Antenatal nephrology – a personalised approach to counselling and risk stratification

Kidney and urinary tract anomalies are among the most common problems diagnosed antenatally, with congenital anomalies of the kidneys and urinary tract accounting for around half of chronic kidney disease in children. Fetal medicine diagnostics have advanced greatly over recent decades, particularly through improvements in ultrasound imaging and broad access to antenatal care for women. As a result, paediatric nephrologists are increasingly having counselling conversations related to kidney disease before a child is born.Paediatricians, fetal medicine specialists, nephrologists and urologists have relatively few diagnostic tools available prenatally. These include antenatal imaging, biomarkers, genetic information and clinical history. The majority of antenatal diagnoses and risk stratification are based on antenatal ultrasound findings, but there is increasing availability of genetic testing and the potential for more non-invasive genetic testing in the future with the expansion of non-invasive prenatal testing for monogenic disorders.There is a limited evidence base for antenatal nephrology prognostication, but the three main antenatal imaging factors that predict postnatal kidney outcomes are amniotic fluid volume (1), kidney echotexture and kidney size. These factors not only help guide prognostication and counselling conversations but also help determine which fetuses may benefit from antenatal interventions such as vesico-amniotic shunting (2).Additional information to support evidence-based antenatal nephrology counselling can be found in published registry studies. While such registries typically include only neonates who survive after birth, they provide valuable information about kidney outcomes, particularly the likelihood of needing kidney replacement therapy during childhood (3). Where specific disorders or genetic diseases are confirmed antenatally, disease-specific registry data can provide additional information to help personalise antenatal counselling discussions. However, it is imperative that any registry data are considered in the context of their denominator and that the antenatal counselling conversation is adapted and personalised to the diagnostic information available for that specific case.Antenatal counselling requires the healthcare professional to convey uncertainties to a family at what may be the most challenging time of their lives (4). Where there are antenatal decisions to be made by the family, it is imperative that a non-directive approach to counselling is taken. There is evidence that what healthcare professionals want to impart during antenatal counselling is often different from what prospective parents are most interested to hear (5), and therefore careful tailoring of both the volume and content of information is critical to ensure a personalised, family-centred approach. For the most challenging cases, a multidisciplinary approach is essential, including fetal medicine, nephrology, urology, neonatology and other specialties such as clinical genetics or palliative care, where appropriate. While an antenatal counselling conversation may stay with a healthcare practitioner for weeks or months, it is likely to stay with the family forever.