Chapter 46 Renal/Urinary Tract Disorders  Review A&P  Review normal urinalysis & child’s output- pg 1347  Review diagnostic studies  Dialysis covered in critical care-procedure same for children

Exstrophy of the Bladder  Midline closure defect during first 8 weeks of embryonic life  Bladder lies open & exposed on abdomen  Pic 1354

 Assessment-revealed by fetal sonogram  Bladder appears bright red & continually drains urine from open surface  Epispadius may also be present-males  Mgt-surgical repair

 Preop-keep exposed bladder covered by a sterile plastic bowel bag  Prevent skin from excoriation  Infants legs may be flexed & brought together & wrapped to prevent further separation of the symphysis  Position on back

 Postop- one or two step procedure  Position infant on back or in infant seat, prevent contamination from feces, indwelling or suprapubic catheter inserted to allow new bladder to rest. Immediately postop-urine may be blood tinged but should clear after couple of hours.  Antispasmodics, antibiotics & analgesics, bracing of pubic bones(4-6 weeks)

Hypospadius  Urethral opening not at end of penis but on lower aspect  Pics 1355  Assess for other defects  Mgt-don’t circumcise-foreskin may be needed for surgical repair  Postop-urinary urethral catheter-may notice painful bladder spasms as long as the catheter is in place (3-7 days)  Analgesics, antispasmodics

UTI  Assessment-dysuria, frequency, burning & hematuria  Low grade fever, abdominal pain & enuresis  Pyelonephritis-high fever, abdominal or flank pain, vomiting & malaise  Mgt-antibiotics, analgesics, increased fluids.  Teaching-1356

Reflux  Retrograde flow of urine from bladder to ureters r/t defective valve  Assess-history of repeated UTI’s, voiding cystogram  Mgt-double voiding techniques, prophylactic antibiotics, corrected by cystoscopy  Postop-suprapubic catheter & 2 ureteral stents- observe closely every hour for first 24 hrs & then every 4. Note color & amount of drainage- initially bloody but will clear in 24-48h.Analgesics & antispasmodics, sterile drsg to absorb leaking urine-no tub baths until suprapubic site closed completely

Hydronephrosis  Enlargement of the pelvis of the kidney with urine as a result of back pressure in the ureter generally caused by obstruction  Children usually asymptomatic, may have repeated UTI’s, elevated BP, flank & abdominal discomfort  Tx-surgical correction of obstruction

Enuresis  Usually nocturnal  Children older than 5 need evaluated for an organic cause  Assess for-stress, abdominal pain, UTI  Mgt-Limit stress, limit fluids after dinner (not if sickle cell ). May be prescribed DDAVP. May need bladder stretching exercises

Kidney Agenesis  Absence of a kidney often has Potter’s syndrome( misshapen low set ears & stiff, inflexible lungs from the lack of amniotic fluid in utero).

 Polycystic kidney-”Potter facies”-wide spaced eyes, epicanthal folds, flattened nose & small jaw. May be associated with a cerebral aneurysm. Tx-surgical removal of kidney or transplantation  Renal hypoplasia-small, underdeveloped kidneys-transplantation

Prune Belly Syndrome  Pic 1361  Severe urinary tract dilation mainly in boys  Three symptoms: deficiency of usual abdominal muscle tone; bilateral undescended testes; dilated faulty development of the bladder & upper urinary tract  Kidney transplantation

Acute Glomerulonephritis  Assessment-usually 5-10 yrs of age post strept infection  All children who had impetigo, strept infections should have a urinalysis 2 weeks post infection to evaluate for glomerulonephritis  Sudden onset of hematuria & proteinuria- urine appears tea colored, reddish-brown or smokey

 Abdominal pain, low grade fever, edema, N&V or headache  Elevated protein, elevated ESR rate, Bun & creatinine increase, mild anemia due to increased blood volume  Mgt-course 1-2 weeks-quiet play-return to school after kidney function is normal. Daily wts, I&O  Diet, antibiotics & diuretics usually not ordered unless heart failure occurs=Lasix, digoxin, semi- fowlers, & oxygen

Chronic glomerulonephritis  May follow acute glomerulonephritis or nephrotic syndrome  Alport’s syndrome-progressive chronic glomerulonephritis inherited as an autosomal dominant disorder  Acute symptoms of edema, hematuria, hypertension or oliguria.  TX-symptomatic-antihypertensives, bedrest, diuretics, corticosteroids  Prognosis poor. May need dialysis or transplantation

Nephrotic Syndrome ( Nephrosis)  Altered glomeruli permeability d/t fusion of the glomeruli membrane surfaces causing abnormal loss of protein in urine  Three forms: congenital: secondary (sickle cell, SLE; or primary  Four characteristic symptoms: proteinuria; edema; low serum albumin; hyperlipidemia

 Assess-periorbital edema usually most prominent when they wake up, ascites- clothes don’t fit, skin becomes pale, stretched & taut  Table-pg1364

 Mgt-corticosteroids such as prednisone- give every other day. Cytoxin for immunosupprssion if don’t respond to corticosteroids  Foods high in potassium-1365  Foods high in potassium especially if receiving diuretics, fluid & sodium may be restricted during acute phase.  Keep child in semi fowlers-more comfortable & reduces periorbital edema

Hemolytic-Uremic Syndrome  Occurs during summer in children 6mon- 4yrs of age following recent Ecoli infection  Transient diarrhea, fever, hematuria, oliguria, edema, petechiae  Supportive tx to maintain heart & kidney function ie peritoneal dialysis  Most recover completely but some have chronic renal impairment or may die

Renal Failure  Oliguria-output <1ml/kg/wt/hr  Azotemia, uremia, hyperkalemia  Tx-IVF’s, diuretics, daily wts, I&O, diet- low pro, K,& Na & high in CHO  Peritoneal or Hemodialysis  Kidney transplantation