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Renal

Renal. Dr.Lakshminarayana. Content. Nephrotic syndrome Hematuria and investigations UTI Eneuresis Renal investigations. Nephrotic syndrome. Nephrotic range proteinuria (> 200mg/mmol) Hypoalbuminaemia (<25 g/l) Oedema. Initial investigation.

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Renal

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  1. Renal Dr.Lakshminarayana

  2. Content • Nephrotic syndrome • Hematuria and investigations • UTI • Eneuresis • Renal investigations

  3. Nephrotic syndrome • Nephrotic range proteinuria (> 200mg/mmol) • Hypoalbuminaemia (<25 g/l) • Oedema

  4. 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.

  5. Complications • Hypovolemia – abdominal pain, unwell, tachycardia, poor perfusion, High Hb, high urea • Peritonitis – difficult to recognise and may be masked due to steroids. • Thrombosis – renal, pulmonary and cerebral Veins Fall in platelets, raised FDP, abnormal PTT, abnormal dopplers

  6. Treatment • Strict input out put – Oliguric patients need fluid restriction.400ml/m2 • Prednisolone 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

  7. Some definitions • Remission – trace or no protein on 3 consecutive days • Relapse – 3+ or more protein on 3 consecutive days • Steroid resistance- failure of remission for 4 weeks How 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.

  8. 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

  9. Hematuria – AGN • Hematuria, proteinuria, odema, hypertension and renal insufficiency • Symptoms and signs • Macroscopic hematuria • Oedema • Breathlessness • Headaches • Weight gain, B.P, JVP, signs of cardiac failure, oliguria

  10. Management • Urine dip • U&E,bicarbonate,phosphate,albumin,C3 and C4 • FBC • ASO, Throat swab • Treatment • Fluid restrict • Monitor BP, weight • Penicillin prophylaxis

  11. UTI • Common cause of fever • Important to recognise this – as implications for further investigations and management • Recognise different urine collection methods • History important

  12. Imaging Recommended imaging schedule for infants younger than 6 months

  13. Imaging Recommended imaging schedule for infants and children 6 months and older but younger than 3 years

  14. Imaging Recommended imaging schedule for children 3 years and older

  15. Imaging tests: atypical UTI • Atypical 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.

  16. The Final Urological Diagnosis of 426 live-born Infants with Significant Prenatally Detected Uropathy British Journal of Urology volume 81 Page 8  - April 1998

  17. Grades of Hydronephrosis • Mild hydronephrosis: • Pelvic APD <=1.5 cm and normal calyces • Moderate 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

  18. Prognosis & Severity of ANH • Prognosis & 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.

  19. 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

  20. Principles of care • 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

  21. 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.

  22. Advice on fluid intake, diet and toileting patterns • 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

  23. Reward systems • 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

  24. 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

  25. Initial treatment: desmopressin • 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

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