Peds GU Alterations

• –  Newborn urine production: approx. 1-2ml/kg/hr
• –  Child urine production: approx. 1 ml/kg/hr
• Nephrons continue to grow in size and function until approximately 2 years of age (although all nephrons are present at birth) --> Initial renal function is not as effective-->Risk for dehydration is heightened & Renal metabolism/excretion of drugs is affected by decreased creatinine clearance/GFR 

• Ph:5-9
• Spec gravity: 1.001 -1.035 (reported as "ten-oh-one or then-thirty-five")
• Protein < 20 mg/dL (trace)
• Color:clear
• Ketones, sugars, leukocytes, WBCs should all = 0. 

• Primary: Bed has never been "dry."
• Secondary: New "wet" episodes have been preceded by 6-12 months of dry bed. 

Physical: decreased bladder capacity, UT abnormalities, neurologic alterations, obstructive sleep apnea, constipation, UTI, pinworms, DM 

Emotional: increased stress due to family disruption, pressure during toilet training, inadequate attn to voiding cues, sexual abuse 

• • Limiting fluids after dinner
• • Frequent voiding
• • Imagery training
• • Reward systems
• • Behavioral conditioning
• • Medications
• – Imiprimine, DDAVP (Vasopressin) 

E. coli.  (80%)

• Congenital urinary tract obstructions
• Individual susceptibility, ie steriod use, cancer pt./immunosupressed. 
• Reflux. Not to be confused with GERD. This is when urine backs up into the ureters and into kidneys. Has nothing to do with the stomach or esophagus. 

• lower: none.
• upper: fever, chills, flank pain. 

• Infants:
• Nonspecific, fever or hypothermia in neonate
• irritability
• dysuria
• change in urine odor or color
• poor weight gain
• feeding difficulties

• Toddlers:
• Abdominal or suprapubic pain
• voiding frequency and
• urgency
• dysuria
• new or increased incidence of enuresis
• fever

• Inflammation caused by bacteria, fungi, protozoa, or viruses that infect the kidneys
• Usually infection is via ascending urethral route (like UTI)
• Preexisting factors (usually)
• – Vesicoureteral reflux (flow of bladder urine into the ureters)
• – Dysfunction of lower urinary tract function like an obstruction or stricture. 

• • Vary from mild to “classic” to very severe
• • Presenting symptoms (more systemic)
• – N/V, anorexia, chills, nocturia, frequency, urgency
• – Suprapubic or low back pain, dysuria
• – Fever, hematuria, foul-smelling urine
•  • Costovertebral tenderness (CVA)
• • Symptoms often subside in a few days without therapy
• – Bacteruria and pyuria still persist

• • Undescended or hidden testes
• Occurs when one or both testes fail to descend through the inguinal canal into the scrotal sac
• Incidence higher in premature and LBW infants since levels of Testosterone dictate the descent of the testes
• Most infants will have spontaneous descent in the first year of life

• Hypo: Under-side (ventral) of penis.
• Epi: top side (dorsal) of penis.

The foreskin. Don't throw away before Sx repair!

• Also called “nephroblastoma.”
• Malignant renal and intraabdominal tumor of childhood. Not actually in the kidnesy, but proximity can cause renal dysfunction. 
• Occurs three times more in African American children
• Peak age of diagnosis is 3 years
• More frequent in males

• • Arises from malignant undifferentiated
• primordial cells
•  • More prevalent in the left kidney 

• Abdominal swelling or mass
• – Firm, nontender and confined to one side -->
• – **Do not palpate abdomen unless absolutely necessary or risk rupture!
• Hematuria (due to pressure exerted against kidneys)
• Fatigue/malaise (due to disrupted function of adrenal gland)
• HTN(occasionally)
• Weight loss
• Fever
• Manifestations resulting from compression of tumor mass

• • Treatment
• – Surgical Removal
• – Chemotherapy and/or Radiation
• • Prognosis
• – Survival rates are among the highest for childhood cancers
• – Localized: 90% cure 

• Occurs as an immune reaction to a group A-beta-hemolytic streptococcal infection of the throat or skin. (Does not actually invade the kidney FROM the throat or skin!)
• Most frequent in children age 5 to 12
• Clinical symptoms usually develop 1-2 weeks after initial strep infection 

• • Hematuria (gross or microscopic)
• • Proteinuria
• • Oliguria
• • Generalized edema due to ineffective filtration. (Begins with periorbital, then progresses to lower extremities and then to ascites)
• • HPTN
• • Mild Anemia due to v production of erythorpoitine in kidneys. 

• – 95% -rapid improvement to complete recovery
• – 5%-15%-chronic glomerulonephritis
• – 1%-irreversible damage 

• – Low sodium
• – Low to moderate protein

• • Most common presentation of glomerular injury in children
• • Etiology: Not fully understood, but glomerular membrane for some reason becomes waaaaaay permiable to proteins so body starts waisting it. 
• • Characteristics
• – Massive proteinuria!
• – Hypoalbuminemia
• – Edema, progressing to severe
• – Usually has normal or even low BP
• • Why? Low blood volume because fluids are third-spacing like crazy.

• • Diet
• – Low to moderate protein (to ^ oncotic pressure)
• – Sodium restrictions (to v fluid retention. Trying to reabsorb fluids back into the vasculature. 
• • Steroids
• – Prednisone is the drug of choice
• – 2mg/kg divided into BID doses
• • Diuretics (with manitol--> ^oncotic pressure) to v fluid volume in vasculature in order to encourage movement from 3rd spaces into vasculature.

• Sudden, severe loss of kidney function
• Kidneys can no longer filter waste products, regulate fluid volume, or maintain chemical balance
• • Etiology
• –  Most common cause in children: HUS (Hemolytic Uremic Syndrome). 
• –  Other potential causes:
• –  Prerenal: dehydration, hypotension, septic shock, renal artery obstruction
• –  Intrarenal: nephrotoxins (aminoglycosides, contrast media)
• –  Post-renal: structural abnormalities, tumors 

• • Most common cause of acquired acute renal failure in children
•  • Occurs primarily in infants and small children
• – Between 6 months to 5 years 
• • Thought to be associated with bacterial toxins, chemicals and viruses
• – Coxsackie virus, echovirus, and adenovirus
• – Also some cases due to E.Coli
• • 1996 - Odwalla juice prior to pasteurization 

• The triad of anemia, thrombocytopenia and renal failure is significant for diagnosis
• Vomiting, irritability, lethargy
• Marked pallor, oliguria or anuria
• CNS involvement (due to toxins not be filtered)
•  – Seizures
•  – stupor
• Hemorrhagic manifestations (due to platelet agregation--> thrombocytopenia and v platelet count). 
• – Bruising
• – Petechiae
• – Jaundice (hemolysis--> ^bilirubin which can't be excreted because of renal failure.)
• – Bloody diarrhea

• • Early diagnosis and aggressive!
• • Treat ARF and Hemolytic anemia
• – Dialysis (hemo, peritoneal)
• – Blood transfusions
• • FFP (clotting factors)
• • Packed RBCs 

• • Irreversible loss of kidney function that occurs over months to years
• • Progresses to ESRD (End Stage Renal Disease)
• • Initial symptom
• – Polyuria with very dilute urine (because of incompetent nephrons in young children), then --> oliguria and anuria
• • Culminate in “uremia”
• – Urine in the blood

• – Congenital anomalies are most common
• – Reflux associated with recurrent UTIs
• – Chronic pyelonephritis
• – Chronic glomerulonephritis
• – HUS 

• • Manage diet, hypertension, recurrent infections, seizures, electrolyte disturbances, fluid retention
• • Dialysis
• – Peritoneal is the preferred method for children
• – Abdominal cavity acts as a semi-permeable membrane for filtration
• – Warmed solution enters the peritoneal cavity by gravity, remains for a period of time before removal (dwell time)
• – Can be managed at home in some cases 

• • HemoDialysis: Requires creation of vascular access and special dialysis equipment
• – Best suited for children who can be brought to the facility --3 times/week for 4 to 6 hours
• – Achieves rapid correction of F/E imbalance
• • Transplant