RENAL EMERGENCIES BY AHMED SOLIMAN MD-----

RENAL EMERGENCIES BY AHMED SOLIMAN MD
AKI
GN
NEPHROTIC
HYPERTENSION
UTI

1. 1
R E N A L
EMERGENCIES
S I M P L I F I E D Q U I C K A P PR O A C H E S
AHMED S.A SOLIMAN , MD.
LECTURE OF PEDIATRICS & PEDIATRIC NEPHROLOGY DEPARTEMENT , BENHA UNIVERSITY, EGYPT
PEDIATRIC NEPHROLOGY UNIT IN BENHA UNIVERISITY HOSPITALS , EGYPT
PEDIATIC NEPHROLOGY UNIT IN BENHA CHILLDERN HOSPITAL (BENCH)
PEDIATRIC NEPHROLOGY DIVISION , AL-HADA HOSPITAL , KSA
RENAL EMERGENCIES

2. GENERAL PLAN
RENAL EMERGENCIES
IDENTIFY
Identify and
confirm the main
problems
INTIAL
ASSESSMENT
Rapid check for
obvious causes
and any life
threating
complications
IMMEDIATE
ACTION
Deal with
correctable causes
and life
threatening
complications
SECONDRY
ASSESSMENT
More detailed
evaluation if initial
one was
inconclusive
FINALIZE
YOUR
PLAN
Put your diagnostic
& therapeutic &
follow up plan
2
1 2 3 4 5
EMERGENCIES

3. 3
RENAL EMERGENCIES
S I M P L I F I E D Q U I C K A P PR O A C H
1
KIDNEYINJURY
ACUTE

4. RENAL EMERGENCIES
4
PRE-RENAL
True volume depletion
Ineffective perfusion
Intra-renal vasoconstriction
RENAL
Glomerulonephritis
Vascular
Tubulo-interstialnephritis
Infiltration
Nephrotoxic medications
POST-RENAL
Structural
Crystalluria
Stones
Medications
Oliguria
Volume overload
Uremic encephalopathy
Acid base & electrolytes
disturbance
Hyponatremia
Hyperkalaemia
Hypocalcaemia
Metabolic acidosis
ACUTE
KIDNEY
INJURY
B A S I C S

5. ACUTE
KIDNEY
INJURY
5
RENAL EMERGENCIES
•Blood create >26.5 ummol/l above baseline
•Variable oliguria > 6 hours ( < 0.5 ml/kg/h)
•Cause pattern
•Complication pattern
2-INITIAL ASSESSMENT
•CBC ,CRP , Bone p , urine ( chemistry , microscopy ,
electrolytes , protein . Creatinine ) , CXR (overload) , US .
•Check for obvious pre & post renal causes.
•Check obvious cause pattern (HUS , TLS, HSP, ON top of CKD )
•Check emergent or urgent complications .
Encephalopathy
•Check ABCD (initial support )
•Call PICU ( more support )
•Call nephrology (dialysis )
•Check ABCD
•IV intermittent labetalol 0.2 -1 mg/kg/dose ( max 40 mg ) q 10 –
20 minutes (do not give in CHF OR asthmatics )
•IV Furosemide 2-5 mg/kg/dose (IF over load)
•Call PICU & Nephrology
Fluid volume overload
•Check ABCD & No more fluids
•IV Furosemide 2-5 mg/kg/dose then IV infusion 0.1-1 mg/kg/hour
for 6 hours
•Call PICU & Nephrology
Shock /hypovolemia /dehydration
•Check ABCD
•IV NS bolus 10-20 ml/kg ( could be repeated twice ) over 15-30
minutes (albumin 5% IN CASE of Nephrotic)
•Give packed RBCS if massive HAEMORRAGE
•Initiate broad spectrum antibiotics if sepsis was suspected
Obstructive uropathy
•Insert URINARY catheter
•Call paediatric surgery
Hyperkalaemia
Do ECG
Initiate anti-hyperkalemic
measures
A P
P
R O C H
3
-
IMMEDIATE ACTIONS NEEDED
4-SECONDARY ASSESSMENT STEP
See next
5-FINALIZE YOUR PLAN
See next
Hypertensive emergency
1-IDENTIFY

6. SECONDARY ASSESSMENT
PRESENTATION TITLE
6
GLOMERULAR INSULT
Nephritic –nephrotic , associated systemic
manifestations ( ask for ASOT , C3 , C4 , DS DNA ,ANA
, ANCA , BIOPSY )
VASCULAR INSULTS
HUS pattern ( Review blood film , platelet counts,
blood glucose , pancreatic functions ) ,
INTERSTIAL NEPHRITIS
history of viral infection , medications ,
pyelonephritis ( urine eosinophils +biopsy ) .
TUBULAR INSULT
medications , pigments , contrast , prolonged pre-
renal insult
DO NOT FORGET AKI ON TOP OF CKD
FOCUS ON
INTERNISC & COMBIEND
ACUTE
KIDNEY
INJURY
Renal emergencies

7. FINALIZE YOUR PLAN
PRESENTATION TITLE
7
ACUTE
KIDNEY
INJURY
Renal emergencies
REFERRAL PLAN
Paediatric nephrology
•Intrinsic AKI
•Refractory oliguria ,
overload , acid base &
electrolytes disturbances
•Dialysis
Paediatric ICU
•Hypertensive emergency
•Uremic encephalopathy
•Sever electrolytes & acid
base disturbances
•Pulmonary oedema
Paediatric surgery
•Obstructive uropathy
DIAGNOSTIC PLAN
based on your assessment
THERAPEUTIC PLAN
General: avoid nephrotoxins , infection &
dehydrations , GFR medications adjustment
Monitoring: body weight , UOP , vitals ,volume ,
neuro status BUN , blood creatinine ,electrolytes &
acid base .
Fluids: replace UOP , insensible(400ml/m2) & on
going loss in euvolemic but 50% of UOP if
overloaded ( better given oral )
Complications
•Hyponatremia : dilutional or loss
•Hyperthermia : sodium excess or water loss
•Hyperkalaemia : EKG , antihyperkalemic
•Hypocalcaemia : iv calcium if tetany
•Metabolic acidosis
•Hypertension
Cause treatment
DIALYSIS : indications ?

8. APPLY
8
RENAL EMERGENCIES
REMEMBER
•Identify the problem
•Do your initial assessment
•Is immediate action needed ?
•Do your secondary asessement
•Finalize your plan
Referal
Admission
Diagnostic
Therapeutic
Monitor
General
Fluids
Complications
Specific treatment
Dialysis

9. REFERENCES
9
RENAL EMERGENCIES
AlobaidiR, BasuRK, Goldstein SL, Bagshaw SM. Sepsis-associated acute kidney injury. Semin
Nephrol. 2015;35(1):2–11.
Fortenberry JD, Paden ML, Goldstein SL. Acute kidney injury in children: an update on diagnosis and
treatment. PediatrClin North Am. 2013;60(3):669–688.
Kumar G, Vasudevan A. Management of acute kidney injury. Indian J Pediatr. 2012;79(8):1069–1075.
MerouaniA, FlechellesO, JouvetP. Acute kidney injury in children. Minerva Pediatr. 2012;64
(2):121–133.
Shah SR, TunioSA, Arshad MH, et al. Acute kidney injury recognition and management: a review of
the literature and current evidence. Glob J Health Sci. 2015;8(5):120–124.

10. 10
RENAL EMERGENCIES
HAEMATURIA & GN
S I M P L I F I E D Q U I C K A P PR O A C H
2

11. RENAL EMERGENCIES
11
Gross
HEMATURIA
B A S I C S
KIDNEY TRAUMA
EXTRA-RENAL
•Clotting Disorders
•Thrombocytopenia
•SCA
GLOMERULAR (NEPHROLOGICAL )
•Inherited glomerular disorders
•Glomerulonephritis (GN)
•HUS
EXTRA-GLOMERULAR ( UROLOGICAL )
•UTI
•Hypercalciuria
•Stones
•Urinary Tract Anomalies
•Cystic Kidney
•Tumours
•Exercise (diagnosis of exclusion )
•Nutcrakersyndrome ( rare )
Nephritic Criteria (Oedema , hypertension , oliguria ) , Cola ,
Smoky , Dysmorphic RBCS , RBCS Casts , proteinuria
Initial haematuria ( urethral pathology) while terminal haematuria ( bladder pathology )
HEMODYNAMIC INSTABILITY In
Traumatic Or Extra-renal Causes
HYPERTENSION
emergency or urgency
Fluid volume OVERLOADOR Pulmonary oedema
(Oedema , crepitation , HTN , congested lung in CXR)
AKI& Its other complications
OBSTRUCTIVE UROPATHY

12. RENAL EMERGENCIES
12
Gross
HEMATURIA
A P
P
R O A C H
•RBCS > 5 in centrifugate 0r > 10 in
centrifugated urine sample
•Do not forget other causes of dark urine
1 IDENTIFY
2 INITIAL ASSESSMENT
Check for obvious causes or complications
•Rule out trauma & extra-renal causes
•Glomerular pattern ( HTN, edma, oliguria , preceding
respiratory or skin infection , recurrency , family
history of deafness )
•Urological pattern : absent glomerular pattern ,
urinary symptoms , family history of kidney stones or
urinary tract anomalies
•Is it associated complications(vitals unstable ,
anaemia , AKI , Obstructive Uropathy ) ?
•TakeUrine analysis , culture , urine protein , urine
creatinine , urine calcium , CBC , PT , PTT , Renal &
bone profile , US (KUB) .
3
IMMEDIATE ACTIONS NEEDED
HEMODYNAMIC
UNSTABLE / SEVER
ANAEMIA
•Check ABCD
•IV Fluid Bolus
•Packed Red Cell
HYPERTENSION
•Check ABCD
•IV intermittent labetalol 0.2 -1 mg/kg/dose ( max
40 mg ) q 10 –20 minutes (do not give in CHF OR
asthmatics )
•IV Furosemide 2-5 mg/kg/dose (IF over load)
•Call PICU (ER HTN ) & Nephrology
AKI & ITS OTHER COMPLICATIONS
(see AKI )
OBSTRUCTIVE
UROPATHY
•Trial for urinary catheter
•Call urology
4-SECONDARY ASSESSMENT STEP
5-FINALIZE YOUR PLAN

13. RENAL EMERGENCIES
13
Gross
HEMATURIA
A P
P
R O A C H
5 FINALIZE YOUR PLAN 4-SECONDARY ASSESSMENT
LIKELY GLOMERULAR HAEMATURIA
•ASOT
•Serum complement
•Reticulocytes counts
•Hepatitis markers , serum Ig A
•Anti-DNAse, ANA , ANCA
•Anti-GBM (if pulmonary haemorrhage )
•Test siblings for hematuria
•Audio-screen
•Genetic testing ( inherited glomerular
disorders )
•Kidney biopsy
LIKELY NON GLOMERULAR HAEMATURIA
•Urine calcium / create ratio
•24 hours urine calcium ( if high ca/cr)
•Urine adeno virus culture ( URTI)
•US (KUB)
•Doppler ( NCS )
•HRCT ( stone , and US not conclusive )
ADMISSION CRITERIA
-Acute glomerulonephritis with oedema, hypertension, or oliguria
-Acute kidney injury
-Haematuria associated with an abdominal mass
REFERRAL CRITERIA
•Traumatic haematuria , stones (call urology )
•Bleeding disorders , thrombocytopenia , SCA ( Call Haematology )
•Nephritic Pattern (Call nephrology )
•Classic PSCGN ( general paediatrics )
Post streptococcal GN
•Daily body weight , UOP , renal P
•Fluid & salt restriction
•Moderate to sever hypertension respond to short
course of furosemide And calcium channel blockers
•7 days pencilling ( infection eradication)
•If deteriorating call nephrology
See
GLOMERULO
NEPHRITIS
ALGORISM

14. RENAL EMERGENCIES
14
Gross
HEMATURIA
A P
P
R O A C H
GLOMERULONEPHRITIC DIAGNOSTIC PATHWAY

15. RENAL EMERGENCIES
15
Gross
HEMATURIA
CASES
APPLY
Remember
•Identify
•Check Obvious Causes & Complications
•Immediate Actions Needed ?
•ComplelteYour Evaluation
•Finalize Your Plan
Admission
Referral

16. REFERENCES
16
RENAL EMERGENCIES
Leung JC. Inherited renal diseases. Curr Pediatr Rev. 2014;10(2):95–100.
VanDeVoorde RG 3rd. Acute poststreptococcal glomerulonephritis: the most common acute
glomerulonephritis. Pediatr Rev. 2015;36(1):3–12.
Vogt B. Nephrology update: glomerular disease in children. FP Essent. 2016;444:30–40

17. 17
RENAL EMERGENCIES
PROTEINURIA& NEPHROTIC
S I M P L I F I E D Q U I C K A P PR O A C H
3

18. PROTEIURIA
Definition
RENAL EMERGENCIES
NORMAL
PROTEINURIA NEPHROTIC
440mg /m2/hour
24 hours urine
20200
mg/mmol/l creatinine
Spot urine
Protein/creatinine ratio

19. RENAL EMERGENCIES
19
PROTEINURIA
C A U S E S
•Fever
•Exercise
•Dehydration
•Orthostatic (negative supine)
•Tamm-horfall(newborn )
GLOMERULAR
•Nephritic
•Nephrotic
•Chronic kidney disease (DM , Reduced renal
mass )
•Isolated
TUBULAR
•Fanconi syndrome
•Overflow (Haemoglobinuria , Myoglobinurias & leukaemia)
EFFECT OF PATHOLOGICAL PROTEINURIA
PROGRSSIVE KIDNEY DAMAGE
Nephrotic & non nephrotic
Prolonged proteinuria
HYPOVOLEMIA
hypoalbuminemia
OEDEMA/ANASARCA
Decreased oncotic pressure
ACUTE KIDNEY INJURY
Hypovolemia
INFECTION
•Loss od immunoglobins
•Loss of complement
•Oedema
THROMBOSIS
•Hypovolemia
•Loss of coagulation inhibitors
NEPHROTIC RANGE PROTEINURIA
Objective : identify clinically significant proteinuria
(nephrotic or persistent )
TRANSIENT

20. 01
02
03
04
05
PROTEINURIA
APPROACH
IDENTIFY
ABNORMAL
URINE PROTEIN
NEPHROTIC ?
TRANSIENT /ORTHOSTATIC ?
PERSISTENT
NON-NEPHROTIC
NO ACTION
NEPHROTIC
SYNDROME
APPROACH
OBVIOUS CAUSES ?
NEPHROLOGY
REFERRAL
Yes
Yes
NON-MINIMAL DISEASE CRITERIA

21. RENAL EMERGENCIES
21
Nephrotic
syndrome
C A U S E S
GENETIC –NON SYNDROMIC
IDIOPATHIC
SECONDARY
•Minimal change NS : MCD (80%)
•Focal segmental : FSGS (8%)
•Membranoproliferative :MPGN (8%)
•Membranous nephropathy :MN (2%)
•Immune disorders (SLE)
•Infection (Hepatitis , TOCRCH )
•Medications (mercury)
•Metabolic (DM)
•Malignancy
SECONDARY
CONGENITAL & INFANTILE NS CHILDHOOD NS
GENETIC -SYNDROMIC
•NPHS1 (Nephrin)
•NPHS2 (podocin)
•WT1
•LAMB2
•Denys –Drash(WT1)
•Pierson (LAMB2)
•Nail Patella
•Galloway-mowat
•Mitochondrial
•Congenital infections
•Neonatal SLE
•Maternal medications

22. RENAL EMERGENCIES
22
3
-
IMMEDIATE actions needed?
Nephrotic
syndrome
•Nephrotic range proteinuria
•Hypoalbuminemia <30 g/l
•Generalized oedema
1 IDENTIFY
2 INITIAL ASSESSMENT
•TAKE
Urine microscopy , s.urea, creatnine, Elctrolytes,
LFT , lipid ,FBC , C3,C4 ,Hepatitis B , ANA or anti-DS
DNA .VZ serology
•Check Minimal Change Criteria
1.Age : 1-10 years
2.No gross haematuria or hypertension
3.No Kidney injury not related to hypovolemia
4.Normal complement levels
5.No systemic manifestations
6.NoTON top of CAKUT
•Check For Possible Complications
Hypovolemia , infection
4-SECONDARY ASSESSMENT STEP
For non MCD
5-FINALIZE YOUR PLAN
See later
HYPOVOLEMIA HOW TO ASSESS?
Give iv albumin 5% if not available
give 20% combined with diuretics
INFECTION
•Check focus
•Blood & urine cultures
•Stool culture if diarrhoea
•Chest x ray if respiratory symptoms
•LP if sepsis or meningitis suspected
•Start broad spectrum antibiotics
ADRENAL CRISIS
1
2
3
Approach

23. 2 3 41
ADMISSION
& REFRAL
•First Nephrotic
Episode
•Complicated NS
•Non MCD Criteria
(Nephrology)
Prednisolone
•Evaluation Of
Treatment Risk
•First Episode
•Infrequent Relapse
•Frequent Relapse &
Steroid Dependent
•Check Side Effects
•Kidney biopsy if
resistant
Adjuvant therapy
•Diet
•Edema Control
•Prophylactic Antibiotics
•Iv albumin ?
In patient
Follow up
•Daily body weight
•Daily urine volume
•Edema severity
•Daily dipsticks for
protein
•Complications ?
•When discharge ?
5-FINALIZE YOUR PLAN
Nephrotic
syndrome
Renal emergencies
Approach

24. Remember
1.Identify
2.MCD criteria ? & Complications
3.Immediate Actions Needed ?
4.Complete Your Evaluation
5.Finalize Your Plan
Admission
Referral
Prednisolone
Adjuvants
Follow up
RENAL EMERGENCIES
24
Apply

25. REFERENCES
25
RENAL EMERGENCIES
Andolino TP, Reid-Adam J. Nephrotic syndrome. Pediatr Rev. 2015;36(3):117–126
Greenbaum LA, Benndorf R, Smoyer WE. Childhood nephrotic syndrome: current and future
therapies. Nat Rev Nephrol. 2012;8(8):445–458.
Hahn D, Hodson EM, Willis NS, Craig JC. Corticosteroid therapy for nephrotic syndrome in children.
Cochrane Database Syst Rev. 2015;3:CD001533.
Samuel S, Bitzan M, Zappitelli M, et al. Canadian Society of Nephrology commentary on the 2012
KDIGO clinical practice guideline for glomerulonephritis: management of nephrotic syndrome in
children. Am J Kidney Dis. 2014;76(3):354–362.
Sinha A, Bagga A. Nephrotic syndrome. Indian J Pediatr. 2012;79(8):1045–1055

26. 26
RENAL EMERGENCIES
HYPERTENSION
S I M P L I F I E D Q U I C K A P PR O A C H
4

27. RENAL
EMERGENCIES
27
HYPERTENSION
T E R M S
Primary hypertension No cause can be identified
(>90% in adults )
secondary hypertension Cause can be identified
Common in children
(80-90% is renal )
Hypertensive urgency Sever hypertension with symptoms nausea , headache and no target organ damage
Hypertensive emergency Stage 2 HTN with target organ damage
BP: blood pressure; HTN: hypertension. Pediatrics, Vol. 140, doi: 10.1542/peds.2017-1904. Copyright © 2017 by the AAP

28. RENAL
EMERGENCIES
28
HYPERTENSION
How to measure ?

29. RENAL EMERGENCIES
29
HYPERTENSION
C A U S E S
RENAL
CARDIAC
CNS
OVERLOAD
PAIN
ENDOCRINE MEDICATIONS
80%
Below 10 years age
DO NOT FORGET PRIMARY HYPERTENSION in
children above 10 years old
•HEART FAILURE & PUMONARY EDEMA
•LEFT VENTIRCULAR HYPERTROPHY
•AKI
•Progression of CKD
•PAPIILEDEMA & LOSS OF VISION
HYPERTENSIVE
ENCEPHALOPATHY

30. •Correct measurement of blood pressure
•Confirm the severity (emergency & urgency )
IDENTIFY
HYPERTENSION
A P
P
R O A C H
RENAL EMERGENCIES
•Identify obvious causes like : pain , stress , head
trauma , acute CNS insults , volume overload &
medications
•Identify keys for secondary hypertension Dark
urine , oedema , recurrent UTI , AKI or previous
AKI, FH of renal disorders , Systemic
manifestations (renal ) .Higher blood pressure in
UL ( co-arctation) . Dysmorphism ( syndrome
associated HTN like marfan, turner , wiliam, NF )
. Tachycardia , pallor , weight loss , sewating(
endocrinal ) . History of AUC , prematurity .
•Obtain a urinalysis, serum electrolytes, glucose,
BUN and creatinine, chest x-ray, ECG,anda renal
ultrasound. Fundus exam
ASSESSMENT
•Support airway , breathing as needed
•Insert 2 lines ( obtain basic workup & toxicology screen )
•Stop seizure : diazepam 0.2 mg/kg iv( max 10 mg )
•Obtain neuroimaging (haemorrhage , stroke)
•If mass brain lesion call neurosurgery
•If no mass brain lesion start labetalol iv 0.2 mg/kg bolus (
could be repeated q 20 minutes ) then call PICU ( to intiate
continuous labetalol infusion ) max dose 40mgper dose .
•Add furosemide iv if overload as needed
•Check blood pressure q 10 min if no improvement through out
30 minutes increase labetalol infusion rate .
•Decrease in blood pressure should be no more than 25% in
the first 8 hours
•If rapid blood pressure drop , stop iv labetalol and give normal
saline 10 ml/kg iv bolus
•Consider dialysis in refractory overload
Hypertensive
Emergency
IMMEDIATE ACTIONS
Hypertensive
Urgency
•Check for coarctation , sever pain , overload
•If acute elevation give labetalol iv boluses or iv
hydralazine 0.1 -0.2 mg/kg/dose (q 4-6hrs)
•Iv furosemide (1 mg /kg/dose ) if overload
•Oral clonidine 2-5 mcg /kg/dose (q 6-8hrs)
•Correct the cause : Sedation if sever pain
•Refer to nephrology 24 -36 hours
•Refer to cardiology if aortic coarctation
SECONDARY ASSESSMENT
Not applicable in emergency setting

31. HYPERTENSION
A P
P
R O A C H
RENAL EMERGENCIES
Finalize your plan
ADMISSION CRITERIA
•Hypertensive emergency (intensive care unit)
•Hypertensive urgency
•Any degree of hypertension associated with acute glomerulonephritis, chronic renalfailure
FOLLOW UP
•Elevated blood pressure : life style modification and recheck after 6 months and consider basic workup if still elevated
•Stage 1 hypertension : repeat over 3 visits , 3 weeks apart , if confirmed do basic workup

32. Remember
1.Identify
2.Check obvious causes , emergency or
urgency
3.Immediate Actions Needed ?
4.Complete Your Evaluation (not applicable)
5.Finalize Your Plan
Admission
Follow up
RENAL EMERGENCIES
32
Apply
Apply

33. REFERENCES
33
RENAL EMERGENCIES
American Academy of Pediatrics. The fourth report on the diagnosis, evaluation, and treatment of
high blood pressure in children and adolescents. Pediatrics. 2004;114:555–576.
Anyaegbu EI, Dharnidharka VR. Hypertension in the teenager. Pediatr Clin North Am. 2014;61
(1):131–151.
Daniels SR. Diagnosis and management of hypertension in children and adolescents. Pediatr Ann.
2012;41(7):1–10.
Engorn B, Flerlage J. Johns Hopkins: Harriet Lane Handbook (20th ed). Philadelphia, PA: Elsevier
Saunders, 2015; 129–137.

34. 34
RENAL EMERGENCIES
URINARY TRACT INFECTION
S I M P L I F I E D Q U I C K A P PR O A C H
5

35. URINARY
tract infection
Definitions
RENAL EMERGENCIES

36. URINARY
tract infection
Causes & effect
RENAL EMERGENCIES 80%
E-COLI
Urinary Tract Anomalies Obstructive Uropathy Constipation
Bladder Dysfunction
Damage Growing
Kidneys
Kidney scars
Hypertension
Kidney Abscess
Bactermia& Sepsis
Underlaying anomalies

37. •Unexplained fever >38.5 c
•Signs & symptoms suggestive UTI
•Sepsis
•Alternative site of infection who remain unwell
•Positive urine nitrite with or without leucocytes
•Urine WBCS >5 and or bacteriuria
1-SUSPECT AND IDENTIFY
URINARY
tract infection
A P
P
R O A C H
RENAL EMERGENCIES
•Clean void >100000 Colony count /ml
•Transurethral catheter >100000 colony count/ml .
•Suprapubic any number
•Send immediately
•Significant growth of two pathogens (contamination
2-ASSESS (rule out complicated UTI)
•History of recurrency
•History of constipation
•Known case of CAKUT or Family history of CAKUT
•Check general conditions & hydration status
•Check blood pressure
•Check growth parameters
•Check external genitalia
•Check back
4-ANTIBIOTICS
•When to start ?
•Oral or parenteral ?
•Duration of therapy and response ?
3-ADMISSION CRITERIA
•UTI in patient <3 months of age.
•Toxic look , dehydrated
•Immunocompromised
•Non-adherent follow up
•At risk pf decreased renal functions
5-IMAGING /follow up
5-adjuvant
•High fluids intake
•Regular void & hygiene
•Prevent & treat the constipation
To identify structural abnormalities , VUR , Obstructive uropathy and scars

38. Remember
1.Suspect
2.Assessment
3.Confirm
4.Admission ?
5.Antibiotics ?
6.Adjuvants
7.Imaging / follow up
RENAL EMERGENCIES
38
Apply
Apply
URINARY
tract infection

39. REFERENCES
39
RENAL EMERGENCIES
merican Academy of Pediatrics Subcommittee on Urinary Tract Infection, Steering Committee on
Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the
diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics.
2011;128:595–609.
Becknell B, Schober M, Korbel L, Spencer JD. The diagnosis, evaluation and treatment of acute and
recurrent pediatric urinary tract infections. Expert Rev Anti Infect Ther. 2015;13(1):81–90.
Kowalsky RH, Shah NB. Update on urinary tract infections in the emergency department. Curr Opin
Pediatr. 2013;25(3):317–322.
Paintsil E. Update on recent guidelines for the management of urinary tract infections in children: the
shifting paradigm. Curr Opin Pediatr. 2013;25(1):88–94.
Schroeder A, Chang P, Shen M, Biondi E, Greenhow T. Diagnostic accuracy of the urinalysis for
urinary tract infection in infants <3 months of age. Pediatrics. 2015;135:965–971.
Tran A, Fortier C, Giovannini-Chami L, Demonchy D, et al. Evaluation of the bladder stimulation
technique to collect midstream urine in infants in a pediatric emergency department. PLoS One.
2016;11(3):e0152598.