dr.lakshminarayana. content nephrotic syndrome hematuria and investigations uti eneuresis renal...
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Dr.Lakshminarayana
Content Nephrotic syndrome Hematuria and investigationsUTIEneuresis Renal investigations
Nephrotic syndrome
Nephrotic range proteinuria (> 200mg/mmol)
Hypoalbuminaemia (<25 g/l) Oedema
Typical features Atypical features
Age 1- 10 yrs <1 >10 yrs
Normotensive Hypertensive
Normal renal functions Abnormal renal functions
Microscocopic hematuria Macroscopic hematuria
Initial investigation
Blood: FBC, U+E’s; Creatinine; LFT’s; ASOT; C3/C4; Varicella titres
Urine: Urine culture andUrinary protein/creatinine ratio
BP Urinalysis including glucose A urinary sodium concentration can be
helpful in those at risk of hypovolaemia.
Complications 1) Hypovolemia – abdominal pain, unwell,
tachycardia, poor perfusion, High Hb, high urea
2) Peritonitis – difficult to recognise and may be masked due to steroids.
3) Thrombosis – renal, pulmonary and cerebral Veins
Fall in platelets, raised FDP, abnormal PTT, abnormal dopplers
Treatment Strict input out put – Oliguric patients need
fluid restriction.400ml/m2Prednisolone 60mg/m2 – till negative or trace
proteins in urine, then 40mg/m2 on alternate days for 4 weeks
Penicillin prophylaxis Advice on immunisations and contact Teach dipstick technique
Some definitions Remission – trace or no protein on 3 consecutive
daysRelapse – 3+ or more protein on 3 consecutive
daysSteroid resistance- failure of remission for 4 weeksHow often do we check urine :Urine should be checked initially twice weekly, then
weekly after the first episode, and the families instructed to get in contact should a relapse of proteinuria occur, or if there is ++ for more than 1 week.
When to refer to a nephrologist
Age < 1 yr Age > 10-12 yrs Persistent hypertension Macroscopic haematuria Low C3/C4 Failure to respond to steroids within 4 weeks
Hematuria – AGN Hematuria, proteinuria, odema, hypertension
and renal insufficiencySymptoms and signs Macroscopic hematuriaOedemaBreathlessnessHeadaches Weight gain, B.P, JVP, signs of cardiac
failure, oliguria
Management Urine dipU&E,bicarbonate,phosphate,albumin,C3 and
C4 FBCASO, Throat swab Treatment Fluid restrict Monitor BP, weightPenicillin prophylaxis
UTI Common cause of fever Important to recognise this – as implications
for further investigations and management Recognise different urine collection methods History important
Imaging
Recommended imaging schedule for infants youngerthan 6 months
Test Responds well to treatment within 48 hours
Atypical UTI Recurrent UTI
Ultrasound during the acute infection
No Yes Yes
Ultrasound within 6 weeks
Yes No No
DMSA 4–6 months following the acute infection
No Yes Yes
MCUG No Yes Yes
Test Responds well to treatment within 48 hours
Atypical UTI Recurrent UTI
Ultrasound during the acute infection
No Yes No
Ultrasound within 6 weeks
No No Yes
DMSA 4–6 months following the acute infection
No Yes Yes
MCUG No No No
Recommended imaging schedule for infants and children 6 months and older but younger than 3 years
ImagingRecommended imaging schedule for children 3 years and olderTest Responds well
to treatment within 48 hours
Atypical UTI
Recurrent UTI
Ultrasound during the acute infection
No Yes No
Ultrasound within 6 weeks
No No Yes
DMSA 4–6 months following the acute infection
No No Yes
MCUG No No No
Imaging tests: atypical UTIAtypical UTI is defined as any of the
following:
• Seriously ill (for more information refer to ‘Feverish illness in children’ (NICE clinical guideline 47)
• Poor urine flow• Abdominal or bladder mass• Raised creatinine• Septicaemia• Failure to respond to treatment with suitable
antibiotics within 48 hours• Infection with non-E. coli organisms.
18
The Final Urological Diagnosis of 426 live-born Infants with Significant Prenatally Detected Uropathy
British Journal of Urology volume 81 Page 8 - April 1998
19
Grades of HydronephrosisMild hydronephrosis:
Pelvic APD <=1.5 cm and normal calycesModerate hydronephrosis
Pelvic APD > 1.5 cm and caliectasis with no parenchymal atrophy
Severe hydronephrosis:Pelvic APD > 1.5 cm, caliectasis and cortical
atrophy
BJU Inter volume 85 Page 987 - May 2000
20
Prognosis & Severity of ANHPrognosis & severity of hydronephrosis: (%
needed surgery or prolonged follow-up): RPD > 20 mm, 94% RPD 10–15 mm 50% RPD was < 10 mm 3%
Grignon A, Filion R, Filiatrault D, et al: Radiology 1986 Sep; 160(3): 645-7
Outcome of fetal renal pelvic dilatation (Surgery
or UTI): Mild dilation 0% Moderate dilatation 23% Severe hydronephrosis 64%
Ultrasound Obstet Gynecol. 2005 May;25(5):483-8.
Eneuresis• Involuntary wetting during sleep without
any inherent suggestions of frequency of bedwetting or pathophysiology
• Prevalence decreases with age • Causes not fully understood• Treatment has a positive effect on the self-
esteem of children and young people. Healthcare professionals should persist in offering treatments
Inform children and young people with bedwetting and their parents or carers that it is not the child or young person’s fault and that punitive measures should not be used in the management of bedwetting
Principles of care
Assessment and investigation: 1 History taking
Ask about onset of bedwetting, pattern of bedwetting, daytime symptoms, toileting patterns, fluid intake and practical issues.
Assess for comorbidities and other factors that may be associated with bedwetting.
Address excessive or insufficient fluid intake or abnormal toileting patterns before starting other treatment for bedwetting in children and young people (KPI)
Adequate daily fluid intake is important
Advice on fluid intake, diet and toileting patterns
Age Sex Total drinks per day
4 – 8 years FemaleMale
1000 – 1400 ml1000 – 1400 ml
9 – 13 years
FemaleMale
1200 – 2100 ml1400 – 2300 ml
14 – 18 years
FemaleMale
1200 – 2500 ml2100 – 3200 ml
Explain that reward systems with positive rewards for agreed behaviour rather than dry nights should be used either alone or in conjunction with other treatments for bedwetting
• Inform parents or carers that they should not use systems that penalise or remove previously gained rewards
• Advise parents or carers to try a reward system alone for the initial treatment of bedwetting in young children who have some dry nights
Reward systems
Initial treatment: alarms Who to consider
Offer an alarm as the first-line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system, unless the alarm is inappropriate or undesirable.
Alarm may be inappropriate when:• bedwetting is very infrequent (that is, less than
1–2 wet beds per week) • the parents or carers are having emotional
difficulty coping with the burden of bedwetting• the parents or carers are expressing
anger, negativity or blame towards the child or young person
Offer desmopressin to children and young people over 7 years, if:
rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or
an alarm is inappropriate or undesirable
Initial treatment: desmopressin