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Approach to Pediatric Kidney Disease

Approach to Pediatric Kidney Disease. Kamal Akl MD Professor of Pediatrics & Pediatric Nephrology July 2019. Objectives. To familiarize medical students with the pattern of Pediatric Kidney Disease in Jordan

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Approach to Pediatric Kidney Disease

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  1. Approach to Pediatric Kidney Disease Kamal Akl MD Professor of Pediatrics & Pediatric Nephrology July 2019

  2. Objectives • To familiarize medical students with the pattern of Pediatric Kidney Disease in Jordan • To approach children in a focused, geographically, and culturally oriented manner • Such approach will save time, money, and unnecessary investigations

  3. Pediatric Kidney Disease in Jordan

  4. Pediatric Kidney Disease in Jordan • Including influence of : • Cultural Habits • Religion • Economics

  5. Approach to Pediatric Kidney Disease • Children are not small adults • Importance of the history and physical exam • Treat the Patient , not the lab • Developing Clinical sense(Sans Clinique)

  6. Congenital Anomalies of the Kidney and Urinary Tract(CAKUT) • Kidneys • Pelvis • Ureters • Bladder • Urethra

  7. CAKUT

  8. CAKUT • Importance of Antenatal Diagnosis

  9. Antenatal Diagnosis • Severity of Hydronephrosis based on AP pelvic diameter: • Severe > 10 mm in 2nd trimester • Severe > 15 mm in 3rd trimester

  10. Antenatal Diagnosis • Society for fetal urology(SFU) hydronephrosis grading system: • Grade O – no dilatation • Grade 2- Urine fills intrarenal pelvis+/- major calyces • Grade 3- all calyces are visualized • Grade 4- Grade 3+ parenchymal thininng • Nguyen HT et al • J Pediatr Urol. 2010 Jun;6(3):212-31. doi: 10.1016/j.jpurol.2010.02.205. Epub 2010 Apr 15. • The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis.

  11. Antenatal Diagnosis • Red flags for significant pathology: • Oligohydramnios • Additional renal or extrarenal anomalies • Sinha A • Indian J Nephrol. 2013 Mar-Apr; 23(2): 83–97.

  12. Antenatal Diagnosis • Patients with postnatal APD exceeding 10 mm and/or SFU grade 3-4 should be screened for upper or lower urinary tract obstruction and vesicoureteric reflux (VUR). • Sinha A et al Indian J Nephrol. 2013 Mar-Apr; 23(2): 83–97.

  13. Acute Kidney Injury • Prerenal • Intrinsic Renal • Postrenal • Causes in Jordan

  14. Chronic Kidney Disease(CKD) • Should know • CKD stages • Updated Shwartz Formula • Causes in Jordan

  15. CKD Stages • I • II • III • IV • V

  16. Updated Shwartz Formula [Height(cm)/serum creatinine(mg%] x 0.413

  17. End Stage Renal Failure(ESRF) In Jordan • Most Common causes in Jordan • CAKUT: Reflux Nephropathy • Neurogenic Bladder • Posterior Urethral Valve • Heredofamilial • Glomerular Disease • Etc • Akl KF et al • Aetiology of Paediatric End-stage Renal Failure in Jordan: A Multicentre Study. West Indian Med J. 2015 May 11;65(2):263-266.

  18. Urinary Tract Infection(UTI) • UTI in Jordan • E coli resistance • New AAP guidelines 2011

  19. Not all Dysuria is UTI • Causes of Dysuria: • Infectious: • APN • Cystitis • Vaginitis • Balanitis

  20. Not all Dysuria is UTI • Noninfectious: • Dysfunctional voiding • Labial adhesions • Crystalluria Meatal stenosis Chemical irritants Trauma

  21. Vesicoureteral Reflux • Primary • Secondary

  22. Asymptomatic urinary abnormalities • Hematuria • Proteinuria • Hematuria+ Proteinuria

  23. Glomerular Disease • Primary • Secondary • Jordan

  24. Should distinguish • Between - • Glomerular vs Non Glomerular Hematuria

  25. Should distinguish • Between • Acute Nephritis vs Nephrotic syndrome

  26. Classification of glomerular disease • May be based on serum complement • Presentation • Histopathology

  27. Classification based on serum complement • Hypocomplementemic : • (1) Poststrepeptococcal acute GN • (2) Mesangiocapillary GN • (3) Lupus nephritis • (4) Shunt nephritis • Normocomplementemic : Others eg MCD,FSGS , IgA N , HSP nephritis

  28. Classification according to clinical presentation • Asymptomatic urinary abnormalities • Nephritic syndrome • Rapidly progressive glomerulonephritis • Nephrotic syndrome • Chronic glomerulonephritis • Hypertension

  29. Classification based on histopathology • Proliferative • Nonproliferative

  30. Primary Glomerular Disease • IgA Nephropathy • Poststreptococcal Glomerulonephritis • Jordan

  31. Primary Glomerular Disease • Poststreptococcal AGN

  32. Poststreptococcal AGN

  33. Poststreptococcal AGN

  34. Secondary Glomerular Disease • Henoch Schonlein purpura • Systemic Lupus Erythematosis • Hemolytic Uremic Syndrome

  35. Hereditary Nephropathy • Alport syndrome • Nail Patella syndrome • New syndromes in Jordan

  36. Acute Interstitial Nephritis • Mostly under diagnosed • Causes AKI with minimal or no proteinuria

  37. Nephrotic Syndrome • Minimal Change Disease • Focal Segmental Glomerulosclerosis(FSGS) • Mesangioproliferative Glomerulonephritis • Mesangiocapillary Glomerulonephritis • Membranous Glomerulopathy • Seconary causes

  38. Nephrotic syndrome • Most common causes of Steroid resistance in Jordan • FSGS • MesProliferative GN

  39. Not all Edema is secondary to Kidney Disease • Causes of Edema: • Increased Capillary Permeability • Decreased Capillary Oncotic Pressure • Increased Plasma Volume • Lymphatic Obstruction

  40. Should distinguish • Between • Glomerular Disease vs Tubular Disease

  41. Tubular Disorders • Approach to Metabolic acidosis • Calculate Serum anion Gap • Urine Anion Gap

  42. Metabolic Acidosis • Normal Anion Gap( 8-16) • Increased Anion Gap

  43. Normal AG Metabolic Acidosis • Diarrhea • RTA

  44. RTA • Type 1 • Type 2 • Type 4

  45. RTA Type 1 • Ser K: low • Urine pH during acidosis :high • Ser HCO3: 10-20 • Urine pCO2: <20 • Urine citrate:low • Urolithiasis

  46. RTA Type 2 • Ser K:Low • Urine pH during acidosis: low • Serum HCO3: 16-18 • Urine pCO2: > 20 • Urine citrate: high • Fanconi syndrome: may be present

  47. RTA Type 4 • Ser K: High • Urine pH during acidosis: low or high • Serum HCO3: 16-22 • Urine pCO2: >20 • Urine citrate: low

  48. Increased anion Gap Metabolic Acidosis • Poisoning: Salicylate; Toluene; ethylene Glycol;Methanol • Ketoacidosis: Diabetic; starvation • Medications • Shock • Inborn errors of Metabolism; Methanol

  49. Metabolic Alkalosis • Chloride Responsive(U cl < 15 mEq/L) • Chloride Resistant(U cl > 20 mEq/L)

  50. Chloride Responsive Metabolic Alkalosis • Vomiting • Cystic Fibrosis • Pyloric Stenosis

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