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General Pediatrics Board Review Nephrology Fluids and Electrolytes. Jeff rey M. Saland , M.D. Department of Pediatrics Mount Sinai School of Medicine.

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slide1

General Pediatrics Board Review

Nephrology

Fluids and Electrolytes

Jeffrey M. Saland, M.D.

Department of Pediatrics

Mount Sinai School of Medicine

slide2

An 8 year old proudly announces to you that she did a report on jellyfish and they are 96% water. She asks you what is her “percent water?” What is the best estimate of her fluid compartments by percent of body weight?

slide3

An 8 year old proudly announces to you that she did a report on jellyfish and they are 96% water. She asks you what is her “percent water?” What is the best estimate of her fluid compartments by percent of body weight?

composition of body fluids
Composition of Body Fluids

Babies are moist– but not quite jellyfish!

slide5

Finberg L. Water and Electrolytes in Pediatrics 1993 (data from Friis-Hansen BJ Pediatrics 1961)

TBW

ICW

ECW

slide6

Distribution of body water as a percentage of body weight

Compiled by Finberg, L. from data by BJ Friis-Hansen, ActaPaed Scand 1958

Technique: D2O for TBW and thiosulfate for ECW

slide7

Approx Body Composition > 1 year

TBW = 60% Lean Body Mass:

ICF = 2/3 TBW

ECF = 1/3 TBW

Plasma = 1/4 ECF

(rest is interstitial fluid)

TBW

Na ~ 13

K ~ 140

Na ~ 140

K ~ 4

Plasma

ICF

ECF

slide8

A previously healthy 23 kg child is admitted for gingivostomatitis and refusal of oral intake. What is the most appropriate maintenance intravenous fluid prescription?

slide9

A previously healthy 23 kg child is admitted for gingivostomatitis and refusal of oral intake. What is the most appropriate maintenance intravenous fluid prescription?

slide10

What are maintenance fluids?

The fluid and electrolytes necessary for a person to remain in net balance over the long term

INTAKE

ICF

ECF

Plasma

OUTPUT

slide12

What are maintenance fluids?

Barratt M: Pediatric Nephrology 4th Ed 1998

slide13

What are maintenance fluids?

Why did that graph estimate caloric needs?

We need to know how many mL of fluid to order, not how many calories!

slide14

For the “average” patient, the use of 1 Cal corresponds to the use of 1 mL of water

Insensible losses:

respiratory 30 cc / 100 Cal

+ evaporative not sweat 15 cc / 100 Cal

45 cc / 100 Cal

Urine output losses 50-75 cc / 100 Cal

Stool losses 5-10 cc / 100 Cal

Growth “loss” 0-15 cc / 100 Cal

Water of oxidation (a gain) 10-15 cc / 100 Cal

TOTAL Approximately100 cc / 100 Cal

slide15

Summary “maintenance fluids”

Fluid needs are linked to the metabolic rate.

Maintenance is approximately insensible plus urine losses.

Maintenance fluids of the “average” patient are approximately:

slide16

Changes in the metabolic rate or the environment change insensible fluid loss

Increased INSENSIBLE Losses

Fever (each deg > 38): 12.5%

Prematurity 100-300%

Radiant warmer 50-100%

Phototherapy 25-50%

Increased activity 5-25%

Decreased INSENSIBLE Losses

Ventilation (humidified air) 25-40%

Sedation 5-25%

Decreased activity 5-25%

Hypothermia 5-15%

Enclosed Incubator 25-50%

slide17

Maintenance Fluid DOES NOT

Include Abnormal Losses

Common / “Community” losses

Gastrointestinal: diarrhea, vomiting

Activity: sweating, increasedventilation, heat

Burns: (evensunburn!)

Uncommon / “Nosocomial” losses

Drainage (egchesttube, NG tube, et cetera)

Bleeding

Pathological renal losses (egsaltwasting, diabetes)

Theselosses are universallyhypo- orisotonic

slide19

“Salt” Maintenance Requirements

Na: 2-5 mEq / kg /day

K: 1-2 mEq / kg /day

There is a large variability in the intake of Na, and to a lesser extent K, by healthy people.

Renal ability to conserve or excrete Na is very large.

The ability to conserve or secrete K is also larger than the average variation in intake.

slide21

An 18 month old boy presents to the ER with a history of vomiting and diarrhea for several days. He is lethargic, has poor skin turgor, dry mucus membranes, and has tachycardia. He took 5 ml oral fluid but vomited almost immediately. The next most appropriate step is to:

  • Give 20 ml/kg of D5 ½ NS intravenously over 20-30 min
  • Give 5 ml/kg of D5 NS intravenously over 20-30 min
  • Give 20 ml/kg of NS intravenously over 20-30 min
  • Give 10 ml/kg of 3% NS intravenously over 20-30 min
  • Await serum electrolytes before giving IV fluid
slide22

A nearly 1 month old boy has been vomiting his feedings forcefully for 2 days. He is afebrile and has no diarrhea. He had 1 wet diaper in the last day. He appears dehydrated. He eagerly takes fluids but vomits (non-bilious) immediately and while he does so you note “waves” on his abdomen. What is the most likely set of labs?

slide23

A nearly 1 month old boy has been vomiting his feedings forcefully for 2 days. He is afebrile and has no diarrhea. He had 1 wet diaper in the last day. He appears dehydrated. He eagerly takes fluids but vomits (non-bilious) immediately and while he does so you note “waves” on his abdomen. What is the most likely set of labs?

slide24

Signs & Symptoms of Dehydration I

(fairly reliable)

Harriet Lane Handbook

slide25

Signs & Symptoms of Dehydration II

(less reliable)

Harriet Lane Handbook

slide26

A 2 year-old presents with a 1 day history diarrhea and a 5% weight loss. Which of the following best represents the distribution of the fluid loss?

slide27

A 2 year-old presents with a 1 day history diarrhea and a 5% weight loss. Which of the following best represents the distribution of the fluid loss?

3 or more days: the correct answer would have been B. The ICF is relatively protected from volume loss.

Harriet Lane Handbook

slide28

A nearly 13 month old girl has had diarrhea for 5 days. She has few wet diapers. Her BP is 86/40, pulse is 135. She weighs 9 kg and you estimate she is 10% dehydrated based on clinical parameters. Disregarding Na losses from the ICF, which of the following estimates is best?

slide29

A nearly 13 month old girl has had diarrhea for 5 days. She has few wet diapers. Her BP is 86/40, pulse is 135. She weighs 9 kg and you estimate she is 10% dehydrated based on clinical parameters. Disregarding Na losses from the ICF, which of the following estimates is best?

slide30

A 13 month old child was seen for a checkup and weighed 10 kg. 10 days later in the ER with gastroenteritis she weighs 9 kg. 10% Dehydration.

A liter weighs 1 kg.

A pint’s a pound the world around.

slide31

A high school student and her friend have multiple episodes of vomiting and watery diarrhea after sharing lunch from a food cart at the park earlier in the day. Her bp is 95/45 and her pulse increases from 90 to 115 standing. She feels light-headed and has not urinated in the last 6 hours. Which is the most likely type of dehydration?

slide32

A high school student and her friend have multiple episodes of vomiting and watery diarrhea after sharing lunch from a food cart at the park earlier in the day. Her bp is 95/45 and her pulse increases from 90 to 115 standing. She feels light-headed and has not urinated in the last 6 hours. Which is the most likely type of dehydration?

slide33

A 14 year old girl is treated with a prolonged course of antibiotics for sinusitis. She develops profuse watery diarrhea that lasts several days. She had not been eating due to abdominal pain but had taken at least 2 liters of a yellow sports drink each day. In the ER, she still appears moderately dehydrated. You diagnose C. Dificile colitis. The most likely type of dehydration is:

slide34

A 14 year old girl is treated with a prolonged course of antibiotics for sinusitis. She develops profuse watery diarrhea that lasts several days. She had not been eating due to abdominal pain but had taken at least 2 liters of a yellow sports drink each day. In the ER, she still appears moderately dehydrated. You diagnose C. Dificile colitis. The most likely type of dehydration is:

slide35

A 14 year old boy with cerebral palsy and mental retardation develops fever to 40 °C. He is able to tolerate his usual liquid formula diet by gastric tube. You diagnose him with streptococcal pharyngitis but also note he has very dry mucus membranes and his skin feels thick. Which is the most likely set of lab findings?

slide36

A 14 year old boy with cerebral palsy and mental retardation develops fever to 40 °C. He is able to tolerate his usual liquid formula diet by gastric tube. You diagnose him with streptococcal pharyngitis but also note he has very dry mucus membranes and his skin feels thick. Which is the most likely set of lab findings?

slide39

A 10 year old boy has high fever and dehydration due to seasonal influenza. He has not urinated in over 24 hours. His serum creatinine is elevated from 0.7 to 1.6. Urine is taken to calculate fractional excretion of Na. Two days later he is rehydrated and has normal urine output and his creatinine is baseline. What best describes his diagnosis and most likely FENa on presentation?

  • Acute kidney injury 3%
  • Acute kidney injury 0.3%
  • Pre-Renal Azotemia 3%
  • Pre-Renal Azotemia 0.3%
slide40

Consider a child with sepsis and decreased urine output with the following labs:

SERUM: Na 124, K 4, Cl 94, Total CO2 12

Creat 0.8 mg/dL, BUN 40, Glucose 70

URINE: specific gravity 1.030, trace protein, no blood or glucose, small ketones; urine Na 15, creat 40

slide41

FENa is a useful test when:

  • The urine output is low.
  • No current use of diuretics.
  • < 1% (0.01): pre-renal azotemia (“acute renal success”)
  • > 2% (0.02): acute kidney injury (“acute renal failure”)
  • Exceptions: acute GN has low FENa, obstruction can vary
slide42

A 4 year-old girl with a ventriculoperitoneal shunt presents with a week of vague symptoms progressing toward listlessness and decreased speech, finally with a 5 minute seizure. The bulb of the shunt empties with pressure but is slow to refill. She does not appear dehydrated. The most likely set of laboratory findings is:

slide43

A 4 year-old girl with a ventriculoperitoneal shunt presents with a week of vague symptoms progressing toward listlessness and decreased speech, finally with a 5 minute seizure. The bulb of the shunt empties with pressure but is slow to refill. She does not appear dehydrated. The most likely set of laboratory findings is:

slide44

SIADH: Too Much ADH

  • Etiologies:
  • CNS disease (hydrocephalus, meningitis, etc)
  • Lung (pneumonia, RSV, etc)
  • Nausea or Pain
  • Cancer or Stem Cell transplantation
  • Drugs (SSRI’s)
  • Should exclude:
  • Thyroid, adrenal, cardiac, or renal disease
  • Volume deficits / dehydration
  • Hyponatremia, inappropriately high urine Osm (>100)
  • Urine Na can be variable– usually “highish”
slide45

A 7 year-old girl presents for secondary enuresis. On review of systems she has significant polyuria, polydipsia, and severe daily headaches that awaken her in the morning. Urinalysis in your office is negative for glucose and ketones. The most likely set of laboratory findings is:

slide46

A 7 year-old girl presents for secondary enuresis. On review of systems she has significant polyuria, polydipsia, and severe daily headaches that awaken her in the morning. Urinalysis in your office is negative for glucose and ketones. The most likely set of laboratory findings is:

slide47

Diabetes Insipidus: Not Enough ADH

Or ADH not Effective

  • Etiologies:
  • CNS disease (pituitary infiltration, damage)
  • Drugs (lithium)
  • Nephrogenic (V2 receptor or aquaporin defect)
  • Others more rare
  • With access to water, just polyuria, polydipsia
  • Without access to water, hypernatremia, polyuria, polydipsia
  • Hypernatremic dehydration
  • Inappropriately dilute urine
  • Water deprivation test diagnostic but dangerous
  • Response to DDAVP diagnostic of central DI
  • Genetic testing for nephrogenic DI
slide48

An overweight 15 year old girl is admitted with polyuria and severe dehydration. Severe hyperglycemia of 800 mg/dl without ketoacidosis is discovered. Serum electrolytes are significant for Na of 140, K of 4.3, Cl of 98, CO2 of 19, BUN is 53, Creatinine is 1.6. Which of the following is NOT true?

  • Excessive 0.9% NS may exacerbate the situation
  • Serum K can be expected to fall with rehydration
  • Serum Na can be expected to rise with rehydration
  • Hyperglycemia causes the lab equipment to malfunction and produce falsely low Na values
  • Dehydration is the result of osmotic diuresis
slide49

Acid / Base

Mr. Osborne, may I be excused? My brain is full.

slide50

A 6 month old girl born at term and with no apparent illnesses presents with failure to thrive. She is mildly tachypneic at rest. Lab evaluation is remarkable for serum Na 140, K 2.5, Chloride of 115, bicarbonate of 11 and creatinine of 0.3 mg/dL. Which of the following is most consistent with distal (type I) renal tubular acidosis (RTA)?

slide51

A 6 month old girl born at term and with no apparent illnesses presents with failure to thrive. She is mildly tachypneic at rest. Lab evaluation is remarkable for serum Na 140, K 2.5, Chloride of 115, bicarbonate of 11 and creatinine of 0.3 mg/dL. Which of the following is most consistent with distal (type I) renal tubular acidosis (RTA)?

slide52

Renal Tubular Acidosis

  • Associated with growth failure
  • Low anion gap metabolic acidosis
  • May be compensated by pulmonary hyperventilation
  • Urine anion gap should be positive: (Na+ + K+) > Cl-
  • Clinical pearls:
  • Confirm metabolic acidosis with a VBG
  • Distal RTA (type I) is most common
  • Types I and II have hypokalemia
  • Type IV has hyperkalemia (aldosterone defect)
  • Can be treated with bicitra with varying success
slide53

Renal Tubular Acidosis: Urine Anion Gap

Na+

+ K+

__– Cl-____

Anion Gap

What is NOT measured is ammonium (NH4+)

Na++K+ < Cl-

UAG Negative

Non-renal acidosis

Na++K+ > Cl-

UAG Positive

RTA

Carmody, PREP 2011

slide54

Renal Tubular Acidosis: Distal vs Proximal

  • Distal (type 1)
  • Commonly associated with hypercalcURIA, stone risk
  • Late nephron defect, urine pH “always” < 5.5
  • Low urine citrate
  • Distal RTA (type I) can associate with deafness
  • Proximal (type 2)
  • More rare
  • Often associated with Renal Fanconi Syndrome
  • Lower threshold of bicarbonate reabsorption
  • Urine pH depends on plasma bicarbonate, “always” > 5.5
slide55

An 8 year-old with type 1 diabetes mellitus is admitted to the ICU with pneumonia. His blood sugar is 450 mg/dL, serum Na is 133, K is 5.1, Cl 95, HCO3- 8. The most likely acid-base disturbance is:

slide56

An 8 year-old with type 1 diabetes mellitus is admitted to the ICU with pneumonia. His blood sugar is 450 mg/dL, serum Na is 133, K is 5.1, Cl 95, HCO3- 8. The most likely acid-base disturbance is:

Don’t forget– we ASSUMED the pH was low because metabolic acidosis is so likely. We really need a blood gas to know for sure!

slide57

High Anion Gap Metabolic Acidosis:

M: methanol (and metabolic diseases)

U: uremia

D: diabetes (ketoacids), d-lactic acidosis

P: (paraldehyde); propylene glycol

I: Isoniazid, Iron

L: Lactate

E: Ethanol, Ethylene glycol

S: Salicylates

slide58

A 3 day old male is referred to the ER by his pediatrician because he seems mildly lethargic. Electrolytes are Na 140, K 5.6, Cl 105, HCO3 12. He is afebrile, has BP 84/40 and a rr of 52. A blood ammonia level is markedly elevated. The MOST likely arterial blood gas result is:

slide59

A 3 day old male is referred to the ER by his pediatrician because he seems mildly lethargic. Electrolytes are Na 140, K 5.6, Cl 105, HCO3 12. He is afebrile, has BP 84/40 and a rr of 52. A blood ammonia level is markedly elevated. The MOST likely arterial blood gas result is:

slide60

A 10 year old girl with ALL and neutropenia after chemotherapy develops shock. She has stable ventilatory status but is mildly tachypneic. Electrolytes and an arterial blood gas is obtained while she is provided isotonic fluid boluses and dopamine infusion is prepared. The most likely results of the ABG and plasma bicarbonate are:

slide61

A 10 year old girl with ALL and neutropenia after chemotherapy develops shock. She has stable ventilatory status but is mildly tachypneic. Electrolytes and an arterial blood gas is obtained while she is provided isotonic fluid boluses and dopamine infusion is prepared. The most likely results of the ABG and plasma bicarbonate are:

slide62

A 10 year old with dilated cardiomyopathy is admitted with pulmonary edema, intubated, and given 72 hours of continuous IV furosemide. The laboratory results return:

What is the best interpretation of these results?

slide63

A 10 year old with dilated cardiomyopathy is admitted with pulmonary edema, intubated, and given 72 hours of continuous IV furosemide. The laboratory results return:

What is the best interpretation of these results?

slide64

A 6 month old boy develops diarrhea for 4 days. He appears dehydrated and is given a bolus of 0.9% NS and promptly produces a generous wet diaper. Electrolytes are obtained with difficulty during the blood draw and return the following values: Na 143, K 7.3, Cl 109, CO2 14, Ca is 10.1 mg/dl. The next step in management is

slide65

A 6 month old boy develops diarrhea for 4 days. He appears dehydrated and is given a bolus of 0.9% NS and promptly produces a generous wet diaper. Electrolytes are obtained with difficulty during the blood draw and return the following values: Na 143, K 7.3, Cl 109, CO2 14, Ca is 10.1 mg/dl. The next step in management is

slide66

A 9 year old boy is chronically treated with oral furosemide for vascular congestion related to dilated cardiomyopathy. All of the following electrolyte disturbances are likely EXCEPT:

slide67

A 9 year old boy is chronically treated with oral furosemide for vascular congestion related to dilated cardiomyopathy. All of the following electrolyte disturbances are likely EXCEPT:

slide71

An otherwise healthy, well-grown 4 year-old girl has had 3 febrile UTIs, the first at age 3 years. She has been taking TMP/SMX since the 2nd UTI. Review of systems reveals constipation. She has occasional enuresis but no frequency or dysuria. Renal sonography and voiding cystourethrogram (VCUG) are normal. Which of the following is likely to be helpful in her evaluation and treatment?

slide72

An otherwise healthy, well-grown 4 year-old girl has had 3 febrile UTIs, the first at age 3 years. She has been taking TMP/SMX since the 2nd UTI. Review of systems reveals constipation. She has occasional enuresis but no frequency or dysuria. Renal sonography and voiding cystourethrogram (VCUG) are normal. Which of the following is likely to be helpful in her evaluation and treatment?

slide73

A 3 month old male has a febrile UTI with E. Coli.

His renal ultrasound is negative. The best test to evaluate for vesicoureteral reflux (VUR) is:

slide74

A 3 month old male has a febrile UTI with E. Coli.

His renal ultrasound is negative. The best test to evaluate for vesicoureteral reflux (VUR) is:

slide77

An 8 month old male is found to have grade II VUR on the right and grade IV VUR on the left with mild hydronephrosis. Which of the following are immediately appropriate:

slide78

An 8 month old male is found to have grade II VUR on the right and grade IV VUR on the left with mild hydronephrosis. Which of the following are immediately appropriate:

slide81

An 8 year old boy in the 3rd grade develops secondary nocturnal enuresis. On review of systems he has constipation. When he was a newborn you had ordered a spinal ultrasound and x-ray after noting a sacral dimple, and both were normal. Urinalysis is negative for leukocyte esterase and nitrates. The next most appropriate steps are:

slide82

An 8 year old boy in the 3rd grade develops secondary nocturnal enuresis. On review of systems he has constipation. When he was a newborn you had ordered a spinal ultrasound and x-ray after noting a sacral dimple, and both were normal. Urinalysis is negative for leukocyte esterase and nitrates. The next most appropriate steps are:

slide84

A 3 year-old boy is referred to pediatric nephrology for sudden onset of edema and 4+ proteinuria. True statements about the nephrotic syndrome in this child include:

slide85

A 3 year-old boy is referred to pediatric nephrology for sudden onset of edema and 4+ proteinuria. True statements about the nephrotic syndrome in this child include:

slide86

A 14 year-old overweight girl has proteinuria 100 mg/dL on two separate occasions, first noted during a screening examination for summer camp. The remainder of the urinalysis is normal and the blood pressure is normal. The most appropriate next step in management is:

slide87

A 14 year-old overweight girl has proteinuria 100 mg/dL on two separate occasions, first noted during a screening examination for summer camp. The remainder of the urinalysis is normal and the blood pressure is normal. The most appropriate next step in management is:

slide88

A 14 year old boy has microscopic hematuria on a urinalysis done for a school form. Family history is significant for his mother having microscopic hematuria since childhood. A maternal uncle required dialysis. Which of the following is true of this boy’s condition?

slide89

A 14 year old boy has microscopic hematuria on a urinalysis done for a school form. Family history is significant for his mother having microscopic hematuria since childhood. A maternal uncle required dialysis. Which of the following is true of this boy’s condition?

slide90

A 14 year old boy has microscopic hematuria on a urinalysis done for a school form. Family history is significant for his father and a paternal grandparent having long-standing microscopic hematuria. There is no family history of kidney failure. There is no proteinuria. Blood pressure, urine calcium, and renal/bladder sonography is normal. Which of the following is true?

slide91

A 14 year old boy has microscopic hematuria on a urinalysis done for a school form. Family history is significant for his father and a paternal grandparent having long-standing microscopic hematuria. There is no family history of kidney failure. There is no proteinuria. Blood pressure, urine calcium, and renal/bladder sonography is normal. Which of the following is true?

slide92

A 3 day old male infant has been is brought to the ER for blood in the diaper, which the family produces. The diaper has multiple brick-red discolorations in the front. There is no significant perinatal history. Exam finds a vigorous infant in no distress with normal blood pressure. Bagged urinalysis is negative for blood by dipstick and by microscopy. The most likely cause of these findings is:

slide93

A 3 day old male infant has been is brought to the ER for blood in the diaper, which the family produces. The diaper has multiple brick-red discolorations in the front. There is no significant perinatal history. Exam finds a vigorous infant in no distress with normal blood pressure. Bagged urinalysis is negative for blood by dipstick and by microscopy. The most likely cause of these findings is:

hematuria red u rine h ematuria
HematuriaRed Urine Hematuria

SeeHarrietLanelist– favoritesfortheboards!

(egbeets, blackberries, urates, rifampin)

In reality, red urinethatisnotbloodisnotcommonlyencountered in practice, exceptmaybe red diaperurates.

Importantuncommon causes:

hemoglobinuria

myoglobinuria

slide95

A 16 year old boy develops sharp flank pain and gross hematuria. Sonography shows multiple large cysts in each kidney. The mother reports that her mother, who lived in a developing country, suffered from episodes of painful blood in the urine and died with a kidney disease in her 40’s. Which of the following is true?

slide96

A 16 year old boy develops sharp flank pain and gross hematuria. Sonography shows multiple large cysts in each kidney. The mother reports that her mother, who lived in a developing country, suffered from episodes of painful blood in the urine and died with a kidney disease in her 40’s. Which of the following is true?

polycystic kidney disease
Polycystic Kidney Disease
  • Autosomal Dominant PKD (ADPKD)
  • More commonly affects adults
  • Larger cysts, liver cysts
  • Intracranial aneurysms, mitral valve prolapse
  • Common: affects about 1:500 to 1:800
  • Autosomal Recessive PKD (ARPKD)
  • More commonly affects infants
  • Smaller cysts, liver fibrosis (ductal plate malformation)
  • May need liver and/or kidney transplant
  • Rare: affects about 1 in 20,000
slide98

2 days following a fall trip to a farm and apple cider press in the country, a 3 year old boy develops bloody diarrhea. The next day, the is brought to the ER lethargic and pale. He has not urinated in over 8 hours. Lab testing finds WBC of 26,000, hemoglobin of 9.8 g/dL, platelets 65,000, serum creatinine of 1 mg/dL, BUN 54 mg/dL. All of the following statements about this condition are true EXCEPT:

slide99

2 days following a fall trip to a farm and apple cider press in the country, a 3 year old boy develops bloody diarrhea. The next day, the is brought to the ER lethargic and pale. He has not urinated in over 8 hours. Lab testing finds WBC of 26,000, hemoglobin of 9.8 g/dL, platelets 65,000, serum creatinine of 1 mg/dL, BUN 54 mg/dL. All of the following statements about this condition are true EXCEPT:

slide100

A 4 month old girl is brought to the ER lethargic and pale. She has not urinated in over 8 hours. Lab testing finds WBC of 26,000, hemoglobin of 8.8 g/dL, platelets 56,000, serum creatinine of 1 mg/dL, BUN 54 mg/dL. The blood smear shows schistocytes and helmet cells. True statements about this case include all of the following EXCEPT:

slide101

A 4 month old girl is brought to the ER lethargic and pale. She has not urinated in over 8 hours. Lab testing finds WBC of 26,000, hemoglobin of 8.8 g/dL, platelets 56,000, serum creatinine of 1 mg/dL, BUN 54 mg/dL. The blood smear shows schistocytes and helmet cells. True statements about this case include all of the following EXCEPT:

slide102

A 6 year-old girl develops tea-colored urine. Urine dip finds 4+ blood and 3+ protein. There is mild edema present and the blood pressure is 114/74. Review of systems is negative. Her twin brother currently has fever and a sore throat. Which of the following statements is CORRECT?

  • Complement C3 & C4 may remain low for 4-6 weeks
  • The brother can be protected from the same condition by prompt antibiotic treatment
  • There is high risk of rheumatic heart disease also
  • Rapid progression and need for dialysis is uncommon and requires renal biopsy
  • Hypertension is uncommon and requires renal biopsy
slide103

A 14 year old boy is uncharacteristically tired in the afternoons and appears somewhat pale to his mother. Laboratory findings consistent with chronic kidney disease with decreased glomerular filtration rate (GFR) include:

MCV = mean corpuscular volume

PTH = parathyroid hormone

slide104

A 14 year old boy is uncharacteristically tired in the afternoons and appears somewhat pale to his mother. Laboratory findings consistent with chronic kidney disease with decreased glomerular filtration rate (GFR) include:

MCV = mean corpuscular volume

PTH = parathyroid hormone

slide105

A 7 year-old boy with a history of posterior urethral valves and stage 3 CKD has short stature. All of the following factors commonly contribute to short stature in children with CKD EXCEPT:

  • IGF: insulin-like growth factor
slide106

A 7 year-old boy with a history of posterior urethral valves and stage 3 CKD has short stature. All of the following factors commonly contribute to short stature in children with CKD EXCEPT:

  • IGF: insulin-like growth factor
slide107

A newborn has a sonogram due to an abnormal prenatal sonogram. The left kidney is bit large but otherwise normal. The right kidney has multiple cystic areas and abnormal cortex. The right side shows no uptake on nuclear renal scan. All of the following statements are correct EXCEPT:

slide108

A newborn has a sonogram due to an abnormal prenatal sonogram. The left kidney is bit large but otherwise normal. The right kidney has multiple cystic areas and abnormal cortex. The right side shows no uptake on nuclear renal scan. All of the following statements are correct EXCEPT:

slide109

The parents of a 15 year-old followed in the renal clinic for advancing kidney disease ask your advice about what will happen as his kidneys fail. All of the following are true about End Stage Renal Disease (ESRD) EXCEPT:

slide110

The parents of a 15 year-old followed in the renal clinic for advancing kidney disease ask your advice about what will happen as his kidneys fail. All of the following are true about End Stage Renal Disease (ESRD) EXCEPT:

slide112

A 9 year-old girl with no symptoms has BP 145-165 / 90-100 discovered on a routine physical and confirmed several times. The remainder of her examination is normal. True statements about this case include:

slide113

A 9 year-old girl with no symptoms has BP 145-165 / 90-100 discovered on a routine physical and confirmed several times. The remainder of her examination is normal. True statements about this case include:

slide115

All of the following statements about normal blood pressure in children are true EXCEPT:

Increased BP with height is physiologic and normal.

Increased BP with obesity is pathophysiological and abnormal.

blood pressure tables1
Blood Pressure Tables

PEDIATRICS Vol. 114 No. 2 August 2004, pp. 555-576

slide119

A 9 year-old girl with asymptomatic stage 2 HTN is evaluated first by renal sonography then by magnetic resonance arteriography. A long right-sided renal arterial narrowing with high velocities is suspicious for renal artery stenosis. She was not in the NICU after birth and never had central venous nor arterial access. The MOST likely etiology of this disease is:

slide120

A 9 year-old girl with asymptomatic stage 2 HTN is evaluated first by renal sonography then by magnetic resonance arteriography. A long right-sided renal arterial narrowing with high velocities is suspicious for renal artery stenosis. She was not in the NICU after birth and never had central venous nor arterial access. The MOST likely etiology of this disease is:

slide121

A 13 year old girl with a BMI in the 96th percentile is referred for stage 1 HTN. Initial management should include all of the following EXCEPT:

slide122

A 13 year old girl with a BMI in the 96th percentile is referred for stage 1 HTN. Initial management should include all of the following EXCEPT:

Just making a point here– obesity-related HTN is common and frequently responds to diet and exercise (TLC). Don’t forget these other items– all are fair game for questions.