Pediatric Renal Disorders

For my third year pediatrics rotation at American University of the Caribbean

Transcript

1. PEDIATRIC RENAL DISORDERS CHRISTINE HAWKS
2. URINARY TRACT INFECTIONS
3. URINARY TRACT INFECTIONS Upper UTI (pyelonephritis) vs lower UTI (cystitis)! Most commonly E. coli or other gram-negative rods! 2.4-2.8% of children in the U.S. annually ! May lead to discovery of urinary tract abnormalities
4. URINARY TRACT INFECTIONS Children under 2 years may present with unexplained fever as the only symptom! All ages: vomiting, fever (pyelonephritis)! 0-2 months: jaundice, failure to thrive! 2 months-2 years: abdominal pain, strong-smelling urine
5. URINARY TRACT INFECTIONS 2-6 years: enuresis, dysuria, urgency, frequency ! Older than 6 years: flank pain, enuresis, dysuria, urgency, frequency! Adolescent girls: vaginitis and STIs may present with similar symptoms
6. URINARY TRACT INFECTIONS Urine culture: at least 10,000 CFU/mL in a patient younger than 2 months! Urine culture: at least 50,000 CFU/mL in a patient older than 2 months! Urinalysis: pyuria, bacteriuria, nitrite, leukocyte esterase, blood! Urinary ultrasound and voiding cystourethrography (VCUG): first febrile UTI in patient age 2-24 months
7. URINARY TRACT INFECTIONS Outpatient treatment: ! Oral hydration! Third generation cephalosporin, amoxicillin/ clavulanic acid, or TMP-SMX
8. URINARY TRACT INFECTIONS Admit to hospital:! Signs of urinary tract obstruction! Sepsis! Unable to tolerate oral fluids! Age less than 1 month! Age less than 2 months with fever
9. VESICOURETERAL REFLUX
10. VESICOURETERAL REFLUX Regurgitation of urine from the bladder into the kidneys due to primary or secondary structural abnormalities! Mode of inheritance may be autosomal dominant with variable penetrance! Reported incidence less than 1%
11. VESICOURETERAL REFLUX Asymptomatic! Presentation with a febrile UTI! Complications include pyelonephritis, hydronephrosis, hypertension, chronic renal insufficiency
12. VESICOURETERAL REFLUX Diagnose with voiding cystourethrography (VCUG) or radionuclear cystourethrography (RNC)! Repeat VCUG or RNC every 1-2 years until reflux resolves or is corrected
13. PEDIATRIC VCUG DEMONSTRATING REFLUX
14. VESICOURETERAL REFLUX Low-grade reflux has a high chance of spontaneous resolution! Initial treatment:! Continuous prophylactic antibiotics! TMP-SMX, nitrofurantoin, or amoxicillin! Regular VCUG or RNC
15. VESICOURETERAL REFLUX Surgical correction is indicated for high-grade reflux that does not resolve spontaneously! Ureteral reimplantation has a >95% success rate! Antibiotic prophylaxis can be discontinued after resolution! Continue imaging for 3 years
16. ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS
17. ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS Immunologically mediated complication of group A streptococcal pharyngitis or impetigo! Usually occurs in children 2-12 years old! 95% of cases resolve completely
18. ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS Classic signs are periorbital edema, hematuria, and hypertension 1-3 weeks after streptococcal infection! Some children are asymptomatic or present with edema only! Patients with severe hypertension may present with hypertensive encephalopathy! Headache, vomiting, confusion, convulsions
19. ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS Streptozyme test for 5 different streptococcal antibodies! Urinalysis ! Proteinuria up to 3+! Hematuria ! Hyaline casts! Red blood cell casts
20. ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS Acute phase management! Limited sodium, protein, and fluid intake! Bedrest! Monitoring! Blood pressure and urinalysis every 4-6 weeks for the first 6 months! Blood pressure and urinalysis every 3-6 months until findings have been normal for one year! Hospitalization of patients with anuria or severe hypertension
21. ALPORT SYNDROME
22. ALPORT SYNDROME Progressive hereditary nephritis with sensorineural deafness due to defects in type IV collagen! 3% of children with end-stage renal disease in the US! Mode of inheritance:! X-linked: 85%! Autosomal recessive: 10-15%! Autosomal dominant: Rare
23. ALPORT SYNDROME Persistent microscopic hematuria before age 10! Hematuria may be intermittent in females! Episodes of gross hematuria preceded by upper respiratory infection! Hypertension ! Progressive, bilateral high-frequency hearing loss beginning by early adolescence ! Progressive deterioration of vision due to anterior lenticonus
24. ANTERIOR LENTICONUS
25. ALPORT SYNDROME Renal biopsy! Irregularly thickened and split glomerular basement membrane! Skin biopsy! Absence of alpha-5 collagen chains! Urinalysis! Hematuria! Proteinuria
26. ALPORT SYNDROME ACE inhibitor or ARB in patients with proteinuria! Monitoring of urine protein, creatinine, and serum chemistry:! Yearly with mild or no renal insufficiency! Every 6 months with moderate renal insufficiency! Every 1-3 months with advanced renal failure
27. ALPORT SYNDROME End-stage renal disease! Erythropoietin, vitamin D, antihypertensive therapy, hemodialysis! Renal transplantation! 3-5% risk of anti-GBM nephritis in transplanted kidney
28. NEPHROTIC SYNDROME
29. NEPHROTIC SYNDROME Proteinuria, hyperlipidemia, hypoalbuminemia, and edema due to a number of conditions:! Minimal change nephrotic syndrome: 77%! Focal segmental glomerulosclerosis: 7%! Membranous glomerulonephritis, IgA nephropathy, idiopathic crescentic glomerulonephritis, systemic diseases, drugs, infections
30. NEPHROTIC SYNDROME Most patients undergo remissions and relapses! Mortality rate of 2-5%
31. NEPHROTIC SYNDROME Edema is the most common presenting symptom! Intermittent periorbital edema may be mistaken for allergies! Gross hematuria! Onset is often preceded by a respiratory tract infection or allergic reaction
32. NEPHROTIC SYNDROME Urine studies:! Protein excretion > 40 mg/m2/h! First morning urine protein/creatinine ratio of at least 2-3 mg protein/1 mg creatinine ! Serum albumin! Lipid panel
33. NEPHROTIC SYNDROME Generally treated with corticosteroids! Perform kidney biopsy prior to initiating corticosteroid therapy in these cases:! Patient is younger than 1 or older than 8 years! Findings indicate etiology may be other than minimal change disease
34. NEPHROTIC SYNDROME Home monitoring:! Daily weight! Daily first morning urine protein! Steroid-resistant disease may be treated with cyclosporine
35. PEDIATRIC RENAL DISORDERS CHRISTINE HAWKS