Glomerulonephritis Case Presentation

Case of Hematuria in the pediatric population. Working differentials and diagnosis.

1. Paediatrics Case Presentations “When one teaches, two learn” -Robert Heinlein Rhea Marcano~

2. RENAL Case 4

3. History 10 year old boy 3/7 day complaint of “brown urine” Patient known from birth No major illnesses or injuries Active in a band & Cross-country Track Denies drug use & Sexual activity

4. History (cont’d) 2/52 weeks ago, he had 2/7 day of fever & sore throat improved spontaneously, has been well since R.O.S remarkable ONLY for puffy eyes (attributed to late night studying)

5. Physical Examination Afebrile BP 135/90 active & non-toxic in appearance peri orbital edema present urine dipstick:- Specific gravity 1.035 2+ Bloods 2+ Proteins RBC cast by microscopy

6. Quick Review

7. Anatomy Kidney Urethra Bladder Sphincter Ureter Renal Capsule Renal Cortex Renal Medulla Pyramid Ureter Renal Artery & Vein Calyx Interlobar Arteries

8. Physiology Of the Renal System

9. Differentials Please!!!

10. Differentials Rhabdomyolitis secondary to Post viral infection Urinary Tract Infection Pyelonephritis Nephrotic Syndrome

11. Rhabdomyolitis How to diagnose? Tests to determine muscle and kidney health may include determining levels of: • Creatine kinase, which is an enzyme found in the skeletal muscles, the brain, and the heart. • Myoglobin in blood and urine, which is a protein that’s a byproduct of muscle breakdown. • Potassium, which is another important mineral that may leak from injured bone and muscles. • Creatinine in blood and urine, which is a breakdown product created by muscle that’s normally removed from the body by the kidneys. Elevated levels of these substances are signs of muscle damage . Learn More about Rhabdomyolitis http://www.healthline.com/health/rhabdomyolysis#causes3

12. Urinary Tract Infection How to diagnose? Analyze a urine sample Urine Culture CT or MRI (frequent infections) Cystoscopy Learn more about UTI’s: http://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/basics/tests-diagnosis/con-20037892

13. Pyelonephritis How to diagnose? Urinalysis Urine Culture Ultrasound Computerized tomography (CT) Dimercaptosuccinic acid (DSMA) scintigraphy Learn more about Pyelonephritis: https://www.niddk.nih.gov/health-information/kidney-disease/kidney-infection-pyelonephritis

14. Nephrotic Syndrome How to diagnose? Urinalysis Blood Test Biopsy Learn more about nephrotic syndrome: http://www.mayoclinic.org/diseases-conditions/nephrotic-syndrome/basics/tests-diagnosis/con-20033385

15. Nephrotic Syndrome Nephrotic Syndrome is a kidney disorder that causes your body to excrete too much protein in the urine. It is usually caused by damage to the small blood vessels of the Glomeruli that filters blood. It causes oedema in the periorbital area, ankles and feet first and can lead to Anasarca if not properly managed. Nephrotic Syndrome can lead to serious long term health problems and must be managed seriously.

16. Brown Urine Hx. of URTI Fever UTI Pyelo Cross Country Track Rhabdo Fever Resolved Not ill appearing No nitrites on dipstick Periorbital Oedema Nephrotic Syndrome Dipstick protein <3 ?Specific gravity elevated Normal BP elevated specific gravity (1.035) Urine dipstick protein 2+ Afebrile Active & non-toxic Presence of Cast

17. Rhabdomyolitis

18. Laboratory Test to support Diagnosis Elevated Creatinine Kinase >600 (usuaully markedly elevated, can reach up to the 100,000 depending on the extent. Myoglobin in the urine and blood Elevated Potassium (leaked minerals bone and muscle)(Normal 3.6 - 5.2 mmol/L) Creatinine in blood or urine

19. Prognosis Paediatric patients tend to have a better prognosis than adult Have Heme in the urine < 2+ is also associated with a better prognosis (>2+ associated with Acute Renal Failure) 20% of person in the study with heme >2+ had acute renal failure 30-40% of patients in another study developed renal failure, therefore it is safe to say between 1/5 to 2/5 of patients.

20. Signs of Renal Failure Peak CK level higher than 6000 IU/L Dehydration (hematocrit >50, serum sodium level >150 mEq/L, orthostasis, pulmonary wedge pressure < 5 mm Hg, urinary fractional excretion of sodium < 1%) Sepsis Hyperkalemia or hyperphosphatemia on admission Hypoalbuminemia

21. Follow up Care after Diagnosis ABC’s is always first Fluid Resuscitation ( IV fluids should be started immediately with added bicarbonate) with strict input/output charting Place a large bore needle Start with >400ml/hr then titrate till urine output is aleast 200ml/hr (adults), 20ml/kg children, 1-2L/h adolescence, subsequently 2-3 times the maintenance is also a good average Medication (diuretics, bicarbs, underlying illness if one ) ECG if clinical cardiac symptoms/signs present (can be due to electrolyte abnormality)

22. Follow up (cont’d) Dialysis ( last line if Acute Renal Failure occurs or person has impaired kidney function from before) Monitor for Disseminated intravascular coagulation, compartment syndrome, renal failure & hyperkalemia Trend bloods (CK q6-12hrly, LFT, Potassium levels)

23. References http://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/basics/tests-diagnosis/con-20037892 http://www.healthline.com/health/rhabdomyolysis#causes3 https://www.niddk.nih.gov/health-information/kidney-disease/kidney-infection-pyelonephritis http://www.mayoclinic.org/diseases-conditions/nephrotic-syndrome/basics/tests-diagnosis/con-20033385 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043460/ http://www.aafp.org/afp/2009/1115/p1129.html

24. Learning Resources https://www.youtube.com/watch?v=Ioir82UA9x4&list=PLqTetbgey0afTLV4nZaKgPZH0AHuDqLNj https://www.youtube.com/watch?v=KWHasxDRf54 https://www.youtube.com/watch?v=8Mn0IUCTg3U https://www.youtube.com/watch?v=Ioir82UA9x4 http://emedicine.medscape.com/article/1007814-treatment#d6