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How is the urinary system of the child different than that of of adult?
- – Newborn urine production: approx. 1-2ml/kg/hr
- – Child urine production: approx. 1 ml/kg/hr
- Nephrons continue to grow in size and function until approximately 2 years of age (although all nephrons are present at birth) --> Initial renal function is not as effective-->Risk for dehydration is heightened & Renal metabolism/excretion of drugs is affected by decreased creatinine clearance/GFR
What are some normal pediatric values for GU labs?
- Spec gravity: 1.001 -1.035 (reported as "ten-oh-one or then-thirty-five")
- Protein < 20 mg/dL (trace)
- Ketones, sugars, leukocytes, WBCs should all = 0.
Primary vs. secondary enuresis?
- Primary: Bed has never been "dry."
- Secondary: New "wet" episodes have been preceded by 6-12 months of dry bed.
What are some physical etiologies of enuresis?
Physical: decreased bladder capacity, UT abnormalities, neurologic alterations, obstructive sleep apnea, constipation, UTI, pinworms, DM
What are some emotional etiologies of enuresis?
Emotional: increased stress due to family disruption, pressure during toilet training, inadequate attn to voiding cues, sexual abuse
Tx of enuresis?
- • Limiting fluids after dinner
- • Frequent voiding
- • Imagery training
- • Reward systems
- • Behavioral conditioning
- • Medications
- – Imiprimine, DDAVP (Vasopressin)
What is the most common pathogen associated with UTI?
E. coli. (80%)
What are some not-so-obvious predispositions to getting UTIs?
- Congenital urinary tract obstructions
- Individual susceptibility, ie steriod use, cancer pt./immunosupressed.
- Reflux. Not to be confused with GERD. This is when urine backs up into the ureters and into kidneys. Has nothing to do with the stomach or esophagus.
What are the SnSs associated with upper and lower tract UTI?
- lower: none.
- upper: fever, chills, flank pain.
How do UTIs present differently in infants vs. toddlers?
- Nonspecific, fever or hypothermia in neonate
- change in urine odor or color
- poor weight gain
- feeding difficulties
- Abdominal or suprapubic pain
- voiding frequency and
- new or increased incidence of enuresis
What is Acute pyelonephritis?
- Inflammation caused by bacteria, fungi, protozoa, or viruses that infect the kidneys
- Usually infection is via ascending urethral route (like UTI)
- Preexisting factors (usually)
- – Vesicoureteral reflux (flow of bladder urine into the ureters)
- – Dysfunction of lower urinary tract function like an obstruction or stricture.
SnSs of Acute Pyelonephritis?
- • Vary from mild to “classic” to very severe
- • Presenting symptoms (more systemic)
- – N/V, anorexia, chills, nocturia, frequency, urgency
- – Suprapubic or low back pain, dysuria
- – Fever, hematuria, foul-smelling urine
- • Costovertebral tenderness (CVA)
- • Symptoms often subside in a few days without therapy
- – Bacteruria and pyuria still persist
What is Cryptorchidism?
- • Undescended or hidden testes
- Occurs when one or both testes fail to descend through the inguinal canal into the scrotal sac
- Incidence higher in premature and LBW infants since levels of Testosterone dictate the descent of the testes
- Most infants will have spontaneous descent in the first year of life
Hypo vs. Epispadias
- Hypo: Under-side (ventral) of penis.
- Epi: top side (dorsal) of penis.
What part of the skin is used to repair hypo/epispadias?
The foreskin. Don't throw away before Sx repair!
What is von Wilm's Tumor?
- Also called “nephroblastoma.”
- Malignant renal and intraabdominal tumor of childhood. Not actually in the kidnesy, but proximity can cause renal dysfunction.
- Occurs three times more in African American children
- Peak age of diagnosis is 3 years
- More frequent in males
Interesting things about Wilm's Tumor your should probably be aware of:
- • Arises from malignant undifferentiated
- primordial cells
- • More prevalent in the left kidney
SnSs of Wilm's Tumor?
- Abdominal swelling or mass
- – Firm, nontender and confined to one side -->
- – **Do not palpate abdomen unless absolutely necessary or risk rupture!
- Hematuria (due to pressure exerted against kidneys)
- Fatigue/malaise (due to disrupted function of adrenal gland)
- Weight loss
- Manifestations resulting from compression of tumor mass
What is the Tx and prognosis for child with Wilm's Tumor?
- • Treatment
- – Surgical Removal
- – Chemotherapy and/or Radiation
- • Prognosis
- – Survival rates are among the highest for childhood cancers
- – Localized: 90% cure
What is Acute Post-Steptococcal Glomerulonephritis?
- Occurs as an immune reaction to a group A-beta-hemolytic streptococcal infection of the throat or skin. (Does not actually invade the kidney FROM the throat or skin!)
- Most frequent in children age 5 to 12
- Clinical symptoms usually develop 1-2 weeks after initial strep infection
SnSs of Actue Post-Steptococcal Glomerulonephritis?
- • Hematuria (gross or microscopic)
- • Proteinuria
- • Oliguria
- • Generalized edema due to ineffective filtration. (Begins with periorbital, then progresses to lower extremities and then to ascites)
- • HPTN
- • Mild Anemia due to v production of erythorpoitine in kidneys.
What is the prognosis for pt with Actue Post-Streptococcal Glomerulonephritis?
- – 95% -rapid improvement to complete recovery
- – 5%-15%-chronic glomerulonephritis
- – 1%-irreversible damage
What nutritional guidance do you want to give a pt. recovering from Acute Post-Streptococcal Glomerulonephritis?
- – Low sodium
- – Low to moderate protein
What is Nephr-O-tic Syndrome?
- • Most common presentation of glomerular injury in children
- • Etiology: Not fully understood, but glomerular membrane for some reason becomes waaaaaay permiable to proteins so body starts waisting it.
- • Characteristics
- – Massive proteinuria!
- – Hypoalbuminemia
- – Edema, progressing to severe
- – Usually has normal or even low BP
- • Why? Low blood volume because fluids are third-spacing like crazy.
Tx for pt with Nephr-O-tic Syndrome?
- • Diet
- – Low to moderate protein (to ^ oncotic pressure)
- – Sodium restrictions (to v fluid retention. Trying to reabsorb fluids back into the vasculature.
- • Steroids
- – Prednisone is the drug of choice
- – 2mg/kg divided into BID doses
- • Diuretics (with manitol--> ^oncotic pressure) to v fluid volume in vasculature in order to encourage movement from 3rd spaces into vasculature.
What is Acute Renal Failure?
- Sudden, severe loss of kidney function
- Kidneys can no longer filter waste products, regulate fluid volume, or maintain chemical balance
- • Etiology
- – Most common cause in children: HUS (Hemolytic Uremic Syndrome).
- – Other potential causes:
- – Prerenal: dehydration, hypotension, septic shock, renal artery obstruction
- – Intrarenal: nephrotoxins (aminoglycosides, contrast media)
- – Post-renal: structural abnormalities, tumors
What is Hemolytic Uremic Syndrome?
- • Most common cause of acquired acute renal failure in children
- • Occurs primarily in infants and small children
- – Between 6 months to 5 years
- • Thought to be associated with bacterial toxins, chemicals and viruses
- – Coxsackie virus, echovirus, and adenovirus
- – Also some cases due to E.Coli
- • 1996 - Odwalla juice prior to pasteurization
What is the pathology of HUS?
SnSs of HUS
- The triad of anemia, thrombocytopenia and renal failure is significant for diagnosis
- Vomiting, irritability, lethargy
- Marked pallor, oliguria or anuria
- CNS involvement (due to toxins not be filtered)
- – Seizures
- – stupor
- Hemorrhagic manifestations (due to platelet agregation--> thrombocytopenia and v platelet count).
- – Bruising
- – Petechiae
- – Jaundice (hemolysis--> ^bilirubin which can't be excreted because of renal failure.)
- – Bloody diarrhea
Tx of ARF/HUS?
- • Early diagnosis and aggressive!
- • Treat ARF and Hemolytic anemia
- – Dialysis (hemo, peritoneal)
- – Blood transfusions
- • FFP (clotting factors)
- • Packed RBCs
What is Chronic Renal Failure?
- • Irreversible loss of kidney function that occurs over months to years
- • Progresses to ESRD (End Stage Renal Disease)
- • Initial symptom
- – Polyuria with very dilute urine (because of incompetent nephrons in young children), then --> oliguria and anuria
- • Culminate in “uremia”
- – Urine in the blood
What are some possible causes of Chronic Renal Failure?
- – Congenital anomalies are most common
- – Reflux associated with recurrent UTIs
- – Chronic pyelonephritis
- – Chronic glomerulonephritis
- – HUS
Management of Chronic Renal Failure?
- • Manage diet, hypertension, recurrent infections, seizures, electrolyte disturbances, fluid retention
- • Dialysis
- – Peritoneal is the preferred method for children
- – Abdominal cavity acts as a semi-permeable membrane for filtration
- – Warmed solution enters the peritoneal cavity by gravity, remains for a period of time before removal (dwell time)
- – Can be managed at home in some cases
Tell me your thoughts on hemodialysis.
- • HemoDialysis: Requires creation of vascular access and special dialysis equipment
- – Best suited for children who can be brought to the facility --3 times/week for 4 to 6 hours
- – Achieves rapid correction of F/E imbalance
- • Transplant