Typical featuresAtypical features Age yrs 10 yrs NormotensiveHypertensive Normal renal functionsAbnormal renal functions Microscocopic hematuriaMacroscopic hematuria
Initial investigation Blood: FBC, U+Es; Creatinine; LFTs; ASOT; C3/C4; Varicella titres Urine: Urine culture andUrinary protein/creatinine ratio BP Urinalysis including glucose A urinary sodium concentration can be helpful in those at risk of hypovolaemia.
Complications 1) Hypovolemia – abdominal pain, unwell, tachycardia, poor perfusion, High Hb, high urea 2) Peritonitis – difficult to recognise and may be masked due to steroids. 3) Thrombosis – renal, pulmonary and cerebral Veins Fall in platelets, raised FDP, abnormal PTT, abnormal dopplers
Treatment Strict input out put – Oliguric patients need fluid restriction.400ml/m2 Prednisolone 60mg/m2 – till negative or trace proteins in urine, then 40mg/m2 on alternate days for 4 weeks Penicillin prophylaxis Advice on immunisations and contact Teach dipstick technique
Some definitions Remission – trace or no protein on 3 consecutive days Relapse – 3+ or more protein on 3 consecutive days Steroid resistance- failure of remission for 4 weeks How often do we check urine : Urine should be checked initially twice weekly, then weekly after the first episode, and the families instructed to get in contact should a relapse of proteinuria occur, or if there is ++ for more than 1 week.
When to refer to a nephrologist Age < 1 yr Age > yrs Persistent hypertension Macroscopic haematuria Low C3/C4 Failure to respond to steroids within 4 weeks
Hematuria – AGN Hematuria, proteinuria, odema, hypertension and renal insufficiency Symptoms and signs Macroscopic hematuria Oedema Breathlessness Headaches Weight gain, B.P, JVP, signs of cardiac failure, oliguria
UTI Common cause of fever Important to recognise this – as implications for further investigations and management Recognise different urine collection methods History important
Imaging Recommended imaging schedule for infants younger than 6 months TestResponds well to treatment within 48 hours Atypical UTIRecurrent UTI Ultrasound during the acute infection NoYes Ultrasound within 6 weeks YesNo DMSA 4–6 months following the acute infection NoYes MCUGNoYes
Imaging TestResponds well to treatment within 48 hours Atypical UTIRecurrent UTI Ultrasound during the acute infection No YesNo Ultrasound within 6 weeks No Yes DMSA 4–6 months following the acute infection NoYes MCUGNo Recommended imaging schedule for infants and children 6 months and older but younger than 3 years
Imaging Recommended imaging schedule for children 3 years and older TestResponds well to treatment within 48 hours Atypical UTI Recurrent UTI Ultrasound during the acute infection NoYesNo Ultrasound within 6 weeks No Yes DMSA 4– 6 months following the acute infection No Yes MCUGNo
Imaging tests: atypical UTI Atypical UTI is defined as any of the following: Seriously ill (for more information refer to Feverish illness in children (NICE clinical guideline 47) Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Failure to respond to treatment with suitable antibiotics within 48 hours Infection with non-E. coli organisms.
18 The Final Urological Diagnosis of 426 live-born Infants with Significant Prenatally Detected Uropathy British Journal of Urology volume 81 Page 8 - April 1998
19 Grades of Hydronephrosis Mild hydronephrosis: Pelvic APD <=1.5 cm and normal calyces Moderate hydronephrosis Pelvic APD > 1.5 cm and caliectasis with no parenchymal atrophy Severe hydronephrosis: Pelvic APD > 1.5 cm, caliectasis and cortical atrophy BJU Inter volume 85 Page May 2000
20 Prognosis & Severity of ANH Prognosis & severity of hydronephrosis: (% needed surgery or prolonged follow-up): RPD > 20 mm, 94% RPD 10–15 mm 50% RPD was < 10 mm 3% Grignon A, Filion R, Filiatrault D, et al: Radiology 1986 Sep; 160(3): Outcome of fetal renal pelvic dilatation (Surgery or UTI): Mild dilation 0% Moderate dilatation 23% Severe hydronephrosis 64% Ultrasound Obstet Gynecol May;25(5):483-8.
Eneuresis Involuntary wetting during sleep without any inherent suggestions of frequency of bedwetting or pathophysiology Prevalence decreases with age Causes not fully understood Treatment has a positive effect on the self-esteem of children and young people. Healthcare professionals should persist in offering treatments
Inform children and young people with bedwetting and their parents or carers that it is not the child or young persons fault and that punitive measures should not be used in the management of bedwetting Principles of care
Assessment and investigation: 1 History taking Ask about onset of bedwetting, pattern of bedwetting, daytime symptoms, toileting patterns, fluid intake and practical issues. Assess for comorbidities and other factors that may be associated with bedwetting.
Address excessive or insufficient fluid intake or abnormal toileting patterns before starting other treatment for bedwetting in children and young people (KPI) Adequate daily fluid intake is important Advice on fluid intake, diet and toileting patterns AgeSexTotal drinks per day 4 – 8 yearsFemale Male 1000 – 1400 ml 9 – 13 yearsFemale Male 1200 – 2100 ml 1400 – 2300 ml 14 – 18 yearsFemale Male 1200 – 2500 ml 2100 – 3200 ml
Explain that reward systems with positive rewards for agreed behaviour rather than dry nights should be used either alone or in conjunction with other treatments for bedwetting Inform parents or carers that they should not use systems that penalise or remove previously gained rewards Advise parents or carers to try a reward system alone for the initial treatment of bedwetting in young children who have some dry nights Reward systems
Initial treatment: alarms Who to consider Offer an alarm as the first-line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system, unless the alarm is inappropriate or undesirable. Alarm may be inappropriate when: bedwetting is very infrequent (that is, less than 1–2 wet beds per week) the parents or carers are having emotional difficulty coping with the burden of bedwetting the parents or carers are expressing anger, negativity or blame towards the child or young person
Offer desmopressin to children and young people over 7 years, if: rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or an alarm is inappropriate or undesirable Initial treatment: desmopressin