1. Renal Disorders in Children

2. Hypospadias
Urethral opening of male is located below the glans or underneath the penile shaft
Incidence 1 out of 300 live births
Cause unknown
Familial tendency
Website1 and Website 2 with hypospadias repair

3. Chordee Ventral curvature of the penis
Often accompanies more severe forms of hypospadias
Foreskin may be absent ventrally
Hooded or crooked appearance of penis
Surgical repair

4. Surgical Repair Objectives of repair
Enhance ability to void standing up w/straight stream
Improve physical appearance of genitalia for psychological reasons
Preserve sexually adequate organ
Repair best done between 6-18 mos
Before develops body image and castration anxiety
Nursing care:
Prepare parents w/simple explanations
Stent may be placed, but Catheter care essential– discharge instructions
Increase PO fluids
Loose clothing, no straddle toys, swimming, tub baths, rough play or sandboxes

5. Renal Development in Peds
Fluid larger % of total body wt.
GFR not adult level til 1-2 yrs.
Short loop of Henle in newborn
Less efficient first 2 yrs.
No bladder control first 2 yrs.
Smaller bladder capacity
Newborn production about 1 to 2 mL/kg/hr
Child production about 1 mL/kg/hr
Shorter urethra

6. Lab & Diagnostic Tests Routine UA Specific gravity pH BUN and Cr IVP
VCUG
Ultrasounds
Angiography

7. Normal Urinalysis pH 5 to 9 Sp gr 1.001 to 1.035 Protein <20 mg/dL
Urobilinogen up to 1 mg/dL
WBC’s: 0—5
NONE OF THE FOLLOWING:
Glucose – RBCs
Ketones – Casts
Hgb – Nitrites

8. UTI Classification
Upper Tract: Pyelonephritis, VUR, Glomerulonephritis
Typically causes fever, chills, flank pain
Lower Tract: Urethritis, Cystitis
No systemic manifestations
E. coli causes about 80%

9. Upper and Lower Tract UTIs

10. Urinary Tract Infections
Typical Symptoms: (box 30-1, p th ed. Hockenberry)
Dysuria
Frequent urination (>q2h), foul-smelling urine
Urgency
Suprapubic discomfort or pressure
Urine may contain visible blood or sediment (cloudy appearance)
General malaise, poor feeding or appetite, vomiting, fussiness/irritability.
Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)

11. Pediatric Manifestations
Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia
Frequency
Fever in some cases
Odiferous urine
Blood or blood-tinged urine
Sometimes no symptoms except generalized sepsis
Dx: Hx, PE, UA & culture

12. UTI Collaborative Care: Drug Therapy—Antibiotics
Uncomplicated cystitis: short-term course of antibiotics
Complicated UTIs: long-term treatment
Trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim) or nitrofurantoin (Macrobid)
Amoxicillin, Cephalexin, Gentamycin
Eliminate cause, ID contributing factors

13. Teaching Enc. freq. voiding & complete emptying ↑ fluid intake
Acidify urine (cranberry juice, Vit. C)-present research does NOT support the efficacy of this. pH needs to be at 5.0 or < in order to have a significant impact on e.coli. (P. 1145)
Avoid bubble baths, hot tubs, whirlpools
No tight panties or nylon
Good hygiene; wipe front to back
Void after sexual activity
Avoid Constipation

14. Vesicoureteral Reflux (VUR)
Urine swept up ureters w/each void then empties back into bladder (p. 1269)
↑s chance for infections - most common cause of pyelonephritis in children
Scarring by 5-6 yrs
Dx: ultrasound; cystography; VCUG
Tx: continuous low dose antibiotics w/freq urine cultures OR surgical repair with stent placement.

15. Acute Glomerulonephritis
APSGN most common – days after strep infection (skin or throat)
Inflammation of glomeruli; damage by antigen- antibody complex
↓ GFR & renal bld flow → HTN & edema
Most common s/s: HTN—monitor regularly, edema (periorbital), hematuria/proteinuria
Daily wt – IMPORTANT
Maintain fluid balance & treat HTN
Loop diuretics or anti-hypertensives may be used
1st sign of improvement-- ↑ urine & ↓ wt.

16. Nephrotic Syndrome
Glomerular injury → massive proteinuria, hypoalbuminemia, hyperlipemia, edema
Other s/s: wt. gain, periorbital edema early in day → ankle edema later in day, anorexia, pallor, fatigue, oliguria (dark & frothy)
More common between 2-4 yrs old
Compare APSGN with Nephrotic Syndrome—see chart at end of Ppt.

17. Types Most common in peds: MCNS Secondary: result of glomerular damage
Minimal-Change Nephrotic Syndrome
80% of cases – cause unknown
Precipitated by viral URI
Secondary: result of glomerular damage
Acute Glomerulonephritis
Collagen Diseases (Lupus)
Drug toxins/poisons/venons
AIDS, sickle cell, hepatitis & others

18. Nephrotic Syndrome (p. 1155, 9th ed)
Wong 7th ed p. 1276; 6th ed p. 1386

19. Diagnosis History of S/S Labs Urine Blood Proteinurea >2 gm/day
Specific gravity ↑
Blood
↓ serum protein
Hgb/Hct – nl or slightly ↑ due to hemoconcentration
Platelets ↑ and serum Na+ ↓
Cholesterol ↑

20. Treatment Goals: Must try to ↓ excretion of protein & ↓ inflammation
Meds: Corticosteroids till urine is free from protein & normal days
Immunosuppressants – Cytoxan
Loop Diuretics – not always effective
During massive edema→ ↓salt
No restriction on water

21. Nursing Considerations
Monitor for infection (esp. peritonitis)
Monitor for side effects of steroids
Monitor wt, I & O, abd. girth
Urinalysis for albumin
Protect skin from breakdown d/t edema
VS for signs of complications
Monitor diet restrictions
Support and educate family

22. Prognosis If diuresis within 7-21 days – GOOD
If not after 28 days → chance of response ↓
80% OK
50% relapse after 5 yrs
20% relapse after 10 yrs
Key: early ID and Tx
If responds to steroids, relapse is less

23. Minimal Change Nephrosis
Manifestations
Acute Glomerular
Nephritis
Minimal Change Nephrosis
ASO Titers 
Normal BP
Normal or 
Edema
Primarily peripheral or periorbital
Generalized, severe
Circulatory congestion
Common
Absent
Proteinuria
Mild –moderate
Massive
Hematuria
Gross or microscopic
Microscopic or none
RBC casts
Present
Azotemia
Serum K+ levels
Normal or 
Serum Protein levels
Minimal reduction
Markedly 
Serum lipid levels
Elevated
Peak age at onset (Yr)
5-7
2-3