Perinatal Urinary Tract Dilation — Management Based on Postnatal Ultrasound Risk Stratification — Clinical Pathway: Inpatient, Outpatient Specialty Care and Primary Care

Perinatal Urinary Tract Dilation Clinical Pathway — ICU, Inpatient, Outpatient Specialty Care, Primary Care

Management Based on Postnatal Ultrasound Risk Stratification

Low Risk (P1)

Unilateral or bilateral 10-15 mm

or

Central calyceal dilation
  • Urology
    • Outpatient referral if not already being followed
  • Ultrasound
    • Repeat RBUS at 3 months of age
  • Antibiotics
    • Not recommended if antenatal unilateral low risk (A1)
  • VCUG/CeVUS
    • Not recommended
Intermediate Risk (P2)

Unilateral or bilateral > 15 mm

and

peripheral calyceal dilation
  • Urology
    • Inpatient consult or expedited referral
  • Ultrasound
    • Repeat at 6-12 weeks of age
  • Antibiotics
    • Begin ABX upon discharge (or after US if prolonged hospital stay)
      • Amoxicillin 10 mg/kg PO QD
      • Continue antibiotics until follow-up with urology
  • VCUG/CeVUS
    • Not required, but at discretion of Urology
  • MAG 3/fMRU
    • Recommended at > 6 weeks of age to rule out UPJ obstruction fMRU preferred if abnormal/complex anatomy
  • BMP*
    • Recommended if bilateral dilation (Obtain before discharge. Note reflection of maternal Cr during first week of life. Trend Cr to rule out dysplastic kidneys if elevated)

Unilateral or bilateral > 15 mm

and

Ureters abnormal
  • Urology
    • Inpatient consult or expedited referral
  • Ultrasound
    • Repeat at 6-12 weeks of age
  • Antibiotics
    • Begin ABX upon discharge
      - Amoxicillin 10 mg/kg PO QD
      - Continue antibiotics until follow-up with urology
  • VCUG/CeVUS
    • Recommended to rule out bladder outlet obstruction, severe vesicoureteral reflux.
  • MAG 3/fMRU
    • Consider at > 6 weeks of age if concern for concurrent upper tract obstruction
  • BMP*
    • Recommended if bilateral dilation (Obtain before discharge. Note reflection of maternal Cr during first week of life. Trend Cr to rule out dysplastic kidneys if elevated)
High Risk (P3)

Unilateral or Bilateral > 15 mm

and

peripheral calyceal dilation or parenchymal thickness and appearance abnormal

and

bladder and ureters normal
  • Urology
    • Consult inpatient or expedited referral
  • Ultrasound
    • Repeat at 6-12 weeks of age
  • Antibiotics
    • Begin ABX upon discharge
      • Amoxicillin 10 mg/kg PO QD
      • Continue antibiotics until follow-up with urology
  • VCUG/CeVUS
    • Consider to rule out concurrent VUR, at discretion of Urology
  • MAG 3/fMRU
    • Recommended at > 6 weeks of age
  • BMP*
    • Recommended if bilateral dilation

Unilateral or Bilateral > 15 mm

and

ureters or bladder abnormal
  • Urology
    • Consult Inpatient or immediate referral and possible transfer
      If transfer to CHOP recommended in consultation with urology, call CHOP Transport to be connected with the N/IICU Medical
      Command Physician to arrange transfer.
  • Ultrasound
    • Repeat at 4-6 weeks of age
  • Antibiotics
    • Begin ABX
      • Amoxicillin 10 mg/kg PO QD
      • Continue antibiotics until follow-up with urology
  • VCUG/CeVUS
    • Recommended transfer to CHOP for VCUG to evaluate for bladder outlet obstruction and/or severe vesicoureteral reflux
  • MAG 3/fMRU
    • Consider to rule out concurrent upper tract obstruction
  • BMP*
    • Recommended if bilateral

*Renal dysplasia or abnormal renal function on BMP should be followed by nephrology. Recommend nephrology consult or outpatient follow-up if these findings are present.