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Urinary system

Urinary system. Department of Pediatrics Soochow University Affiliated Children’s Hospital. You should have an understanding of :. The management of urinary tract infections The investigation of a child with proteinuria The investigation of a child with haematuria

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Urinary system

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  1. Urinary system Department of Pediatrics Soochow University Affiliated Children’s Hospital

  2. You should have an understanding of : • The management of urinary tract infections • The investigation of a child with proteinuria • The investigation of a child with haematuria • The basic symptoms and signs suggestive of renal failure, and have a working overview of its management.

  3. World Kidney Day • March 9th 2006 was the first WKD and then the second Thursday on march will be anniversary for kidney diseases. • About 10% population involved Chronic Kidney disease (CKD) in USA • About 100 million CKD in china • ¼ of the total medical cost

  4. Introduction :background • Effective management of the patient with renal disease is dependent upon establishing an accurate diagnosis. • The clinician must be aware of the possible presentations of renal diseases and gather these symptoms and signs which form recognized diseases and syndrome • What is the possible presentations suggesting renal problem ?

  5. Clinical presentation of renal disease • The patient is asymptomatic, but an abnormality has been detected on clinical or laboratory examination which indicates an underlying renal disorder. • The patient complains of a symptom or has a physical sign which directly or indirectly indicates underlying renal diseases • The patient has a systemic disease which is known to be associated with renal involvement • The patient has a family history of an inherited renal disorder.

  6. Symptoms of urinary tract disease • A fever; dysuria; frequency; loin pain/abdominal pain; urinary inconsistency;offensive smelling;cloudy urine; • Proteinuria : frothy urine • Haematuria: Smokey urine

  7. Signs of urinary tract disease Dysmorphic syndromes; Anemia; Oedema; High blood pressure; Renal masses; Distended bladder.

  8. Congenital abnormalities • Renal agenesis : Potter facies : • Maldevelopment : ectopic kidneys; horseshoe kidneys; renal hypoplasia; dysphasia • Polycystic kidney disease: ADPKD; ARPKD • Hydronephrosis and hydroureters • Vesiocoureteric reflux:

  9. Presentations of urinary tract anomalies: • Recurrent Urinary tract infection • Recurrent abdominal pain • Palpable mass • Haematuria • Failure to thrive • Dysmorphosis：Potter syndrome: Characteristic facies, Postural deformities

  10. Urine tract infection 尿路感染

  11. Introduction: • UTI is the most common problem involving the urinary tract in childhood • Affecting up to 1% of boys and 2 % girls • As many as 25% of those with recurrent UTIs develop renal scarring, especially if VUR is also present. • The risk of renal scarring is particularly great in infancy and can result in hypertension and chronic renal failure

  12. Causes of UTIs • Gram-negative Escherichia coli (85%), Klebsiella spp, Proteus spp, Pseudomonas spp • Gram-positive bacteria streptococcus faecalis, Staphylococcus Saprophyticus • Viruses • Mycoplasma • Fungi Candida spp.

  13. Predisposing factors for urinary tract infection • Renal factors: congenital anomalies; Vesicoureteric reflux; Urinary obstruction and stasis; Urinary calculi (hypercalciuria); Bladder dysfunction • Other factors: chronic constipation; sexual abuse; immunosuppressant; diabetes mellitus

  14. Diagnosis of UTI-- How to Collect a clean specimen of urine? Clean catch midstream Clean void urine Suprapubic puncture Bladder Catheterization Bag collection

  15. Diagnosis • Confirmation of diagnosis requires culture of a pure growth of a single pathogen of at least 108 colony-forming units per liter of urine or 105 CFU/ml • A positive nitrite stripe test is a reliable test for coliform infection • The presence and absence of pyuria and leukocyte esterase is an unreliable guild.

  16. UTI –further investigations obstruction • Renal function • Urea and electrolytes • Ultrasound: excluding congenital anomalies, dilation , obstruction, calculi • A plain abdominal x-rays : excluding spinal anomalies and small calculi • DMSA: scarring • DTPA or MAG3: differential renal function, obstruction • MCUG: vesicoureteric reflux (VUR) • IVU: obstruction , hydronephrosis

  17. . [99Tcm]DMSA scan showing the effect of reflux into a lower moiety of a duplex kidney on the left and a lower pole scar in the right kidney.

  18. Vesiocoureteric reflux • VUR is a common problem in childhood • Always with UTI • Caused by lower ureteric sphincter incompetence, sometimes as a results of malinsertion of ureter into the bladder • Varying degrees of Hydronephrosis and hydroureters • Renal scarring with recurrent urinary infections

  19. The indirect vesicoureteric reflex study shows positive reflux on the right side using [99Tcm]DTPA. (a) Premicturation; (b) right-sided reflux at the initiation of micturation; (c) further reflux as the bladder empties; and (d) rapid drainage partially to refill the bladder. .

  20. Management of UTI --Antibiotics: • 7 day course of trimethoprim, first generation cephalosporin or nitrofurantoin • Infants should be given with intravenosus antibiotics aggressively such as gentamicin and cefotaxime • Prophylactic trimethoprim (single night dose ) under 4 yrs old until investigation finished

  21. Indications for antibiotic prophylaxis 1.First UTI prior to investigation; 2.Recurrent UTI; 3.Reflux; 4. Renal tract anomalies; 5.Renal scars; 6.Compromised renal function

  22. Management of UTI –reflux surgery • Recurrent breakthrough infection • Persistence of reflux • Development of scars on DMSA • Deteriorating renal function • Underlying renal tract anomalies

  23. Proteinuria

  24. Estimation of proteinuria • Not more than 150mg/24hrs • Comprises 60% albumin and 40%T-H protein • A good estimate is obtained by calculating Up/Ucr (normal <0.5 and 0.2 g/g in infants and older children, respectively) • Proteinuria in excess of 1000mg in 24 hours: pathologic

  25. Benign proteinuria • Transient proteinuria <1 g/ 24hrs : exercise or intercurrent febrile illnesses • Orthostatic proteinuria : positive at daytime while negative in night time ** require long-term monitoring of blood pressure, renal function, protein loss.

  26. Pathological proteinuria Acquired Congenital Tubular Tubular necrosis tubular acidosis Interstitial nephritis cystinosis Toxins(heavy metals) Wilson’s disease Drugs Galactosaemia(半乳糖血症） Glomerular Nephrotic syndrome congenital NS glomerulonephritis Drugs Toxins(heavy metals)

  27. Summary • Urinary tract infection • Haematuria: Poststreptococcal glomerulonephritis • Proteinuria: Nephrotic syndrome • Renal failure

  28. Homework • The investigation of a child with haematuria • The basic symptoms and signs suggestive of renal failure, and have a working overview of its management.

  29. Reference • Pediatrics: Mosby’s crash course, edited by Christine Budd & Mark Gardiner • Pediatrics: 6th edited by 杨锡强 • Pediatrics:/edited by Simon Attard montalto. • Practical Pediatric Nephrology / editors Man Chun Chiu and Hui Kim YAP

  30. Thank you for your attention !!!

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