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Implementation of a standardized clinical pathway in a dedicated posterior urethral valves clinic: short-term
Mandy Rickard1, Armando J Lorenzo2,3, Juliane Richter2
1Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, 555 University Avenue, Toronto, ON, Canada. mandy.rickard@sickkids.ca.
Insights
Implementing a posterior urethral valves (PUV) clinic and standardized pathway improved infant kidney outcomes. This approach led to earlier diagnoses, interventions, and medication initiation, reducing the time to nadir creatinine.
Area of Science:
- Pediatric Urology
- Nephrology
- Medical Management
Background:
- Posterior urethral valves (PUV) are a common cause of bladder outlet obstruction in male infants.
- Standardized management pathways are crucial for optimizing short-term kidney outcomes in infants with PUV.
Purpose of the Study:
- To evaluate the impact of a dedicated PUV clinic and standardized management on short-term renal outcomes in infants.
- To assess improvements in diagnostic timing, surgical intervention, and medical management.
Main Methods:
- A retrospective study comparing 50 infants with PUV, divided into pre-clinic (BPUV) and post-clinic (APUV) implementation groups.
- Data collected included age at diagnosis and surgery, type of intervention, medication use, nadir creatinine levels, and development of chronic kidney disease (CKD).
Main Results:
- The APUV group showed significantly higher rates of prenatal diagnosis and earlier initial surgical intervention compared to BPUV.
- Standardized management in the APUV group led to earlier initiation of alpha-blockers and anticholinergics.
- Nadir creatinine was reached at an earlier age in the APUV group, with fewer patients progressing to advanced CKD.
Conclusions:
- A specialized PUV clinic with a standardized pathway effectively expedites postnatal management.
- This integrated approach improves prenatal detection, facilitates timely surgical and medical interventions, and positively impacts short-term kidney function in infants with PUV.
Background:
To determine if the implementation of a posterior urethral valves (PUV) clinic and standardized management pathway improves the short-term kidney outcomes of infants with PUV.
Methods:
From 2016-2022, 50 consecutive patients were divided into groups after the implementation of the clinic (APUV, n = 29) and before (BPUV, n = 21) during a comparable timeframe. Assessed data included age at initial visit, timing and type of surgery, frequency of follow-up visits, medications, nadir creatinine, and development of CKD/kidney failure. Data are shown as median with interquartile range (IQR) and odds ratios (OR) with 95% confidence interval (CI).
Results:
APUV had higher rates of prenatal diagnoses (12/29 vs. 1/21; p = 0.0037), earlier initial surgical intervention (8 days; IQR 0, 105 vs. 33 days; IQR 4, 603; p < 0.0001), and higher rates of primary diversions (10/29 vs. 0/21; p = 0.0028). Standardized management led to earlier initiation of alpha blockers (326 days; IQR 6, 860 vs. 991; IQR 149, 1634; p = 0.0019) and anticholinergics (57 days; IQR 3, 860 vs. 1283 days; IQR 477, 1718; p < 0.0001). Nadir creatinine was reached at earlier ages in APUV (105 days; IQR 2, 303 vs. 164 days; IQR 21, 447; p = 0.0192 BPUV). One patient progressed to CKD5 in APUV compared to CKD3, CKD5 and one transplant in BPUV.
Conclusion:
Implementing the PUV clinic with standardized treatment expedited postnatal management and resulted in a higher number of cases detected prenatally, a shift in primary treatment, younger ages at initial treatment, reduced time to nadir creatinine, and timely initiation of supportive medications. A higher resolution version of the Graphical abstract is available as Supplementary information.
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