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