Renal system complete

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INTRODUCTION:
Disorders of kidney and urinary tract are commonly seen in pediatric units as medical and surgical
problems. Congenital malformations, neoplasms, infections, inflammations and progressive impairment of renal
functions are common conditions found in children.
NORMAL EMBRYOLOGY
The Urinary system goes through three phases on its way to becoming fully functioning:
1. Pronephros
2. Mesonephros
3. Metanephros
 Pronephros – Transient rudimentary and nonfunctioning system that begins in the fourth week of
gestation (ie, day 22) and disappears by end of the fourth week (i.e, day 28). Degeneration of the
pronephros is required for normal kidney development.
 Mesonephros – Derived from the intermediate mesoderm by day 26 and by the fifth week develops into
20 paired tubules that produce small amounts of urine. The mesonephros ultimately fuses with the
cloaca and contributes to the formation of the urinary bladder, and in the male, the genital system is
derived from the mesonephric ducts and some tubules.
 Metanephros – The metanephros, which is composed of the metanephric mesenchyme and ureteric bud
epithelium (caudal portion of the mesonephric duct), is the last stage of renal development and forms the
permanent kidney beginning at the fifth week of gestation.
Starting from 4
th
week & end on 36 week of intra uterine life:
 4 wks gestation : kidney start development
 9 wks : first glomeruli , Bladder
 36 wks: nephrogenesis ceases (1 million glomeruli in each kidney).
 Postnatal increase in the size of the kidney is due to enlargement of the Glomerular diameter &
significant increase in tubular volume & length
 Active period of nephrogenesis between 20-36wks, cease around 36 wks.
DEVELOPMENT OF RENAL FUNCTION IN THE CHI LD
Renal function in an infant is subnormal by adult standards especially in the premature neonate, which
put them into high risk to develop acute renal failure. Glomerular filtration begins between 9 to 12 weeks of
gestation, initiating formation of urine. Fetal urine is the major component of amniotic fluid and significant

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reduction of amniotic fluid (oligohydromnios) is usually associated with renal disease in the baby. It is expected
the neonate produces urine and voids in 12 – 24 hours after birth. The GFR at birth is 10-20ml in the first 3 days
but increases rapidly to 75-80ml by 8 weeks. The pH of urine of a newborn is inappropriately high due to the
limited bicarbonate and sodium reabsorbtion. Prior to birth fetus does not require intact renal function because
the mother provides homeostasis., therefore a child with bilateral agenesis will be able to survive for several
days after birth. Renal function continues to improve during the first two years of life. At the end of this period,
various parametres of renal function appraoch adult values, if corrected to a standard surface area.

ANATOMY AND PHYSIOLOGY OF RENAL SYSTEM:
The organs, tubes, muscles, and nerves that work together to create, store, and carry urine are the renal
system. It is one of the excretory systems of the body. The renal system includes two kidneys, two ureters, the
bladder, two sphincter muscles, and the urethra. The development starts from intra uterine period.

2 kidneys- which secrete urine
The kidneys are situated retro peritoneally on each side of the vertebral column. Each kidney contains
about one million nephrons, the functional units. A nephron consists of a glomerulus, proximal tubule, the thin
limbs, the distal tubule and the collecting segment.
2 ureters- which convey the urine from kidneys to the urinary bladder
1 urinary bladder- where urine collects and is temporarily stored
1 urethra- through which the urine is discharged from the urinary bladder to the exterior.
2 sphincters- Internal: involuntary sphincter of smooth muscle
External: skeletal muscle inhibits urination voluntarily until proper time

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FUNCTIONS
The regulation of fluid volume, blood pressure, excretion of metabolic waste products and drug
metabolites are the primary functions of renal system. The kidneys are also responsible for conversion of
vitamin D to its active form, serum pH regulation and synthesis of hormones such as erythropoietin and rennin.
There are 3 functions of renal system.
1. Excretion & Elimination
2. Homeostatic regulation
3. Endocrine function
1. Excretion & Elimination:
Removal of organic wastes products from body fluids (urea, creatinine, uric acid)
 Excretion of excess electrolytes, nitrogenous wastes and organic acids
 The maximal excretory rate is limited or established by their plasma concentrations and the rate of their
filtration through the glomeruli.
 The maximal amount of substance excreted in urine does not exceed the amount transferred through the
glomeruli by ultrafiltration except in the case of those substances capable of being secreted by the
tubular cells.
2. Homeostatic regulation:
Water -Salt Balance
Blood volume is associated with Salt volume. The greater the blood volume, the greater the blood
pressure. Removing water lowers blood pressure.
Regulate blood volume and blood pressure: Regulate plasma ion concentrations:
by adjusting volume of water lost in
urine
releasing renin from the juxtra
glomerular apparatus
sodium, potassium, and chloride ions (by
controlling quantities lost in urine)
calcium ion levels

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Acid - base Balance
The kidneys control this by excreting H+ ions and reabsorbing HCO3 (bicarbonate).
If plasma pH is low (acidic): If plasma pH is high (alkaline):
H+ secretion in the urine and HCO3¯
reabsorption back to the plasma increases thus
urine becomes more acidic, and the plasma more
alkaline.
H+ secretion in the urine and HCO3¯
reabsorption back to the plasma decreases thus
urine becomes more alkaline, and the plasma
more acidic.

3. Endocrine function:
Kidneys have primary endocrine function since they produce hormones (erythropoietin, renin and
prostaglandin).
 Erythropoietin is secreted in response to lowered oxygen content in the blood. It acts on bone marrow,
stimulating the production of red blood cells.
 Renin the primary stimuli for renin release include reduction of renal perfusion pressure and
hyponatremia. Renin release is also influenced by angiotensin II and ADH.
 The kidneys are primarily responsible for producing vitamin D3
 In addition, the kidneys are site of degradation for hormones such as insulin and aldosterone,

The body takes nutrients from food and uses them to maintain all bodily functions including energy and
self-repair. After the body has taken what it needs from the food, waste products are left behind in the blood and
in the bowel. The renal system works with the lungs, skin, and intestines-all of which also excrete wastes-to
keep the chemicals and water in the body balanced.
The renal system removes urea from blood. Urea is carried in the bloodstream to the kidneys. The sensation
to urinate becomes stronger as the bladder continues to fill and reaches its limit. At that point, nerves from the
bladder send a message to the brain that the bladder is full, and the urge to empty your bladder intensifies.
When the person urinates, the brain signals the bladder muscles to tighten, squeezing urine out of the bladder.
At the same time, the brain signals the sphincter muscles to relax. As these muscles relax, urine exits the
bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.

GLOMERULAR FILTRATION
The glomerular filtration rate is approximately 20ml/min in full term newborns and 10 – 13 ml/min in
infants born at 28-30 weeks gestation. It reaches its adult level by 12 – 24 months. Until then the kidneys are
unable to fully maintain water balance and to filter solutes and medications out of the blood stream. Any fluid

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that is not returned to the circulation becomes a component of urine. The daily urine production is
approximately 1-3ml/kg/h for a neonate.

RENAL PERFUSION
The renal blood flow rate averages 20% to 25% of cardiac output each minute. Adequate blood flow to
the kidneys is required to produce a sufficient glomerular filtration rate and urine production. When the
sympathetic nervous system is stimulated, such as occurs in a stress response, both the afferent and efferent
renal arterioles constrict, producing a decrease in blood flow.
DIURESIS (MICTURITION)
When bladder fills with 200 ml of urine, stretch receptors transmit impulses to the CNS and produce a reflex
contraction of the bladder (PNS)

RENAL SYSTEM IN A NUTSHELL
It is the body‘s drainage system for removing wastes and extra water. The urinary system includes two
kidneys, two ureters, a bladder, and a urethra. The kidneys are a pair of bean-shaped organs, each about the size
of a fist and located below the ribs, one on each side of the spine, toward the middle of the back. Every minute,
a person‘s kidneys filter about 3 ounces of blood, removing wastes and extra water. The wastes and extra water
make up the 1 to 2 quarts of urine an adult produces each day. Children produce less urine each day; the amount
produced depends on their age. The urine travels from the kidneys down two narrow tubes called the ureters.
The urine is then stored in a balloon like organ called the bladder. Routinely, urine drains in only one
direction—from the kidneys to the bladder. The bladder fills with urine until it is full enough to signal the need
to urinate. In children, the bladder can hold about 2 ounces of urine plus 1 ounce for each year of age. For
example, an 8-year-old‘s bladder can hold about 10 ounces of urine.
When the bladder empties, a muscle called the sphincter relaxes and urine flows out of the body through
a tube called the urethra at the bottom of the bladder. The opening of the urethra is at the end of the penis in
boys and in front of the vagina in girls.

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DIAGNOSTIC EVALUATION
Diagnostic evaluation of the problems should include details of history of illness, clinical examination,
blood tests, imaging of urinary tract and renal biopsy. There are only a few specific manifestations of renal
diseases in infants and children. Therefore a careful family history of renal disease should always be obtained.

HISTORY OF ILLNESS
Past medical history
- Mother‘s pregnancy history
- Maternal polyhydramnios
- Oligohydramnios
- DM
- HTN
Neonatal history
- Presence of single umbilical artery
- Abdominal mass
- Chromosome abnormality
- Congenital malformation
Present history
- Burning micturition
- Change in voiding pattern
- Vaginal or urethral discharges
- Poor growth
- Weight gain
- Trauma
- Diabetes increases risk of UTI
- Assess output changes, voiding pattern changes, changes in urine color or pain
Past history
- Past UTI, kidney trauma, stones, incontinence and leakage of urine Medications
- Childhood problems, alcohol and illicit drug use Nephrotoxicity
- Hypertension contributes to renal failure and nephropathy
Family history
Renal or cardiovascular disorders, diabetes, cancer or chronic illness

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PHYSICAL EXAMINATION
A. INSPECTION
What to test What to look for What is the procedure What if the interpretation

General observation
Wellness of the child
Mental status
Growth (short stature)
Nutrition

Bony defects
Observe whether child looks sick
or well.
Is child depressed, drowsy
Height, weight,% charts
Muscle bulk, subcutaneous fat,
skin folds

Rickets
Sick look suggests chronic renal failure,
UTI, altered mental state suggests
uremia. Short, thin stature suggests CRF.
Obese, moon face suggests steroid
effect. Loss of muscle mass,
subcutaneous fat suggests CRF.

Renal rickets and chronic glomerular
disease

General examination

General examination
Face

Eyes

Ear

Mouth

Neck
Malar flush
Hirsuitism
Periorbital edema
Anemia, cataract, icterus
Lenticonus, deafness

Dry tongue
Uremic breath

Elevated jugular venous pressure
SLE
Steroid therapy in nephritic syndrome
Nephritis, nephritic syndrome
Alports syndrome
Dehydration

Uremia

Volume overload in CHF, acute
glomerulonephritiss, CRF

Chest
Ribs

CVS

RS
Beading, harrison‘s sulcus

Cardiomegaly, congestive heart
failure, pericardial effusion

Tachypnea, crepitations
Renal rickets

Chronic renal failure, anemia

Pleural effusion, pulmonary edema

Abdomen
Distention

Kidneys

Peritoneal free fluid

Bladder
Tenderness on palpation

Ballotable kidneys

Ascites – on percussion

Enlarged, urine retension
Peritonitis

Enlarged kidneys

Nephritic syndrome, CRF

Obstructive uropathy, neurogenic
bladder

Genitalia
Scrotum

testis
Scrotal edema

Absence of testis
Nephritic syndrome

Cryptorchidism

Upper and lower
limbs
Muscle bulk

Ankle edema

Bony deformity

Gait

Blood pressure
Poor muscle mass

Pitting on pressure

Bowed legs, epiphyseal thickening

Foot slapping

Elevated blood pressure
CRF

Nephrotic syndrome, acute nephritis

Renal osteodystrophy

Peripheral neuropathy

AGN, CRF

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Palpation
Check the status of the kidneys and urinary bladder.
KIDNEY – with the child in supine position and the abdomen relaxed, place the palm of one hand
posteriorly at the flank pushing the kidneys forward, while other hand is placed anteriorly below costal
margin, pushing abdominal wall backward and upward. Kidneys is felt best in deep inspiration.
The kidneys lie in the costovertebral area, the region bounded by the lumbar spine and the 12th rib on
either side.
To detect tenderness due to kidney inflammation, gently tap over the costovertebral area with a fist. This
usually does not cause pain unless the underlying kidney is inflamed.
BLADDER – the bladder can be palpated in the neonate and infants easily. In older children it is easily
percussible when it is distended.
The urinary bladder can be palpated just superior to the pubic symphysis. However, on the basis of
palpation alone, urinary bladder enlargement can be difficult to distinguish from the presence of an
abdominal mass.
Abnormal findings:
Kidney: Bladder:
Lump or mass: tumor
Tenderness: infection
Unequal size: hydronephrosis
Bilateral enlargement: polycystic kidney
disease
Lump or mass: tumor or cyst
Distention: retention or obstruction
Percussion:
Percuss the abdomen for unusual dullness ( normal heard over the spleen at the right costal margin, over
the kidneys, and 1 – 3 cm below the left costal margin) or flatness. A full bladder may yield dullness
above the symphysis pubis.
Tenderness in the flank may be detected by fist percussion. If CVA tenderness & pain are present,
indicate a kidney infection or polycystic kidney disease.
Abnormal findings:
Kidney Percussion: Bladder percussion:
Tenderness and pain indicates inflammation
(glomerulonephritis or glomerulonephrosis)
Dull sounds in a patient who has just
voided indicates bladder dysfunction or
infection

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Auscultation:
Listen for heart sounds – murmur may be present in the anemic child with renal disorder
-elevated heart rate
Auscultate blood pressure noting elevation or depression.
Absence of bowel sounds may indicate peritonitis
The abdominal aorta & renal arteries are auscultated for a bruit, which indicates impaired blood flow to
the kidneys.
Abnormal findings:
Systolic Bruits
Renal artery stenosis
CLINICAL FEATURES OF RENAL DISEASE
The primary symptoms of urinary system disorders are pain and changes in the frequency of urination.
The nature and location of the pain can provide clues to the source of the problem.
 Pain
•Pain in the superior pubic region may be associated with urinary bladder disorders.
•Pain in the superior lumbar region or the flank that radiates to the right upper quadrant or left upper quadrant
can be caused by kidney infections such as glomerulonephritis, pyelonephritis, or kidney stones.
•Dysuria may occur with cystitis and urinary obstructions.
 Frequency of urination
Individuals with urinary system disorders may urinate more or less frequently than usual and may
produce normal or abnormal amounts of urine:
•Incontinence
It is an inability to control urination voluntarily, may involve periodic involuntary urination, or a
continual, slow trickle of urine from the urethra. Incontinence may result from urinary bladder or urethral
problems, damage or weakening of the muscles of the pelvic floor. Renal function and daily urinary volume are
normal.
•Urinary retention
In this renal function is normal, at least initially, but urination does not occur. Urinary retention in males
often results from prostatic enlargement and compression of the prostatic urethra. In both sexes, urinary
retention may result from obstruction of the outlet of the urinary bladder, or from CNS damage.
 Hematuria
The presence of blood in the urine should be confirmed by the microscopic examination of urine. The
colour may vary from frank red to shades of brown, described as tea or cola – coloured. It may be glomerular or

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extra glomerular. Blood in the initial urine suggests urethral origin and terminal hematuria indicates bladder
origin. If it is uniform throughout, then that is most often AGN. Hypercalciuria, clotting disorders, renal trauma,
hemorrhagic cystitis, hemoglobinuria, methemoglobinuria and injestion of certain drugs such as rifapicn also
leads to hematuria.
 Edema
GN manifests with facial puffiness and gross hematuria. Edema is turgid and does not pit readily on
pressure. In nephrotic syndrome edema develops incidiously, starting with puffiness around the eyes and then
involving the feet and legs. Edema is soft and easily pits on pressure.
 Abnormalities of micturition
A poor urinary stream in a male infant especially in the presence of a full bladder, suggests obstruction,
most commonly due to posterior urethral valve. Crying during micturition and straining suggests obstruction.
Retention of urine may be due to neurologic bladder or obstruction by stone or tumor. Persistent dribbling of
urine indicates abnormal urethral insertion distal to bladder neck.
 Oliguria
It is the passage of insufficient volume to maintain homeostasis. (<500ml/24h/1.73m
2
; in infant it is
<1ml/kg/hr). Decreased urine output is an important feature of renal disease. A cause such as gastroenteritis
other conditions that lead to prenatal type of renal failure may be detected. It is an important feature of moderate
or severe AGN and other conditions causing glomerular injury.
 Polyuria
It is the passage of excessive amount of urine (5-6 ml/kg/hr). Impairment of urinary concentration is an
early feature of obstructive uropathy and other disorders characterized by tubulointerstitial lesions.
 Fever
A fever commonly develops when the urinary system is infected by pathogens. Urinary bladder
infections (cystitis) often result in a low grade fever; kidney infections, such as pyelonephritis, usually produce
very high fevers.

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Diagnostic Evaluations – Flowchart

LABORATORY EXAMINATION
URINE EXAMINATION
The urine examination should be fresh and relatively concentrated. A midstream urine specimen is
generally adequate. In infants, a specimen obtained by supra pubic or transurethral catheterization is preferred
for culture. Dipstick method is now widely used to test for proteinuria and many other constituents. Composite
Hematuria
RBC deposits
⁺ -
Hemoglobinuria,
myoglobinuria
KUB ultrasound
Abnormal,Hydronephrosis,
Calculus,cyst, tumor
Normal
Renal function, protienuria
abnormal normal
Recurrent Family history
Present
Hereditary
nephritis (alport)
Absent
IgA nephropthy
Renal biopsy

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strips that measure pH, glucosuria, hematuria, leucocytouria and bacteriuria are available and useful as
screening tests.
Microscopic examination- a fresh centrifuged specimen should be examined.
Red cell casts – glomerular inflammation
Clumping of neutrophills – acute pyelonephritis
- A 24 hour urine collection is difficult but such procedure is resorted when actually needed. E.g. calcium,
phosphate, creatinine, magnesium, oxalate.
- Spot urine samples are sufficient for nephrotic syndrome and various forms of GN, protein / creatinine
ratios tests.

URINALYSIS
The normal characteristics of urine:
Color- pigment is urochrome
Yellow color due to metabolic breakdown of hemoglobin (by bile or bile pigments)
Beets or rhubarb- might give a urine pink or smoky color
Vitamins- vitamin C- bright yellow
Infection- cloudy
Water: specific gravity = 1g/liter;
Urine: specific gravity = 1.001 to 1.030
Pyelonephritus- urine has high s.g.; form kidney stones
Diabetes insipidus- urine has low s.g.; drinks excessive water; injury or tumor in pituitary
Odor- normal is ammonia-like
diabetes mellitus- smells fruity or acetone like due to elevated ketone levels
diabetes insupidus- yucky, asparagus
pH - range 4.5-8 average 6.0
specific gravity– more than 1.0; ~1.001-1.003
vegetarian diet- urine is alkaline
protein rich and wheat diet- urine is acidic

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Abnormal Constitutes of Urine
Glucose - when present in urine condition called glycosuria (nonpathological)
Indicative of:
• Excessive carbohydrate intake
• Stress
• Diabetes mellitus
Albumin-abnormal in urine; it‘s a very large molecule, too large to pass through glomerular membrane >
abnormal increase in permeability of membrane
Albuminuria- nonpathological conditions- excessive exertion, pregnancy, overabundant protein intake--
leads to physiologic albuminuria
Pathological condition- kidney trauma due to blows, heavy metals, bacterial toxin
Ketone bodies- normal in urine but in small amounts
Ketonuria- find during starvation, using fat stores
Ketonuria is couples w/a finding of glycosuria-- which is usually diagnosed as diabetes mellitus
RBC- hematuria
Hemoglobin-
Hemoglobinuria- due to fragmentation or hemolysis of RBC; conditions: hemolytic anemia, transfusion
reaction, burns or renal disease
Bile pigments-
Bilirubinuria (bile pigment in urine)- liver pathology such as hepatitis or cirrhosis
WBC-
Pyuria- urinary tract infection; indicates inflammation of urinary tract
Casts- hardened cell fragments, cylindrical, flushed out of urinary tract
WBC casts- pyelonephritus
RBC casts- glomerulonephritus
Fatty casts- renal damage

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BLOOD TESTS
Normal range of blood urea level is 20-40 mg/dl. The levels increases in case of reduced renal perfusion,
increased tissue break down, trauma, gastrointestinal bleeding and use of corticosteroids and tetracycline.
Serum albumin is reduced in patients with heavy proteinuria, occasionally below 1.5g/dl. It is typically present
in children with nephrotic syndrome and hypercholesterolemia.
IMAGING STUDIES
Expert ultrasonography is the initial modality in most renal disorders. Radionuclide examinations have
clear indications particularly in the investigation of renal and urinary tract anomalies, obstructive uropathy,
urinary tract infections and renovascular hypertension.
Imaging Of The Urinary Tract
 Micturing cystourethrogram (MCU)
It is necessary for the diagnosis and evaluation of severity of vesico ureteric reflux and the detection of
abnormalities of bladder and urethra. The contrast agent is introduced into the bladder through a catheter or
directly by supra pubic puncture. Films are taken when the child is voiding.
 Intra venous pylogram (IVP)
The functional anatomy of the urinary system can be examined by administering a radiopaque
compound that will enter the urine which permits the creation of an intravenous pyelogram, by taking an X-ray
of the kidneys. This procedure permits detection of unusual kidney, ureter, or bladder structures and masses.
 Ultrasonography
It gives excellent information about the anatomical aspects. It is ideal for children as it is painless and
requires no sedation or a contrast agent. It can be carried out even at bedside and repeated a required. In some
interventions also ultra sound guidance is used. Considerable expertisation is required for interpretation of
findings.
 Radionuclide imaging
This in non invasive, highly sensitive and expose the patient to a much smaller amount of radiation. The
techniques include:
a) Renal perfusion study (renography)
It monitors the arrival, uptake and elimination of a radiopharmaceutical by the kidney.
b) Renal static imaging
It gives a two dimentional depiction of the concentration and distribution of the radionuclide.
c) Clearance studies
It accurately assesses the individual kidney function.
d) Direct radionuclide cystography

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It is more reliable for detecting VUR as the radiation dose to patient is greatly reduced compared to MCU. It
provides a visual representation of the rate of bladder emptying, residual urine volume and evidence of VUR.

RENAL BIOPSY
Usually percutaneous specimen ix obtained s by inserting a needle through the skin and into the kidney.
The sample of the kidney is then microscopically examined.
It is usually not necessary in uncomplicated cases.
Indications of renal biopsy:
i. Nephrotic syndrome
Secondary
Suspected
Corticosteroid non minimal lesion
Congenital
ii. Acute nephrotic syndrome
Unresolving or progressive GN
Associated systemic features
iii. Acute renal failure
Prolonged anuria
Undetermined causes
iv. Recurrent gross hematuria
v. Persistent proteinuria
vi. Hereditory nephropathies
vii. Interstitial nephritis

CONGENITAL ABNORMALITIES
Congenital anomalies of the kidney and urinary tract constitute approximately 20 to 30 percent of all
anomalies identified in the prenatal period. Defects can be bilateral or unilateral, and different defects often
coexist in an individual child.
CLASSIFICATIONS
1) Dysgenesis of the kidney
a. Renal agenesis(absent kidney)
b. Renal hypoplasia
c. Renal dysplasia

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2) Abnormalities in shape & position:
a. Ectopic kidney
b. Fusion anomalies
c. horseshoe kidney
d. crossed fused ectopia

3) Abnormalities of the collecting system:
a. Hydronephrosis
b. Bladder extrophy
c. PUV
d. Patent urachus

1. DYSGENESIS OF THE KIDNEY
a)Renal agenesis
Renal agenesis is the name given to a congenital absence or under development of one or both kidneys.
The kidneys develop between the 5th and 12th week of fetal life, and by the 13th week they are normally
producing urine. When the embryonic kidney cells fail to develop, the result is called renal agenesis. It is due to
failure of ureteric bud formation or mesenchymal blastoma differentiation of final mesenchymal condensation.
ETIOLOGY
- Usually there is no family history of renal agenesis, but in 20-36% of cases, there is a genetic cause.
- The risk of recurrence in future pregnancies is 3% unless one parent has unilateral renal agenesis, in
which case the risk is about 15%.
- Women with uncontrolled diabetes in pregnancy may deliver a baby with bilateral renal agenesis.
TYPES
i. Unilateral
ii. Bilateral
1.UNILATERAL
Unilateral renal agenesis is much more common, but is not usually of any major health consequence, as
long as the other kidney is healthy. It is associated with an increased incidence of mullerian duct abnormalities
which are abnormalities of the development of the female reproductive tract and can be a cause of infertility.
Children with this condition are advised to approach contact sports with caution.
INCIDENCE
Unilateral renal agenesis occurs in 1 of 1000-2000 live births.

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CLINICAL MANIFESTATIONS
no other symptoms at all.
premature birth.
low-set ears (This is because the ears and kidneys are formed at the same time in fetal development)
The ureters may also be abnormal
2.BILATERAL
Bilateral renal agenesis is the uncommon and serious failure of both a fetus' kidneys to develop
during gestation. Bilateral renal agenesis with associated malformations is known as Potters Syndrome. This
absence of kidneys causes oligohydramnios, which can place extra pressure on the developing baby and cause
further malformations. The condition is frequently, but not always the result of a genetic disorder, and is more
common in infants born to one or more parents with a malformed or absent kidney. When this condition is not
compatible with survival; in fact, 40% of babies with bilateral renal agenesis will be stillborn, and if born alive,
the baby will live only a few hours.
Prior to birth fetus does not require intact renal function because the mother provides homeostasis.,
therefore a child with bilateral agenesis will be able to survive for several days after birth.
INCIDENCE
Bilateral renal agenesis occurs in 1 of 4500 live births and is usually found in boys.
CLINICAL MANIFESTATIONS
They may have a number of unique characteristics:
dry loose skin
wide-set eyes
prominent folds at the inner corner of each eye
sharp nose
large low-set ears with lack of ear cartilage
underdeveloped lungs
absent urinary bladder
anal atresia
esophageal atresia
unusual genitals
The lack of amniotic fluid causes some of the problems (undeveloped lungs, sharp nose, clubbed feet)
DIAGNOSIS
It is often detected on fetal ultrasound because there will be a lack of amniotic fluid (called
oligohydramnios). It is detected by US at 12
th
wk of gestation.

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TREATMENT
a. Short-term treatment
Bilateral renal agenesis is fatal. If one kidney is present (unilateral renal agenesis) the child will develop
normally. Many times the absence of a kidney is detected only incidentally when an older child or adult has an
abdominal x-ray for some other reason. The remaining kidney, if properly functioning, can very effectively
remove the wastes from the blood and keep the body entirely healthy.
Once detected, families where renal agenesis has occurred will be offered genetic counseling because of the
possibility of recurrence in future pregnancies.
b. Long-term treatment
Once diagnosed, children with one kidney (solitary kidney) will be encouraged to protect the remaining
kidney from infection or injury. Periodic examinations of the kidney and prompt treatment of any urinary tract
infection is required. These children may be counseled to avoid contact sports where the kidney could be
injured.
NURSING MANAGEMENT
Protecting the kidney function is very important. Sometimes children will be prescribed a low dose of an
antibiotic to take once a day to prevent kidney infection and damage. Blood pressure should be carefully
monitored and elevations treated. Dialysis or kidney transplant are the only options to treat children whose
solitary kidney has ceased to function.
COMPLICATIONS
frequent urinary tract infections
high blood pressure
kidney stones
reflux
hydronephrosis
b)Renal hypoplasia
This may appear as one small kidney with the other one larger. It occurs due to the partial development
of kidney. Small kidneys also have small arteries and are associated with hypertension requiring nephrectomy.

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c)Renal dysplasia
Multicystic dysplastic kidney is a condition that results from the malformation of the kidney during fetal
development. The kidney consists of irregular cysts of varying sizes and has no function. It is the most common
type of renal cystic disease, and it is one of the most common causes of an abdominal mass in infants.
TYPES
I. Bilateral
II. Unilateral
INCIDENCE
the disease is found to be bilateral in 19% to 34% of cases.
CLINICAL MANIFESTATIONS
Those with bilateral disease often have other severe deformities.
In bilateral cases, the newborn has the classic abnormal facies
Oligohydramnios
Characteristic of Potter's syndrome
Contralateral ureteropelvic junction
Hypertension
(Malignant transformation to Wilm's tumor has been reported)
DIAGNOSIS
It is usually diagnosed by ultrasound examination antenatally. Mean age at the time of antenatal
diagnosis is about 28 weeks, with a range of 21 to 35 weeks.
TREATMENT
It is not treatable. The patient is observed periodically for the first few years to ensure the healthy kidney is
functioning properly and that the unhealthy kidney is not causing adverse effects. In case of renal hypertension
or malignant transformation, the unhealthy kidney is removed entirely
CONSERVATIVE MANAGEMENT
1. cysts < 5cm , high chance of involution, or cause no problems.
2. reviewed annually for:
- BP
- urinary protein.
- US for cysts involution, of MCDK.
growth of contra-lateral kidney. Up to 2yrs of age then at 5yrs of age if normal.

20

Nephrectomy:
1- no involution by 2 yrs of age.
2- HTN
3- infections
COMPLICATIONS
Malignancy: Wilm's‘ tumor, adenocarcinoma& embryonic carcinoma.
HTN: cured by nephrectomy.
Infection, bleeding into, or rupture of cysts if large.

2. ABNORMALITIES IN SHAPE & POSITION:
a)Ectopic kidey
Renal ectopia or ectopic kidney describes a kidney that is not located in its usual position. It results from
the kidney failing to ascend from its origin in the true pelvis or from a superiorly ascended kidney located in the
thorax.
b)Fusion anomalies
1. Horse Shoe Kidney
It develops when the lower poles of the kidneys are fused in the midline due to fusion of ureteric buds
during fetal development. These kidneys are more prone to develop wilms tumour than general. Diagnosis
could be done with IVP. Surgery is indicated when uncontrolled urinary infections result in pyelonephritis.
2.Crossed fused ectopia
After horseshoe kidney, crossed fused ectopia of the kidneys is the most frequent fusion abnormality of
the urinary tract. In this abnormality, both the kidneys are located on the same side with two separate ureters
arising from the respective kidneys. The ureter arising from the crossed over kidney travels back to the opposite
side and inserts in the bladder.
This congenital anomaly is the result of the abnormal development of the ureteric bud and metanephric
blastema during the fourth to eighth weeks of gestation.

21

3. ABNORMALITIES OF COLLECTING SYSYTEM
a) Hydronephrosis
It is the dilatation of the renal pelvis which may be found as unilateral or bilateral. It may be due to
obstruction of urine flow in the distal urinary tract or reflux of urine up the ipsilateral ureter or due to bladder
neck obstruction or urethral obstruction.
ETIOLOGY
Uretero Pelvic Junction Obstruction
Vesico Urethral Reflux
Megaureter
Ureterocoele
PUV
CLINICAL MANIFESTATIONS
urinary infections
large abdominal mass
abdominal pain
failure to thrive
anemia
hypertension
Hematuria
renal failure.
DIAGNOSIS
Antenatal US ( 18-20 WKS)
- severity of antenatal US
- Unilateral vs. bilateral
- Renal parenchyma thin
- Bladder
- Amniotic fluid
Post natal
- Physical exam: Abdominal mass, palpable bladder
- USG
- IVP
- MCU
- diuretic isotope renography
MANAGEMENT
Surgical removal or pyloplasty is done and in case of complication nephrectomy or percutaneous
nephrostomy is indicated.

22

b) Posterior urethral valve (PUV)
It is the most frequent cause of distal urinary tract obstruction. The valves are found usually at the point
of junction of posterior urethra with anterior urethra.
CLINICAL MANIFESTATION
- dribbling of urine
- abnormal urine stream
- palpable bladder
- recurrent urinary tract infections
- vomiting
- failure to thrive
- pulmonary hypoplasia.
- Poor urinary stream
- Voiding dysfunction.
- Urosepsis.
DIAGNOSIS
- US suggestive at < 24 wks gestation
- MCU
- USG
- Endoscopy
MANAGEMENT
- It could be done by urinary catheterization
- Defenitive management is by transurethral destruction of valvular leaflet by balloon catheter.
- In some cases temporary urinary diversion is done.
NURSING MANAGEMENT
- correction of electrolytes.
- Treatment of sepsis.
- Resp.distress
- Temporary relieve of pressure
c) Exstrophy of bladder (ectopia vesicae)
In this the lower portion of abdominal wall and the anterior wall of the bladder are missing, so that the
bladder is everted through the opening and may found on the lower abdomen just above the symphysis pubis,
with continuous passage of urine to outside. It occurs as a result of altered, not arrested embryogenesis.
INCIDENCE:
-It is the most common congenital anomaly of lower urinary and genital tracts.

23

-It occurs in 1 in 30,000 to 40,000 live births.
-it occurs frequently in males than in females.
CLINICAL MANIFESTATION:
This condition is diagnosed on inspection at birth.
-Urinary dribbling through defect
-skin excoriation
-infection & ulceration of bladder mucosa
-ambigous genetalia
-wadling unsteady gait
-UTI
-Growth failure
DIAGNOSTIC EXAMINATION:
- physical examination
-cystoscopy
-X-ray
-USG
-IVP
-urodynamic testing
MANAGEMENT:
-surgical closure of bladder within 48 hours
-urinary diversion
-complete correction in stages by reconstruction
-orthopedic surgery in case of musculoskeletal problems
(should be done by school age)

24

NURSING MANAGEMENT:
Supporting nursing care is important before and after reconstructive surgery to prevent complications.
Pre-operative care:-
-Protection of bladder area from infections and trauma
-avoid irritating clothing over exposed bladder
-position by back or side
-humidifying with wet gauze
-Preparation of parents and child for surgery
Post-operative care:-
-close monitoring of child‘s condition
-special attention to urinary catheter, drainage
-teaching the parents regarding follow up care, complications and prevention

d)Patent urachus
The urachus is a remnant of allantois, a channel between the bladder and the umbilicus (belly button)
where urine initially drains in the fetus during the 1
st
trimester of pregnancy. The channel of the urachus
usually seals off and obliterates around the 12
th
week of gestation and all that is left is a small fibrous cord
between the bladder and umbilicus called the median umbilical ligament.
A patent urachus occurs when the urachus did not seal off and there is a connection between the bladder
and the umbilicus. A patent urachus can cause varying amounts of clear urine to leak at the umbilicus. If the
urachus remains open all the way to the bladder, there is the danger that bacteria will enter the bladder through
the open tube and cause infection. For this reason, the patent urachus of the infant must be removed

TREATMENT
A surgical incision is made in the baby's abdomen and the patent urachus is removed, then the opening
to the bladder is closed.
OTHER:
Uretero pelvic junction stenosis
It is the narrowing of the ureter at the junction between the ureter and renal pelvis of the kidney. It
produces blockage of urine drainage from the kidney (similar to the waist in an hourglass). It produces
increased backpressure on the kidney and can cause impaired kidney function and ultimately long term potential

25

damage to the kidney itself. It is found as a cause of hydronephrosis. It can be associated with ectopic or horse
shoe kidney.
INCIDENCE
Ureteropelvic junction stenosis and obstruction is the most common cause of kidney blockage or
obstruction in children.
It is the most common site of obstruction in the upper urinary tract
It occurs nearly 1 in 500 to 1:1250 live births.
ETIOLOGY
The two main causes of PUJ obstruction are:
intrinsic muscular defect causing impaired peristalsis and urine drainage
extrinsic obstruction caused by an aberrant or accessory vascular stalk leading to the lower pole of the
kidney and crossing anteriorly to the PUJ or upper ureter.
CLINICAL MANIFESTATIONS
recurrent renal colic
o flank or abdominal pain
o nausea
o vomiting
flank mass without symptoms
often associated with UTI
upper abdominal pain
DIAGNOSIS
Prenatal ultrasonography
USG
IVP
Renal scan
Renal function test
MANAGEMENT
Surgery; pyloplasty is indicated to remove obstruction and to avoid complications. The indications for
conservative or surgical therapy of PUJ obstruction are still developing. PUJ obstruction by crossing renal
vessels is essential in choosing the appropriate surgical approach.

 Pyeloplasty, is a surgical procedure to correct the obstruction.
- If the obstruction is diagnosed during pregnancy or in the early newborn period, if possible, the health
team typically tries to wait until the child is approximately 3 months of age to perform the surgery. This
allows the child to grow and develop and mature to minimize any risk of anesthetic complications.

26

- After 3 months of age, the anesthetic risk has dropped and will remain minimal throughout the
remainder of the child's life until older adult age. Conversely, surgical correction at that time still allows
the kidney to recover from the blockage and ultimately grow and develop normally during the important
first years of life and then into adulthood.
- The surgery takes approximately 2-3 hours under a general anesthetia.
- An incision (cut) will be made, usually on the child‘s side. A catheter (small tube) will be inserted
through the urethra into the bladder during surgery to drain the urine. The obstructed part of the
kidney/ureter is removed and then the remaining parts joined. The wound will be closed with dissolvable
stitches and sometimes paper tapes (steristrips) are also applied. A few children will have a small stent
left in place which goes between the kidney and incision site. This stent can be used if necessary to help
drain urine or, if needed, to insert dye during an x-ray. It can be removed with ease after drainage has
stopped.

Epispadiasis
It is the congenital abnormal urethral opening on the dorsal aspect of penis. Urethra is displaced dorsally
due to the abnormal development of the infraumbilical wall and upper wall of the urethra. It is associated with
extrophy of bladder and ambiguous genetalia.
TYPES:
In male child In female child
Anterior with normal continence
Posterior epispadiasis
Male infants have short and broad penis with dorsal
curvature.
Bifid clitoris with no incontinence of urine
Subsymphyseal with incontinence of urine
A cleft extends along the roof or entire urethra,
involving the bladder neck.
DIAGNOSIS:
-diagnosed at birth itself
-IVP
-MCU
-vesicourethral reflux
-bladder capacity
MANAGEMENT:
Surgical correction
1
st
stage - it is done about 1.5 to 2 years of age for penile lengthening, elongation of urethral strip and chordee

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correction.
2
nd
stage – it is done atleast 6 months after 1
st
stage urethral reconstruction
3
rd
stage – it is done about 3 - 4 years of age for bladder neck reconstruction and correction of VUR.
Cytoplasty can be done to enhance the bladder capacity after 2 – 3 years of 3
rd
stage operation.
Supportive nursing care should emphasize on prevention of infection.

Hypospadiasis
It is a congenital abnormal urethral opening on the ventral aspect of the penis. Undescended testes,
inguinal hernia or upper urinary tract anomalies may be associated with hypospadiasis. It may be found in
females as urethral opening in the vagina with dribbling of urine.
INCIDENCE:
It is a commonest malformation in a male child occurs 1-3
Occurs in 1-3 males per 1000 live births
Close relatives of the patients are most likely to have compared to other population
TYPES:
It can be classified depending upon the site of urethral meatus.
Anterior Middle Posterior
65-70%
May be found as glandular or
coronal or on distal penile shaft.
10-15%
Penile shaft hypospadiasis
20%
May be found on proximal penile
shaft or as penoscrotal, scrotal or
perineal type
DIAGNOSIS:
-Mostly observed at birth
-observe for any abnormal voiding pattern
- observe for inability of the boy to stand to urinate, he must sit to void.
MANAGMENT:
-surgical reconstruction to obtain straight penis at erection, to form urethral meatus at the tip of glans
penis.
-meatotomy is done at any age after birth.
-chordee correction and advancement of prepuce can be done at 2 – 3 years of age.

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-urethroplasty is done 3 – 4 months after chordee correction.
(Surgical correction should be completed before admission to school.)
SURGICAL COMPLICATIONS
Surgical complication rates depend on the chosen procedure, and include urethrocutaneous fistula,
meatal stenosis, urethral strictures, urethral diverticula, complete breakdown, skin necrosis, residual or recurrent
curvature and hypospadiac cripple.

Phimosis
Phimosis refers to the narrow opening of the prepuse that prevents it being drawn back over the glans
penis. The inability to retract the prepuse after the age of 3 years should be considered as true phimosis. It also
can be acquired by the inflammation of glans or prepuse. It can predispose UTI. The term may also refer
to clitoral phimosis in women, whereby the clitoral hood cannot be retracted, limiting exposure of the glans
clitoridis.
TYPES
Different authors calssify it differently
o Pathological
o Physical
o Physiological
ETIOLOGY
- balanitis (inflammation of the glans penis)
- Preputial stenosis or narrowness that prevents retraction, by fusion of the foreskin with the glans penis in
children
- unusual masturbation practices
- secondary to chronic inflammation
- repeated catheterization
- forcible foreskin retraction
- Untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin
CLINICAL MANIFESTATIONS
- inability to retract the foreskin during routine cleaning or bathing
- ballooning of the prepuce during urination
- painful erections
- Hematuria
- recurrent urinary tract infections
- preputial pain

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- weakened urinary stream
 Physical Phimosis, the foreskin cannot be retracted proximally over the glans penis.
 Physiologic phimosis, the preputial orifice is unscarred and healthy appearing.
 Pathologic phimosis, a contracted white fibrous ring may be visible around the preputial orifice

MANAGEMENT:
Phimosis in infancy needs to be treated only if it is causing obvious problems such as urinary discomfort
or obstruction. If phimosis in older children or adults is not causing acute and severe problems, nonsurgical
measures may be effective.
1.Non surgical methods include:
 Steroid therapy
Application of topical steroid cream, such as betamethasone, for 4–6 weeks to the narrow part of the
foreskin is relatively simple, less expensive than surgical treatments and highly effective.

 Manual stretching
Stretching of the foreskin can be accomplished manually, with balloons

or with other tools. Skin that is
under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching
over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out
without the aid of a medical doctor. The tissue expansion promotes the growth of new skin cells to permanently
expand the narrow preputial ring that prevents retraction.
2.Surgical methods
It range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:
 Circumcision
It is the excision of the foreskin of the glans penis is choice of operative intervention don to treat phimosis.
Other measure is the use of betamethasone cream to the narrowed preputial skin for two times daily for 4
weeks. This treatment usually becomes successful as the foreskin becomes soft, elastic and can be retracted
gently and gradually.
 Dorsal slit (superincision)
Dorsal slit is a single incision along the upper length of the foreskin from the tip to the corona, exposing the
glans without removing any tissue.
 Ventral slit (subterincision)
It is an incision along the lower length of the foreskin from the tip of the frenulum to the base of the glans,
removing the frenulum in the process. Often used when frenulum breve occurs alongside the phimosis.
 Preputioplasty
It is in which a limited dorsal slit with transverse closure is made along the constricting band of skin can be
an effective alternative to circumcision.

It has the advantage of only limited pain and a short time of healing
relative to circumcision, and avoids cosmetic effects.

30

PROGNOSIS
The most acute complication is paraphimosis. In this condition, the glans is swollen and painful, and the
foreskin is immobilized by the swelling in a partially retracted position. The proximal penis is flaccid.

Paraphimosis
It may develop in phimotic child. It is an uncommon medical condition where the foreskin becomes
trapped behind the glans penis, and cannot be reduced (that is, pulled back to its normal flaccid position
covering the glans penis). It is the retraction of a phimotic foreskin, behind coronal sulcus forming a tight
constricting ring around the glans. The foreskin is retracted behind the glans penis and cannot be replaced to
its normal position.
CLINICAL MANIFESTATIONS
painful, swollen glans penis in the uncircumcised or partially circumcised patient
irritability
Flaccidity of the penile shaft proximal to the area of paraphimosis is seen
Erythematous and edematous glans
The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color
changes to blue or black and the glans becomes firm to palpation.
ETIOLOGY
The foreskin may be retracted during penile examination, penile cleaning, urethral catheterization, or
cystoscopy; if the foreskin is left retracted for a long period, some of the foreskin tissue may become edematous
(swollen with fluid), which makes subsequent reduction of the foreskin difficult.
PREVENTION
o Paraphimosis can be avoided by bringing the foreskin back into its reduced position after retraction is no
longer necessary
o Phimosis is a risk factor for paraphimosis;

physiologic phimosis resolves naturally as a child matures,
but it may be advisable to treat pathologic phimosis via long-term stretching or elective surgical
techniques
MANAGEMENT
 Manual manipulation of the swollen foreskin tissue
This involves compressing the glans and moving the foreskin back to its normal position, perhaps with the
aid of a lubricant, cold compression, and local anesthesia as necessary.
 Dorsal slit
 Circumcision
 The Dundee technique

31

It entails placing multiple punctures in the swollen foreskin with a fine needle, and then expressing the
edema fluid by manual pressure.
Prune belly syndrome ( Eagle-Barrett syndrome, Triad syndrome)
It is a rare, genetic birth defect characterized by a triad of symptoms.
1.Deficiency or absence of anterior abdominal wall musculature.
2.Bilateral cryptorchidism
3.Ureter, bladder,& urethral abnormalities( megacystis, Megaureter, 2°dysplasia)
The syndrome is named for the mass of wrinkled skin that is often (but not always) present on
the abdomens of those with the disorder. Other names for the syndrome include Abdominal Muscle Deficiency
Syndrome, Congenital Absence of the Abdominal Muscles, Eagle-Barrett Syndrome, Obrinsky
Syndrome, Frohlich Syndrome,

or Triad Syndrome
INCIDENCE
About 1 in 40,000 births
About 97% of those affected are male
SYMPTOMS
A partial or complete lack of abdominal muscles. There may be wrinkly folds of skin covering the
abdomen.
Undescended testicles in males
Urinary tract abnormality such as unusually large ureters, distended bladder, accumulation and backflow
of urine from the bladder to the ureters and the kidneys
Frequent urinary tract infections due to the inability to properly expel urine.
Later in life, a common symptom is post-ejaculatory discomfort. Most likely a bladder spasm, it lasts
about two hours.
DIAGNOSIS
Via ultrasound while a child is still in-utero.
sAn abnormally large abdominal cavity resembling that of an obese person is the key indicator, as the
abdomen swells with the pressure of accumulated urine.
In young children, frequent urinary tract infections
Blood tests to check kidney function
Voiding cystourethrogram
Orthopedic evaluation

32

TREATMENT
The type of treatment depends on the severity of the symptoms.
 Vesicostomy
Vesicostomy allows the bladder to drain through a small hole in the abdomen, thus helping to prevent
urinary tract infections. Similarly, consistent self catheterization, often several times per day, can be an effective
approach to preventing infections. A more drastic procedure is a surgical "remodeling" of the abdominal wall
and urinary tract. Boys may have an orchiopexy, which moves the testicles to their proper place in the scrotum.
Even with treatment, many patients experience renal failure.
COMPLICATIONS
distending and enlarging of internal organs such as the bladder and intestines
Surgery is often required but will not return the organs to a normal size. Bladder reductions have shown
that the bladder will again stretch to its previous size due to lack of muscle.
Also many complications can come from enlarged/malformed kidneys which warrant the child to go on
dialysis or require a kidney transplant. With proper treatment long healthy lives are possible.
Musculoskeletal abnormalities include pectus excavatum, scoliosis, and congenital dislocations
including the hip.

CRYPTORCHIDISM (UNDESCENDED TESTIS)
It is the absence of one or both testes from the scrotum. It is the most common birth defect regarding
male genitalia. In unique cases, cryptorchidism can develop later in life, often as late as young adulthood.
Cryptorchidism is distinct from monorchism the condition of having only one testicle.
INCIDENCE
- About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis.
- By the age of 1 year the incidence decreases to less than 1% and does not change thereafter.
- Frequency 3.4 % in term boys
FACTORS RESPONSIBLE FOR DESCENT
- Initiated by-androgens
- Prompted by-differential growth
- Permitted by-lengthening of ductus
- Fascilitated by-gubernaculum
TYPES
1.undescended testes
In this type testis neither resides nor can be manipulated into the scrotum

33

- Abdominal – proximal to the internal inguinal ring
- Canalicular – between the internal and external inguinal rings
- Ectopic – outside the normal pathways of descent between the abdominal cavity and the scrotum
2.Retractile testes
It can be manipulated into scrotum where it remains without tension
3.Anorchia
Absence of testis
CAUSES AND RISK FACTORS
In most full-term infant boys with cryptorchidism but no other genital abnormalities, a cause cannot be
found, making this a common, sporadic, idiopathic birth defect. A combination of genetics, maternal health and
other environmental factors may disrupt the hormones and physical changes that influence the development of
the testicles.
- Endocrine abnormalities affecting hypothalamic pituitary testicular axis
- Denervation of genitofemoral nerve
- Traction of gubernaculum
- Abnormal development of epididymis
- Premature birth
- Congenital hernia
- Low birth weight
- endocrine disruptors that interfere with normal fetal hormone balance (pesticides)
- Diabetes and obesity in the mother
- exposure to regular alcohol consumption during
- Family history of undescended testicle or other problems of genital development
- congenital malformation syndromes (Down syndrome, Prader-Willi syndrome)
- In vitro Fertilization
- use of cosmetics by the mother
- pre-eclampsia
CLINICAL MANIFESTATIONS
- Nonpalpabe testes (either one or both)
- Retractile testes can be milked/ ushed back into scrotum
DIAGNOSIS
Physical examnination
- Softer testes
- Not well developed rugae

34

Cremasteric Reflex
In normal males, as the cremaster muscle relaxes or contracts, the testis moves lower or higher ("retracts")
in the scrotum. This reflex is elicited by lightly stroking the superior and medial (inner) part of the thigh
regardless of the direction of stroke. The normal response is an immediate contraction of the cremaster
muscle that pulls up the testis on the side stroked (and only on that side).
Various maneuvers
using a crosslegged position, soaping the examiner's fingers, or examining in a warm bath
Pelvic ultrasound / MRI
locate the testes while confirming absence of a uterus.
karyotype
confirm or exclude forms of dysgenetic primary hypogonadism, such as Klinefelter syndrome or mixed
gonadal dysgenesis.
Hormone levels
especially gonadotropins and AMH can help confirm that there are hormonally functional testes worth
attempting to rescue, as can stimulation with a few injections of human chorionic gonadotropin to elicit a rise of
the testosterone level.
Abdominal laproscopy
TREATMENT
The primary management of cryptorchidism is watchful waiting, due to the high likelihood of self-resolution.
Where this fails surgery is indicated.
Refractile testis can be manipulated into scrotum by milking / pushing back into scrotum.
Hormone therapy
With lutenizing hormone releasing spray(nasal spray) and HCG injection(10 injections over 5 weeks is
common).
orchiopexy
it is effective if inguinal testes have not descended after 4–6 months. It could be performed between 1 -
2 years of age. Surgical repair is done to
o Prevent damage to undescended testicles by exposure to heat thus maintaining future fertility
o Avoid trauma & torsion
o Decrease incidence of tumour formation
o Prevent cosmetic handicap
An incision is made over the inguinal canal. The testis with accompanying cord structure and blood
supply is exposed, partially separated from the surrounding tissues, and brought into the scrotum. It is sutured to

35

the scrotal tissue or enclosed in a "subdartos pouch." The associated passage back into the inguinal canal,
an inguinal hernia, is closed to prevent re-ascent.

HYDROCELE
It is defined as a collection of fluid within the tunica vaginalis of the testis. It is the presence of fluid in
the processus vaginalis and is result of the same developmental process as an inguinal hernia.
INCIDENCE
10 – 60/1,000 newborn full term babies
TYPES
1. Congenital
- Communicating (―vogbreuk‖)
It is one in which processes vaginalis remains open and into which peritoneal fluid may
be forced by intra abdominal pressure and gravity.
- Infantile
tunica & processes vaginalis distended upto internal ring but sac has no connection with
peritoneal cavity
- Interstitial
- Cord
smooth,oval swelling associated with spermatic cord
2. Primary
- Idiopathic (aetiology not known)
- Imbalance between the fluid secretion and absorption of the tunica vaginalis
3. Secondary
- Infection
- Trauma
- Tumor
- Abnormalities in inguinal lymph nodes
CLINICAL MANIFESTATION
- scrotal mass that transilluminates
- testis not palpable
- fluctuant
- can get above swelling
- testicular sensation can be elicited
CAUSES
- Incomplete closure of the processus vaginalis from the peritoneum
- Residual peritoneal fluid that has yet to be reabsorbed after processus closure

36

- In older boys it is due to abnormal absorption or secretion secondary to another pathologic
process(Trauma,Ischemia,Infection)
- Secondary to intrascrotal or intra-abdominal pathology
- Filariasis may produce hydrocele in infected boys and men
- Hydrocele may be seen following ipsilateral renal transplantation
- secondary to testicular torsion or incarcerated/strangulated hernia
- secondary to testicular cancer
RISK FACTORS
- Premature and low-birth-weight infants
- Indirect inguinal hernia
- Primary testicular/intrascrotal pathology
- Trauma
- Surgery
- Increased intra-abdominal pressure
- Lymphatic obstruction
- Ventriculoperitoneal shunt
- Peritoneal dialysis
- Bladder exstrophy
MANAGEMENT
Surgical:
Lords placation
The hydrocele is opened with a small skin incision without further preparation. The hydrocele sac is
reduced (plicated) by suture
Von Bergmann's technique
Partial resection of the hydrocele sac, leaving a margin of 1–2 cm. Care is taken not to injure testicular
vessels, epididymis or ductus deferens. The edge of the hydrocele sac is oversewn for haemostasis
Winkelmann's or Jaboulay's technique
Same as von Bergmann's technique but the edges are sewn together behind the spermatic cord
COMPLICATIONS
- infection
- pyocele,hematocele
- infertility
- atrophy of testis
- herniation of hydrocele sac (rare)
- rupture (rare)

37

AMBIGUOUS GENETALIA (Hermaphroditism)
Ambiguous genitalia is a congenital defect in which the external genitalia - penis or vulva - of the child
do not have the typical appearance of either a male or female. The genitalia usually show a combination of male
and female characteristics.
Normal Genetalia & Reproductive Organ Develoment:
During conception, the mother of a child contributes an X chromosome and the father contributes an X
or Y chromosome. If the father contributes an X chromosome, then a genetically female fetus (XX) will
develop and if he contributes a Y chromosome, a genetically male fetus (XY) will be formed. In the early stages
of fetal life, both male and female fetuses are identical. At a certain stage - about 8 weeks for an XY fetus and
12 weeks for an XX fetus - the changes that cause them to differentiate into male and female respectively,
occur. These changes occur in the same fetal tissue in both types of fetuses. Cases of ambiguous genitalia occur
when there is a disorder in the process of differentiation of this fetal tissue.
In humans, biological sex is determined by five factors present at birth:
- the number and type of sex chromosomes;
- the type of gonads—ovaries or testicles;
- the sex hormones,
- the internal reproductive anatomy (such as the uterus in females), and
- the external genitalia.
People whose five characteristics are not either all typically male or all typically female are intersexed.
ETIOLOGY
A failure or abnormality in any of the steps of genetalia and reproductive development can lead to abnormal
development.
Abnormal gender determination
Chromosome abnormalities result in disturbance of development.
Abnormal differentiation of gonads
When induction of the bipotential gonad fails, gender differentiation proceeds in the direction of the
female phenotype, regardless of karyotype.
Abnormal differentiation of ductal systems
Biological inactivity of androgenic male organizer substances or insensitivity of ductal tissue to the
action of these substances results in a persistent female duct system, which leads to the presence of a
uterus and uterine tubes.
Abnormal secretion of testicular androgen
Complete failure of male hormone secretion produces female external genetalia in a genetic male.
Partial or incomplete masculination with ambiguity of the external genetalia.

38

TYPES
 True Hermaphroditism:
Ovaries and testicles are present and the external genitalia are not clearly male or female. This
condition is very rare.
 Female Pseudohermaphroditism
The child has ovaries and a penis-like structure (usually due to clitoromegaly).
 Male Pseudohermaphroditism
The child has undescended testicles and external female genitalia.
 Mixed Gonadal Dysgenesis
Genetalia vary greatly, but in those who appear predominately female, the dysplastic testis may
cause musculination at puberty.
 Congenital Adrenal Hyperplasia
Inherited deficiency of adrenal corticosteroid hormones.
Female - In this certain forms of this condition, the adrenal glands of the fetus produce excessive
amounts of androgens (male hormones) which cause the female genitalia to look male.
Male -Certain forms of this condition cause reduced male hormone production which allows
female-looking genitalia to develop.
TREATMENT
Goal:
To enable the affected child to grow into a well adjusted, psychosocially stable person who is able to
identify with the assigned gender and is content with the same.
1.Counselling: Having ambiguous genitalia causes a lot of emotional distress for the individual.
2. Determination of the Individual's Sex: This will include
- Physical examination of the external genitalia by a physician
- Chromosomal analysis to determine genetic sex
- Pelvic ultrasound to check for the presence of reproductive organs e.g. undescended testes, ovaries,
uterus etc.
- Ability or potential of the individual to actually belong or adapt to either of the sexes.
3. Reconstructive Surgery:
To make the genitalia look more natural according to the chosen gender and to promote sexual function.
4. Hormone Therapy
If the condition which caused the ambiguous genitalia is not very severe, hormone replacement therapy
could be used. Hormone therapy is used to promote development of secondary sexual characteristics during
puberty and sometimes, throughout life.

39

INGUINAL HERNIA
A hernia occurs when an intestinal part of the body, such as an organ, pushes through a weakness in the
muscle or surrounding tissue wall. The muscles are usually strong but sometimes fails to kep organs in place
resulting hernia.
An inguinal hernia is a lump or protrusion of abdominal-cavity contents through the inguinal canal. It
occurs in the groin region and may extend to scrotum in male children.
Inguinal canal
In male inguinal canal transmit the spermatic cord, ilioinguinal nerve & genital branch of genitofemoral
nerve.
In female round ligament replace the spermatic cord.
INCIDENCE
- It accounts 80% of childhood hernias
- More common in male children
- 10-20/1000 live births.
- 30% occurring in preterm infants
ETIOLOGY
- an opening in the muscle wall does not close as it should before birth which leaves a weak area in the
belly muscle. Pressure on that area can cause tissue to push through and bulge out.
- Overweight
- Lifting
- Coughing
- Straining
TYPES
Direct inguinal hernia:
It occur medial to the inferior epigastric vessels when abdominal contents herniated through a weak spot
in the fascia of the posterior wall of the inguinal canal which is formed by the tranvalis fascia.
Indirect inguinal hernia
It occur when abdominal contents protrude through the deep inguinal ring, lateral to the inferior epigastric
vessels, this may be caused by failure of embryonic closure of the processus vaginalis.
Other types
Reducible hernia
It can be pushed back into abdomen by manual pressure into it.
Irreducible hernia
It cannot be pushed back into abdomen by manual pressure into it.

40

- Obstructed
In this lumen of herniated part of intestine is obstructed but the blood supply to hernia sac is
intact
- Incarcerated hernia
In this adhesions develop between the wall of hernia sac and wall of intestine.
- Strangulated hernia
In this the blood supply of the sac is cut off, thus, leading to ischemia. The lumen of the intestine
may be patent or not.
PATHOPHYSIOLOGY
In males the testis are initially located in the abdomen. Around the seventh month of gestation, the testis
migrate down into the scrotum via a passage, the inguinal canal. This canal begins to close before birth and is
usually completely fused or shut by the 1
st
year of life. If this canal does not close completely and the muscles
in the wall of the abdomen do not cover the opening well enough a hernia may develop.
Descending testes

Migrate from abdomen to scrotum during
development of urinary and reproductive organs

Large sized inguinal canal transmits testicles and accommodates spermatic cord

Weak posterior wall of inguinal canal and shutter mechanism

Lower intra abdominal pressure

Hernia formation
CLINICAL MANIFESTATIONS
- Swelling/ visible lump / bulge in the groin or scrotum
- Appears when the child lifting heavy weights, coughing, bending, straining, or laughing
- Smooth and soft swelling
- Swelling increase while crying, coughing or straining
- may be painful
- sometime bulge without pain
- swelling and a feeling of heaviness, tugging, or burning in the area of the hernia
- symptoms may get better when child lie down

41

- Sudden pain
- Nausea & vomiting
- Bloating
DIAGNOSIS
- History collection
- Physical examination
- USG
- Urine routine
MANAGEMENT
Conservative
No medical recommendation for inguinal hernia but elective surgery is recommended
Making truss with non intrusive flat pads to hold the hernia securely during all activities
Surgical management
It is called hernia repair. It is not recommended in minimally symptomatic
hernia.
There are three different approaches to pediatric hernias.
 Open repair –
This involves making an incision just below the belt line and dissecting down to the hole in the muscle
layer. This hernia is closed with stitches. The deeper tissues and skin are then sewn together with dissolvable
sutures that are hidden under the skin so that there are no stitches to be removed.
 Open repair with laparoscopic exploration –
This is the same as the open repair except that before closing the hernia hole, a small camera (about 3 mm in
diameter) is passed into the abdomen to examine the opposite groin from the inside. If a hernia is detected, a
matching incision is made on the opposite side to allow repair of the second hernia.
 Laparoscopic repair –
In this approach the hernia is closed using laparoscopic techniques. A 3-mm or 5-mm camera is inserted
through the umbilicus and additional instruments are introduced through needle holes to perform the hernia
closure. There a number of different laparoscopic hernia repair techniques in children (eversion technique,
intracorporeal suturing technique, single stitch technique) that a can use depending upon the particular patient.

NURSING MANAGEMENT OF THE CHILD WITH UROLOGIC SURGERY
Basic pre-operative care to be provided with special attention for the followings:
Promoting understanding of parents about the planned surgical interventions by explanations according
to level of understanding.
Preparing for necessary diagnostic procedures
Involving the parents in child‘s care
Promoting normal urinary functions by monitoring intake and output, care of urinary catheter and
drainage tube, encouraging adequate fluid intake and hygienic measures and observing signs of urinary
infections.

42

Preventing infections by aseptic precautions, hand washing practices, taking care of wound,
administering prescribed medications, I/V fluid therapy, monitoring features of infections and vital signs
etc.
Providing comfort by rest, sleep, comfortable positioning operated side with support, administering
analgesics, antispasmodics and organizing diversions and recreation by toys and play.
Providing adequate nutrition to promote healing and prevent infection along with adequate fluid to
promote urinary function.
Teaching the parents about related care, prevention of infections and complications, importance of fluid
intake, diet and follow up. Available support services and facilities.

URINARY TRACT INFECTIONS
A UTI is an infection in the urinary tract. Infections are caused by microbes—organisms too small to be
seen without a microscope—including fungi, viruses, and bacteria. Bacteria are the most common cause of
UTIs. Normally, bacteria that enter the urinary tract are rapidly removed by the body before they cause
symptoms. However, sometimes bacteria overcome the body‘s natural defenses and cause infection. An
infection in the urethra is called urethritis. A bladder infection is called cystitis. Bacteria may travel up the
ureters to multiply and infect the kidneys. A kidney infection is called pyelonephritis.

INCIDENCE
3-8% of girls and 1-2% of boys develop a UTI during childhood.
Peak incidence is between 2 – 6 years of age.
CLASSIFICATION
Various terms used to describe urinary tract disorders:
 Bacteriuria – presence of bacteria in urine
 Asymptomatic bacteriuria – significant bacteriuria with no evidence of clinical infection
 Symptomatic bacteriuria – accompanied by physical signs
 Recurrent UTI – repeated episodes of bacteriuria
 Persistent UTI – persistence of bacteriuria despite antibiotic
 Febrile UTI – accompanied by fever, other physical signs of urinary infection
 Urethritis - inflammation of urethra
 Cystitis - inflammation of the bladder
 Pyelonephritis – inflammation of upper urinary tract and kidneys
 Urosepsis – febrile UTI coexisting with systemic signs of bacterial illness; blood culture reveals
presence of urinary pathogen.
ETIOLOGY
Escherichia coli – 80% of cases
Gram negative enteric organisms are frequently implicated. These are found in anal and perineal region
Other organisms include Proteus, pseudomonas, klebsiella, staphylococcus aureus, haemophilus etc.

43

Anatomic and physical factors
Structure of lower urinary tract accounts to bacteriuria in females
Short urethra in young girls (2cm) & in mature women (4cm) provides pathway for organism to invade
Closure of urethra in the end of micturition may lead to return of bacteria to bladder
Longer male urethra and prostatic secretions inhibit entry of pathogens in males
Urinary stasis
The act of completely and repeatedly emptying of bladder flushes away the organisms but the
incomplete emptying result from reflux , anatomic abnormalities, dysfunction of voiding mechanism,
extrinsic ureteral compression caused by constipation etc leads to UTI.
Altered urine and bladder chemistry
The mechanical and chemical properties of urine and bladder mucosa maintain urinary sterility.
Normally urine is acidic. An alkaline medium is favored by the pathogens. A urine pH of about 5
hampers the bacterial multiplication.
RISK CATEGORY
- Throughout childhood, the risk of having a UTI is 2 percent for boys and 8 percent for girls.
- Having an anomaly of the urinary tract increases the risk of a UTI.
o Vesicoureteral reflux
o Urinary obstruction
o Dysfunctional voiding
- Boys who are younger than 6 months sold who are not circumcised are at greater risk for a UTI than
circumcised boys the same age.

PATHOPHYSIOLOGY
Cause : UVR, catheterization , postponement of voiding, DM, low fliud intake etc
bacteria ascends the urethra
Lining of urinary tract becomes inflammed
Micturition reflex triggered
Urgency, frequency, burning hematuria, irritability, failure to thrive, pyuria

DIAGNOSTIC EVALUATION
A urine sample will be collected and examined. The way urine is collected depends on the child‘s age:
- If the child is not yet toilet trained, the health care provider may place a plastic collection bag over
the child‘s genital area. The bag will be sealed to the skin with an adhesive strip. If this method is
used, the bag should be removed right after the child has urinated, and the urine sample should be
processed immediately. Because bacteria from the skin can contaminate this sample, the methods
listed below are more accurate.

44

- A health care provider may need to pass a small tube called a catheter into the urethra of an infant.
Urine will drain directly from the bladder into a clean container.
- Sometimes the best way to collect a urine sample from an infant is by placing a needle directly into
the bladder through the skin of the lower abdomen. Getting urine through a catheter or needle will
ensure that the urine collected does not contain bacteria from the skin.
- An older child may be asked to urinate into a container. The sample needs to come as directly into
the container as possible to avoid picking up bacteria from the skin or rectal area.

Urine culture
 First morning urine specimen
 Clean catch mid stream specimen
 Collection bag
 Supra pubic aspiration
 Bladder catheterization
Urinalysis
- Increased number of RBC
- Nitrate test positive
- Significant bacteriuria
Renal ultrasound
- GU tract anatomy
- Pelvi calceal dilatation
- Hydronephrosis
- Renal scarring
Dipstick tests
USG
VCUG
- GU anatomy
IVP
THERAPEUTIC MANAGEMENT
Goals -eliminate current infection
-Identify contributing factors and reduce risk of occurrence
-prevent systemic spread of infection
-preserve renal function
PHARMACOLOGIC MANAGEMEN T
antibiotic therapy based on:
identification of pathogen
history of antibiotic use
location of infection

45

 Antibiotics
- amoxicillin – 20-40mg/kg in 3 doses
- cefixime – 8mg/kg in 2 doses
- Cephalexin – 50-100mg/kg in 4 doses
- Gentamycin – 1-4mg/kg single dose
- Trimethoprim – 6-12mg/kg & 30-60mg/kg in 2 doses
- Cefotaxim – 100mg/kg in 3 divided doses
- Ciprofloxacin – 20-30mg/kg in 2 divided doses

 Antimicrobial drugs (sometimes it will not be effective due to resistance of organism)
 Anti-infective agents
- penicillin
- sulfonamide
- cephalosporin
- nitrofurantoin
SURGICAL MANAGEMENT
For primary reflux or bladder neck obstruction, surgical correction is needed to avoid recurrence.
NURSING MANAGEMENT
- Careful history taking regarding voiding habits, stooling pattern
- Caution the parents in suspected cases
- Collect appropriate specimen
- Checking diaper half hourly for straining, dripping of small amounts of urine.
- Explanation of procedure according to their age
- Administer proper dosage of medications
- Increase the fluid intake

COMPLICATIONS
Most UTIs are not serious, but some infections can lead to serious problems, such as kidney infections.
- Chronic kidney infections
Infections that recur or last a long time can cause permanent damage, including kidney scars, poor kidney
growth, poor kidney function, high blood pressure, and other problems.
- Some acute kidney infections
infections that develop suddenly can be life threatening, especially if the bacteria enter the bloodstream, a
condition called septicemia.

PREVENTION
- Simple hygienic habits should be followed
- Practice habit of voiding soon as they feel the urge
- Adolescent girls are advised to urinate soon after an intercourse

46

- Reinforce parents and older children the importance of compliance
- Circumcision in males
- Plenty of oral fluids
- Treatment of constipation, pinworms

GLOMERULAR DISEASE
Many diseases affect kidney function by attacking the glomeruli, the tiny units within the kidney where
blood is cleaned. The glomerulus may be injured by several mechanisms, but it has only a limited number of
histopathologic responses; different disease states can produce similar microscopic changes. Glomerular injury
may be a result of genetic, immunologic, perfusion, or coagulation disorders.
TYPES
The three basic types of glomerular disease include: focal nephritic, diffuse nephritic, and nephrotic.
Focal nephritic — The key feature of focal nephritic disease is blood in the urine (hematuria) without
significant impairment of kidney function or proteinuria. A person with focal glomerulonephritis may not have
any symptoms and their condition may go unnoticed until blood and protein are found during a routine
urinalysis.
The following conditions may cause focal glomerulonephritis.
 Mild postinfectious glomerulonephritis, IgA nephropathy, thin basement membrane disease, hereditary
nephritis(Alport syndrome), Henoch-Schönlein purpura (IgA vasculitis), mesangial proliferative
glomerulonephritis
Diffuse nephritic — Persons with diffuse nephritic disease have hematuria with impaired kidney function and
proteinuria. This may be a severe form of focal nephritic disease for some people, or may be caused by a
bodywide disease. Urinalysis may also show high levels of protein, and patients may have edema (swelling in
the lower legs) or high blood pressure.
The following conditions may cause diffuse glomerulonephritis.
 Less than 15 years old – Postinfectious glomerulonephritis, membranoproliferative glomerulonephritis
Nephrotic syndrome — People with nephrotic syndrome generally have protein in the urine (proteinuria) but
little to no blood in the urine. Kidney function may worsen as nephrotic syndrome progresses.
The following conditions may cause nephrotic syndrome.
 Less than 15 years old – Minimal change disease, focal segmental glomerulosclerosis, mesangial
proliferative glomerulonephritis

47

Nephrotic Syndrome
Nephrotic syndrome, a manifestation of glomerular disease, characterized by nephrotic range proteinuria
and the triad of clinical findings associated with massive proteinuria, hypoalbuminemia, edema, and
hyperlipidemia. (Nephrotic range proteinuria - protein excretion of > 40 mg/m
2
/hr or a first morning protein:
creatinine ratio of >2-3: 1)
INCIDENCE:
The annual incidence is 2-3 cases per 100,000 children per year in most Western countries and higher in
underdeveloped countries resulting predominantly from malaria. Miniml change nephrotic syndrome constitutes
80% of nephrotic syndrome cases.

ETIOLOGY:
Most children with nephrotic syndrome have a form of primary or idiopathic nephrotic syndrome.
a) Idiopathic nephrotic syndrome include minimal change disease (the most common), focal segmental
glomerulosclerosis, membranoproliferative glomerulonephritis, membranous nephropathy and diffuse
mesangial proliferation
b) Associate with glomerular damage (systemic lupus erythematosus, lymphoma ,leukemia and infections)
c) Hereditary proteinuria syndromes are caused by mutations in genes that encode critical protein
components of the glomerular filtration apparatus. Such as Alport syndrome, sickle cell anemia.

TYPES:
1. Idiopathic Nephrotic syndrome
It is the primary disease which also known as childhood nephrosis, or minimal change nephrotic syndrome.
Approximately 90% of children with nephrotic syndrome have idiopathic nephrotic syndrome. Idiopathic
nephrotic syndrome is associated with primary glomerular disease without evidence of a specific systemic
cause. Idiopathic nephrotic syndrome includes multiple histologic types: minimal change disease, mesangial
proliferation, focal segmental glomerulosclerosis (FSGS), membranous nephropathy, and
membranoproliferative glomerulonephritis.

2. Secondary Nephrotic Syndrome
It is a secondary disorder that occurs as a clinical manifestation after or in assosciation with glomerular
damage. It occurs secondary to systemic diseases such as systemic lupus erythematosus, Henoch-Schönlein
purpura, malignancy (lymphoma and leukemia), and infections (hepatitis, HIV, and malaria). Secondary
nephrotic syndrome should be suspected in patients >8 yr and those with hypertension, hematuria, renal
dysfunction, extrarenal symptoms (rash, arthralgias, fever), or depressed serum complement levels.
Nephrotic syndrome has also developed during therapy with numerous drugs and chemicals. The
histologic picture can resemble membranous glomerulopathy (penicillamine, captopril, gold, nonsteroidal anti-
inflammatory drugs, mercury compounds), MCNS (probenecid, ethosuximide, methimazole, lithium), or
proliferative glomerulonephritis (procainamide, chlorpropamide, phenytoin, trimethadione, paramethadione).

3. Congenital Nephrotic Syndrome
It is inherited as autosomal recessive disorder. Congenital nephrotic syndrome is defined as nephrotic
syndrome manifesting at birth or within the first 3 months of life. Congenital nephrotic syndrome may be
classified as primary or as secondary to a number of etiologies.

48

a) Primary congenital nephrotic syndrome is due to a variety of syndromes inherited as autosomal
recessive disorders. Affected infants most commonly present at birth with edema due to massive
proteinuria, and they are typically delivered with an enlarged placenta (>25% of the infant‘s weight).
Severe hypoalbuminemia, hyperlipidemia, and hypogammaglobulinemia result from loss of filtering
selectivity at the glomerular filtration barrier. Prenatal diagnosis can be made by the presence of
elevated maternal and amniotic α-fetoprotein levels.

b) Secondary congenital nephrotic syndrome can be occurred from underlying causes such as syphilis.

PATHOPHYSIOLOGY
- In nephrotic syndrome, type III hypersensitivity reaction occurs in which the immune complex
precipitated in the tissue.
- Activation of the complement system also stimulates vaksoaktive amines (including histamine) and this
substance causes retraction of endothelial cells thus increasing vascular permeability.
- Changes in membrane glomerolus, causing increased permeability, allowing the proteins (especially
albumin) out through the urine (proteinurine).
- Decreased oncotic pressure causing albumin moves from intra vascular space into interstitiel.
- Transfer of proteins to the interstitial cavity causing lipoproteinemia.
- It stimulates the liver to compensate by increasing the production of lipoproteins and increased
concentrations of blood fats (hyperlipidemia).
- When the liver is not able to compensate for damage in fat and protein metabolism.
- Transfer of protein exit the vascular system, causing fluid to move into the space plasma interstitisel
resulting edema and hypovolemia.
- Decrease in vascular volume stimulates renin angiotensin system, which allows the secretion of
aldosterone and antidiuretic hormone (ADH).
- Aldosterone stimulates increased reabsorsi distal tubules of the sodium and water, leading to increased
edema.

49

metabolic, biochemical, physiochemical or immune mediated disturbances

basement membrane of glomeruli permeable to proteins

loss of albumin in urine through the membrane

hypoalbuminemia

decrease in colloidal osmotic pressure in capillaries

vascular hydrostatic pressure exceeds the pull of colloidal
osmotic pressure

fluid accumulation

in interstitial space abdominal cavity
(edema) (ascitis)
Hypovolemia

Decreased renal blood flow increased secretion EDEMA
of ADH and aldosterone

Rennin release Na
+
and water reabsorption

Vasoconstriction increased hydrostatic pressure

CLINICAL MANIFESTATIONS
Weight gain
Puffiness on face (facial edema)
o Especially around the eyes
o Apparent on arising the morning
o Subsides during the day
Abdominal swelling (ascitis)
Pleural effusion
Labial or scrotal swelling
Edema of intestinal mucosal which result in:
o Diarrhea
o Anorexia
o Poor intestinal absorption
Ankle / leg swelling
Irritability
Easily fatigued
Lethargic

50

BP normal or slightly decreased
Susceptible to infections
Urine alterations
o Decreased volume
o Frothy
DIAGNOSTIC EVALUATION
History collection
o weight gain, anorexia, irritability, less active
Physical examination
o Clinical manifestations
Urine dipstick test for protienuria
Blood tests –presence of casts, RBC
o Serum protein low concentration
o Reduced albumin
o GFR normal or high
o Hb normal or elevated
o Elevated platelet count
Renal biopsy if not respond to steroid treatment
THERAPEUTIC MANAGEMENT
Goals
 Reduce excrtion of urinary protein
 Reduce fluid retension
 Preventing infection
 Minimize complications related to treatment

DIETARY MANAGEMENT
- Low salt diet
- Fluid restriction

PHARMACOLOGICAL MANAGEMENT
- Diuretic therapy for temporary relief from edema
- Infections are treated with appropriate antibiotics
- Corticosteroids for MCNS
Prednisolone – 2mg/kg body weight/day in one or two divide doses
- Relapse is treated with high dose steroid therapy
- For children who do not respond to steroid therapy, immune - suppressants are given.

STEROID THERAPY
 Extended APN schedule
o 60mg/m
2
/day as a single dose for 6 weeks
o If remission is present , then 40 mg/m
2
/every other day for next 6 weeks
o If remission is maintained, taper steroids in EOD in 2 weeks
 Definition of response

51

- Remission
No albumin on three consecutive early morning urine samples
- Relapse
2+ or more albumin on 3 consecutive early morning urine samples
- Frequent relapse
3 or more relapses in 6 months or 4 or more relapses in 1 year
- Steroid resistance
No remission after 8 weeks of adequate daily steroids
- Steroid dependence
Relapse within 15 days of stopping steroids after inducing remission or on tapering, on more than 2
occasions

NURSING MANAGEMENT
a. Focus Assessment

 Urinary System (oliguric, urine retention, proteinurin and urine discoloration).
 Fluid and electrolyte balance (excess fluid, edema, ascites, weight gain, dehydration)
 Circulation (increased blood pressure)
 Neurology (decreased level of consciousness due to dehydration)
 Breathing (shortness of breath, tachypnea)
 Mobility (redness, malaise)

b. Nursing Diagnosis

1. Impaired Urinary Elimination related to Na and water retention.
2. Excess Fluid Volume related to edema
3. Imbalanced Nutrition Less Than Body Requirements related to damage protein metabolism
4. Ineffective Breathing Pattern related to suppression of the diaphragm due to ascites

c. Nursing interventions
1. Administer medications, such as diuretics, antibiotics, and corticosteroids as ordered.
2. Ask dietitian to plan a low-sodium diet with moderate amounts of protein.
3. Provide meticulous skin care to combat the edema that usually occurs with nephrotic syndrome.
4. Encourage activity and exercise and provide antiembolismstockings as ordered.
5. Frequently check the patient‘s urine for protein, indicated by frothy appearance.
6. Monitor and document the location and charater of edema.
7. Measure blood pressure while the patient is in s supine position and standing.
8. Monitor intake and output hourly.
9. Assess the patient‘s response to prescribed medications.
10. Stress the importance of adhering to the special diet

52

COMPLICATIONS
1. Due to drugs
2. Due to the disease
1.Due to drugs
Toxicity of the following drugs may occur
Furosemide, siranolactone
Steroids
Cyclophosphamide
Levamisole
Anticoagulants

2.Due to the disease
Edema
Biochemical hypothyroidism
Hypocalcemic tetany
Anemia
Hypercoagulable states
Acute renal failure
Infection
- Children in relapse have increased susceptibility to bacterial infections because of urinary losses of
immunoglobulins, defective cell-mediated immunity, their immunosuppressive therapy,
malnutrition, and edema or ascites acting as a potential culture medium.
- Spontaneous bacterial peritonitis is a common infection, although sepsis, pneumonia, cellulitis, and
urinary tract infections may also be seen.
Thromboembolic events
- Both arterial and venous thromboses may be seen, including renal vein thrombosis, pulmonary
embolus, sagittal sinus thrombosis, and thrombosis of indwelling arterial and venous catheters.
- To minimize the risk of thromboembolic complications, aggressive use of diuretics and the use of
indwelling catheters should be avoided if possible.
Cardiovascular disease
- Hyperlipidemia, may be a risk factor for cardiovascular disease; myocardial infarction is a rare
complication in children.
Steroid therapy
- Complications incude weight gain, ounding of face, increased appetite, hirsuitism, growth
retardation, cataracts, HTN, gastro intestinal bleeding, infection and hyperglycemia.

IMMUNISATIONS
The children with NS should receive:
- 23- serotype pneumococcal vaccine
- 7-valent conjugate pneumococcal vaccine
- routine childhood immunization schedule( for child is in remission and off daily prednisone therapy)

53

- Live virus vaccines should not be administered to children who are receiving daily or alternate-day
high-dose steroids (≥2 mg/kg/day of prednisone or its equivalent, or ≥20 mg/day if the child weighs
>10 kg).
- Vaccines can be administered after corticosteroid therapy has been discontinued to nephrotic
children in relapse
- if exposed to varicella, should receive varicella-zoster immunoglobulin (1 dose ≤96 hours after
significant exposure)
- Influenza vaccine should be given on a yearly basis

PROGNOSIS
Ultimate recovery in most cases is good. It is a self timing disease. In children who receives steroid
therapy the tendency to relapse decreases with time. With early detection and treatment, the membrane damage
could be minimized. About 80% of affected children have favorable prognosis.

Hemolytic-Uremic Syndrome
Hemolytic-uremic syndrome (HUS) is one of the most common causes of community-acquired acute
kidney failure in young children. It is characterized by the triad of microangiopathic hemolytic anemia,
thrombocytopenia, and renal insufficiency .
CLINICAL DESCRIPTION
Hemolytic uremic syndrome (HUS) is characterized by the acute onset of microangiopathic hemolytic
anemia, renal injury, and a low platelet count. Most cases of HUS occur after an acute gastrointestinal illness
(usually diarrheal).
INCIDENCE
- Occurs in infants and small children between the ages of 6 months and 5 years.
CASE CLASSIFICATION
Probable
• An acute illness diagnosed as HUS or TTP that meets the laboratory criteria in a patient who does not
have a clear history of acute or bloody diarrhea in the preceding 3 wk
• An acute illness diagnosed as HUS or TTP that (a) has onset within 3 wk after onset of an acute or
bloody diarrhea and (b) meets the laboratory criteria except that microangiopathic changes are not
confirmed.
Confirmed
• An acute illness diagnosed as HUS or TTP that both meets the laboratory criteria and began within 3
wk after onset of an episode of acute or bloody diarrhea

54

CLASSIFICATION OF HEMOLYTIC UREMIC SYNDROME
 Infection Induced
Verotoxin-producing Escherichia coli
Shiga toxin-producing Shigella dysentereriae type 1
Neuraminidase-producing Streptococcus pneumoniae
Human immunodeficiency virus
 Genetic
von Willebrand factor-cleaving protease (ADAMTS 13) deficiency
Complement factor H (or related proteins) deficiency or mutation
Membrane cofactor protein (MCP) mutations
Thrombomodulin mutations
Complement factor I mutations
Vitamin B12 metabolism defects
Familial autosomal recessive of undefined etiology
Familial autosomal dominant of undefined etiology
Sporadic, recurrent, undefined etiology without diarrhea prodrome
 Other Diseases Associated With Microvascular Injury
Systemic lupus erythematosus
Antiphospholipid antibody syndrome
Following bone marrow transplantation
Malignant hypertension
Primary glomerulopathy
HELLP (hemolytic anemia, elevated liver enzymes, low platelet count) syndrome
 Medication-Induced
Calcineurin inhibitors (cyclosporine, tacrolimus)
Cytotoxic, chemotherapy agents (mitomycin C, cisplatin, gemcitabine)
Clopidogrel and ticlopidine
Quinine
SUBGROUPS
1
st
– associated with a diarrheal prodrome ( D
+
/ typical HUS)
2
nd
– not associated with antecedent diarrhea ( D
-
/ atypical HUS)

55

ETIOLOGY
- Rickettsia
- Bacterial toxins (e-coli, salmonella, pneumococci)
- Chemicals
- Viruses (coxsackie virus, echovirus, adenovirus)
- Usually transmitted by undercooked meat or unpasteurized milk or apple cider
- HUS outbreaks have also been associated with municipal water supply; petting farms; swimming in
contaminated ponds and consuming cheese, lettuce, or raw spinach contaminated with toxin
PATHOPHYSIOLOGY
Primary injury in endothelial lining of small glomerular arterioles

Deposits of platelets and fibrin clots

Swelling in the glomerular arterioles

RBC damage resulted by the attempt to move through occluded blood vessels

Spleen removes the damage

Results in hemolytic anemia

Result in characteristic thrombocytopenia
CLINICAL MANIFESTATIONS
History of a prodromal disease (gastroenteritis or an upper respiratory infection)
Acquired hemolytic anemia
Sudden onset of hemolysis
Thrombocytopenia
Renal injury
Central nervous system symptoms
DIAGNOSTIC EVALUATION
History collectuion
Clinical examination:
- Triad of anemia, thrombocytopenia and renal failure

56

Laboratory examination:
Urine - proteinuria, hematuria, urinary cast presence
Blood - Elevated blood urea, nitrogen, creatinine
- Low hemobglobin, hematocrit
- High reticulocyte count
THERAPEUTIC MANAGEMENT
- early recognition of the disease
- monitoring for potential complications
- meticulous supportive care.
careful management of fluid and electrolytes
correction of volume deficit
control of hypertension
early institution of dialysis if the patient becomes anuric or significantly oliguric
Red cell transfusions are usually required because hemolysis can be brisk and recurrent until the
active phase of the disease has resolved.
- Blood transfusion
Fresh, washed packed cells for anemic child with caution to prevent circulatory overload
Fresh frozen plasma and plasma pherisis
PROGNOSIS
The acute prognosis, with careful supportive care, for diarrhea associated HUS (D
+
) has <5% mortality in
most major medical centers. Half of the patients require dialysis support during the acute phase of the disease.
Most recover renal function completely, but of surviving patients, 5% remain dependent on dialysis, and up to
20-30% are left with some level of chronic renal insufficiency. The recovery rate is about 95%, but residual
renal impairment ranges from 10% to 50% in various cases.

Immunoglobulin A Nephropathy (Berger Nephropathy)
IgA nephropathy is the most common chronic glomerular disease. The disease derives its name from
deposits of Immunoglobulin A (IgA) in a granular pattern in the mesangium a region of the renal glomerulus. It
is characterized by a predominance of IgA immunoglobulin within mesangial glomerular deposits in the
absence of systemic disease (e.g., symptomatic systemic lupus erythematosus or Henoch-Schönlein purpura).
INCIDENCE
It is seen more often in male than in female patients.
-is often benign in childhood in comparison to that of adults.

57

-is an uncommon cause of end-stage renal failure during childhood.
CLINICAL MANIFESTATIONS
Gross hematuria associated with loin pain.
Proteinuria often <1000 mg/24 hr.
Mild to moderate hypertension.
Normal serum levels of C3
DIAGNOSIS
History collection
Physical examination (clinical features)
Laboratorical investiagationss
Renal biopsy
TREATMENT
- The primary treatment is appropriate blood pressure control
- Fish oil, which contains anti-inflammatory omega-3 polyunsaturated fatty acids
- Immunosuppressive therapy with corticosteroids
- Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists are effective in
reducing proteinuria and retarding the rate of disease progression.
- Kidney transplantation
PROGNOSIS
Although IgA nephropathy does not lead to significant kidney damage in most children, progressive disease
develops in 20-30% of patients 15-20 yr after disease onset. Therefore, most children with IgA nephropathy do
not display progressive renal dysfunction until adulthood, prompting the need for careful long-term follow-up.
Poor prognostic indicators at presentation or followup include persistent hypertension, diminished renal
function, and heavy or prolonged proteinuria.

Alport Syndrome (hereditary nephritis)
AS, hereditary nephritis, is a genetically heterogeneous disease caused by mutations in the genes coding
for type IV collagen, a major component of basement membranes. These genetic alterations are associated with
marked variability in clinical presentation, natural history, and histologic abnormalities.
GENETICS
Approximately 85% of patients have X-linked disease caused by a mutation. Autosomal recessive forms
of AS are caused by mutations in the COL4A3 and COL4A4 genes on chromosome 2 encoding the α3 and α4

58

chains, respectively, of type IV collagen. An autosomal dominant form of AS linked to the COL4A3-COL4A4
gene locus occurs in 5% of cases.
CLINICAL MANIFESTATIONS
- Asymptomatic microscopic Hematuria
- Single or recurrent episodes of gross hematuria commonly occurring 1-2 days after an upper
respiratory infection.
- Proteinuria
- Bilateral sensorineural hearing loss
- Ocular abnormalities
- Leiomyomatosis of the esophagus, tracheobronchial tree, and female genitals in association with
platelet abnormalities is rare.
DIAGNOSIS
- Family history
- Screening urinalysis of first-degree relatives
- Audiogram,
- Ophthalmologic examination
- Diagnostic renal biopsy
- Mutation screening or linkage analysis is not readily available for routine clinical use.
- Prenatal diagnosis is available for families with members who have X-linked AS and who carry an
identified mutation.
TREATMENT
- No specific therapy is available to treat AS
- Angiotensin converting enzyme inhibitors can slow the rate of progression
- Careful management of renal failure complications such as hypertension, anemia, and electrolyte
imbalance is critical.
- Patients with ESRD are treated with dialysis and kidney transplantation.
PROGNOSIS
- The risk of progressive renal dysfunction leading to end-stage renal disease (ESRD) is highest
among hemizygotes and autosomal recessive homozygotes. Risk factors for progression are gross
hematuria during childhood, nephrotic syndrome, and prominent GBM thickening.

59

Acute Glomerulo Nephritis
AGN is an immune mediated inflammatory disease of the capillary loops in the renal glomeruli. AGN may
be a primary event or a manifestation of a systemic disorder that can range from minimal to severe.
INCIDENCE
-Acute post streptococcal glomerulo nephritis (APGN) is the most common of post infectious renal
disease in childhood.
-It is common in early school age children.
-And male female ratio is 2:1.
ETIOLOGY
It is an immune complex disease that occurs after an antecedent streptococcal infection with certain
strains of group A β-hemolytic streptococcal infection. Acute post streptococcal glomerulonephritis is the most
common. A latent period of 10 to 21 days occurs for the onset of clinical manifestations.
PHASES
Phase 1 – edema and oliguria present
Phase 2 – edema reduces and urine output increases
PATHOPHYSIOLOGY
Immune complexes are deposited in the glomerular basement membrane. The glomeruli becomes
edematous ad infiltrated with polymorphonuclear leukocytes, which occlude the capillary lumen. The resulting
decrease in plasma filtration results in an excessive accumulation of water and retention of sodium that expands
plasma and interstitial fluid volumes, leading to circulatory congestion and edema. Excess rennin may also be
produced.
Streptococcal infection

Production of antigen antibody complex in glomerular loops

Inflammatory reaction

Proliferation and swelling of endothelial cells

Diminish the amount of glomerular filtrate and allow the
passage of blood cells and protein in the filtrate

Sodium and water retention

Damage of glomerular membrane

Progressive renal failure

60

CLINICAL MANIFESTATIONS
Sore throat/pyoderma/scabies/impetigo
Oliguria
Edema
Periorbital puffiness
Pedal edema
Rapid weight gain
Hypertension
Circulatory congestion
Hematuria
Proteinuria
Fever
Headache
Nausea and vomiting
Anorexia
Abdominal pain
Malaise
Hypertension
DIAGNOSIS
- History collection
Affected children are in good helath typically until streptococcal infection occurs. Sometimes there
will be history of only mild cold. An average latent period is about 10 days.
- Physical examination
Edema is relatively moderate.
- Urine examination
specific gravity, reduced total amount of urine, microscopic examination for red cells, WBC, pus
cells, epithelial cells, granular cast
- Blood examination
increased level of urea, creatinine, ESR, decreased Hb, hyponatremia, hyperkalemia, reduced
C3(serum complement) in early stages.
- Throat swab culture
Streptococci from culture of the pharynx
- Chest X-ray

61

Cardiac enlargement, pulmonary congestion, pleural effusion.
COMPLICATIONS
- CCF
- Acyte renal failure
- Hypertensive encephalopathy
- Persistent hypertension
- Anemia
- Growth failure
- Chronic glomerulonephritis

MANAGEMENT
Therapeutic management includes general supportive measures and early recognition and treatment of
complications.
-Bedrest for weeks till urine got free from RBC
-Diet management
Protein restricted
Restricted salt and fluid
Freely allow carbohydrate containing food
-Daily weight recording to assess increase and decrease edema
- Regular measurement of vital signs, body weight and input and output is essential in order to monitor the
progress of the disease and to detect complications.
-symptomatic management
administration of antibiotic
Antihypertensive drugs
Tranquilisers for convulsions and encephalopathy
Diuretics are not indicated since edema is rarely massive & gradually disappears with the return of renal
function. For pulmonary edema IV frusemide (2.4 mg/kg) is given.
-dialysis may be needed in renal failure and severe electrolyte imbalance
-management of complications
CCF
Hypertensive encephalopathy
Respiratory support

62

NURSING MANAGEMENT
Careful assessment of diseases status
Regular monitoring of vital signs
Maintain input and output
Children with restricted fluid intake and those who does not have much edema should be observed for
signs of dehydration if he lost weight.
Administer antibiotics
Promote rest, sleep and comfortable position
Skin care for edematous part
Dietary management
PROGNOSIS
Almost all children correctly diagnosed as having APSGN recover completely and specific immunity is
conferred, so that subsequent recurrences are uncommon. A few of these children have been reported to develop
chronic disease, but most of these cases are now believed to be different glomerular diseases misdiagnosed as
post streptococcal disease.

Chronic Glomerulo Nephritis
It is not a single disease , it comprises advanced stages of several forms of GN. It is an advanced
irreversible impairment of renal function with or without symptoms. It may develop as a primary disease or may
occur in SLE or drug induced nephropathies.
CLINICAL MANIFESTATIONS
It may remain asymptomatic
edema
Severe hypertension
Hematuria
Nocturia
Persistent anemia
Bone pain
Bony deformities
Failure to thrive

63

DIAGNOSIS
- Physical examination
Growth retardation
Long standing hypertension
Bony changes
- Urine examination
- Blood examination
anemia, increase urea, creatinine, low GFR
- Urine analysis
protein, RBC, cast
- USG
shrunken kidneys
MANAGEMENT
It can be done with steroid therapy and other immune suppressive drugs.
Anti hypertensive drugs and antibiotics are useful for symptomatic measurement.

URINARY LITHIASIS
A kidney stone is a solid concretion or crystal aggregation formed in the kidneys from dietary
minerals in the urine. Kidney stones (nephrolithiasis or urolithiasis or renal calculus) develop when a collection
of minerals or other material form a small "stone." The stone can cause pain, block the flow of urine, and rarely
cause long-term kidney problems if it is not recognized and treated promptly.
INCIDENCE
Stones are less common in children than in adults. Approximately 7% of urinary calculi occur in
children less than 16 years of age. About 80% of those with kidney stones are men.
ETIOLOGY
There are wide geographic variations with relation to climate, diet and socio economic factors. Most children
who develop kidney stones have an underlying condition that increases their risk of stones, although some
children develop a stone for unknown reasons.
1. High conc. of metabolic products in glomerular filtrate
2. Changes in urine pH
3. Urinary stagnation
4. Deficiency of stone-forming inhibitors in urine

64

1. High conc. of metabolic products in glomerular filtrate is due to:
o Low urinary volume (with normal renal function) due to restricted fluid intake
o Increased fluid loss from the body
o Increased excretion of metabolic products forming stones
o High plasma volume (high filtrate level)
o Low tubular reabsorption from filtrate
2. Changes in urine pH due to:
o Bacterial infection
o Precipitation of salts at different pH
3. Urinary stagnation is due to:
o Obstruction of urinary flow
4. Deficiency of stone-forming inhibitors:
o Citrate, pyrophosphate, glycoproteins inhibit growth of calcium phosphate and calcium oxalate
crystals
o In type I renal tubular acidosis, hypocitraturia leads to renal stones
STONE FORMATION
A kidney stone usually forms when substances that are normally found in the urine, such as calcium,
oxalate, cystine, or uric acid, are at high levels. In some children, stones can also form if these substances are at
normal levels. The substances form crystals, which become anchored in the kidney and gradually increase in
size, forming a kidney stone. Stones that are very small (less than 5 millimeters (0.2 inches)) can usually pass
on their own, while larger stones usually require treatment. A kidney stone moves through the urinary tract and,
if it is small enough, it will be passed in the urine. A larger stone can become stuck within the urinary tract,
causing pain and sometimes blocking the flow of urine.
CLINICAL MANIFESTATIONS
 Abdominal or flank pain (renal colic)
 Gross or microscopic hematuria
 Nausea or vomiting
 Needing to rush to the bathroom to urinate
 Young children may not have any symptoms, and the kidney stone is found when an imaging test (like
an X-ray) is done for another reason.
DIAGNOSIS
- Plain abdominal x-ray ( to know the size and nature)
Radio opaque – struvite,
Radiolucent – cystine, uric acid calculi
- Noncontrast spiral CT scan
Number and location of calculi
Hydronephrosis
- Plain radiograph of abdomen and pelvis.

65

- Renal USG
Growth or diminished size or movement of calculus
TYPES
Urinary stones are typically classified by their location in the kidney (nephrolithiasis), ureter (ureterolithiasis),
or bladder (cystolithiasis), or by their chemical composition (calcium-containing, struvite, uric acid, or other
compounds)
Calcium stones ( calcium oxalate & calcium phosphate)
- Hypercalciuria
- Hyperuricosuria
- hyperoxaluria
- Heterozygous cystinuria
- Hypocitruria
- Renal tubular acidosis
Uric acid stones
- Hyperuricosuria
- Myeloproliferative disorders
- Inflammatory bowel disease
- After chemotherapy
Struvite stones (magnesium ammonium phosphate)
- UTI
- Foreign body
- Urinary stasis
Cystine stones
- Cystinuria
Indinavir stones
Nephrocalcinosis

1. Calcium salt stones
- 80% of kidney stones contain calcium
- The type of salt depends on
a. Urine pH
b. Availability of oxalate
- General appearance:
c. White, hard, radioopaque
d. Calcium PO4: staghorn in renal pelvis (large)
e. Calcium oxalate: present in ureter (small)

66

Causes of calcium salt stones:
 Hypercalciuria:
- Increased urinary calcium excretion
- Men: > 7.5 mmols/day
- Women > 6.2 mmols/day
- May or may not be due to hypercalcemia
 Hyperoxaluria:
- Causes the formation of calcium oxalates without hypercalciuria
- Diet rich in oxalates
- Increased oxalate absorption in fat malabsorption
 Primary hyperoxaluria:
- Due to inborn errors
- Urinary oxalate excretion: > 400 mmols/day
Treatment:
- Treatment of primary causes such as infection, hypercalcemia, hyperoxaluria
- Oxalate-restricted diet
- Increased fluid intake
- Acidification of urine (by dietary changes)
Calcium salt stones are formed in alkaline urine

2. Uric Acid Stones
- About 8% of renal stones contain uric acid
- May be associated with hyperuricemia (with or without gout)
- Form in acidic urine
- General appearance:
a. Small, friable, yellowish
b. May form staghorn
c. Radiolucent (plain x-rays cannot detect)
d. Visualized by ultrasound or IVP
Treatment:
e. Purine-restricted diet
f. Alkalinization of urine (by dietary changes)
g. Increased fluid intake
3. Struvite stones (magnesium ammonium phosphate)
- About 10% of all renal stones contain Mg amm. PO4

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- Also called struvite kidney stones
- Associated with chronic urinary tract infection
a. Microorganisms (such as from Proteus genus) that metabolize urea into ammonia
b. Causing urine pH to become alkaline and stone formation
- Commonly associated with staghorn calculi
- 75% of staghorn stones are of struvite type
Treatment:
c. Treatment of infection
d. Urine acidification
e. Increased fluid intake
4. Cystine stones
- A rare type of kidney stone
- Due to homozygous cystinuria
- Form in acidic urine
- Soluble in alkaline urine
- Faint radio-opaque
Treatment:
- Increased fluid intake
- Alkalinization of urine (by dietary changes)
- Penicillamine (binds to cysteine to form a compound more soluble than cystine)
5. Indinavir stones
- Indinavir sulfate is a protease inhibitor used in the treatment of HIV and 12% of medicine is
excreted through urine after each dose
- 4 % aquire symptomatic nephrolitiasis
- Urine often contains crystals (starburst, rectangular, fan shaped)
Treatment:
- Dissolution therapy by urine acidification with ammonium chloride/ascorbic acid
6. Nephrocalcinosis
- Refers to calcium deposition within the renal tissue
Cause:
- Furosemide administration
- Hyperparathyroidism
- Cortical necrosis
- Renal candidiasis
RISK FACTORS
Certain factors can increase a child's risk of developing kidney stones.

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History of kidney stones
Children who have had a kidney stone in the past have the highest risk of developing a stone in
the future. Preventive measures can decrease the risk of developing a stone in the future.
Less water intake
The amount of fluids a child drinks directly affects the amount of urine the body makes.
Drinking a small amount of fluids means that the kidneys make a small amount of urine, which increases
the concentration of stone-forming substances in the urine. Drinking more fluids can reduce the risk of
recurrent stones.
Ketogenic diet
Diets that include a very small amount of carbohydrates, called ketogenic diets, can increase the
risk of developing kidney stones. Ketogenic diets are sometimes used to treat seizure disorders.
Urinary tract abnormalities
Congenital abnormalities in the kidneys, ureters, or bladder can increase the risk of developing a
kidney stone.
Medicines
Some medicines increase the risk of forming crystals in the urine. These include furosemide
(Lasix), acetazolamide (Diamox), and allopurinol (Aloprim, Zyloprim).
Inherited disorders
Several uncommon inherited disorders can increase a child's risk of developing kidney stones.
MANAGEMENT
HOME
If the stone is small, pain is manageable, and the child is otherwise healthy, it is often possible to treat
the stone at home. Stones smaller than 5 millimeters (0.2 inches) often pass on their own without treatment.
Pain management should be done with the help of analgesics. The child should also drink more fluids than usual
to help flush the stone out.
HOSPITAL
In some cases, the child will need to be hospitalized for treatment. The two most common reasons for
hospitalization are that:
 The stone is blocking the urinary tract, preventing the normal flow of urine. If the blockage is not treated
quickly, it can cause permanent damage to the kidneys.
 The child's pain cannot be controlled because it is severe or because the child is vomiting.
- Analgesia
Management of pain often requires intravenous administration of NSAIDs or opioids.
[1]
Orally
administered medications are often effective for less severe discomfort.
- Expulsion therapy
The use of medications to speed the spontaneous passage of ureteral calculi is referred to as medical
expulsive therapy. Several agents, including alpha adrenergic blockers (such as tamsulosin) and calcium

69

channel blockers (such as nifedipine), have been found to be effective. A combination of tamsulosin and
a corticosteroid may be better than tamsulosin alone. These treatments also appear to be a useful adjunct to
lithotripsy.
- Shock wave lithotripsy
Shock wave lithotripsy is the treatment of choice for kidney stone in many children. Lithotripsy is done by
directing a high-energy shock wave toward the stone. The energy causes the stone to break into fragments that
can be passed. The procedure takes about 20 minutes. Some, although not all, children are given anesthesia to
prevent movement during the treatment.
The success of lithotripsy depends, in part, on the size of the stone; larger stones are more difficult to break
up and sometimes need more than one treatment. It can take three months after lithotripsy for all of the stone
fragments to pass.
- Percutaneous nephrolithotomy
Large stones or stones that do not break up with lithotripsy will require a minimally invasive surgical
procedure to remove the stone. During the procedure, small instruments are passed through the skin
(percutaneously) into the kidney to remove the stone. The child is given anesthesia before the procedure to
prevent pain.
- Ureteroscopy
Ureteroscopy is a procedure that can be done if the stone is in the middle and lower portion of the ureter.
The doctor passes a small instrument through the urethra and bladder, into the ureter. The instrument contains a
camera and other instruments, which allows the doctor to see the stone. The stone can be removed or broken up
into smaller pieces that can pass more easily.
PREVENTION
Children who develop a kidney stone have a significant chance of developing stones in the future.
Studies have estimated the chances to be between 30 and 65 percent. A number of steps can decrease the
chances of developing another stone.
Blood and urine tests
After a child has had a kidney stone, blood and urine tests are performed to identify factors that can
increase the risk of future stones. Testing is not done until the child is at home, walking and playing normally,
eating a normal diet, and has finished any treatment for urinary tract infection.

Stone testing
If the stone was passed and saved, it should be analyzed to determine the type of stone. Based on what
the stone is made of, one or more treatments might help to reduce the risk of future stones.

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Drink more fluids
Drinking more fluids can help to decrease the risk of forming all types of kidney stones. The goal is to
increase the amount of urine that flows through the kidneys and ureters and to lower the concentration of
substances that promote stone formation.
 Infants – 750 mL or more (25 ounces or three cups)
 Children younger than five years of age – 1000 mL or more (33 ounces or four cups)
 Children between five and ten years of age – 1500 mL or more (50 ounces or six cups)
 Children greater than 10 years of age – 2000 mL or more (66 ounces or eight cups)
Monitoring
After a first kidney stone, the child's doctor or nurse might recommend an imaging test (like ultrasound)
to monitor for new stones. This is especially important for children who are at high risk of kidney stones.

RENAL FAILURE
1.Acute Renal Failure
ARF develops when renal function is diminished to the point where body fluid homeostasis can no
longer be maintained. It is the severe deterioration of renal function, manifested as sudden reduction of urine
excretion as oliguria or anuria leading to fluid and electrolyte imbalance and accumulation of metabolic
nitrogenous wastes and other biochemical products.
ARF is an acute and potentially reversible irritability of the kidneys to perform their normal functions to
maintain homeostasis.
INCIDENCE
Variable
ETIOLOGY
The causes are divided into three groups:
Prerenal factors include shock, congestive heart failure, volume depletion from vomiting/diarrhea or
diabetic acidosis. The most common cause of decreased renal perfusion in children is dehydration. In
prerenal ARF urine osmolality is high, urine and specific gravity is less than 1.020. Although renal
perfusion is greatly decreased, renal tubular function is normal. Children may exhibit nonspecific
symptoms such as fever, dehydration and tachycardia.

Intrarenal ARF results from injury to the kidney itself. This type of ARF may be caused by HUS,
nephrotoxins such as contrast dye, ingestion of poison, glomerulonephritis, acute tubular necrosis,
severe infections, liver failure and chemotherapy, resulting in large amounts of calcium and uric acid

71

excretion. Because of glomerular damage sodium cannot be conserved and urine cannot be concentrated.
The child may present with nausea/vomiting, hypertension and oliguria.

Postrenal or obstructive ARF results from urinary tract outflow obstruction by renal calculi, tumours,
trauma resulting in hematoma, neurogenic bladder or structural abnormalities such as ureterovesical
junction stricture. Newborn delayed voiding after birth, electrolyte imbalance, a poor urinary stream
and/or abdominal mass suggests a structural abnormality and should be investigated promptly. Urine
osmolality and sodium levels are usually unaffected.
PHASES
1. Initial
Although renal damage is occurring, the child may be asymptomatic
2. Oliguric
Less than 1ml/kg/hr of urine is produced. This stage usually lasts from <10 days to several weeks. Impaired
glomerular filtration causes solute and water reabsorption, urine output declines and serum waste products
cannot be removed. As the child becomes symptomatic, uremia develops. Neurotoxicity from uremia causes an
altered mental status and altered peripheral sensation. Electrolyte imbalance causes dysrhythmias, water
retension may lead to congestive heart failure and hypertension and metabolic acidosis may develop because of
the kidney‘s inability to excrete hydrogen ions. In addition to anemia caused by decreased erythropoietin
production, blood loss may be caused by gastrointestinal bleeding secondary to platelet and protein
anticoagulant dysfunction.
3. Diuretic phase
It lasts days to weeks, there is a gradual return of renal function due to cellular regeneration and healing.
Excessive urine output leading to dehydration and electrolyte imbalance may occur during this stage as a result
of incompetent tubular transport of water and solutes.
4. Recovery phase
It may take several months. If left untreated ARF can result in fluid overload, electrolyte imbalance,
metabolic acidosis, uremia and coma. Can be treated by supportive care, including volume restoration, diuretic
administration and dialysis.
CLINICAL MANIFESTAIONS
Depend upon underlying causes and duration
Severe oliguria/ Anuria
Child may be markably well / extremely sick
Nausea / Vomiting
Lethargy

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Dehydration
Acidotic breathing
Altered consciousness
Irregular cardiac rate, rhythm
Edema
Hypertension
DIAGNOSIS
Careful history taking
Vomiting, diarrhea, fever, other renal disease
Laboratory investigations
Anemia, raised serum creatinine level, blood urea, electrolytes, pH, bicarbonate and complete blood
count, reduced C3,
Urine examination
Protienuria, Hematuria, presence of casts
USG
Structural abnormalies, calculi
IVP
Acute tubular necrosis
Radionuclide studies
Evaluate GFR, renal blood flow
Renal biopsy
Ultimate cause
PATHOPHYSILOGY
Due to the different etiological factors, renal hypoperfusion and renal outflow obstruction will occur. It leads to
impairment of renal function and renal failure.
Marked reduction in GFR and renal blood flow due to vasoconstriction results in sodium and fliud
retention which leads to edema.
HTN may develop due to rennin – angiotensin mechanism caused by arteriolar constriction, increased
circulatory overload and sodium retention.
Metabolic acidosis may develop from failure of excretion of hydrogen ions due to reduced functions od
nephron and hypercatabolic states, which lead to increased production of acids.
Hyperkalemia may develop due to disturbed sodium and potassium exchange in the distal tubules and
increased extra cellular potassium level resulting from damage tissue cells, RBCs and hypercatabolic
states.

73

Due to etiologic factors

Renal vasoconstriction arteriolar constriction function damaged tissue cells
of nephrons & RBCs

GFR HTN failure of excretion disturbed Na
+
& K
+

Of H2 ions exchange

Na & H2O retention circulatory overload production of extra cellular
& Na
+
retention acids K
+
overload

Edema metabolic acidosis hyperkalemia
TREATMENT
Medical treatment
o Fluid and dietary restrictions
o Use of diuretics
o Maintain Electrolytes
o May need dialysis to jump start renal function
o May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.
o Hemodialysis
- Subclavian approach
- Femoral approach
- Peritoneal dialysis
- Continous renal replacement therapy (CRRT)
- Does not require dialysate
Nursing interventions
- Monitor I/O, including all body fluids
- Monitor lab results
- Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle weakness, EKG
changes
- Watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions
- Maintain nutrition
- Safety measures
- Mouth care
- Daily weights
- Assess for signs of heart failure

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- Skin integrity problems
PROGNOSIS
Mortality rate of ARF is about 20 to 40% which is influenced by the cause and duration of renal failure
with severity of pathological changes. Poor prognosis is related to associated sepsis, HUS, prolonged anemia,
cardiac failure, hepatic failure and respiratory failure with delayed initiation of treatment.

CHRONIC KIDNEY DISEASE
2. Chronic Renal Failure
It is a permanent irreversible destruction of nephron leading to severe deterioration of renal function,
finally resulting to end stage renal disease.
ETIOLOGY
Cause below 5 years of age is mostly congenital anomalies
After 5 that is acquired glomerular disease, hereditary disease
o Glomerular disease
o Congenital anomalies
o Obstructive uropathy
o Miscellaneous
CLINICAL MANIFESTATIONS
Renal
- Hyponaturmia
- Dry mouth
- Poor skin turgor
- Confusion, salt overload, accumulation of K with muscle weakness
- Fluid overload and metabolic acidosis
- Proteinuria, glycosuria
Cardiovascular
- Hypertension
- Arrythmias
- Pericardial effusion
- CHF
- Peripheral edema
Neurological
- Burning, pain, and itching, parestnesia
- Motor nerve dysfunction
- Muscle cramping
- Shortened memory span

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- Apathy
- Drowsy, confused, seizures, coma, EEG changes
GI
- Stomatitis
- Ulcers
- Pancreatitis
- Uremic fetor
- Vomiting
- consitpation
Respiratory
- chance of infection
- Pulmonary edema
- Pleural friction rub and effusion
- Dyspnea
Endocrine
- Stunted growth in children
- Amenorrhea
- Male impotence
- Increased aldosterone secretion
- Impaired glucose levels R/T impaired CHO metabolism
- Thyroid and parathyroid abnormalities
- Hemopoietic
- Anemia
- Decrease in RBC survival time
- Blood loss from dialysis and GI bleed
- Platelet deficits
- Bleeding and clotting disorders – purpura and hemorrhage from body orifices , ecchymoses
Skeletal
- Muscle and bone pain
- Bone demineralization
- Pathological fractures
- Blood vessel calcifications in myocardium, joints, eyes, and brain
Skin
- Yellow-bronze skin with pallor
- Puritus
- Purpura
- Uremic frost
- Thin, brittle nails
- Dry, brittle hair, and may have color changes and alopecia

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Early symptoms Late manifestations Indications of poor prognosis
Weakness
Anorexia
Nausea
Failure to thrive
Unexplained anemia
Osteodystrophy
Growth failure
Gastrointestinal bleeding
Pericarditis
Congestive cardiac failure
Altered sensorium

Convulsions
Coma
Cardiomyopathy

DIAGNOSIS
Blood examination
Decreased hematocrit, Hb%, Na
+
, Ca
++
, HCO
-
3, increased K
+
& phosphorus
Renal function test
Gradual increase in BUN, uric acid & creatinine
Urinalysis
Variation in specific gravity, increased urine creatinine, change in total urine output
X-Ray
Chest, hands, knees, pelvis, spine to detect bony defect
ECG, IVP, MCU, radio nuclide imaging
Extent of complications
Other abnormal findings
- Metabolic acidosis
- Fluid imbalance
- Insulin resistance
- Immunoligical problems
PATHOPHYSIOLOGY
In the early stage of disease child remains asymptomatic. Advance renal damage will occur only in late
stages. Increased numbers of neurons are destructed at various degrees and a few remain intact but
hypertrophied and functional. This less number of nephrons are enough to make sufficient adjustments in fluid
and electrolyte balance. As the disease progress to end stage severe reduction in number of nephrons occur and
the kidney will not b able to maintain fliud and electrolyte balance. The accumulatin of various substances in
blood result in complications
STAGES OF CRF
I. Diminished Renal Reserve
Normal BUN, and serum creatinine absence of symptoms
II. Renal Insufficiency

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GFR is about 25% of normal, BUN Creatinine levels increased
III. Renal Failure
GFR <25% of normal increasing symptoms
IV. ESRD or Uremia
GFR < 5-10% normal, creatinine clearance <5-10 ml/min resulting in a cumulative effect
COMPLICATIONS
- Azotemia
- Metabolic acidosis
- Electrolyte imbalance
- CCF
- HTN
- Severe anemia
- Growth retardation
- Delayed or absent sexual maturation
MANAGEMENT
Conservative management
- Correction of reversible component of renal dysfunction
- Preservation of renal function
- Treatment of metabolic and psycho-social problems
- Optimization of growth
- Preparation for treatment of ESRD
- Treat for infection, accelerated hypertension, CCF, obstruction of urine flow - to improve renal
function
Dietary therapy
- Low protein diet
- Severe protein restriction may produce protein calorie malnutrition
- Diet should consist of 100 percent RDA for calories
- Protein should be of high biological value and should comprise 6 – 10 % of all calories
- Salt restriction in patients with hypertension and fluid overload
- Patients with salt losing nephropathy should take a liberal amount of salt and water
- If the GFR falls below 10ml/min/1.73m
2
, potassium intake should be restricted.(hyperkalemia may
develop)
- Vit D is essential to raise the serum calcium and suppress parathormone secretion.
Dialysis
Renal transplatation
NURSING MANAGEMENT
Frequent monitoring
o Hydration and output
o Cardiovascular function

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o Respiratory status
o Electrolytes
o Nutrition
Mental status
o Emotional well being
Ensure proper medication regimen
Skin care
Bleeding problems
Care of the shunt
Education to client and family

3. End Stage Renal Disease
ESRD represents the state in which a patient‘s renal dysfunction has progressed to the point at which
homeostasis and survival can no longer be sustained with native kidney function and maximal medical
management. At this point, renal replacement therapy (dialysis or renal transplantation) becomes necessary. The
ultimate goal for children with ESRD is successful kidney transplantation because it provides the most normal
lifestyle and possibility for rehabilitation for the child and family.

RENAL REPLACEMENT THERAPIES
Dialysis
It is a treatment modality used to manage ESRD. Dialysis is the diffusion of solute molecules through a
semipermiable membrane, passing from higher concentration to that of lower concentration. It is the process of
separating colloids and crystalline substances in solution by the difference in their rate of diffusion through a
semi permeable membrane.
The purpose of dialysis is to remove endogenous and exogenous toxins and to maintain fluid electrolyte
and acid- base balance till the renal function recovers. It is a substitute for some excretory functions of kidneys
but does not replace the endocrine and metabolic functions.
GENERAL PRINCIPAL:
Movement of fluid and molecules across a semi permeable membrane from one compartment to another
INDICATIONS
a) Uremic symptoms with neurologic abnormalities
b) Persistent hyperkalemia, above 6.5 mEq/L
c) Blood urea level more than 150 mg./dl
d) Severe acidosis, pH less than 7.2, TCO2 less than 10-12 mEq/L

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e) Hyperphosphatemia
f) Pulmonary edema and CCF
METHODS OF DIALYSIS
1. Hemodialysis
2. Peritoneal dialysis
Continuous ambulatory peritoneal dialysis
Automated peritoneal dialysis (Continuous cycling peritoneal dialysis)
3. Continuous renal replacement therapies
Continuous venovenous hemofiltration
Continuous venovenous hemodialysis
Continuous venovenous hemodiafiltration
1.Hemodialysis
Pediatric hemodialysis is referred to extracorporeal renal replacement therapy in children under the age
of 15 years. The neonates, infants and smaller children have special requirements for dialysis. Pediatric dialysis
program could start even from a neonate who is less than 1 kg. The treatment requirements almost are similar to
adults but there are certain differences as:
1. Renal replacement therapies
2. Growth and development
3. Psychological demands.

SPECIFIC CONSIDERATIONS:
The choice of dialyser, extracorporeal circuit volume and blood flow rates requires specific consideration.
 The extracorporeal circuit
The amount of blood occupied by the blood vessels and the dialyser should not exceed more than 10%
of the total blood volume of the child. If the child is severely anemic ( Hb < 5-6g/dL) the extracorporeal
circuit volume should not exceed 7%. The total blood volume can be calculated by multiplying the
child‘s weight by 80mls.
 Blood lines and dialysers
The surface area of the dialyser should not exceed the body surface area (BSA) of the child.
BSA (Mostellar equation) = Multiply the child‘s height by its weight
Divide the result by 3600
Determine the square root of result
i.e., SA(m
2
)= √([Ht in cms x Wt in kgs]÷3600)
 Blood flow rate
It is determined by the child‘s size, blood volume, blood pressure and tolerance for dialysis.
-Blood flow rate should not exceed 2.5 x weight (kg) ÷ 100
TREATMENT PARAMETERS:

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 Fluid replacement for hypotension should not exceed a maximum of 10ml/kg body weight and may
given in divided doses.
 Ultra filtration should not exceed 5% of total body weight for each dialysis session.
 Clearance rates for urea should not exceed 3 mls/min/kg body weight with 1.5 to 2ml/min/kg body
weight for extremely uremic children.
VASCULAR ACCESS:
Hemodialysis requires the creation of a vascular access and the use of special dialysis equipment – the
hemodialyzer (artificial kidney). Vascular access are of the three types:
1. Fistulas
Arterio vascular fistula is an access in which a vein and artery are connected surgically. The preferred
site is the radial artery and a forearm vein that produces dilation and thickening of superficial vessels of
the forearm to provide easy access for repeated venipuncture.
2. Grafts
Subcutaneous (internal) arteriovenous graft is a synthetic prosthetic graft for circulatory access made by
the anastomosis of artery and vein.
3. External vascular access
For this percutaneous catheters are inserted in the femoral, subclavian or internal jugular veins. A central
catheter into internal jugular vein is more permanent form.
COMPLICATIONS
- more prone to cardiovascular instability due to small blood volume.
- Excessive weight loss
- Hypotension
- Hypothermia in infants
- Dialysis equilibrium syndrome:
Fluid removal and decrease in BUN during hemodilaysis cause changes in blood osmolarity. These
changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause
cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of
consciousness.
Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation,
disorientation and seizures
Treatment: Hypertonic saline, Normal saline
if immediate treatment for disequilibrium is not provided it leads to:
Convulsions
Coma
Cardiac arrhythmia
ADVANTAGES
suited for children who do not have someone in family to perform home peritoneal dialysis
easy for those who live near dialysis center
achieves rapid correction of fluid and electrolyte abnormality

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DISADVANTAGES
associated to the rapid change, it can cause muscle cramping and hypotension
school absence during dialysis
strict fluid and dietary restrictions
boredom for child during the session
2. Peritoneal dialysis
The difficulty in finding a vascular access and maintaining adequate blood flow for hemodialysis makes
peritoneal dialysis as a preferred choice. Peritoneal dialysis is a technique that employs the patient‘s peritoneal
membrane as a dialyzer. Excess body water is removed by an osmotic gradient created by the high dextrose
concentration in the dialysate; wastes are removed by diffusion from the peritoneal capillaries into the dialysate.
Because peritoneal dialysis is not as efficient as hemodialysis, it must be performed daily rather than 3 times
weekly as in hemodialysis. Children and adolescents typically have three 3- to 4-hr sessions per week during
which fluid and solute wastes are removed.
The peritoneal dialysis exchange procedure consists of 3 steps/ phases (exchanges):

Infusion :
A sterile, dialysis solution flows into your peritoneal cavity by gravity via a catheter or tube that has
been surgically placed into the abdomen. The filling takes about 10 minutes. Once the filling is complete, the
catheter is shut so that it does not leak.

Dwell :
The lining of the peritoneal cavity called the peritoneum acts as a natural filter. It lets the waste products
and excess fluids in the blood filter through into the dialysis solution, while holding back important substances
that the body needs. The length of time varies from 3 - 6 hours. While the solution is in the body you can move
about.

Drain :
The dialysis solution containing the wastes is drained again by gravity from your body through the
catheter into an empty bag. This takes about 10-20 minutes. A bag containing sterile dialysis solution replaces
the bag containing waste products. The whole process is then repeated. Each of these replacements is called a '
Bag Exchange'.

TYPES
1. Continuous ambulatory peritoneal dialysis
It is the most commonly used method of peritoneal dialysis. The filtration process occurs most hours of the
day. The exchange usually take about 3 minutes 3-4 times a day and only require a solution bag with tubing
attached to it that connects to the child‘s blood stream. It gives freedom.
2. Automated Peritoneal Dialysis (Continuous cycling peritoneal dialysis)
Continuous Cyclic Peritoneal Dialysis

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 Continuous regimen means that the dialysis solution is present in the peritoneal cavity continuously,
with the exception of short significant periods between exchange.
 It uses duel lumen catheterization, i.e., 2 catheters, one for inflow and other for outflow.
Intermittent Peritoneal Dialysis
 It means the dialysis sessions are performed several times a week.
 This technique uses one catheter for inflow and outflow. Flow is interrupted after both inflow and
outflow during exchange.
Nocturnal intermittent peritoneal dialysis
It is a form of intermittent peritoneal dialysis which is performed every night. For an efficient dialysis a
total time upto 12 hours is required. So this method helps dialysis become more efficient and to reduce
frequency of dialysis and increase the resting time.
PROCEDURE
The abdomen is cleaned in preparation for surgery, and a catheter is surgically inserted with one end in the
abdomen and the other protruding from the skin. Before each infusion the catheter must be cleaned, and flow
into and out of the abdomen tested. The warmed solution is allowed to enter the peritoneal cavity by gravity and
remains a variable length of time (usually 10-15 minutes) according to the rate of solute removal and glucose
absorption in individual patients. The total volume is referred to as dwell while the fluid itself is referred to as
dialysate. The dwell can be as much as 2.5 litres, and medication can also be added to the fluid immediately
before infusion. The dwell remains in the abdomen and waste products diffuse across the peritoneum from the
underlying blood vessels. After a variable period of time depending on the treatment (usually 4–6 hours), the
fluid is removed and replaced with fresh fluid.
RISKS
HTN & other cardiac complications
Seizure
Obstructed catheter
Dialysate leakage
Hyperglycemia
Increased triglyceride levels
Increased protein loss
Parental stress and burnout
ADVANTAGES
Ability to perform dialysis treatment at home
Technically easier than hemodialysis, especially in infants
Ability to live a greater distance from medical center
Freedom to attend school and after-school activities
Less-restrictive diet
Less expensive than hemodialysis
Independence (adolescents)

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DISADVANTAGES
Catheter malfunction
Catheter-related infections (peritonitis, exit site)
Impaired appetite (due to full peritoneal cavity)
Negative body image
Caregiver burnout
3.Continuous Renal Replacement Therapies
It is useful in patients with unstable hemodynamic condition, sepsis etc. it is an extra corporeal therapy I
which fluid and electrolytes are continuously removed from blood using a special pump-driven machine. It
continuously pass patient‘s blood across a highly permeable filter.
Continuous venovenous hemofiltration
Large amount of fluid moves by pressure across the filter bringing with it by convection other molecules
such as urea, creatinine, uric acid and phosphorus. It is replaced with desirable electrolyte composition similar
to blood.
Continuous venovenous hemodialysis
It utilizes the principle of diffusion by circulating dialysate in a countercurrent direction on the ultra
filtrate side of the membrane, no replacement fluid is used.
Continuous venovenous hemodiafiltration
It employs both the replacement fluid and dialysate, offering the most effective solute removal of all
forms of renal replacement therapies.
ADVANTAGES
Hemodynamic stability
– Avoid hypotension complicating hemodialysis
– Avoid swings in intravascular volume
Easy to regulate fluid volume
– Volume removal is continuous
– Adjust fluid removal rate on an hourly basis
Customize replacement solutions
Lack of need of specialized support staff

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DISADVANTAGES
Lack of rapid fluid and solute removal
– GFR equivalent of 5 - 20 ml/min
– Limited role in overdose setting
SLED – Developing role
Filter clotting
– Take down the entire system

RENAL TRANSPLANTATION
Kidney transplantation is recognized as the optimal therapy for children with end-stage renal disease
(ESRD). Even though renal transplantation has been conducted from 1954, children were not considered as
suitable candidates until 1960s. The psychological, physiological and social difficulties of children (side effects
of immune suppression, technical difficulties etc.) were successfully addressed and it is now universally
accepted to provide maximum opportunity for normal growth and development and the best quality of life.
Vigilant medication administration is required after transplantation to prevent organ rejection. The child
may achieve 40 – 80 % renal function with the transplant and demonstrate improved growth, enhanceded
cognitive development, and improved psychosocial development and quality of life.
INCIDENCE AND ETIOLOGY
Congenital, hereditary, and cystic diseases are the cause in more than 52% of children 0 to 4 yr of age,
Glomerulonephritis, focal segmental glomerulosclerosis account for 38% of cases in 10 to 19 yr of age.
Structural disease (49%)
Various forms of glomerulonephritis (14%)
Focal segmental glomerulosclerosis (12%)
INDICATIONS
 Almost all children with ESRD
 renal replacement therapy
DONOR SELECTION
1. Living related donor
Living related donor is preferred for a pediatric patient because it allows transplantation to be planned when
the child ad donor is in optimal health. The suitable donors include parents, siblings, grandparents, uncles and
aunts. This method accounts more survival rate than from the cadaveric donors. It also allows a immune
conditioning regimen to be commenced during pre-transplant week. (mycophenolate mofetil and prednisolone).
It allows for a final cross match.

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2. Cadaveric donor
A cadaveric transplant is placed when there is no availability of a related living donor. A cadaver is a patient
declared brain dead who had previously given consent for organ donation. After permission for donation is
granted, the kidneys are removed and stored until a recipient has been selected.
PREPARATION FOR TRANSPLATATION
 A pre–emptive transplantation i.e.; transplantation occurs prior to dialysis is preferred for children.
 Clinical and laboratory evaluation of kidney donor and recipient
Blood Type Testing
The recipient and donor should have either the same blood type or compatible ones.
If the recipient blood type is A Donor blood type must be A or O
If the recipient blood type is B Donor blood type must be B or O
If the recipient blood type is O Donor blood type must be O
If the recipient blood type is AB Donor blood type can be A, B, AB, or O
The AB blood type is the easiest to match because that individual accepts all other blood types.
Blood type O is the hardest to match. Although people with blood type O can donate to all types, they can only
receive kidneys from blood type O donors.
Tissue Typing
It is a blood test for human leukocyte antigens (HLA), is called tissue typing. To receive a kidney where
recipient's markers and the donor's markers all are the same is a "perfect match" kidney. Perfect match
transplants have the best chance of working for many years. Most perfect match kidney transplants come from
siblings.
Crossmatch
crossmatch is done to ensure the recipient does not have pre-formed antibodies to the donor .
Serology
Testing is also done for viruses, such as HIV (human immunodeficiency virus), hepatitis, and CMV
(cytomegalovirus) to select the proper preventive medications after transplant.
CONTRAINDICATIONS
Pre-existing metastatic malignancy or HIV
Patients with remission of malignancy off maintenance treatment for a minimum of 2 yr may be
reconsidered on an individual basis for transplantation, with close post-transplantation surveillance
Patients with autoimmune diseases resulting in ESRD are candidates for transplantation after a
period of immunologic quiescence of the primary disease for a period of at least 1 year before
transplantation.
Severe neurologic dysfunction

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SPECIAL CONSIDERATIONS
- Dialysis may be required for a period before transplantation to optimize nutritional and metabolic
conditions, to achieve an appropriate size in small children or to keep a patient stable until a suitable
donor is available
- For young infants, a recipient may need to weigh at least 8-10 kg to minimize the risk for vascular
thrombosis and to accommodate an adult-sized kidney. This can require a period of dialysis support
until the child is at least 12 to 18 mo of age.
- It would be best match the recipient with an appropriately sized cadaveric kidney. But it increases
the chance of vascular thrombosis. Sibling donors of same size are best suitable.
- Transplantation with an adult-sized kidney has been successful in children who weighed <10 kg or
were <6 months of age.
- For children weighing 20kg or more, the kidney is placed extra peritoneally. Intraperitoneal
approach is required for those weighing less than 20 kg and receiving adult kidney. If the donor is
less than 2 years, the kidneys are transplanted ‗en-block‘, together with donor aorta and venacava.
- Many surgeons prefer to remove the appendix at the time of transplantation as it will be difficult to
differentiate between appendicitis and tenderness that accompanies acute rejection.
PROCEDURE
The transplant surgery is performed under general anesthesia. The operation usually takes 2-4
hours. This type of operation is a heterotopic transplant meaning the kidney is placed in a different location
than the existing kidneys. (Liver and heart transplants are orthotopic transplants, in which the diseased organ is
removed and the transplanted organ is placed in the same location.) The kidney transplant is placed in the front
(anterior) part of the lower abdomen, in the pelvis.
The original kidneys are not usually removed unless they are causing severe problems such as
uncontrollable high blood pressure, frequent kidney infections, or are greatly enlarged. The artery that carries
blood to the kidney and the vein that carries blood away is surgically connected to the artery and vein already
existing in the pelvis of the recipient. The ureter, or tube, that carries urine from the kidney is connected to the
bladder. Recovery in the hospital is usually 3-7 days.
POST TRANSPLANTATION COMPLICATIONS
 Rejection is a major problem
- Hyperacute rejection: occurs within minutes to hours after transplantation
Renal vessels thrombosis occurs and the kidney dies
There is no treatment and the transplanted kidney is removed
- Acute Rejection: occurs 4 days to 4 months after transplantation
It is not uncommon to have at least one rejection episode
Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids,
muromonab-CD3, ALG, or ATG)
Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP,
tenderness over the transplanted kidneys
- Chronic Rejection: occurs over months or years and is irreversible.

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The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing, low grade
immunological mediated injury
Gradual occlusion renal blood vessels
Signs: proteinuria, HTN, increase serum creatinine levels
Supportive treatment, difficult to manage
Replace on transplant list
- Infection
- Hypertension
- Malignancies (lip, skin, lymphomas, cervical)
- Recurrence of renal disease
- Retroperioneal bleed
- Arterial stenosis
- Urine leakage
NURSING MANAGEMENT
Immediate post operative management
(Preventing rejection and promoting renal function)
- Administer immuno suppressants accurately on time.
 Medication that prevent rejection
 Cyclosporine
 Tacrolimus
 Azathioprine
 Mycophenolate mofetil
 Prednisone
 Antithymocyte Ig (ATGAM)
 Sirolimus
- Focus on achieving graft functioning
- Early mobilization
- Monitor closely for few days with attention to fluid and electrolyte replacement
- Assess for rejection and infections.
- Care should be given to
 central venous catheter for fluid replacement and central venous pressure measurement
 arterial line for blood pressure monitoring blood taking.
 Indwelling urine catheter to measure intake and output
 Drain tube to collect leakage from anastomoses

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- Routine monitoring includes vital signs, central venous pressure and urine output.
- Fluid balance and central venous pressure should be monitored to ensure appropriate renal perfusion

RENAL TUBULAR ACIDOSIS (RTA)
INTRODUCTION
Lungs and Kidneys are responsible for Normal acid base balance
Alveolar ventilation removes CO2
Kidneys reabsorb filtered Bicarbonate and excrete a daily quantity of Hydrogen ion equal to that
produced by the metabolism of dietary proteins.
Hydrogen ions are excreted primarily by enhancing the excretion of ammonium ions in the urine
Renal tubular acidosis: A group of disorders characterized by an inability of the kidney to reabsorb
bicarbonate or secrete hydrogen ions, resulting in hyperchloremic, normal anion gap acidosis.
DEFINITION
The term "renal tubular acidosis" (RTA) refers to a group of disorders in which, despite a relatively
well-preserved glomerular filtration rate, metabolic acidosis develops because of defects in the ability of the
renal tubules to perform the normal functions required to maintain acid-base balance.
INCIDENCE
Predominant age: All ages
Predominant sex: Male > Female (with regard to type II RTA with isolated defect in bicarbonate
reabsorption)
TYPES
Distal or type 1 RTA
Proximal or type 2 RTA
Hypoaldosteronism or type 4 RTA
There is a transiently severe form of distal RTA in infants, the term type 3 or mixed RTA is now most often
applied to a rare autosomal recessive syndrome with features of both distal and proximal RTA.
 Acidosis - the tendency for RTA to lower the blood's pH
 Acidemia - when the blood pH is below normal (7.35)

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Type 1-Distal RTA
Distal RTA (dRTA) is the classical form of RTA. Inability of the distal tubule to acidify the urine. Due to
impaired hydrogen ion secretion, increased backleak of secreted hydrogen ions, or impaired sodium
reabsorption (causing less negative potential in the lumen and hence less hydrogen/potassium secretion).
Urine pH >5.5.
Pathophysiology:
- failure of acid secretion by the alpha intercalated cells of the cortical collecting duct of the distal nephron.
- it leads to an inability to acidify the urine to a pH of less than 5.3
- renal excretion is the primary means of eliminating acid from the body, there is consequently a tendency
towards acidemia
- There is an inability to excrete H+ while K+ cannot be reabsorbed, leading to acidemia (as H+ builds up
in the body) and hypokalemia (as K+ cannot be reabsorbed).
- Since calcium stones demonstrate a proclivity for deposition at higher pHs (alkaline), the substance of the
kidney develops stones bilaterally; this does not occur in the other RTA types.

Type 2-Proximal RTA
Type II (proximal) RTA: Defect of the proximal tubule in bicarbonate (HCO3) reabsorption. HCO3 fully
reabsorbed only when plasma HCO3 concentration <15–16 mEq/L (compared with normal threshold of 24
mEq/L). Urine pH <5.5 unless plasma HCO3 above reabsorptive threshold.
Pathophysiology:
- Proximal RTA (pRTA) is caused by a failure of the proximal tubular cells to reabsorb filtered bicarbonate
from the urine, leading to urinary bicarbonate wasting and subsequent acidemia.
- The distal intercalated cells function normally, so the acidemia is less severe than dRTA and the urine can
sacidify to a pH of less than 5.3.
- occasionally be present as a solitary defect
- it is usually associated with a more generalized dysfunction of the proximal tubular cells called Fanconi's
syndrome, in which there is also phosphaturia, glycosuria, aminoaciduria, uricosuria, and
tubular proteinuria. The principal feature of Fanconi's syndrome is bone demineralization
(osteomalacia or rickets) due to phosphate wasting.

Type 3 RTA-Combined proximal and distal RTA
Extremely rare autosomal recessive syndrome with features of both type I and type II. This term is no longer
used. In some patients, there are features of both dRTA and pRTA. This form of RTA has also been referred to
as juvenile RTA.

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- Combined dRTA and pRTA is also observed as the result of inherited carbonic anhydrase II deficiency.
Mutations in the gene encoding this enzyme give rise to an autosomal recessive syndrome
of osteopetrosis, renal tubular acidosis, cerebral calcification, and mental retardation.

Type 4 RTA
Due to aldosterone resistance or deficiency that results in hyperkalemia.
- It is not actually a tubular disorder at all nor does it have a clinical syndrome similar to the other types of
RTA described above.
- It was included in the classification of renal tubular acidoses as it is associated with a mild (normal anion
gap) metabolic acidosis due to a physiological reduction in proximal tubular ammonium excretion
(impaired ammoniagenesis), which is secondary to hypoaldosteronism, and results in a decrease in urine
buffering capacity. Its cardinal feature is hyperkalemia, and measured urinary acidificsation is normal,
hence it is often called hyperkalemic RTA or tubular hyperkalemia.
Urine pH usually <5.5.
RISK FACTORS
Genetics
Type I RTA: Autosomal dominant or recessive. May occur in association with other genetic diseases
(e.g., Ehlers-Danlos syndrome, hereditary elliptocytosis, or sickle cell nephropathy). The autosomal
recessive form is associated with sensorineural deafness.
Type II RTA: Autosomal dominant form is rare. Autosomal recessive form is associated with
ophthalmologic abnormalities and mental retardation. Occurs in Fanconi syndrome, which is associated
with several genetic diseases (e.g., cystinosis, Wilson disease, tyrosinemia, hereditary fructose
intolerance, Lowe syndrome, galactosemia, glycogen storage disease, and metachromatic
leukodystrophy).
Type IV RTA: Some cases familial, such as pseudohypoaldosteronism type I (autosomal dominant)
ETIOLOGY
Type I RTA:
Genetic: Autosomal dominant, autosomal recessive associated with sensorineural deafness
Sporadic
Ehlers-Danlos syndrome
Autoimmune diseases: Sjögren syndrome, rheumatoid arthritis (RA), systemic lupus
erythematosus
Hematologic diseases: Sickle cell disease, hereditary elliptocytosis

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Medications: Amphotericin B, lithium, ifosfamide, foscarnet, analgesics, K+-sparing
diuretics (amiloride, triamterene), trimethoprim
Toxins: Toluene, glue
Hypercalciuria, diseases causing nephrocalcinosis
Vitamin D intoxication
Medullary cystic disease
Glycogenosis type III
Fabry disease
Wilson disease
Hypergammaglobulinemic syndrome
Obstructive uropathy
Chronic pyelonephritis
Chronic renal transplant rejection
Leprosy
Hepatic cirrhosis
Malnutrition
Type II RTA:
Diseases associated with Fanconi syndrome
Sporadic
Multiple myeloma and other dysproteinemic states
Amyloidosis
Heavy-metal poisoning (e.g., cadmium, lead, mercury, copper)
Medications: Acetazolamide, sulfanilamide, ifosfamide, outdated tetracycline, topiramate
Autoimmune disease
Interstitial renal disease
Nephrotic syndrome
Congenital heart disease
Defects in calcium metabolism (hyperparathyroidism)
Type IV RTA:
Medications: Nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme
inhibitors, angiotensin receptor blockers, heparin/LMW heparin, calcineurin inhibitors
(tacrolimus, cyclosporine) (1)
Diabetic nephropathy
Obstructive nephropathy
Nephrosclerosis due to hypertension
Tubulointerstitial nephropathies
Primary adrenal insufficiency
Pseudohypoaldosteronism (end-organ resistance to aldosterone)

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Gordon syndrome
Sickle cell nephropathy
CLINICAL MANIFESTATIONS
- Distal (Type I) RTA
non-anion gap metabolic acidosis
growth failure
nephrocalcinosis
hypercalciuria
- Patients with isolated, sporadic, or inherited proximal RTA (Type II)
growth failure in the 1
st
year of life
polyuria
dehydration
anorexia
vomiting
constipation
hypotonia
Patients with primary Fanconi syndrome will have additional symptoms secondary to phosphate
wasting such as rickets.
Those with systemic diseases will present with additional signs and symptoms specific to their
underlying disease
- Hyperkalemic (Type IV) RTA
with growth failure in the first few years of life
Polyuria
Dehydration
Rarely, with life-threatening hyperkalemia
Patients with obstructive uropathies may present acutely with signs and symptoms of
pyelonephritis,
o Fever
o Vomiting
o foul-smelling urine
hyperkalemic non-anion gap metabolic acidosis
Alkaline or acidic urine
Elevated urine sodium levels & inappropriately low urine potassium levels reflect the absence of
aldosterone effect.
DIAGNOSIS
- History collection
• Often asymptomatic (particularly type IV)
• Failure to thrive in children
• Anorexia, nausea/vomiting

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• Weakness or polyuria (due to hypokalemia)
• Rickets in children
• Osteomalacia in adults
• Constipation
• Polydipsia
- Diagnostic Tests
• Electrolytes reveal hyperchloremic metabolic acidosis.
Plasma anion gap normal (anion gap = Na - [Cl + HCO3]). Normal values (in mEq/L): Neonates ≤16;
infants/children ≤14–16; adolescents/adults 8 ± 4).
Hypokalemia or normokalemia: Type I (if due to impaired distal H+ secretion or increased H+
backleak), type II
Hyperkalemia: Type IV, type I (if due to impaired distal Na+ reabsorption)
Plasma HCO3 (in untreated RTA): Type I: <15 mEq/L; type II: 12–20 mEq/L; type IV: >17 mEq/L
Blood urea nitrogen and creatinine usually normal (rules out renal failure as cause of acidosis)
Urine pH: Inappropriately alkaline (pH >5.5) despite metabolic acidosis in type I or in type II when
HCO3 above reabsorptive threshold (15–16 mEq/L)
Urine culture: Rule out urinary tract infection (UTI) with urea-splitting organism (may elevate pH) and
chronic infection
Urine anion gap (urine Na+, K+, and Cl- on random urine): Reflects unmeasured urine anions, so
inversely related to urine NH4+ (or acid) excretion. Positive urine anion gap in an acidemic patient
indicates impaired renal acid excretion. Results tend to be:
o Negative in HCO3 losses due to diarrhea, or UTI caused by urea-splitting organisms
o Negative in other extrarenal causes of normal anion gap metabolic acidosis
o Variable in type II RTA
o Positive in type I RTA, type IV RTA (3)[C]
o Positive in impaired acid excretion due to renal failure
Urine calcium:
o High in type I
o Typically normal in type II
• A renal ultrasound - to identify underlying structural abnormalities such as obstructive uropathies as
well as to determine the presence of nephrocalcinosis.

94

TREATMENT
 correction of the acidemia with oral sodium bicarbonate, sodium citrate or potassium citrate. This
will correct the acidemia and reverse bone demineralization
 Hypokalemia and urinary stone formation and nephrocalcinosis can be treated with potassium
citrate tablets which not only replace potassium but also inhibit calcium excretion and thus do not
exacerbate stone disease as sodium bicarbonate or citrate may do
 Patients with proximal RTA often require large quantities of bicarbonate, up to 20 mEq/kg/24 hr in
the form of sodium bicarbonate or sodium citrate solution (Bicitra or Shohl's solution). Also we
have( polycitra solution) which same as bictra with adding of potassium citrate.
 The base requirement for distal RTAs is generally in the range of 2-4 mEq/kg/24 hr, although patient
requirements may vary .
 Patients with Fanconi syndrome generally require phosphate supplementation .
 Patients with distal RTA should be monitored for the development of hypercalciuria. Those with
ssymptomatic hypercalciuria (e.g., recurrent episodes of gross hematuria), nephrocalcinosis, or
nephrolithiasis may require thiazide diuretics to decrease urine calcium excretion.
 Patients with type IV RTA may require chronic treatment for hyperkalemia with sodium-potassium
exchange resin
 Rickets may be present in primary renal tubular acidosis (RTA), particularly in type II or proximal
RTA. Administration of sufficient bicarbonate to reverse acidosis stops bone dissolution and the
hypercalciuria that is common in distal RTA. Proximal RTA is treated with both bicarbonate and
oral phosphate supplements to heal bone disease. Doses of phosphate similar to those used in
familial hypophosphatemia or Fanconi syndrome should be used . Vitamin D is needed to offset the
secondary hyperparathyroidism that complicates oral phosphate therapy
 The mainstay of therapy in all forms of RTA is bicarbonate replacement .
PROGNOSIS
Depends on associated disease, otherwise good with therapy
Transient forms of all types of RTA may occur.
COMPLICATIONS
Nephrocalcinosis, nephrolithiasis (type I)
Hypercalciuria (type I)
Hypokalemia (type I, type II if given bicarbonate)
Hyperkalemia (type IV, some causes of type I)
Osteomalacia (type II due to phosphate wasting)

95

VESICO URETERAL REFLUX
VUR implies the passage of urine into the ureter and kidney during micturition. Normally the long
submucosal and intra vascular segment of the ureter at the ureterovesical junction closes when bladder
contracts, effectively preventing VUR. So it is an abnormal retrograde flow of bladder urine into the ureters.
Urine normally travels from the kidneys via the ureters to the bladder. In vesicoureteral reflux the direction of
urine flow is reversed.
INCIDENCE
 VUR is present in more than 10% of the population.
 In children without urinary tract infections 17.2-18.5% have VUR.
 In those with urinary tract infections the incidence may be as high as 70%.
 Younger children are more prone to VUR.
 It decreases to 15% by the age of 12.
 It is more common in males ante-natally, in later life there is a female preponderance with 85% of cases.
ETIOLOGY
- Vesicoureteral reflux may present before birth as prenatal hydronephrosis, an abnormal widening of
the ureter or with a urinary tract infection or acute pyelonephritis.
- It is associated with recurrent UTI
CLINICAL MANIFESTATIONS
- Newborns may be lethargic with faltering growth
UTI
- If the child is with UTI, he may have:
- pyrexia
- dysuria
- frequent urination
- malodorous urine
- Chills
- Vomiting
- feeling that the bladder does not empty completely
DIAGNOSTIC EVALUATION
- History Collection & Physical Examination
inheritance
urinary tract infection
- Nuclear cystogram
for subsequent evaluations as there is less exposure to radiation
- Fluoroscopic voiding cysto urethrogram
Grading the initial work up
- Ultrasonic cystography
- Abdominal ultrasound

96

Urethral dialation
- urine culture
to check for a UTI
- Ultrasound of the kidneys
to find out the size and shape of the kidneys. It can't detect reflux.
TYPES
Primary VUR
Primary VUR is present at birth. It is caused by a defect in the development of the valve at the end of the
tube that carries urine from the kidneys to the bladder (ureter). This is the most common type of VUR and is
usually detected shortly after birth.
Insufficient submucosal length of the ureter relative to its diameter causes inadequacy of the valvular
mechanism. This is precipitated by a congenital defect/lack of longitudinal muscle of the intravesical ureter
resulting in an ureterovesicular junction (UVJ) anomaly.
Secondary VUR
Secondary VUR occurs when an obstruction in the bladder or urethra causes urine to flow backward into
the kidneys. Secondary VUR can occur at any age and can be caused by surgery, injury, a pattern of emptying
the bladder that's not normal, or a past infection that puts pressure on the bladder. It is more common in children
who have other birth defects, such as spina bifida.
In this category the valvular mechanism is intact and healthy to start with but becomes overwhelmed by
raised vesicular pressures associated with obstruction, which distorts the ureterovesical junction. The
obstructions may be anatomical or functional.
The severity is graded using the International Classification of I to V based on the appearance of the
urinary tract on contrast voidig cysto urethrogram. The more the reflux the higher the rate of injury.
Grade I - reflux into non-dilated ureter
Grade II - reflux into the renal pelvis and calyces without dilatation
Grade III - mild/moderate dilatation of the ureter, renal pelvis and calyces with minimal blunting of the
fornices
Grade IV – dilation of the renal pelvis and calyces with moderate ureteral tortuosity
Grade V – gross dilatation of the ureter, pelvis and calyces; ureteral tortuosity; loss of papillary
impressions
TREATMENT
- The goal of treatment is to minimize infections,renal injury and other complications of reflux.
In newborn nd infants , prophylactic antibiotics
In lder children, bowel and bladder management

97

(sulfamethaxole – trimethoprim, Cephalosporins, nitrofurantoin)
- Good perineal hygiene, and timed and double voiding are also important aspects of medical treatment.
Bladder dysfunction is treated with the administration of anticholinergics.

Medical management is recommended in children with Grade I-III VUR as most cases will resolve
spontaneously. When medical management fails to prevent recurrent urinary tract infections, or if the kidneys
show progressive renal scaring then surgical interventions may be necessary.
Endoscopic injection
Deflux is a gel that is used in endoscopic injections to treat Vesicoureteral Reflux. It is the material that
the surgeon injects around the ureteral opening to create a valve function and stop urine from flowing back up
the ureter. Deflux consists of two types of sugar-based molecules called dextranomer and hyaluronic acid. Both
substances are well-known from previous uses in medicine. Both materials are also biocompatible, which means
that they do not cause significant reactions within the body. In fact, hyaluronic acid is produced and found
naturally within the body.
Surgical Management
A surgical approach is necessary in cases where a breakthrough infection results despite prophylaxis, or
there is non-compliance with the prophylaxis.
There are three types of surgical procedure available for the treatment of VUR:
endoscopic (STING/HIT procedures)
laparoscopic
open procedures (Cohen procedure, Leadbetter-Politano procedure).
Follow up
- Annual evaluation
Blood pressure, weight, height, VCU, urine culture

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