1. Pediatric Renal RoundsBy
Brent Lee Lechner
MAJ, MC, USA

2. Agenda
One Case Presentation:
Oh, Dear Abby !
One Trivia Question

3. History 4-year-old white female Dx: Left otitis media
Started on Amoxicillin
Developed Rash on Back: Day 5
Antibiotic change to Zithromax
Day 2 on Zithromax – nausea/vomiting (bilious)
Noted to have hematuria on dipstick
Sent to the Emergency Department

4. Emergency Department Vitals: normal including BP and HR
Diffuse, tender abdomen
10 % Volume Depletion
Lab:
Normal LFTs, Amylase and Lipase
UA:
SG: LE(2+) Glucose(-)
Protein (2+) Nitrite (-) WBC /hpf
Blood (Large) Ketones(-) RBC > 50/ hpf
CT Abdomen with contrast
137
103 16 92
4.1 20
0.7

5. Admission: Outside Hospital
Negative CT scan of Abdomen
Normal Vitals
Normal Exam except volume depletion
Admitted to Pediatrics for serial abdominal exam and volume repletion
Urine output tapered off even with Rehydration

6. Admission History Negative History for the following:
Fever
URI symptoms or UTI symptoms
Joint Pain, Swollen Joints
Sore throat
Impetigo
Rashes (Drug Rash disappeared)
Transferred to our hospital after overnight hydration and minimal UOP

7. Labs on Transfer Urine Culture: negative
Serologies: UA: Micro of urine:
C3: SG RBC/hpf
ASO: Negative Blood (Large) (40 % Dysmorphic)
ANA: Negative Protein (2+) Granular Cast/hpf
ESR: LE(2+) RBC casts
Nitrite(-)
Ketones (-)
Glucose (-)
12.0
148
110 63
15.8
440 82
35.8
5.0
16.5
3.2

8. Hospital Course Urine Output: minimal (<0.2 cc/kg/d)
Peritoneal Dialysis initiated in am
T-catheter placement by Transplant Surgery
Renal US: [two days after admission]
Hyperechogenic kidneys
9 cm Bilaterally (Large for Age)
No Hydronephrosis
Patent Renal Vessels with good blood flow

9. Hospital Course Peritoneal Dialysis Complication:
Nausea/Vomiting persisted
Work-up included upper GI series & abdominal US
Pancreatitis:
amylase and lipase
Very Large pancreas on ultrasound
TPN initiated on Day 4
Repeat Serologies: C3, C4, and ANA (-), C3NeF, Factor H

10. Next Move
Day 18: Renal Biopsy!

21. Treatment Approach Methylprednisolone 500 mg IV for 3 Days
35 mg/kg/d for 3 days
Converted to Methylprednisolone (2mg/kg/d)

22. Abby Goes Home
After 28 days of PD and minimal urine output, Abby began to produce urine and her creatinine dropped to 0.8 mg/dl at the time of discharge !

23. MPGN Type II Children > 5 years of age (5-15), Male=Female
Caucasians and reports of familial clusters
Less than 4% of Children with Nephrotic Syndrome
95% low plasma C3
Less than 20 % of all MPGN in children
80% of MPGN Type II patients are positive for C3NeF
Genetic Mutations
Factor H
Partial Lipodystrophy (C3NeF)
50% Anemic (hemolysis driven – autoantibody)

24. Complement refresher
C3NeF

25. MPGN Type II Initial Studies
50 % 10-year renal survival (Cameron et al)
1983
West CD Alternate day 60 mg/m2 Prednisone
Retrospective study
71 patients: Renal Survival at 10 year mark 82, 56% after 20 years

26. Do steroids aid in the regression of MPGN ?
“Regression of Membranoproliferative GN Type II (DDD): Observations in Six Children” McEnery and Adams AJKD 1988

27. Do steroids aid in the regression of MPGN ?
“Treatment of MPGN with qod prednisone – a report of The International Study of Kidney Disease in Children” Tarish (1992) Ped Nephrology
Controlled, double-blinded Study
Years:
Ages: 5-17
80 Children
End Point: Increase in creatinine 0.4 mg.dl

28. Do steroids aid in the regression of MPGN ?
“Treatment of MPGN with qod prednisone – a report of The International Study of Kidney Disease in Children” Tarish (1992) Ped Nephrology

29. Trivia Question
The current active U.S. Navy fleet of aircraft carriers includes the following list of vessels named after Presidents.
USS Abraham Lincoln
USS Theodore Roosevelt
USS Ronald Reagan
USS Dwight D. Eisenhower
USS George Herbert Walker Bush

30. What is the only current active aircraft carrier named after democratic President?