caso clínico simbólico, realizamos uma revisão não sistemática da literatura médica. Síntese dos dadosOs resultados sugerem que os seguintes dados devem ser utilizados como alerta para o diagnóstico precoce das crianças acometidas: a) anomalias do trato urinário compostas (anomalias cromossômicas, sequências de malformações – VACTERL e Prune-Belly, malformações musculoesqueléticas, do trato digestivo, cardíacas e do sistema nervoso), b) antecedentes (anomalias congênitas do rim e trato urinário (CAKUT) na família,baixo peso ao nascer e oligoâmnio), c) sinais clínicos (polaciúria/noctúria, infecção urinária, hipertensão arterial sistêmica, baixo ganho de peso, jato urinário fraco, dificuldade para iniciar a micção, bexigoma, enurese não monossintomática, urge/incontinência urinária, disfunção do intestino e da bexiga)e d) alterações ultrassonográficas ante e pós-natais (diâmetro ântero-posterior da pélvis renal aumentado principalmente no terceiro trimestre da gestação, rim único, hidronefrose associada a outras anomalias e hidronefrose com comprometimento de parênquima na avaliação pós-neonatal). ConclusãoAs sugestões apresentadas podem ajudar o pediatra a estabelecer hipóteses clínicas para o diagnóstico precoce das anormalidades do desenvolvimento do trato geniturinário sem utilização de metodologias caras e invasivas." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fontes dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Síntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Nogueira PC, Paz IP. Signs and symptoms of developmental abnormalities of the genitourinary tract. J Pediatr (Rio J). 2016;92(3 Suppl 1):S57–63." ] ] "multimedia" => array:10 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Stage \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GFR (mL/min/1.73m2) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Kidney damage with normal or increased GFR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Kidney damage with mild decrease in GFR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60–89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Kidney damage with moderate decrease in GFR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30–59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Kidney damage with severe decrease in GFR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15–29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Renal failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><15 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1351918.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of chronic kidney disease stages." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AD, autosomal dominant; AR, autosomal recessive." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Renal differentiation abnormalities \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Renal dysplasia \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Renal mass abnormalities</td><td class="td" title="table-entry " align="left" valign="top">Renal agenesis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal hypoplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Shape and position abnormalities</td><td class="td" title="table-entry " align="left" valign="top">Supernumerary kidney \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ectopic kidney \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Horseshoe kidney \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Upper urinary tract abnormalities</td><td class="td" title="table-entry " align="left" valign="top">Pelvis and ureter duplication \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ureteropelvic junction stenosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Congenital megaureter \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Lower urinary tract abnormalities</td><td class="td" title="table-entry " align="left" valign="top">Ureterovesical junction stenosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Posterior urethral valve \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bladder agenesis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bladder exstrophy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neurogenic bladder \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Cystic kidney diseases</td><td class="td" title="table-entry " align="left" valign="top">Isolated kidney cyst \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multicystic dysplastic kidney \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AD polycystic kidney disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AR polycystic kidney disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spinal cysts – nephronophthisis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1351915.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Congenital abnormalities of the kidneys and urinary tract." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "VSD, ventricular septal defect; ASD, atrial septal defect.Modified from Stoll et al.<a class="elsevierStyleCrossRef" href="#bib0245">11</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Chromosomal abnormalities (n=119)</td><td class="td" title="table-entry " align="left" valign="top">Trisomy 18 (n=33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trisomy 21 (n=26) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trisomy 13 (n=24) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Turner syndrome (n=11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others (n=25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Non-chromosomal associations (n=168)</td><td class="td" title="table-entry " align="left" valign="top">VACTERL (n=56) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meckel-Gruber (n=36) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prune-Belly (n=23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others (n=53) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown associations (n=276) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Skeletal muscle tissue (n=97)</td><td class="td" title="table-entry " align="left" valign="top">Polydactyly/syndactyly (n=45) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shortening of limbs (n=30) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others (n=22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Digestive tract (n=91)</td><td class="td" title="table-entry " align="left" valign="top">Anal atresia (n=38) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pathological rotation (n=29) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others (n=24) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Cardiac malformations (n=88)</td><td class="td" title="table-entry " align="left" valign="top">VSD (n=42) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASD (n=21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others (n=25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Nervous system (n=60)</td><td class="td" title="table-entry " align="left" valign="top">Spina bifida (n=21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Encephalocele (n=15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Microcephaly (n=8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others (n=16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Head and neck (n=53)</td><td class="td" title="table-entry " align="left" valign="top">Facial dysmorphia (n=21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertelorism (n=19) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others (n=13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Respiratory system (n=28)</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary hypoplasia (n=21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others (n=7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Abdominal wall (n=23)</td><td class="td" title="table-entry " align="left" valign="top">Omphalocele (n=14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastroschisis (n=9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Others (n=29)</td><td class="td" title="table-entry " align="left" valign="top">Cleft lip (n=23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diaphragmatic hernia (n=6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1351920.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Malformations associated with CAKUT found in 346,381 cases in France from 1979 to 2004 (total of 1678 CAKUT, of which 563 had other associated malformations)." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Severity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Second trimester \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Third trimester \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 to <7mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 to <9mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 to ≤10mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 to ≤15mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>10mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>15mm \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1351919.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Antenatal hydronephrosis classification according to the anteroposterior diameter of the renal pelvis." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SFU, Society of Fetal Urology." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SFU – grade 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SFU – grade 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SFU – grade 3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SFU – grade 4 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="201702240038198501"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201702240038198502"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201702240038198503"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201702240038198504"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal sinus with urine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Filled pelvis with dilated major calyces \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Uniform dilation of major and minor calyces \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Parenchymal thinning \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1351916.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Graphic representation and classification of the ultrasonographic alterations in hydronephrosis (adapted from Timberlake & Herndon<a class="elsevierStyleCrossRef" href="#bib0315">25</a>)." ] ] 5 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "US, ultrasonography; APD, anteroposterior diameter; UTI, urinary tract infection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Perinatal history \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical data \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Associated malformations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low birth weight Intrauterine growth restriction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nocturia Polyuria Pollakiuria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chromosomal aberrations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oligoamnios \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> Urge-incontinence Bowel and bladder dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sequences (VACTERL/Prune-Belly) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prematurity US with increased APD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> Non-monosymptomatic enuresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Musculoskeletal tissue Digestive system \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">US with thinning of the parenchyma US with single-kidney \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weak urinary stream Difficulty to start urination Distended bladder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Congenital heart defects Nervous system \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Failure to thrive Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">US with small kidneys \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">UTI with fever in patients <2 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary hypoplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1351917.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Warning signs for the diagnosis of CAKUT in children." ] ] 6 => array:5 [ "identificador" => "201702240038198501" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 315 "Ancho" => 479 "Tamanyo" => 27246 ] ] ] 7 => array:5 [ "identificador" => "201702240038198502" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx2.jpeg" "Alto" => 315 "Ancho" => 484 "Tamanyo" => 34683 ] ] ] 8 => array:5 [ "identificador" => "201702240038198503" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx3.jpeg" "Alto" => 315 "Ancho" => 473 "Tamanyo" => 30535 ] ] ] 9 => array:5 [ "identificador" => "201702240038198504" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx4.jpeg" "Alto" => 315 "Ancho" => 488 "Tamanyo" => 29443 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N.K. Foundation" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Kidney Dis" "fecha" => "2002" "volumen" => "39" "paginaInicial" => "S1" "paginaFinal" => "S266" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11904577" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0200" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolving importance of kidney disease: from subspecialty to global health burden" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.U. Eckardt" 1 => "J. Coresh" 2 => "O. Devuyst" 3 => "R.J. Johnson" 4 => "A. Köttgen" 5 => "A.S. Levey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(13)60439-0" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2013" "volumen" => "382" "paginaInicial" => "158" "paginaFinal" => "169" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23727165" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0205" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Worldwide access to treatment for end-stage kidney disease: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Liyanage" 1 => "T. Ninomiya" 2 => "V. Jha" 3 => "B. Neal" 4 => "H.M. Patrice" 5 => "I. 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Review article

Sinais e sintomas das anormalidades do desenvolvimento do trato geniturinário

Paulo Cesar Koch Nogueira

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pckoch@uol.com.br

Corresponding author.

, Isabel de Pádua Paz

Department of Pediatrics, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil

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              0 => "isabelppaz&#64;gmail&#46;com"
            ]
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Department of Pediatrics&#44; Escola Paulista de Medicina&#44; Universidade Federal de S&#227;o Paulo &#40;UNIFESP&#41;&#44; S&#227;o Paulo&#44; SP&#44; Brazil"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
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    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Sinais e sintomas das anormalidades do desenvolvimento do trato geniturin&#225;rio"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical case</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient&#44; H&#46;O&#46;R&#46;S&#46;&#44; aged 12 years and 3 months&#44; was born at term with no complications during childbirth&#46; He was discharged 72<span class="elsevierStyleHsp" style=""></span>h after delivery in the mother&#39;s company&#44; who was instructed to carry on the follow-up with a specialist&#44; as the prenatal ultrasonography had shown the presence of bilateral hydronephrosis with anteroposterior renal pelvis diameter of approximately 12<span class="elsevierStyleHsp" style=""></span>mm&#46; However&#44; after birth&#44; the parents were lost to follow-up with the nephrologist&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The consultations with the pediatrician were irregularly attended&#46; At 8 years old&#44; the child was referred for consultation with a hematologist and an endocrinologist due to stunting and anemia unresponsive to treatment with oral iron&#59; these specialists did not find the cause for the alterations&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Only at the age of 10 years and 11 months was the child diagnosed with chronic kidney disease &#40;CKD&#41; secondary to bilateral ureteropelvic junction stenosis&#46; At the time of diagnosis&#44; he had already shown signs of chronic nephropathy with bilateral tapering of the renal parenchyma at the ultrasonographic assessment&#46; The parents stated that at the age of 2 years the child already had daytime sphincter control&#44; but they observed polyuria&#44; nocturia&#44; and excessive water consumption&#46; There were no alterations in urinary stream or episodes of urinary tract infection&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">At 11 years and 3 months&#44; he underwent a pyeloplasty with double J catheter implantation on the right in order to prolong the conservative treatment and delay the onset of renal replacement therapy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">At the age of 12 years and 3 months&#44; one year and four months after the diagnosis&#44; he underwent preemptive kidney transplantation from a living donor &#40;his mother&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The case described above is factual and common&#44; evidencing the disturbing problem of late diagnosis of CKD in children in Brazil&#46; CKD is defined as the existence of any kidney injury&#44; associated with varying degrees of glomerular filtration rate decrease&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Stage 5 CKD&#44; requiring renal replacement therapy &#40;RRT&#59; whether dialysis or transplantation&#41;&#44; is a public health problem and there is evidence of the increasing incidence and prevalence of this condition&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> In 2010&#44; the number of individuals receiving RRT worldwide was estimated at 2&#46;7 million&#44; but it is also estimated that the similar number of patients who had the indication for RRT did not receive it due to lack of access to the treatment&#44; especially for financial reasons&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> It is further estimated that the proportion of CKD patients in stages 2 to 4 is much higher than that of CKD patients in stage 5&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Fortunately&#44; the proportion of children with CKD is much lower than that of adults&#44; but CKD in children has devastating consequences on growth&#44; weight&#44; height&#44; and intellectual development&#44; resulting in increased morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> The prevalence of pediatric CKD in Brazil is lower than that reported in developed Western countries&#44; probably due to the lack of diagnosis&#46; A study carried out in Brazil in 2012 estimated a total of approximately 1300 pediatric patients on dialysis in the country&#44; resulting in a prevalence of 20 cases per million age-related population &#40;pmarp&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> In Europe&#44; for instance&#44; records show a prevalence rate of 65 pmarp&#44; whereas in the United States&#44; these numbers reach 85 pmarp&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In developed countries&#44; the main cause of CKD in childhood are inherited diseases&#44; particularly congenital anomalies of the kidneys and urinary tract &#40;CAKUT&#41;&#44; which amount to approximately 30&#37; to 60&#37; of children with CKD on RRT&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6</span></a> In contrast&#44; the main etiological diagnosis that was given to children on dialysis in Brazil was &#8220;unknown cause&#8221;&#44; comprising 32&#37; of the cases&#44; which is much higher than that reported in Western countries&#44; suggesting that this condition is underdiagnosed in Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> Another noteworthy aspect is the time between CKD diagnosis and the start of RRT&#44; which in Brazil was 14 months in the Southeast&#44; nine months in the Midwest&#44; and zero months in the Northeast&#44; suggesting a delay in establishing the diagnosis&#44; which also impairs the final prognosis of these children&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the aforementioned clinical case&#44; the patient already had anemia and stunting at the time of the diagnosis&#44; which are signs of the late diagnosis&#46; This deserves discussion because&#44; similarly to this case&#44; many others can go undiagnosed&#44; causing harm to the patients&#46; The early diagnosis of CKD is an opportunity for the generalist pediatricians&#44; not for the specialists&#46; It allows for the initiation of medical therapies and indication of surgical procedures when necessary&#44; which can slow the progression of CKD and the need to start RRT&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The genetic diagnosis of CAKUT is challenging and not yet accessible&#44; due to the high costs of genetic tests and the complexity of interactions among multiple candidate genes to explain the diseases&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> and will not be discussed here&#46; This study aimed to review the clinical signs and symptoms associated with the most prevalent CAKUT in childhood&#44; in order to provide the generalist pediatrician with elements for the early diagnosis and treatment&#44; aiming to attain a better prognosis of affected children&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Classification of congenital abnormalities of the kidneys and urinary tract</span><p id="par0055" class="elsevierStylePara elsevierViewall">The CAKUT are a heterogeneous group of diseases of the kidney and urinary tract development &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In a German study of 30&#44;940 newborns&#44; stillbirths&#44; and miscarriages&#47;abortions&#44; it was estimated that approximately 7&#37; had major malformations&#46; CAKUT were the second most frequent abnormality&#44; with an estimated prevalence of 1&#46;6&#37; of the total&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> In a Brazilian study of 6245 perinatal and pediatric autopsies&#44; the authors observed that CAKUT were present in 2&#46;9&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In addition to its role as a main cause of CKD in children&#44; it is understood that CAKUT represent an important CKD etiology also in adults&#46; A recent study of 212&#44;930 adult individuals with CKD showed that patients with CAKUT started RRT at 31 years old&#44; whereas individuals with other etiologies required RRT only at 61 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> This suggests that adults with kidney failure have CAKUT&#44; which&#44; as during childhood&#44; can be identified and treated early&#44; increasing the importance of this diagnosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Subsidies for the diagnosis of congenital abnormalities of the kidneys and urinary tract</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Associated malformations</span><p id="par0065" class="elsevierStylePara elsevierViewall">CAKUT have very different genetic causes and factors&#44; such as hereditary chromosomal abnormalities and mutations in genes that regulate the development of the urinary tract&#44; which can be the underlying cause of the malformation&#46; Moreover&#44; environmental effects on fetal development are also important&#44; resulting in a complex association between genotype and phenotype in these diseases&#46; As a starting point to try characterizing this complexity&#44; it is important to consider that CAKUT may appear alone or may be associated with other malformations or syndromes&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In a recent study with 346&#44;841 abortions&#47;miscarriages&#44; stillbirths&#44; or live births&#44; it was estimated that 34&#37; of the 1678 observed cases of CAKUT had other non-urinary associated malformations&#46; The distribution of these associations is shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a> and their importance for the generalist pediatrician is that their presence should be a warning to search for CAKUT cases&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Important past medical history and clinical signs and symptoms</span><p id="par0075" class="elsevierStylePara elsevierViewall">Past medical history in the antenatal period that is associated with CAKUT most often includes oligoamnios&#44; prematurity&#44; low birth weight&#44; and intrauterine growth restriction&#46; A study carried out in Japan showed an association between perinatal history and CAKUT&#44; suggesting signs to indicate the screening of children&#46; Of the assessed data &#40;14&#37; of patients with CAKUT were preterm&#44; 18&#37; had low birth weight&#44; 79&#37; showed failure to thrive&#44; 18&#37; had asphyxia&#44; 8&#37; had oligoamnios&#44; and 12&#37; had jaundice&#41;&#44; it was found a total of 82&#37; with a history of oligoamnios and failure to thrive&#44; suggesting these two signs are markers to select individuals at higher risk for CAKUT&#44; with a specificity of 95&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> In a Brazilian study that assessed previous historical data&#44; the latter were a predictor of mortality associated with CAKUT in 29&#44;653 newborns between 1996 and 2006&#46; This study showed 524 cases of CAKUT&#44; corresponding to 17&#46;7 per 1000 live births and the risk factors for mortality were oligoamnios&#44; CAKUT associated with other malformations&#44; low birth weight&#44; and prematurity&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> Another noteworthy past medical history is CAKUT in the family&#46; A recent study showed that 14&#37; of 107 cases of CAKUT had a family history with a confirmed diagnosis in at least one family member&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In a study involving 1994 patients with CKD &#40;diagnosed before the age of 21&#41; and 20&#44;032 controls&#44; low birth weight and maternal pre-gestational diabetes were significantly associated with the risk of renal dysplasia&#47;aplasia&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The literature is quite scarce on the description of warning signs and symptoms of urinary system impairment&#46; In the case of CAKUT&#44; the clinical expression of malformations can conceptually be due to&#58; &#40;a&#41; impairment of the upper urinary system leading to renal dysfunction&#44; and can be expressed as polyuria&#44; pollakiuria&#44; nocturia&#44; urinary tract infection&#44; systemic arterial hypertension&#44; and low weight gain<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">14&#44;16&#8211;18</span></a> or &#40;b&#41; signs of lower urinary tract impairment with urinary tract obstruction&#44; such as weak urinary stream&#44; difficulty to start urination&#44; distended bladder&#44; non-monosymptomatic enuresis&#44; urinary urge&#47;incontinence&#44; and bowel and bladder dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The controversy on the use of episodes of urinary tract infection as a CAKUT indicator is quite intense&#44; but it appears that some situations represent a higher probability of association with CAKUT&#46; Age younger than 2 years and high fever &#40;higher than 38&#46;3<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; are the factors that can predict urological abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Finally&#44; another evidence that is relevant to allow for the early diagnosis of congenital nephropathy is blood pressure&#46; It is known that hypertension is more common in children with nephropathy and&#44; conversely&#44; that blood pressure control has an effective therapeutic response by slowing CKD progression in children&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> These associations reinforce the importance of the recommendation of blood pressure measurement in children&#44; which should be performed in all pediatric visits&#44; from the age of 3 years onwards&#44; and in children younger than 3 years in the presence of any of the following situations&#58; &#40;a&#41; preterm birth&#44; low birth weight or neonatal complications requiring admission to the neonatal intensive care unit&#59; &#40;b&#41; congenital heart diseases&#59; &#40;c&#41; urinary tract infection&#44; hematuria&#44; or proteinuria&#59; &#40;d&#41; known kidney disease or urologic malformations&#59; &#40;e&#41; family history of congenital kidney disease&#59; &#40;f&#41; solid organ transplantation&#59; &#40;g&#41; malignancies or bone marrow transplantation&#59; &#40;h&#41; systemic diseases associated with hypertension&#59; and &#40;i&#41; evidence of high blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Antenatal ultrasonographic alterations</span><p id="par0100" class="elsevierStylePara elsevierViewall">The use of ultrasonography in the monitoring of pregnancy and neonates began in the late 1970s&#46; Currently&#44; gestational ultrasonography is part of the medical routine in most countries&#44; with at least two examinations during pregnancy to monitor fetal development and identify possible malformations&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> Gestational ultrasonography greatly improved the diagnosis and prognosis of children with CAKUT&#44; reaching a level of sensitivity for the detection of obstructive uropathies between 80&#37; and 90&#37;&#46; In a European study conducted in 12 countries&#44; the sensitivity to renal malformation detection was 81&#46;2&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Hydronephrosis is the ultrasonographic finding most often identified and described&#46; Antenatal hydronephrosis is the presence of one or both kidneys with some degree of pyelocalyceal system dilation in the fetus&#46; The diagnosis is attained through obstetric ultrasonography&#44; using as the main parameter the anteroposterior diameter &#40;APD&#41; of the renal pelvis and the presence of caliectasis&#46; There is hydronephrosis when the pelvis APD is above certain limits&#44; but there is no consensus on the definition of these limits yet&#46; The most frequently cited values&#44; above which there is a greater risk of renal function deterioration or need for surgery&#44; are those proposed by the Society for Fetal Urology &#40;SFU&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> which are summarized in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The highest positive predictive value &#40;PPV&#41; is found in the examination performed in the third trimester of pregnancy&#46; The PPV for APD values &#62;7<span class="elsevierStyleHsp" style=""></span>mm in the third trimester is 69&#37; vs&#46; 49&#37; for APD<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mm in the second trimester&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> The reported incidence of fetal disease varies from 1&#37; to 5&#37; of pregnancies&#44; depending on diagnostic criteria&#59; it is more frequent in boys &#40;3 to 4&#47;1&#41; predominantly unilateral&#44; and only 20&#37; of cases will have postnatal clinical significance&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Another ultrasonographic finding that is important for the diagnosis and prognosis of children with CAKUT is the hydronephrosis classification proposed by the SFU&#44; which is based on the degree of pyelocalyceal dilation and also takes parenchyma integrity into account&#46; Grade 0 represents a normal ultrasonography&#59; the other grades are shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">This classification system was developed for ultrasonography performed after birth&#46; However&#44; it has been applied to antenatal ultrasonography&#44; and there is evidence that children with grades 3 and 4 of hydronephrosis have increased risk of need for surgery and renal function deterioration&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Regardless of the classification of hydronephrosis&#44; the postnatal follow-up of children with images of hydronephrosis detected during the gestational period shows resolution in approximately 50&#37; of cases&#44; caliectasis with no obstructive factor including extrarenal pelvis in 15&#37;&#44; ureteropelvic junction stenosis in 11&#37;&#44; vesicoureteral reflux in 9&#37;&#44; megaureter in 4&#37;&#44; multicystic dysplastic kidney in 2&#37;&#44; ureterocele in 2&#37;&#44; renal cysts in 2&#37;&#44; and posterior urethral valve in 1&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">25&#8211;27</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Other imaging findings obtained at the gestational ultrasonography that help with the diagnosis and prognosis of children with CAKUT and are also associated with renal function deterioration are&#58; &#40;a&#41; the finding of single kidney&#44; in which case 1&#47;3 of the affected individuals has associated CAKUT&#44;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">28&#44;29</span></a> &#40;b&#41; hydronephrosis associated with other anomalies&#44; when the probability of CKD at 2 years of age is 15&#37; vs&#46; only approximately 2&#37; in children with isolated hydronephrosis<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> and &#40;c&#41; bilateral hydronephrosis&#44; which represents a risk of renal function deterioration that is 9&#46;4-fold higher than cases with unilateral alteration&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In addition to the aspect and degree of hydronephrosis&#44; other ultrasonographic findings should be taken into account&#44; such as&#58; &#40;a&#41; ureteral dilatation&#44; which is present in megaureter&#59; ureterovesical-junction stenosis&#44; posterior urethral valve&#44; and absent in the ureteropelvic junction stenosis&#59; &#40;b&#41; kidney size&#44; which can be affected in renal hypo&#47;dysplasia&#44; or even in hydronephrosis&#59; &#40;c&#41; bladder size and bladder wall thickness&#44; with or without formation of trabeculae&#44; alterations that may be present in the hypertrophic or hypotonic bladder&#59; &#40;d&#41; increased post-voiding residual urinary volume&#44; associated with poor bladder function&#59; and &#40;e&#41; ureterocele&#44; usually present in ureteral duplicity&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a></p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">This study aimed to review the medical literature to list the main clinical data that might be useful in pediatric practice for the early identification of patients with CAKUT&#46; This diagnosis is important&#44; since CAKUT are the most common cause of CKD in children&#46; In the present epidemiological scenario&#44; characterized by a decrease in morbidity and mortality secondary to infectious diseases&#44; chronic diseases in general &#40;and particularly CKD&#41; have become more important in clinical practice&#44; which should become even more prominent with time&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Current evidence shows that CKD has its origins in intrauterine life&#44; and at present it is known that the number of nephrons in each kidney can vary greatly between individuals&#44; and that a lower number of kidney functional units increases the risk of CKD and cardiovascular disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">33&#44;34</span></a> This consideration is even more important in children with urinary system development abnormalities&#44; in which nephrogenesis is often disturbed&#44; resulting in a lower number of nephrons&#46; These findings anticipate to the pediatric range the moment of greatest interest to attain an early diagnosis of patients at risk for CKD&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The time to perform this diagnostic search should be as early as possible&#44; preferably before birth&#46; It is known that even in situations where well-organized follow-up services are available&#44; incomplete adherence of families to the necessary procedures for diagnostic research is a frequent phenomenon&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Some countries seek the early diagnosis of risk for CKD using compulsory programs of urinary sediment tests or imaging assessment at certain ages&#44;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">36&#44;37</span></a> but the cost-effectiveness analyses of such programs never conclusively demonstrated that this initiative was advantageous&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> In a situation such as this one&#44; clinical evaluation is an invaluable resource to screen which patients should be studied through more detailed laboratory tests&#46; This strategy appears to be particularly accurate in countries with limited resources in the health care area&#46; In Brazil&#44; with the exception of the Southeast region&#44; the unknown cause is the most common diagnosis of advanced CKD in children&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> suggesting that there is an important gap to be filled in order to better categorize the diagnosis of CKD&#46; It is plausible that many children reach the final stage of the CKD evolution without having access to diagnosis of CAKUT&#44; which is the most important cause of this disease worldwide&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A noteworthy observation in this review was that there are no studies with a robust methodology to provide answers based on solid evidence about the subject&#46; Most of the reviewed studies were descriptive and single-centered and&#44; therefore&#44; the findings summarized herein must be considered as preliminary data&#46; Warning signs for the identification of children with CAKUT are summarized in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The authors believe that&#44; even with the methodological limitations of the reviewed studies&#44; the suggestions can help pediatricians to establish clinical hypotheses for the early diagnosis of abnormalities of the genitourinary tract development&#44; by using clinical data and information from the gestational ultrasonography&#44; without resorting to expensive and invasive methods&#46; As there are no prospective data to evaluate which clinical signs and symptoms listed here are more important to identify the risk&#44; the authors believe that&#44; for the moment&#44; the occurrence of any of them should be an indication to investigate children regarding the possible existence of CAKUT&#44; as early as possible&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Subsidies for the diagnosis of congenital abnormalities of the kidneys and urinary tract"
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                0 => array:2 [
                  "identificador" => "sec0025"
                  "titulo" => "Associated malformations"
                ]
                1 => array:2 [
                  "identificador" => "sec0030"
                  "titulo" => "Important past medical history and clinical signs and symptoms"
                ]
                2 => array:2 [
                  "identificador" => "sec0035"
                  "titulo" => "Antenatal ultrasonographic alterations"
                ]
              ]
            ]
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          "identificador" => "sec0040"
          "titulo" => "Conclusions"
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        7 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicts of interest"
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        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-01-15"
    "fechaAceptado" => "2016-01-15"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec803716"
          "palabras" => array:4 [
            0 => "Urinary tract malformations"
            1 => "Chronic kidney disease"
            2 => "Early diagnosis"
            3 => "Child"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec803715"
          "palabras" => array:4 [
            0 => "Malforma&#231;&#227;o do trato urin&#225;rio"
            1 => "Doen&#231;a renal cr&#244;nica"
            2 => "Diagn&#243;stico precoce"
            3 => "Crian&#231;a"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The abnormalities of the genitourinary tract development are the leading cause of chronic kidney disease &#40;CKD&#41; in children&#46; The diagnosis of this disease in Brazil is late and incomplete&#44; which results in increased morbidity and mortality in this age group&#46; Early diagnosis of this condition is the prerogative of generalist pediatricians&#44; and the aim of this study was to review the clinical signs and symptoms associated with developmental abnormalities of the genitourinary tract&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data sources</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Based on the description of a symbolic clinical case&#44; the authors conducted a non-systematic review of medical literature&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Data synthesis</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The results suggest that the following data should be used as a warning for early diagnosis of affected children&#58; &#40;a&#41; combined urinary tract abnormalities &#40;chromosomal abnormalities&#59; sequence of malformations &#91;VACTERLand Prune-Belly&#93;&#59; and musculoskeletal&#44; digestive tract&#44; heart&#44; and nervous system malformations&#41;&#59; &#40;b&#41; previous history &#40;congenital anomalies of the kidney and urinary tract &#91;CAKUT&#93; in the family&#44; low birth weight&#44; and oligoamnios&#41;&#59; &#40;c&#41; clinical signs &#40;polyuria&#47;nocturia&#44; urinary tract infection&#44; systemic arterial hypertension&#44; failure to thrive&#44; weak urinary stream&#44; difficulty to start urination&#44; distended bladder&#44; non-monosymptomatic enuresis&#44; urinary&#47;urge incontinence&#44; and bowel and bladder dysfunction&#41;&#59; and &#40;d&#41; pre- and postnatal ultrasonographic alterations &#40;increased anteroposterior diameter of the renal pelvis&#44; mainly in the third trimester of pregnancy&#59; single kidney&#59; hydronephrosis associated with other abnormalities&#59; and hydronephrosis with parenchymal involvement in the post-neonatal assessment&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The suggestions shown here can help the pediatrician to establish clinical hypotheses for the early diagnosis of developmental abnormalities of the genitourinary tract without resorting to expensive and invasive procedures&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Data sources"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Data synthesis"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">As anormalidades do desenvolvimento do trato geniturin&#225;rio s&#227;o a principal causa de doen&#231;a renal cr&#244;nica &#40;DRC&#41; em crian&#231;as&#46; O diagn&#243;stico dessa doen&#231;a no Brasil &#233; formulado de maneira incompleta e tardia&#44; o que resulta em aumento na morbi-mortalidade nessa faixa et&#225;ria&#46; O diagn&#243;stico precoce dessa condi&#231;&#227;o &#233; prerrogativa dos pediatras generalistas e o objetivo desse trabalho foi revisar os sinais e sintomas cl&#237;nicos associados &#224;s anormalidades do desenvolvimento do trato geniturin&#225;rio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fontes dos dados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A partir da descri&#231;&#227;o de um caso cl&#237;nico simb&#243;lico&#44; realizamos uma revis&#227;o n&#227;o sistem&#225;tica da literatura m&#233;dica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">S&#237;ntese dos dados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Os resultados sugerem que os seguintes dados devem ser utilizados como alerta para o diagn&#243;stico precoce das crian&#231;as acometidas&#58; a&#41; anomalias do trato urin&#225;rio compostas &#40;anomalias cromoss&#244;micas&#44; sequ&#234;ncias de malforma&#231;&#245;es &#8211; VACTERL e Prune-Belly&#44; malforma&#231;&#245;es musculoesquel&#233;ticas&#44; do trato digestivo&#44; card&#237;acas e do sistema nervoso&#41;&#44; b&#41; antecedentes &#40;anomalias cong&#234;nitas do rim e trato urin&#225;rio &#40;CAKUT&#41; na fam&#237;lia&#44;baixo peso ao nascer e oligo&#226;mnio&#41;&#44; c&#41; sinais cl&#237;nicos &#40;polaci&#250;ria&#47;noct&#250;ria&#44; infec&#231;&#227;o urin&#225;ria&#44; hipertens&#227;o arterial sist&#234;mica&#44; baixo ganho de peso&#44; jato urin&#225;rio fraco&#44; dificuldade para iniciar a mic&#231;&#227;o&#44; bexigoma&#44; enurese n&#227;o monossintom&#225;tica&#44; urge&#47;incontin&#234;ncia urin&#225;ria&#44; disfun&#231;&#227;o do intestino e da bexiga&#41;e d&#41; altera&#231;&#245;es ultrassonogr&#225;ficas ante e p&#243;s-natais &#40;di&#226;metro &#226;ntero-posterior da p&#233;lvis renal aumentado principalmente no terceiro trimestre da gesta&#231;&#227;o&#44; rim &#250;nico&#44; hidronefrose associada a outras anomalias e hidronefrose com comprometimento de par&#234;nquima na avalia&#231;&#227;o p&#243;s-neonatal&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">As sugest&#245;es apresentadas podem ajudar o pediatra a estabelecer hip&#243;teses cl&#237;nicas para o diagn&#243;stico precoce das anormalidades do desenvolvimento do trato geniturin&#225;rio sem utiliza&#231;&#227;o de metodologias caras e invasivas&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Fontes dos dados"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "S&#237;ntese dos dados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Nogueira PC&#44; Paz IP&#46; Signs and symptoms of developmental abnormalities of the genitourinary tract&#46; J Pediatr &#40;Rio J&#41;&#46; 2016&#59;92&#40;3 Suppl 1&#41;&#58;S57&#8211;63&#46;</p>"
      ]
    ]
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Stage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GFR &#40;mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney damage with normal or increased GFR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney damage with mild decrease in GFR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#8211;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney damage with moderate decrease in GFR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#8211;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kidney damage with severe decrease in GFR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#8211;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;15&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Classification of chronic kidney disease stages&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AD&#44; autosomal dominant&#59; AR&#44; autosomal recessive&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Renal differentiation abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Renal dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Renal mass abnormalities</td><td class="td" title="table-entry  " align="left" valign="top">Renal agenesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal hypoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Shape and position abnormalities</td><td class="td" title="table-entry  " align="left" valign="top">Supernumerary kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ectopic kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Horseshoe kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Upper urinary tract abnormalities</td><td class="td" title="table-entry  " align="left" valign="top">Pelvis and ureter duplication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ureteropelvic junction stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Congenital megaureter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Lower urinary tract abnormalities</td><td class="td" title="table-entry  " align="left" valign="top">Ureterovesical junction stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Posterior urethral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bladder agenesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bladder exstrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neurogenic bladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Cystic kidney diseases</td><td class="td" title="table-entry  " align="left" valign="top">Isolated kidney cyst&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multicystic dysplastic kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AD polycystic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AR polycystic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spinal cysts &#8211; nephronophthisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Congenital abnormalities of the kidneys and urinary tract&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">VSD&#44; ventricular septal defect&#59; ASD&#44; atrial septal defect&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Modified from Stoll et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a></p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Chromosomal abnormalities &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>119&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Trisomy 18 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trisomy 21 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trisomy 13 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Turner syndrome &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Non-chromosomal associations &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>168&#41;</td><td class="td" title="table-entry  " align="left" valign="top">VACTERL &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meckel-Gruber &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prune-Belly &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown associations &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>276&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Skeletal muscle tissue &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>97&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Polydactyly&#47;syndactyly &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shortening of limbs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Digestive tract &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>91&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Anal atresia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pathological rotation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Cardiac malformations &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>88&#41;</td><td class="td" title="table-entry  " align="left" valign="top">VSD &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASD &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Nervous system &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Spina bifida &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Encephalocele &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Microcephaly &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Head and neck &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>53&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Facial dysmorphia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertelorism &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Respiratory system &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Pulmonary hypoplasia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Abdominal wall &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Omphalocele &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastroschisis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>29&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Cleft lip &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diaphragmatic hernia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1351920.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Malformations associated with CAKUT found in 346&#44;381 cases in France from 1979 to 2004 &#40;total of 1678 CAKUT&#44; of which 563 had other associated malformations&#41;&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Severity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Second trimester&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Third trimester&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 to &#60;7<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 to &#60;9<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 to &#8804;10<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 to &#8804;15<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;15<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1351919.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Antenatal hydronephrosis classification according to the anteroposterior diameter of the renal pelvis&#46;</p>"
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      4 => array:8 [
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">SFU&#44; Society of Fetal Urology&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SFU &#8211; grade 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SFU &#8211; grade 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SFU &#8211; grade 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SFU &#8211; grade 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="201702240038198501"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201702240038198502"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201702240038198503"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201702240038198504"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal sinus with urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Filled pelvis with dilated major calyces&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uniform dilation of major and minor calyces&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Parenchymal thinning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1351916.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Graphic representation and classification of the ultrasonographic alterations in hydronephrosis &#40;adapted from Timberlake &#38; Herndon<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a>&#41;&#46;</p>"
        ]
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      5 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at6"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">US&#44; ultrasonography&#59; APD&#44; anteroposterior diameter&#59; UTI&#44; urinary tract infection&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Perinatal history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Associated malformations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low birth weight<br>Intrauterine growth restriction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nocturia<br>Polyuria<br>Pollakiuria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chromosomal aberrations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oligoamnios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>Urge-incontinence<br>Bowel and bladder dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sequences &#40;VACTERL&#47;Prune-Belly&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prematurity<br>US with increased APD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><br>Non-monosymptomatic enuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Musculoskeletal tissue<br>Digestive system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">US with thinning of the parenchyma<br><br>US with single-kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak urinary stream<br>Difficulty to start urination<br><br>Distended bladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congenital heart defects<br><br>Nervous system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Failure to thrive<br>Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">US with small kidneys&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UTI with fever in patients &#60;2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pulmonary hypoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 00217557
Original language: English

DOI:10.1016/j.jped.2016.01.006

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Year/Month	Html	Pdf	Total

2024 November	4	3	7
2024 October	28	23	51
2024 September	42	42	84
2024 August	55	49	104
2024 July	50	36	86
2024 June	40	32	72
2024 May	42	21	63
2024 April	39	29	68
2024 March	43	25	68
2024 February	37	21	58
2024 January	58	25	83
2023 December	57	28	85
2023 November	68	40	108
2023 October	57	40	97
2023 September	47	38	85
2023 August	25	20	45
2023 July	17	15	32
2023 June	19	13	32
2023 May	18	12	30
2023 April	21	8	29
2023 March	26	22	48
2023 February	15	18	33
2023 January	18	24	42
2022 December	21	26	47
2022 November	19	30	49
2022 October	32	35	67
2022 September	25	24	49
2022 August	29	23	52
2022 July	22	26	48
2022 June	17	20	37
2022 May	22	26	48
2022 April	55	30	85
2022 March	27	28	55
2022 February	16	23	39
2022 January	11	16	27
2021 December	13	22	35
2021 November	12	15	27
2021 October	7	6	13
2021 September	9	9	18
2021 August	7	10	17
2021 July	2	4	6
2021 June	1	1	2
2021 May	9	16	25
2021 April	16	7	23
2021 March	17	14	31
2021 February	5	2	7
2021 January	6	12	18
2020 December	10	6	16
2020 November	10	13	23
2020 October	8	6	14
2020 September	10	9	19
2020 August	3	3	6
2020 July	2	6	8
2020 June	9	5	14
2020 May	3	4	7
2020 April	4	11	15
2020 March	6	4	10
2020 February	7	9	16
2020 January	8	8	16
2019 December	4	3	7
2019 November	6	8	14
2019 October	5	11	16
2019 September	8	6	14
2019 August	7	11	18
2019 July	12	8	20
2019 June	6	11	17
2019 May	15	10	25
2019 April	15	11	26
2019 March	9	10	19
2019 February	5	8	13
2019 January	9	10	19
2018 December	14	16	30
2018 November	18	5	23
2018 October	94	15	109
2018 September	60	20	80
2018 August	6	9	15
2018 July	8	9	17
2018 June	6	3	9
2018 May	6	5	11
2018 April	8	3	11
2018 March	10	0	10
2018 February	3	3	6
2018 January	5	4	9
2017 December	3	1	4
2017 November	6	0	6
2017 October	13	3	16
2017 September	10	2	12
2017 August	3	0	3
2017 July	0	1	1
2017 June	5	14	19
2017 May	3	3	6
2017 April	1	2	3
2017 March	1	10	11
2017 February	5	4	9
2017 January	3	3	6
2016 December	5	5	10
2016 November	3	13	16
2016 October	9	13	22
2016 September	17	2	19
2016 August	19	4	23
2016 July	20	8	28
2016 June	7	9	16
2016 May	14	14	28
2016 April	14	9	23
2016 March	6	5	11

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