Haemodialysis - the British Association for Paediatric Nephrology
Paediatric Nephrology. Teaching website .
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Transcript of Paediatric Nephrology. Teaching website .
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Paediatric Nephrology
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Teaching website
http://paedstudent.cardiff.ac.uk
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UTI – cumulative incidence
Boys Girls
By 2 years 2.2% 2.1%
By 7 years 2.8% 8.2%
By 16 years 3.6% 11.3%
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When to suspect a UTI
Infants Pyrexia (>38.5oC) Poor feeding Vomiting Abdominal discomfort Febrile seizure
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When to suspect a UTI (2)
Older children Frequency Dysuria Wetting Abdominal pain Pyrexia
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Diagnosis
Collect a urine specimen MSU Clean catch specimen Bag specimen Catheter specimen Suprapubic aspirate Pad specimen
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Leucocyte esterase
Identifies presence of white blood cells
High sensitivity for UTI but low specificity
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Nitrite test
Reliable sign of infection when positive
BUT high false negative rate Urine has to have been in the bladder
for at least an hour.This lowers the false negative rate.
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Use of both nitrite & leucocyte esterase tests
Sensitivity 95%
Specificity 69%
Positive predictive value 37%
Negative predictive value 98%
Has not replaced urine culture in patients suspectedof having a UTI.
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What do you do with the urine?
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Aims of treatment
Prevention of renal scarring Achieved through prompt initiation of
antibiotic therapy, particularly in those groups at highest risk Infants Children with vesicoureteric reflux
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Ultrasound - Normal
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Ultrasound - Hydronephrosis
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Ultrasound - Scarring
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DMSA scan - normal
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DMSA - scarring
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DMSA - scarring
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MCUG - normal
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MCUG - normal
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MCUG – R sided grade II VUR
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MCUG – Bilateral VUR
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MCUG – Bilateral VUR
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Management of VUR
Antibiotic prophylaxis until 4 -5 years old
Surgery if continue to get UTIs Reimplantation Injection of Deflux
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IMPORTANT MESSAGE
Only do an investigation if the result will potentially alter your management of the patient.
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Any questions?
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Nephrotic syndrome
Triad of: Heavy proteinuria Hypoalbuminaemia Oedema
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Normal glomerulus (em)
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EM showing foot process fusion
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Interstitial fluid
Ph - Hydrostatic pressure
Po - Oncotic pressure
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Mechanisms of oedema formation (2)
Increased hydrostatic pressure Hypervolaemia Increased venous pressure
Reduced oncotic pressure Hypoalbuminaemia
Increased capillary permeability Sepsis
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Complications
Oedema Hypovolaemia
Cool peripheries Prolonged capillary refill time Abdominal pain Increased blood pressure
Infection Hypogammaglobulinaemia
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Complications (2)
Hypercoaguable state Raised haematocrit Loss of anti-thrombin III
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VQ scan in nephrotic patient
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Complications (2)
Hypercoaguable state Raised haematocrit Loss of anti-thrombin III
Hyperlipidaemia Hypothyroidism
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Treatment
Lots of steroids
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Any questions?
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Red cell cast
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Tubules filled with red blood cells – source of red cell casts
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Dysmorphic red blood cells – Indicates they have had to squeeze through the glomerular basement membrane
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Causative organism - Streptococcus
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Resultant infections
Impetigo Tonsillitis
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Complement
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Normal glomerulus
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Glomerulus showing a proliferative nephritis – note the increased number of nuclei seen
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Higher magnification
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Immunofluorescent staining for C3
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By electron microscopy, the immune deposits of post-infectious glomerulonephritis are predominantly subepithelial, as seen below, with electron dense subepithelial "humps" above the basement membrane and below the epithelial cell. The capillary lumen is filled with a leukocyte demonstrating cytoplasmic granules.
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Features of acute nephritis
Haematuria Proteinuria Oliguria Hypertension Oedema Renal impairment
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Assessment of renal function Glomerular filtration rate (GFR)
mls/min Number of mls of blood cleared of a
freely filtered substance each minute. Correct for body surface area
– mls/min/1.73m2
Creatinine clearance GFR 1 / serum creatinine
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Creatinine clearance Fact
If serum [creatinine] is constant, the rate of production of creatinine must equal its excretion.
If serum [Cr] = 100 µmol/l andUrine [Cr] = 10 mmol/l andUrine production = 60 ml/hrWhat is the rate of creatinine production?What is the creatinine clearance?
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Creatinine production
Urine [Cr] = 10 mmol/l Urine production = 60 ml/hr
Creatinine excretion =
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Creatinine production
Urine [Cr] = 10 mmol/l Urine production = 60 ml/hr
Creatinine excretion =
10 x 0.06 = 0.6 mmol/h = 600 µmol/h
= 10 µmol/min
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Creatinine clearance
Serum [Cr] = 100 µmol/l Creatinine excretion = 10 µmol/min
Creatinine clearance =
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Creatinine clearance
Serum [Cr] = 100 µmol/l Creatinine excretion = 10 µmol/min
Creatinine clearance =
10 ÷ 100 = 0.1 l/min = 100 ml/min
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Renal impairment
What is the creatinine clearance if the serum [Cr] rises to 200 µmol/l?
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Renal impairment
Serum [Cr] = 200 µmol/lCreatinine excretion =
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Renal impairment
Serum [Cr] = 200 µmol/lCreatinine excretion = 10 µmol/min
Creatinine clearance =
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Renal impairment
Serum [Cr] = 200 µmol/lCreatinine excretion = 10 µmol/min
Creatinine clearance =
10 ÷ 200 = 0.05 l/min = 50 ml/min