Pediatric Renal Disorders

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

The Child with Genitourinary Dysfunction

Chapter 27


Renal System Assessment

• Physical assessment

– Palpation, percussion

• Health history

– Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer

– Meds: antibiotics, anticholinergics, antispasmodics

– Urologic instrumentation

– Urinary hygiene

– Patterns of elimination


Nursing Assessment of Urinary Tract Infection (UTI)

• Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency

• Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination


Nursing Assessment of UTI (cont’d)

• Objective data

– Fever

– Hematuria, foul-smelling urine, tender, enlarged kidney

– Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP


Diagnostic Studies

• Renal scan

• Cystogram

• Retrograde Pyelogram

• U/S

• CT

• MRI

• Renal arteriogram

• UA

• Urine C&S

• BUN

• Creatinine

• KUB

• IVP

• VCG/VCUG


Normal Urinalysis

• pH: 5.0-9.0• Sp Gr: 1.001-1.035• Protein: <20 mg/dL• Urobilinogen: up to 1 mg/dL• None of the following:

– Glucose – Ketones – Hgb– WBCs

– RBCs– Casts– Nitrites


Normal Characteristics of Urine

• Color range

• Clear

• Newborn production—approx 1-2 mL/kg/hr

• Child production—approx 1 mL/kg/hr


Urinary Tract Infection (UTI)

• Is it REALLY that serious?


UTI (cont’d)

• Concept of “asymptomatic bacteria” in urinary tract


UTI (cont’d)

• Causes

• E. coli most common pathogen

• Streptococci

• Staphylococcus saprophyticus

• Occasionally fungal and parasitic pathogens


Classification of UTI

• Upper tract: involves renal parenchyma, pelvis, and ureters

– Typically causes fever, chills, flank pain

• Lower tract: involves lower urinary tract

– Usually no systemic manifestations


Classification of UTI (cont’d)

• Lower tract

• Cystitis

• Urethritis

• Upper tract

• Pyelonephritis

• VUR

• Glomerulonephritis


Classification of UTI (cont’d)

• Uncomplicated infection

• Complicated infections

– Stones

– Obstruction

– Catheters

– Diabetes or neurologic disease

– Recurrent infections


Types of UTIs

• Recurrent—repeated episodes

• Persistent—bacteriuria despite antibiotics

• Febrile—typically indicates pyelonephritis

• Urosepsis—bacterial illness; urinary pathogens in blood


Etiology and Pathophysiology of UTI

• Physiologic and mechanical defense mechanisms maintain sterility

– Emptying bladder

– Normal antibacterial properties and urine and tract

– Ureterovesical junction competence

– Peristaltic activity


Etiology and Pathophysiology of UTI (cont’d)

• Alteration of defense mechanisms increases risk of UTI

• Organisms usually introduced via ascending route from urethra

• Less common routes

– Bloodstream

– Lymphatic system



• Contributing factor: urologic instrumentation

– Allows bacteria present in opening of urethra to enter urethra or bladder

• Sexual intercourse promotes “milking” of bacteria from perineum and vagina

– May cause minor urethral trauma



• UTIs rarely result from hematogenous route

• For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract

– Obstruction of ureter

– Damage from stones

– Renal scars



• UTI is a common nosocomial infection

– Often E. coli

– Seldom Pseudomonas

• Urologic instrumentation common predisposing factor


Clinical Manifestations of UTI

• Symptoms

– Dysuria

– Frequent urination (>q2h)

– Urgency

– Suprapubic discomfort or pressure


Clinical Manifestations of UTI (cont’d)

• Urine may contain visible blood or sediment (cloudy appearance)

• Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)


Pediatric Manifestations

• Frequency

• Fever in some cases

• Odiferous urine

• Blood or blood-tinged urine

• Sometimes NO symptoms except generalized sepsis


Pediatric Manifestations (cont’d)

• Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia


So how do you find out?


Diagnostic Studies of UTI

• Dipstick

• Microscopic urinalysis

• Culture


Diagnostic Studies of UTI (cont’d)

• Clean-catch is preferred

• U-bag for collection from child

• Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results

– May be necessary when clean-catch cannot be obtained


Diagnostic Studies of UTI (cont’d)

• Sensitivity testing determines susceptibility to antibiotics

• Imaging studies for suspected obstruction

– IVP or Abd CT


Collaborative Care for UTI Drug Therapy: Antibiotics

• Uncomplicated cystitis: short-term course of antibiotics

• Complicated UTIs: long-term treatment


Collaborative Care for UTI Drug Therapy: Antibiotics (cont’d)

• Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin

• Amoxicillin• Cephalexin• Others

– gentamycin, carbenicillin ++

• Pyridium (OTC)• Combination agents (e.g., Urised) used to

relieve pain– Preparations with methylene blue tint


Collaborative Care for UTI Drug Therapy

• For Repeated UTIs

– Prophylactic or suppressive antibiotics

– TMP-SMX administered qd to prevent recurrence or single dose prior to events likely to cause UTI


Etiology and Pathophysiology of Acute Pyelonephritis

• Inflammation caused by bacteria, fungi, protozoa, or viruses infecting kidneys

• Urosepsis: systemic infection from urologic source

– Can lead to septic shock and death in 15% of cases


Etiology and Pathophysiology of Acute Pyelonephritis (cont’d)

• Usually infection is via ascending urethral route

• Frequent causes

– E. coli

– Proteus

– Klebsiella

– Enterobacter



• Preexisting factor (usually)

– Vesicoureteral reflux

– Dysfunction of lower urinary tract function

• Obstruction

• Stricture



• Commonly starts in renal medulla and spreads to adjacent cortex

• Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis


Clinical Manifestations of Acute Pyelonephritis

• Vary from mild to “classic” and very severe• Presenting symptoms

– N/V, anorexia, chills, nocturia, frequency, urgency

– Suprapubic or low back pain, dysuria– Fever, hematuria, foul smelling urine

• Costovertebral tenderness • Symptoms often subside in a few days, even

without therapy– Bacteriuria and pyuria still persist


Diagnostic Studies of Acute Pyelonephritis

• Urinalysis

• WBC casts

• CBC

• Imaging studies (IVP or CT)

• Ultrasound


Collaborative Care of Acute Pyelonephritis

• Hospitalization

• Parenteral antibiotics


Collaborative Care of Acute Pyelonephritis (cont’d)

• Relapses treated with 6-week course of antibiotics

• Reinfections treated as individual episodes or managed with long-term therapy

– Prophylaxis may be used for recurrent

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insert after recurrent: infections?


Types of Glomerulonephritis

• Most are postinfectious

– Pneumococcal, streptococcal, or viral

• May be distinct entity OR

• May be a manifestation of systemic disorder

– SLE

– Sickle cell disease

– Others


Glomerulonephritis Symptoms

• Generalized edema due to decreased glomerular filtration

– Begins with periorbital

– Progresses to lower extremities and then to ascites

• HTN due to increased ECF

• Oliguria


Glomerulonephritis Symptoms (cont’d)

• Hematuria

– Bleeding in upper urinary tract→smoky urine

• Proteinuria

– Increased amt of protein = increased severity of renal disease


Acute Post-Streptococcal Glomerulonephritis

• Is a non-infectious renal disease

– (Auto immune)

• Onset 5-12 days after OTHER type of infection

• Often group A ß-hemolytic strep

• Most common 6-7 y.o.

• Uncommon in <2 y.o.

• Can occur at any age


Diagnosing APSG


Prognosis

• 95%-rapid improvement to complete recovery

• 5%-15%-chronic glomerulonephritis

• 1%-irreversible damage


Nursing Management of APSG

• Manage edema

– Daily weights

– Accurate I&O

– Daily abdominal girth

• Nutrition

– Low sodium, low-mod protein

• Susceptibility to infections

• Bed rest is not necessary


Nephrotic Syndrome

• Most common presentation of glomerular injury in children

• Characteristics

– Proteinuria

– Hypoalbuminemia

– Hyperlipidemia

– Edema

– Massive urinary protein loss


Types of Nephrotic Syndrome

• Minimal change nephrotic syndrome (MCNS)

– AKA

• Idiopathic nephrosis

• Nil disease

• Uncomplicated nephrosis

• Childhood nephrosis

• Minimal lesion nephrosis

• Congenital nephrotic syndrome

• Secondary nephrotic syndrome


Changes in Nephrotic Syndrome

• Glomerular membrane

– Normally impermeable to large proteins

– Becomes permeable to proteins, especially albumin

– Albumin lost in urine (hyperalbuminuria)

– Serum albumin decreased (hypoalbuminemia)

– Fluid shifts from plasma to interstitial spaces

• Hypovolemia

• Ascites


Nephrotic Syndrome

• “Edema phase”

• “Remission phase”

• Prognosis


Nephrotic Syndrome Management

• Supportive care• Diet

– Low to moderate protein – Sodium restrictions when lg amt edema

present• Steroids

– 2 mg/kg divided into BID doses– Prednisone drug of choice ($$ and safest)

• Immunosuppressant therapy (Cytoxan)• Diuretics


Family Issues

• Chronic condition with relapses

• Developmental milestones

• Social isolation

– Lack of energy

– Immunosuppression/protection

– Change in appearance due to edema self-image


Nursing Interventions

• Aseptic technique during catheterizations

• Avoid unnecessary catheterization and early removal of indwelling catheters

• Prevents nosocomial infections

– Wash hands before and after contact

– Wear gloves for care of urinary system


Nursing Interventions (cont’d)

• Routine and thorough perineal care for all hospitalized patients

• Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals



• Ensure adequate fluid intake (patient with urinary problems may think will be more uncomfortable)

– Dilutes urine, making bladder less irritable

– Flushes out bacteria before they can colonize

– Avoid caffeine, alcohol, citrus juices, chocolate, and highly-spiced foods

• Potential bladder irritants



• Discharge to home instructions

• Follow-up urine culture

• Recurrent symptoms typically occur in 1-2 weeks after therapy

– Encourage adequate fluids even after infection

– Low-dose, long-term antibiotics to prevent relapses or reinfections

– Explain rationale to enhance compliance


Hemolytic-Uremic Syndrome

• Pathophysiology

• Diagnostic evaluation

• Therapeutic management

• Prognosis

• Nursing consideration


Wilms' Tumor

• AKA “nephroblastoma”

• Malignant renal and intraabdominal tumor of childhood

• Three times more common in African-American children

• Peak age of diagnosis is 3 years

• More frequent in males


Wilms' Tumor (cont’d)

• Etiology



– Surgical removal

– Chemotherapy and/or radiation

• Nursing considerations


Renal Failure

• Acute renal failure (ARF)

• Chronic renal failure (CRF)


Acute Renal Failure (ARF)

• Definition: kidneys suddenly unable to regulate volume and composition of urine

• Not common in children

• Principal feature is oliguria

– Associated with azotemia, metabolic acidosis, and electrolyte disturbances

• Most common pathologic cause: transient renal failure resulting from severe dehydration


ARF (cont’d)

• Pathophysiology—usually reversible





Complications of ARF

• Hyperkalemia

• Hypertension

• Anemia

• Seizures

• Hypervolemia

• Cardiac failure with pulmonary edema


Chronic Renal Failure (CRF)

• Begins when diseased kidneys cannot maintain normal chemical structure of body fluids

• Clinical syndrome called UREMIA


Potential Causes of CRF

• Congenital renal and urinary tract malformations

• VUR associated with recurrent UTIs

• Chronic pyelonephritis

• Chronic glomerulonephritis


CRF (cont’d)

• Pathophysiology



– Manage diet, hypertension, recurrent infections, seizures



Dialysis

• Peritoneal dialysis

• Hemodialysis

• Hemofiltration


Peritoneal Dialysis

• The preferred method of dialysis for children

• Abdominal cavity acts as semipermeable membrane for filtration

• Can be managed at home in some cases

• Warmed solution enters peritoneal cavity by gravity, remains for period of time before removal


Hemodialysis

• Requires creation of a vascular access and special dialysis equipment

• Best suited for children who can be brought to facility 3x/week for 4-6 hours

• Achieves rapid correction of fluid and electrolyte abnormalities


Transplantation

• From living related donor

• From cadaver donor

• Primary goal is LT survival of grafted tissue

• Role of immunosuppressant therapy

Pediatric Renal Disorders

Health & Medicine

Transcript of Pediatric Renal Disorders