Theme of lectures.

1. Theme of lectures. Anatomy-physiological featuresof renal system in children. Semiotics of lesion, clinical manifestation. Acute renal failure. Medical care of the child with renal failure. Doc. Nykytyuk S.

2. Normal Kidneys and Their Function

3. EMBRIOLOGY 11-15 days since fertilization-mesoderm 21-25 days-pronephros develops aliantois appears 26-30 days-mesonephros appears 31-35 days- metanephros begins to develop 51-55 days-mesonephros degenerate 56-60 days- anal portion of cloacal membrane reptures

4. The kidneys are a pair of bean-shaped organs • that lie on either side of the spine in the lower middle of the back. Each kidney weighs about ¼ pound and contains approximately one million filtering units called nephrons. Each nephron is made of a glomerulus and a tubule. The glomerulus is a miniature filtering or sieving device while the tubule is a tiny tube like structure attached to the glomerulus.

5. The kidneys are connected to the urinary bladder by tubes called ureters. Urine is stored in the urinary bladder until the bladder is emptied by urinating. The bladder is connected to the outside of the body by another tube like structure called the urethra.

6. The main function of the kidneys is to remove waste products and excess water from the blood.

7. 1. Renal pyramid 2. Efferent artery  3. Renal artery 4. Renal vein 5. Renal hylum 6. Renal pelvis 7. Ureter 8. Minor calyx 9. Renal capsule 10. Inferior renal capsule 11. Superior renal capsule 12. Afferent vein  13. Nephron 14. Minor calyx 15. Major calyx 16. Renal papilla 17. Renal column

9. Renal structure and physiology The structural and functional unit of the kidney is the nephron, which is composed of a complex system of tubules, arterioles, venules, and capillaries. The nephron consists of: • Bowman's capsule, enclosing the capillary tuft of theglomerulus, which is joined successively to the proximalconvoluted tubule, • Henle's loop, • the distal convoluted tubule, • the straight or collecting- duct.

10. Fibrous system of renal Fibrous connective tissue (lig.hepatorenale, lig. lienorenale, lig. duodenorenale) Renal vessels Adipose tissue Renal fascia

11. Renal function • Maintaining the electrical, chemical, concentration and acid-basebalances and the integrity and volume of body fluids at a constant level. • Elimination of metabolic by-products and unessential chemicalsdissolved in water (desintoxication). • The production of certain humoral substances:

12. erythropoietic stimulating factor (ESF, or erythrogenin), whichacts on a plasma globulin to form erythropoietin; renin, which is secreted by the kidneys in response to reducedblood volume, decreased blood pressure, or increased secretionof catecholamines; renin stimulates the production of angiotensins, which producearteriolar constriction and an elevation of blood pressureand stimulate the production of aldosterone by the adrenalcortex. calcitriol, the active form of vitamin D, which helps maintain calcium for bones and for normal chemical balance in the body Humoral substances:

13. These functions are based on 3 processes that provide the urine production: • Processing (ultrafiltration) the blood plasma. • Reabsorption of the most part of fluid and electrolytes fromthe primary urine by the renal tubules. • Excretion of certain substances into the tubular urine.These processes are dynamic, and what is excreted as waste in one moment may be retained as precious in the next.

14. Kidneys play an important part in a child's growth and health. They • remove wastes and extra water from the blood • regulate blood pressure • balance chemicals like sodium and potassium • make a hormone that signals bone marrow to make red blood cells • make a hormone to help bones grow and keep them strong

15. The peculiarities of kidney function in early infancy • Glomerular filtration rate is low and does not reach adult values until the child is between 1 and 2 years of age • There is a large variation in the tubular length between nephrons, although glomerular size is less variable. • The juxtaglomerular nephrons show more advanced development than cortical nephrons. • The concentrating ability of the newborn kidney does not reach adult levels until about the third month of life. • Adequate amounts of antidiuretic hormone are secreted by the newborn pituitary gland, other factors appear to interfere with water reabsorption.

16. The peculiarities of kidney function in early infancy • Urea synthesis and excretion are slower during this time. • The newborn retains large quantities of nitrogen and essential electrolytes in order to meet needs for growth in the first weeks of life. • Consequently the excretory burden is minimized. • The lower concentration of urea, the principal end product of nitrogen metabolism, reduces concentrating capacity, since it also contributes to the concentration mechanism. • Newborn infants are unable to excrete a water load at rates of older persons.

17. The peculiarities of kidney function in early infancy • Hydrogen ion excretion is reduced. • Acid secretion is lower for the first year of life. • Plasma bicarbonate level is low • As a result of these inadequacies of the kidney and less efficient blood buffers, the newborn is more liable to develop severe acidosis.

18. The peculiarities of kidney function in early infancy • Sodium excretion is reduced in the immediate newborn period, and the kidneys are less able to adapt to deficiencies and excesses of sodium. • An isotonic saline infusion may produce edema because the ability to eliminate excess sodium is impaired. Conversely inadequate reabsorption of sodium from tubules may compound sodium losses in disorders such as vomiting or diarrhea. • Infants have a diminished capacity to reabsorb glucose and, during the first few days, to produce ammonium ions.

19. Anatomo- physiological perculiarities of urinary system Kidneys • - has biggest sizes than in adults • -situated more lower • -has very thin fibrous capsule, absence of fat parietal fat capsule in newborns; • -bad fixation of kidneys leads to physiological mobility of them in newborns period to 1,5-2,0 sm and in children under 7 years 1-1.5 sm

20. Renal pelvis • - has biggest sizes in newborns and children under 1 year • -bad developed walls and physiological hypotonia under 7 years; • -different forms, branches; • All perculiarities helps to retention of urine- inflamation process.

21. Ureters • They are more wide more big unders 7 years (dilated lengthenedureteres) • Has the presenes of physiological kinks (twists), when it is situated near the pelvis big vassels. • bad development of muscls lear under 3 years • Wrinkled mucus to the and of 1 year.

22. Urethral canal, urethra • Is more wide, short in children under 3 years - external urethral meatus is opened in girl 3 yeas

23. Urinary bladder Situated more upper (in children under 3 years can be find in public redion of the abdomen) can be palpate) • poor development of vascules elastic tissue under 6 years • Ureteric mouth (orifice) are commonly opened. That’s why in very often developed vesicoureteric reflux, ureteric torsion. Very good developments vascularisation of bladder mucose, leads to development inflammation process of the ureter.

24. Kidney channels More shorts, has small diameter than in adult especially in the peripheral parts of the kidney

25. Capacity of the urinary bladder Newborn 30ml 1 year 35-50 ml 1-3year 50-90 ml 3-5 year 100-150ml 5-9 year 200ml 9-12 year 200-300 ml till 400 ml

26. Morphological peculiarities Kidney (renal) glomerulus The differentiation of glomerulusis not ended at all They have small sites The structure of epithelium – is cylindrical All peculiarities leads to small filtrate surface of glomerulus.

27. Glomerular filtration (filtrative function is more lower) - poor reabsorbtive function • poor water pass function • Small ability to concentrate urine • The physiological urine acid- infarction of kidney in newborns • Physiological anuria in newborn • Great frequency at urination after 3-5 days of life.

28. Localization of kidney. • Newborn – in the level I - V thoracic vertebras. • Older children - X thoracic and IV lumbal vertebras.

29. Length of the ureter newborn– 6-7 sm 1 year – 10 sm 4 year – 15 sm Older of 4 yearandadult – 20-28 sm

30. Urethral canal Short urethra A littlemucousandelastictissue Wideurethra in a girl

31. Daily diuresis 1 month – 200-300 ML 1 Year – 600 ML In children 1-10 yearsfor theEMPIRICAL FORMULE: 600 + 100 (N – 1),N – years of this child Children, older 10 years, have daily diuresis, as adults – 1700-2000 ML

32. Volume of urination Newborn – 10-15 ml 6 month – 30 ml 1 year – 60 ml 3-5 years – 90-100 ml 7-8 years – 150 ml 10-12 years – 250 ml

33. Specific gravity of urine Newborn 1006-1012 1-12 month – 1002-1006 2-5 years – 1009-1016 10-12 years – 1012-1025

34. Investigation of the child with urinary pathology: General condition. 2. Activity. 4.Skin ( color, dryness,). 5. Mucous of the mouth ( state, color). Sizes and form of abdomen. 7. Changes of activity during diuresis.

35. Patients complaints and methods of physical examination The examination of kidneys is impossible without laboratory urine tests. So in this chapter the data of physical examination and interpretation of urine tests will be located together for conve­nient use. All symptoms in case of kidney disorders are divided into renal and extrarenal. Renal symptoms are such clinical signs that directly show on the disorders of kidneys and any part of the collecting system. They are lumbar region pains (costovertebral angle tenderness, flank pain), dysuria and syndrom of urine changes.

36. Only children after 2 years can complain on lumbar region pains, because in this age cortex tissue and renal capsule reach their mature form. The "kidney" pain is caused by expanded capsule. This pain can be found by palpation of kidneys and by Pasternatskiy's sign. Very often children 2 till 5 years of age complain on abdominal pain in case of renal problems. In infants "kidney" pain can be evident as constant squirming, irritability.

37. 1 - expansion of calyces and renal pelvis; 2 - expansion of capsule; 3 - compression of receptors; 4 - renal ischemia; 5 - refluxes. Causes of "kidney"pain:

39. Dysuria means problems with urination. This term is most often used like a synonym to painful urination, but it also includes such changes as: • frequent or infrequent voiding; • urinary urgency; • incomplete voiding; • enuresis.

40. Symptoms of Kidney Disease Changes in Urination Kidneys make urine, so when the kidneys are failing, the urine may change. How? • to get up at night to urinate. • Urine may be foamy or bubbly. Urinate more often, or in greater amounts than usual, with pale urine. • Urinate less often, or in smaller amounts than usual with dark colored urine. • Urine contain blood. • Feel pressure or have difficulty urinating.

41. Symptoms of Kidney Disease Swelling Failing kidneys don't remove extra fluid, which builds up in body causing swelling in the legs, ankles, feet, face, and/or hands. Fatigue Healthy kidneys make a hormone called erythropoietin that tells body to make oxygen-carrying red blood cells. As the kidneys fail, they make less erythropoietin. With fewer red blood cells to carry oxygen, muscles and brain become tired very quickly.

42. Symptoms of Kidney Disease Skin Rash/Itching Kidneys remove wastes from the bloodstream. When the kidneys fail, the buildup of wastes in blood can cause severe itching. Metallic Taste in Mouth/Ammonia Breath A buildup of wastes in the blood (called uremia) can make food taste different and cause bad breath. Stop liking to eat meat, or Losing weight.

43. Symptoms of Kidney Disease Nausea and Vomiting Loss of appetite can lead to weight loss. Feeling Cold Anemia can make feel cold all the time, even in a warm room. Dizziness and Trouble Concentrating Anemia related to kidney failure means that brain is not getting enough oxygen. This can lead to memory problems, trouble with concentration, and dizziness.

44. Symptoms of Kidney Disease Leg/Flank Pain Some children with kidney problems may have pain in the back or side related to the affected kidney. Polycystic kidney disease, which causes large, fluid-filled cysts on the kidneys and sometimes the liver, can cause pain.

45. What are the causes of kidney failure in children? Kidney failure may be acute or chronic. Acute diseases develop quickly and can be very serious. Although an acute disease may have long-lasting consequences, it usually lasts for only a short time and then goes away once the underlying cause has been treated. Chronic diseases, however, do not go away and tend to get worse over time. When the kidneys stop working, doctors use a treatment called dialysis to remove waste products and extra water from patients with chronic kidney failure.

46. Acute Kidney Diseases • Acute kidney disease may result from an injury or from poisoning. Any injury that results in loss of blood may reduce kidney function temporarily, but once the blood supply is replenished, the kidneys usually return to normal. Other kinds of acute kidney disease in children are Hemolytic uremic syndrome. This rare disease affects mostly children under 10 years of age and can result in kidney failure. Eating foods contaminated by bacteria leads to an infection in the digestive system, which in the first stages causes vomiting and diarrhea. When these symptoms subside, the child is still listless and pale. Poisons produced by the bacteria can damage the kidneys, causing acute kidney failure. Children with hemolytic uremic syndrome may need blood transfusion or dialysis for a short time. Most children, however, return to normal after a few weeks. Only a small percentage of children (mostly those who have severe acute kidney disease) will develop chronic kidney disease.

47. Nephrotic syndrome. A child with this syndrome will urinate less often, so the water left in the body causes swelling around the eyes, legs, and belly. The small amount of urine the body makes contains high levels of protein. Healthy kidneys keep protein in the blood, but damaged kidneys let it leak from the blood into the urine. Nephrotic syndrome can usually be treated with prednisone to stop protein leakage, and sometimes a diuretic is used to help the child urinate and reduce the swelling. Usually, the child can take smaller and smaller doses of prednisone and eventually return to normal with no lasting kidney damage. This temporary condition is called minimal change disease. Relapses are common but usually respond to prednisone treatment.

48. Chronic Kidney Diseases • Unfortunately, the conditions that lead to chronic kidney failure in children cannot be easily fixed. Often, the condition will develop so slowly that it goes unnoticed until the kidneys have been permanently damaged. Treatment may slow down the progression of some diseases, but in many cases the child will eventually need dialysis or transplantation.

49. Chronic Kidney Diseases • Birth defects. Some babies are born without kidneys or with abnormally formed kidneys. The kidney abnormality is sometimes part of a syndrome that affects many parts of the body.

50. Agenesia Aplasia Duplication Polycystosis Dystopia Hypoplasia Dysplasia