Renal Problems In Children Notes

Renal Problems in Children

Urinary Tract Infections

• UTI’s are common

  • Occur in 4% of girls

  • 1% of boys

• 90% are due to infection with E.Coli

• A UTI may indicate a congenital abnormality or vesicoureteric reflux, which if left untreated may lead to renal failure

Underlying causes

• Obstructed urinary system

  • Pelviureteric obstruction

  • Urinary stenosis

  • Posterior urethral valves (in boys with poor urinary stream)

  • Duplex kidney with obstructed pole

• Vesicoureteric reflux

  • Retrograde flow of urine from bladder up ureters to renal pelvis

• Poor hygiene

  • Kept in wet nappies

  • Wiping back to front

• Constipation

  • Results in poor bladder emptying

• Idiopathic

History

• Ask about nonspecific fever, irritability + vomiting esp. in infants

• Is there dysuria, frequency or bedwetting?

• Are there signs of pyelonephritis such as loin pain, vomiting or systemic illness?

• Ask about constipation and fluid intake

Examination

• UTI can present with prolonged jaundice, septic shock or failure to thrive in the neonatal period

• Is there any tenderness in abdomen or over the kidneys?

• Check for palpable kidneys and bladder

• Always check for BP to exclude secondary renal impairment

• Examine the spine to exclude neurogenic bladder

• Examine the urine

  • Leukocytes, protein + nitrites on dipstick test

  • MC+S (protein, RBC and organisms on microscopy and gram stain)

• Abnormal crystals may suggest renal stone disease

Investigations

Urine tests

• Pure culture of >10 x 5 CFU wth > 50 white cells per high power view on microscopy confirms a UTI

• Sterile pyuria can occur in any febrile illness or in renal tuborsclerosis or inflammation

• A mixed growth or growth without white cells suggests contamination

• Any organisms seen in suprapubic aspirate sample = infection

Imaging

• Renal USS to look for hydronephrosis, anatomical abnormalities and renal cortical damage

• NICE guidelines

  • < 6 months

  • Recurrent UTIs - 1 major (systemic upset) + 1 minor or 3 minors in 1yr

  • Unusual infections e.g proteus

• KUB xray if ? stones

• DMSA isotope scan to look for renal scarring

• DTPA/mag3 isotope scan to assess obstruction (preferred over IVU)

• In infants a micturating cystogram is also performed to exclude post. Urethral valves and to look for vesicoureteric reflux

Treatment

• Trimethoprim

  • 5 day course

  • Prophylactic night dose may be required for recurrent UTIs

• If signs of systemic illness/pyelonephritis – IV abx

  • Gentamycin = 1^st line

• Analgesia may be necessary to relieve pain

• Treat any constipation

• Give advice on good hygiene and maintaining a high fluid intake

Renal Anomalies

• Congenital renal anomalies (8 per 1000 births) account for >50% of al congenital abnormalities picked up on antenatal ultrasound

• < 5 % will have long term renal complications

Solitary kidney

= Unilateral renal agenesis

• Providing other kidney appears otherwise normal on USS – no further action required

Ectopic kidney

• Due to abnormal migration during embryogenesis there may be a pelvic or horseshoe kidney

• Associated with Turner’s Syndrome

• Due to risk of obstruction, these children need investigating with a Mag-3 isotope scan and DMSA scan to look for ectopic renal tissue

Multicystic Dysplastic Kidney

• 1 in 4500

• Due to ureteric bud anomaly or proximal ureteric atresia

• Kidney is non-functioning on DMSA scan

• Usually involutes and disappears by school age

• Slight increase risk of later malignant transformation

Polycystic Kidney Disease (PKD)

• Autosomal dominant

  • Small cysts throughout kidney

  • Associated with ovarian cysts, berry...

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