Introduction to pediatric nephrology
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Introduction to Pediatric Nephrology. Dr.Fahad Gadi, MD Pediatrics Demonstrator King Abdulaziz University Rabigh Medical School. Kidney ontogenesis.

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Introduction to pediatric nephrology

Introduction to Pediatric Nephrology

Dr.Fahad Gadi, MD

Pediatrics Demonstrator

King Abdulaziz University

Rabigh Medical School

Kidney ontogenesis
Kidney ontogenesis

  • The embryological development of the kidney is a long and continuous process which begins in the 3rd week and is completed by about 34-35 weeks of fetal life.

  • Kidney organogenesis is characterised by 3 distinct and linked stages: pronephros, mesonephros and metanephros.

Kidney ontogenesis1
Kidney ontogenesis

  • In humans, the first two are transient structures with little excretory capacity but they are important for the appropriate development of the metanephros, which is the direct precursor of the adult kidney.


  • The final stage of the kidney is the differentation of the metanephros and arise from the ureteric bud and the metanephric blastema (mesenchyme).

  • The renal pelvis, major and minor calyces and terminal collecting duct are formed by the 10-13th wks of ges.

  • After morphogenesis each kidney contains approx a million nephrons.

Introduction to pediatric nephrology

Renal development





3 t.ż.

4-8 t.ż.

przewód Wolffa



5 t.ż.


pączek moczowodowy

Nerka ostateczna


blastema nerki ostatecznej

Antenatal period
Antenatal Period

  • The most common cause is physiologic dilation.

  • Metanephric urine production begins at 8 weeks, even before ureteral canalization is complete.

  • Transient obstruction with hydronephrosis occurs.

Molecular aspect

  • The development of the metanephric kidney depends on inductive interaction between the ureteric bud (UB) and the metanephric mesenchyme (MM).

  • A large number of genes have been found to be crucial during kidney development.


  • In the fetus at 36 weeks’ gestation there is an adult complement of nephrons- approx. one million

  • All further growth of the kidney is via hyperplasia mainly in the tubules.

Fetal kidney
Fetal kidney

  • Nephrogenesis is completed between the 28 and 36th gestational week in the human, the renal tissue and particularly the tubular cells continue to develop postnatally.

  • Several of the major transporters in the tubular epithelial cells undergo postnatal maturation

Fetal kidney1
Fetal kidney

  • Outer cortical glomeruli are relatively underperfused compared with inner cortical glomeruli.

  • Following birth, renal perfusion to superficial cortical nephrons rises compared with deeper glomeruli

Fetal kidney2
Fetal kidney

  • Angiotensin-converting enzyme inhibitors and angiotensin-receptor antagonists impair nephrogenesis and so are contraindicated in pregnancy

Production of urine
Production of urine

  • Production of urine starts at the age of 10-12 weeks of gestation:

  • 1. very dilute urine

  • 2. small amount of urine

  • Fetal urine is a major constituent of amniotic fluid and urinary flow rate increases from 12ml/hr at 32 weeks’gestation to 28ml/hr at 40 weeks’gestation.

  • Similar increases are described during the maturation of premature newborns.

Glomerular filtration rate gfr
Glomerular Filtration Rate (GFR)

  • Glomerular filtration begins between the 9th and 12th week of gestation in humans.

  • The GFR is relatively low at birth especially in the premature infant.

  • The values of GFR nearly double between 3 and 7 days and thereafter GFR continues to increase, by 1 to 2 yrs of age the GFR is the same as in an older child- 80% of mature kidney.

Kidney of newborn
Kidney of newborn

  • The kidney of the newborn infant has a limited capacity to regulate the excretion of fluid and electolytes.

  • The high sodium excretion during the first 2 to 3 weeks often results in a negative sodium balance and predisposes to hyponatremia.

Creatinine clearance
Creatinine Clearance

  • Newborn: 40-65 ml/min/1.73 m2

  • <40 yrs: 97-137 ml/min/1.73 m2

Renal failure in the newborn
Renal failure in the newborn

  • Renal failure in the newborn:

  • severe asphyxia,

  • the majority suffered from nonoliguric renal failure


  • Congenital

  • Anomalies of

  • Kidney and

  • Urogenital

  • Tract


  • Chronic renal failure (children):

    Obstructive nephropathy- 47%

    Reflux nephropathy- 18,5%

    Hypo/dysplasia 8,7%

Renal abnormalities

  • Renal agenesis:

    bilateral fetal death- Potter syndrome 1:4000 pregnancies

    unilateral other organ- 1:2900 pregnancies abnormalites

Introduction to pediatric nephrology

Renal abnormalities

Agenesis Aplasia Hypoplasia

Renal abnormalities1

  • Hydronephrosis

Renal abnormalities2

  • Obstractive uropathy:

    A. ureteropelvic junction obstruction- dilated renal pelvis with/ without caliectasis and no dilation of the ureter

    B. ureterovesical junction obstruction (megaureter)- pelviectasis and caliectasis with significant ureter dilation

Renal abnormalities3

  • C. posterior urethral valve

  • D. ureterocele- cystic dilatation of the distal ureter that protrudes into the urinary bladder, may extend past the bladder into urethra

  • E. ectopic ureters

  • F. constriction (stenosis)of urethra

Introduction to pediatric nephrology

Posterior urethral valve

Type I – Type II Type III

Introduction to pediatric nephrology

Duplication of urinary tract


duplex fissus

Introduction to pediatric nephrology

Vesico-ureteral reflux

Frequency of VUR

• Isolated1% (0.4-4%)

• UTI in the past 29-50%

• Siblings with VUR 32-45%

• Mothers with VUR in the past 60%

Renal abnormalities4

  • Polycystic kidney:

    autosomal dominant p.k.disease

    autosomal recessive p.k. disease


  • Pronephros is a transitory non-functional kidney, the first tubules appear the middle of the 3rd week and arise from intermediate mesodermal cells.

  • The pronephric tubules persist for only a short time and undergo degeneration by the 5th week.

  • At the time the pronephros is degenerating the mesonephric tubules and duct are developing.

Vesico ureteral reflux
Vesico- ureteral reflux

Normal kidney, ureter, and bladder

Vesico ureteral reflux1
Vesico- ureteral reflux

Grade I Vesicoureteral Reflux:urine (shown in blue) refluxes part-way up the ureter

Vesico ureteral reflux2
Vesico- ureteral reflux

  • Grade II Vesicoureteral Reflux:urine refluxes all the way up the ureter

Vesico ureteral reflux3
Vesico- ureteral reflux

  • Grade III Vesicoureteral Reflux:urine refluxes all the way up the ureter with dilatation of the ureter and calyces (part of the kidney where urine collects)

Vesico ureteral reflux4
Vesico- ureteral reflux

  • Grade IV Vesicoureteral Reflux:urine refluxes all the way up the ureter with marked dilatation of the ureter and calyces

Vesico ureteral reflux5
Vesico- ureteral reflux

  • Grade V Vesicoureteral Reflux:massive reflux of urine up the ureter with marked tortuosity and dilatation of the ureter and calyces