Renal Disorders in Children

1. Renal Disorders in Children

2. Hypospadias • Urethral opening of male is located below the glans or underneath the penile shaft • Incidence 1 out of 300 live births • Cause unknown • Familial tendency • Website1 and Website 2 with hypospadias repair

3. Chordee • Ventral curvature of the penis • Often accompanies more severe forms of hypospadias • Foreskin may be absent ventrally • Hooded or crooked appearance of penis • Surgical repair

4. Surgical Repair • Objectives of repair • Enhance ability to void standing up w/straight stream • Improve physical appearance of genitalia for psychological reasons • Preserve sexually adequate organ • Repair best done between 6-18 mos • Before develops body image and castration anxiety • Nursing care: • Prepare parents w/simple explanations • Stent may be placed, but Catheter care essential– discharge instructions • Increase PO fluids • Loose clothing, no straddle toys, swimming, tub baths, rough play or sandboxes

5. Renal Development in Peds • Fluid larger % of total body wt. • GFR not adult level til 1-2 yrs. • Short loop of Henle in newborn • Less efficient first 2 yrs. • No bladder control first 2 yrs. • Smaller bladder capacity • Newborn production about 1 to 2 mL/kg/hr • Child production about 1 mL/kg/hr • Shorter urethra

6. Lab & Diagnostic Tests • Routine UA • Specific gravity • pH • BUN and Cr • IVP • VCUG • Ultrasounds • Angiography

7. Normal Urinalysis • pH 5 to 9 • Sp gr 1.001 to 1.035 • Protein <20 mg/dL • Urobilinogen up to 1 mg/dL • WBC’s: 0—5 • NONE OF THE FOLLOWING: • Glucose – RBCs • Ketones – Casts • Hgb – Nitrites

8. UTI Classification • Upper Tract: Pyelonephritis, VUR, Glomerulonephritis • Typically causes fever, chills, flank pain • Lower Tract: Urethritis, Cystitis • No systemic manifestations • E. coli causes about 80%

9. Upper and Lower Tract UTIs

10. Urinary Tract Infections • Typical Symptoms: (box 30-1, p. 1140 9th ed. Hockenberry) • Dysuria • Frequent urination (>q2h), foul-smelling urine • Urgency • Suprapubic discomfort or pressure • Urine may contain visible blood or sediment (cloudy appearance) • General malaise, poor feeding or appetite, vomiting, fussiness/irritability. • Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)

11. Pediatric Manifestations • Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia • Frequency • Fever in some cases • Odiferous urine • Blood or blood-tinged urine • Sometimes no symptoms except generalized sepsis • Dx: Hx, PE, UA & culture

12. UTI Collaborative Care: Drug Therapy—Antibiotics • Uncomplicated cystitis: short-term course of antibiotics • Complicated UTIs: long-term treatment • Trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim) or nitrofurantoin (Macrobid) • Amoxicillin, Cephalexin, Gentamycin • Eliminate cause, ID contributing factors

13. Teaching • Enc. freq. voiding & complete emptying • ↑ fluid intake • Acidify urine (cranberry juice, Vit. C)-present research does NOT support the efficacy of this. pH needs to be at 5.0 or < in order to have a significant impact on e.coli. (P. 1145) • Avoid bubble baths, hot tubs, whirlpools • No tight panties or nylon • Good hygiene; wipe front to back • Void after sexual activity • Avoid Constipation

14. Vesicoureteral Reflux (VUR) • Urine swept up ureters w/each void then empties back into bladder (p. 1269) • ↑s chance for infections - most common cause of pyelonephritis in children • Scarring by 5-6 yrs • Dx: ultrasound; cystography; VCUG • Tx: continuous low dose antibiotics w/freq urine cultures

15. Acute Glomerulonephritis • APSGN most common – 10-14 days after strep infection (skin or throat) • Inflammation of glomeruli; damage by antigen-antibody complex • ↓ GFR & renal bld flow → HTN & edema • Most common s/s: HTN—monitor regularly, edema (periorbital), hematuria/proteinuria • Daily wt – IMPORTANT • Maintain fluid balance & treat HTN • Loop diuretics or anti-hypertensives may be used • 1st sign of improvement-- ↑ urine & ↓ wt.

16. NephroticSyndrome • Glomerular injury → massive proteinuria, hypoalbuminemia, hyperlipemia, edema • Other s/s: wt. gain, periorbital edema early in day → ankle edema later in day, anorexia, pallor, fatigue, oliguria (dark & frothy) • More common between 2-4 yrs old • Compare APSGN with Nephrotic Syndrome—see chart at end of Ppt.

17. Types • Most common in peds: MCNS • Minimal-Change Nephrotic Syndrome • 80% of cases – cause unknown • Precipitated by viral URI • Secondary: result of glomerular damage • Acute Glomerulonephritis • Collagen Diseases (Lupus) • Drug toxins/poisons/venons • AIDS, sickle cell, hepatitis & others

18. Diagnosis • History of S/S • Labs • Urine • Proteinurea >2 gm/day • Specific gravity ↑ • Blood • ↓ serum protein • Hgb/Hct – nl or slightly ↑ due to hemoconcentration • Platelets ↑ and serum Na+ ↓ • Cholesterol ↑

19. Treatment • Goals: Must try to ↓ excretion of protein & ↓ inflammation • Meds: Corticosteroids till urine is free from protein & normal 10-14 days • Immunosuppressants – Cytoxan • Loop Diuretics – not always effective • During massive edema→ ↓salt • No restriction on water

20. Nursing Considerations • Monitor for infection (esp. peritonitis) • Monitor for side effects of steroids • Monitor wt, I & O, abd. girth • Urinalysis for albumin • Protect skin from breakdown d/t edema • VS for signs of complications • Monitor diet restrictions • Support and educate family

21. Prognosis • If diuresis within 7-21 days – GOOD • If not after 28 days → chance of response ↓ • 80% OK • 50% relapse after 5 yrs • 20% relapse after 10 yrs • Key: early ID and Tx • If responds to steroids, relapse is less