Urinary%20Tract%20Alterations%20In%20Children.

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Urinary TractAlterations In Children.

• By N. Haliyash MD, BSN

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Renal structure and physiology

• The structural and functional unit of the kidney
  is the nephron
• The nephron consists of
• Bowmans capsule, enclosing the capillary tuft of
  the glomerulus, which is joined successively to
  the proximal convoluted tubule,
• Henles loop,
• the distal convoluted tubule,
• the straight or collecting duct.

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Longitudinal section of kidney
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Embryogenesis

• The kidneys develop from mesoderm located between
  the somites and the lateral portion of the embryo

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Pronephros

• On the 21st day after fertilization the mesoderm
  in the cervical region differentiates into a
  structure called the pronephros, which consists
  of a duct and simple tubules connecting the duct
  with the open celomic cavity. This type of kidney
  is the functional adult kidney in some lower
  chordates, but it is probably not functional in
  the human embryo and soon disappears.

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Mesonephros

• The mesonephros (middle kidney) is a functional
  organ in the embryo. It consists of a duct, which
  is a caudal extension of the pronephric duct, and
  a number of minute tubules, which are smaller and
  more complex than those of the pronephros.
• One end of each tubule opens into the mesonephric
  duct, and the other end forms a glomerulus.

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Formation of the uretra

• As the mesonephros is developing, the caudal end
  of the hindgut begins to enlarge to form the
  cloaca, the common junction of the digestive,
  urinary, and genitale system. The cloaca becomes
  divided by a urorectal septum into two portions
  a digestive portion called the rectum and a
  urogenitalic portion called the uretra.

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Developing of ureter

• The mesonephric duct extends caudally as it
  develops and eventually joints the cloaca. At the
  point of junction another tube, the ureter,
  begins to form.

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Metanephros

• Metanephros starts to develop on the 3rd month
  of gestation from the mesonephrotic tubules and
  distal end of the ureter, which enlarges and
  branches to form the duct system of the
  metanephros.
• Metanephros is the adult kidney, which takes over
  the function of the degenerating mesonephros.

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• Congenital disorders of kidney development.
• Agenesia
• Aplasia
• Duplication
• Polycystosis
• Dystopia
• Hypoplasia
• Dysplasia

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Aplasia of left kidney
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Hypoplasia of left kidney
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Lumbar, vertebra and pelvicdystopia of kidneys
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Anatomical perculiarities of kidneys in infants

• Kidneys have relatively bigger sizes than in
  adults (1/100 of body weight 11-12 g)
• The relation of thickness and length of kidney in
  newborn is 12 (in adult 13)
• Lobular structure is present till 2 years age
• They are situated lower than in adult
• They have very thin fibrous capsule
• Absence of perirenal fat capsule in newborns
  leads to bad fixation of kidneys and to
  physiological hypermobility of them (in infants
  to 1.5-2.0 cm and in children older 7 years
  1-1.5 cm).
• The cortex is undeveloped in neonates (thickness
  of cortex is ¼ of the medulla) comparing to
  school-age children and elder (it is ½ of the
  medulla).

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Localization of kidneys

• Newborn on the level of from 1st to 5th lumbar
  vertebras.
• Older children on the level between the X?
  thoracic and IV lumbar vertebras.
• The longer size of kidney is not bigger than
  height of 4 lumbar vertebras.
• Right kidney is 1 cm longer than left one.

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Localization of kidneys according to vertebra
column.
Age On the left side On the right side
The upper apex The upper apex The upper apex
Newborn on the level of the lower edge of ?? thoracic vertebra on the level of ??? thoracic vertebra
3-5 months on the level of ??? thoracic vertebra on the level of the lower edge of ??? thoracic vertebra
1 year on the level of the lower edge of ??? thoracic vertebra on the level of ? lumbar vertebra
2 years and older Like in adult Like in adult
The lower apex The lower apex
Newborn Below the iliac crest
2 years and older Above the iliac crest
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Ureters

• They are more wide and relatively longer in
  children unders 7 years (dilated ureteres)
• They have the presence of physiological kinks
  (twists), when they are situated near the pelvic
  big vessels.
• Bad development of muscles layer under 3 years
  leads to often urine reflux from the bladder.
• Mucus layer of ureters is wrinkled in infants.

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Urethral canal (urethra)

• Is wider and shorter in children under 3 years
• External urethral meatus is opened in girls
  younger 3 years

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Urinary bladder

• It is situated upper (in children under 3 years
  it can be found above the interpubic joint, so it
  can be palpable)
• The muscular leyer and elastic fibres are poorly
  developed under 6 years
• Ureteric mouth (oribice) are commonly opened due
  to undeveloped muscular sphincters.
• Thats why vesicoureteric refluxes are very
  common in children.
• Very good vascularisation of bladder mucosa leads
  to development of inflammatory processes of the
  ureter and/or urine bladder.

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Volume of the urinary bladder

• Newborn 30ml
• 1 year 35-50
  ml
• 1-3year 50-90
  ml
• 3-5 year
  100-150ml
• 5-9 year 200ml
• 9-12 year 200-300
  ml
• Older 400 ml

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Length of the ureter

• newborn 6-7 cm
• 1 year 10 cm
• 4 year 15 cm
• Older than 4 year 20-28 cm

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Morphological peculiarities of glomerulus in
children

• The differentiation of glomeruluses is not ended
• The glomerular epithelium in Bowmans capsule is
  cylindrical versus flat epithelium in adults
• The glomerular capillary endothelium is composed
  of higher cells than in adults
• All peculiarities result in smaller filtrative
  surface of kidney and lower permeability of
  glomerulus barrier.

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Morphological peculiarities of tubules in children

• Relatively shorter and more narrow than in adult,
  especially in the peripheral parts of the kidney
• Henles loop is shorter and immature in structure

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Renal function

• 1. To maintain the chemical composition and
  volume of the body fluids at a constant level.
• 2. To remove excess levels of waste products
  (desintoxication).
• 3. The production of certain humoral substances
• erythropoietic stimulating factor (ESF, or
  erythrogenin), which acts on a plasma globulin to
  form erythropoietin
• renin, which is secreted by the kidneys in
  response to reduced blood volume, decreased blood
  pressure, or increased secretion of
  catecholamines
• renin stimulates the production of the
  angiotensins, which produce arteriolar
  constriction and an elevation of blood pressure
  and stimulate the production of aldosterone by
  the adrenal cortex.

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3 processes that provide the urine production

• Providing an ultrafiltration of plasma.
• Reabsorption of the most part of fluid and
  electrolytes from the primary urine by the renal
  tubules.
• Secretion of certain substances into the tubular
  urine.

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Filtration of blood

• The plasma of the blood is filtered in the
  glomerulus of capillaries
• The plasma pass into the capsular space (lumen)
  and into the proximal tubules at a rate of about
  125 ml/min/kidney.
• All from blood except the cells and the largest
  elements (proteins) pass into original filtrate
  primary urine
• The primary urine has essentially the same
  composition as plasma

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Tubular absorption

• The pyramid-shaped cells of the proximal tubule
  are responsible for absorption from the filtrate
• 85 of the sodium chloride and water,
• all of the glucose,
• small proteins and amino acids,
• certain vitamins.
• The loop of Henle absorbs the water by drawing
  it into the tissues between the tubules.
• the distal convoluted tubules and collecting
  ducts absorb most of the water remaining so that
  99 of original filtrate has been returned to
  the tissues and 1 passes into the minor
  calyces.

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Secretion of certain substances into the tubular
urine

• Due tubular secretion some substances appear in
  urine
• In the proximal tubule organic acids and bases
  and H ions are secreted into lumen
• In the distal convoluted tubules and collecting
  ducts secretion of Kalium ions and NH3 takes
  place.

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The peculiarities of kidney function in early
infancy

• Glomerular filtration rate is low and does not
  reach adult values until the child is between 1
  and 2 years of age
• The concentrating ability of the newborn kidney
  does not reach adult levels until about the third
  month of life.
• Urea synthesis and excretion are slower during
  this time.
• The newborn retains large quantities of nitrogen
  and essential electrolytes in order to meet needs
  for growth in the first weeks of life.
• Newborn infants are unable to excrete a water
  load at rates of older persons.
• Hydrogen ion excretion is reduced.
• Acid secretion is lower for the first year of
  life.
• Infants have a diminished capacity to reabsorb
  glucose that results in physiological glucosuria
  of neonates.
• Infants have a diminished capacity to produce
  ammonium ions during the first few days.

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As a result of these inadequacies of the kidney

• the newborn is more liable to develop severe
  acidosis.
• kidneys are less able to adupt to deficiencies
  and excesses of sodium. An isotonic saline
  infusion may produce edema because the ability to
  eliminate excess sodium is impaired. Conversely
  inadequate reabsorption of sodium from tubules
  may compound sodium losses in disorders such as
  vomiting or diarrhea.
• the newborn develops physiological anuria during
  the first few days.

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Patients complaints and methods of physical
examination

• The examination of kidneys is impossible without
  laboratory urine tests.
• All symptoms in case of kidney disorders are
  divided into renal and extrarenal.

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Renal symptoms

• Renal symptoms are such clinical signs that
  directly show on the disorders of kidneys and any
  part of the collecting system
• They are
• lumbar region pains (costovertebral angle
  tenderness, flank pain)
• dysuria
• syndrom of urine changes

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Causes of kidney pain.

• 1 expansion of calyces and renal pelvis
  2
  expansion of capsule
  3 compression of receptors
  4 renal ischemia
  5 refluxes.
• Only children after 2 years can complain on
  lumbar region pains, because in this age cortex
  tissue and renal capsule reach their mature form.

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Dysuria

• Dysuria means problems with urination
• painful urination
• frequent or infrequent voiding
• urinary urgency
• incomplete voiding
• enuresis.

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Frequency of urination

• It is age-depended and closely connected with
  fluid intake and surrounding climate (hot or
  cold).
• Voidind of the bladder is more frequent in
  infancy, when it equals approximately the number
  of feeding ? 3.
• For example the 6 months baby empties the
  bladder 5?315 times a day.
• At the age of 1 year urination frequency ranges
  from 9 to 12 times a day, later it decreases to
  6-8 times at 3 years, 5-6 times at 10 and 3-4 in
  adolescence. Normal limits range within 1 to 3
  times more or less.

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Enuresis (urination incontinence)

• It is physiological in children up to 1.5 2
  years.
• Enuresis can be daytime and nighttime.
• Toilet-trained child can perform incontinence in
  case of urinary tract infection or CNS disorders.

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Syndrom of urine changes

• includes the interpretation of qualitative and
  quantitative laboratory data of urine tests
• Colour of urine
• Transparence
• The urine volume (diuresis)
• Specific gravity

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Extrarenal symptoms

• Extrarenal symptoms are the signes, the cause of
  which is kidneys disorders, but the developing
  pathological changes concern other organs and
  systems.
• These are
• Edema
• Hypertension.
• Cardiac pain.
• Skin pallor
• Intoxication syndrom includes fever, chills,
  anorexia, fatigue, irritability, lethargy,
  headaches and vomiting.
• In infants kidney disorders can manifestate with
  feeding problems and failure to thrive.

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Kidney Edema

• develops as a result of fluid retention and
  disbalance of intracapillary and tissue
  hydrostatic pressure.
• Visual evidence of fluid accumulation appears
  when the volume of intersticial fluids enlarges
  more than on 15 .
• The peculiarities of renal edema are
• localization (puffiness of face, especially
  around the eyes)
• time of manifestation (they are more apparent in
  the morning and subsides during the day)
• spreading (as the patients condition is getting
  worse edema spreads to involve extremities and
  genital organs (labial or scrotal swelling),
  abdomen (ascites), thoracic cavity (hydrothorax).
  Edema of intestinal mucosal causes diarrhea,
  anopexia, poor intestinal absorption. The total
  edema is called anasarka.
• surface and concistency (skin above swelling is
  pale, warm and soft by tuch).

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Patient with kidney edema

• Pitting ankle edema Periorbital
  oedema in young
• 
  girl.

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Complex of diagnostic tests and procedures

• 1. Urinanalysis (once per 7-10 days).
• 2. Nechiporenco, Amburgeau, Addis-Kakovskiy test.
  
• 3. Revealing of the so-called active leukocytes
  in the urine sediment.
• 4. Urine culture with detection of microbe
  sensitivity to antibiotics.
• 5. 3-glasses test.
• 6. Zimnitskys test

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• Determination of secretory renal function
  function of distal tubules (ammonia, filtrated
  acidity of urine), proximal tubules
  (a2-microglobulin in urine, calciuria,
  phosphaturia), Henles loop (osmotic
  concentration of the urine).
• Biochemical analyses of blood total serum
  protein, dysproteinemia (with elevated levels of
  a-and ?-globulins), albumin/globulin ratio,
  cholesterol, residual nitrogen, blood urea
  nitrogen, nonprotein nitrogen, creatinine, serum
  sodium and other electrolytes, rise of ciliac
  acids, mucoproteins, antistreptolysin-O, positive
  C-reactive protein, total serum complement
  levels.

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Tests to rule out structural anomalies

• Ultrasonography of kidneys and urinary bladder.
• Intravenous pyelography.
• Retrogradous urography.
• Radiography.
• Cystoscopy.
• Cystography.
• Renal biopsy.

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Urinanalysis (Routine analysis of urine)

• Qualitative characteristics of urine colour,
  smell and transparence
• Quantitative characteristics of urine pH,
  specific gravity, urine chemistry (protein,
  glucose, keton bodies, bile pigments, urobilin
  etc.), microscopy of sediment (leukocytes,
  erythrocytes, cylinders (casts), endothelial
  cells, mucus, pus and bacteria).

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Diuresis

• Diuresis means the process of urine production.
• The urine volume (UV per 24 hrs) is its
  laboratory reflection.

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Daily diuresis

• Newborn 50 300 ml
• 1 month infant 300 ml
• 6 month infant 400 ml
• 1 year child 600 ml
• 1-10 years UV 600100(n-1),where n is age of
  child in years
• Older 10 years 1700 ml (varies with
  intake and other
  factors)

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Volume of 1 urination (voiding)

• Newborn 10-15 ml
• 6 mounth 30 ml
• 1 year 60 ml
• 3-5 years 90-100 ml
• 7-8 years 150 ml
• 10-12 years 250 ml

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Pathological changes of urine volume.

• Poliuria is diagnosed when the urine volume
  exceeds the normal ranges in 2 times and more.
• Oliguria means the decreasing of daily urine
  volume to ¼ of age ranges and less.
• Anuria is diagnosed when the urine volume
  decrease less than 5 of normal data or there is
  no urine per whole day. It is one of the most
  dangerous conditions for the childs life and
  needs the emergency medical help.
• Renal the kidneys dont form the urine due to
  consigerable damage of their tissues.
• Postrenal (mechanical) the urine is produced,
  but it doesnt go into the bladder because of
  upper tract or bladder neck obstruction.

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Nocturia.

• The normal correlation of daytime and nighttime
  urine volume is 21. That means that because of
  bigger fluid intake and physical activity urine
  excretion is more intensive during daytime.
• If the night urine volume is bigger, it is the
  manifestation of decreased renal function.

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Specific gravity of urine

• It is the concentration of electrolits and other
  substances dissolved in urine.
• Normal ranges are
• Newborn 1.006-1.012
• 1-12 month 1.002-1.006
• 2-5 years 1.009-1.016
• 10-12 years 1.012-1.025
• Excretion of 0.1 g of glucose per 1 l of urine
  causes enlargement of specific gravity on 0.004
  0.4 g of protein on 0.001.

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Pathological changes of specific gravity of
urine.

• It is assessed by Zimnitskiys test

Maximal value of specific gravity Symptom
less than 1.008 hypostenuria
1.008-1.010 isostenuria
1.010-1.030 Normal limits
more than 1.030 hyperstenuria
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Proteinuria

• Protein normally is absent in urine.
• But some amount up to 0.033 g/l is permitted.
• Normal ranges of daily protein loss is 50 g per
  day at rest and up to 100-130 g/day after intense
  exercise.
• Excretion of protein with urine is called
  proteinuria

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• mild proteinuria up to 1 g/l is found in case of
  cystitis, urine tract infection, after physical
  exertion or getting cold
• moderate proteinuria (1-3 g/l) develops in case
  of glomerulonephritis, chronic renal failure,
  renal tuberculosis
• significant proteinuria (more than 3 g/l) is one
  of the main signs of nephrotic syndrome or
  terminal stage of renal failure.

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Accordingly to source of protein in urine

• Renal organic proteinuria develops as a result of
  damage of kidneys tissue structure (for example,
  in case of glomerulonephritis), when the
  filtration is enlarged.
• Renal functional proteinuria is the result of
  increased permeability of glomerular endothelium
  or decreasing of blood flow in responce to
  external influences
• albuminuria of a newborn appears due to
  functionally and structurally immature glomerulus
  and significant loss of water with perspiration
  immidiately after birth
• alimentary proteinuria develops after taking food
  rich with proteins
• orthostatic proteinuria is observed in toddlers
  and preschoolers after staying for a long time in
  vertical position.
• Functional proteinuria is less significant than
  organic and disappears as soon as etiological
  factor stops its action.
• Extrarenal proteinuria appears in result of
  inflammatory processes in the genitourinary tract
  (cystitis, urethritis, vulvovaginitis).

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Microscopy of urine sediment

• It helps to find epithelial cells, RBCs and WBCs,
  casts, salt crystals, mucus and bacteria in
  urine.
• Epithelial cells are normally present in urine
  sediment but not more than 2-4 cells in 1 square.
  The enlargement of their quantity shows on
  inflammatory processes in urine bladder or
  urethra (cystitis, urethritis etc).

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Leucocyturia (or pyuria)

• WBCs are also present in urine of healthy person.
  
• If they are found in quantities more than 5-6
  cells in 1 square in male and 10 cells in female,
  it is leucocyturia (or pyuria) which is the
  evidence of UTI.
• According to the source of leucocytes in urine
  there are
• renal leucocyturia (pyuria) is the evidence of
  urine tract infection, acute or chronic
  pyelonephritis, urethritis, cystitis, kidney TB,
  when WBCs go into urine from organs of urinary
  system
• extrarenal leucocyturia is diagnosed in case of
  inflammatory processes of genital organs
  (vulvovaginitis).

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Haematuria

• RBCs are permitted to be found in urine but not
  more than 1-2 cells in 1 square.
• Haematuria means the appearance of blood
  (erythrocytes) in the urine. Less often visible
  blood may appear in the urine as a brown
  discolouration or red.
• It also can be renal and extrarenal.
• According to the quantity of found RBCs there
  are
• microscopic haematuria when blood is present in
  very small quantities (not more than 50 RBCs in 1
  square). In this case urine has its natural
  colour.
• macrohaematuria (more than 50 RBCs in 1 square)
  and is only detected by a simple dipstick test.
  Urine is reddish-brown or smoky brown, resembles
  tea or cola.
• If the urine is bright red, it means that it
  contains fresh erythrocytes that is evidence of
  hemorrhage from kidneys or any part of the
  collecting system.

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Causes of haematuria Blood cells in
urine.
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Casts (cylinders)

• Casts (cylinders) are the moulds from cells or
  molecules formed in renal tubules when the urine
  flow in disturbed. Epithelial casts are formed
  from ruined epithelial cells and are found in
  case of severe renal disorders. Blood casts
  consist from ruined erythrocytes and are present
  at glomerulonephritis or renal bleeding.
  Leucocyte cylinders are formed in case of
  pyelonephritis.

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Quantitative methods

• These methods help to assess exact quantity of
  RBCs, WBCs, and casts in patients urine
• They are
• Nechepurenkos method
• Method by Kakovsky-Addis
• Ambyrzes method

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3-glasses test.
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Bacteriological investigation (urine culture)

• Technique of urine collection collect 2-10 ml of
  urine into sterile test-tube. Take urine from
  the middle stream. Provide accurate intimate-wash
  of child before collecting urine. Send urine to
  the laboratory within 2 hours.
• Result is microbal number (the amount of bacteria
  in 1 ml of urine) that normally not gets over
  50 000.
• The result 10 000-50 000 is suspicious and
  requires further examination.
• If microbal number is more than 50 000 that means
  bacteriuria.
• Also the type of microflora is detalized (for
  example, St. aureus, Proteus vulgaris, E. coli,
  etc) and its sensitiveness to antibiotics.

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Creatinine clearance (endogenous)

• This test helps to assess filtrative function of
  kidneys.
• Endogenous creatinine is a substance that is
  excreted from organism only by kidneys by the way
  of filtration. The concentration of creatinine in
  the blood serum is quitely constant as it does
  not depend on food intake.
• Clearance is the amount of blood serum that is
  completely cleared from the tested substance
  during 1 min.

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Technique of procedure

• the child has to void the bladder in the morning
  (at 8.00), and then to drink a glass of water (NO
  BREAKFAST !)
• at 9 oclock take a blood specimen for creatinine
  concentration
• at 10 oclock the child has to void the bladder
  again (as maximal as possible), in this urine
  creatinine concentration is also measured.
• count the creatinine clearance according formula

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Normal data of creatinine clearance.
Age Creatinine clearance Daily creatinine
Newborn 40-65 ml/min/1.73 m2 8-20 mg/kg/d
Child 80-120 ml/min/1.73 m2 8-22 mg/kg/d
Adult 80-120 ml/min/1.73 m2 14-26 mg/kg/d
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SEMIOTICS OF RENAL SYSTEM DISORDERS

• Urinary tract infection (UTI)
• Acute postsreptococcal glomerulonephritis
• Acute renal failure
• Chronic renal failure

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Renal system disorders syndromes

• Disuria syndrome
• Painful syndrome
• Syndrom of urine changes
• Edematic syndrome
• Hypertension syndrome
• Hypotension syndrome
• Intoxication syndrome
• Nephrotic syndrome
• Nephrytyc syndrome
• Cardiovascular system dysfunction syndrome
• Anemic syndrome
• Hemolytic-uremic syndrome
• Enuresis (urinary incontinence) syndrome

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• Nephrotic syndrome massive proteinuria,
  hypoproteinemia, hyperlipidemia,
  hypersholesterinemia, edemas.
• Nephrytyc syndrome hypertension, hematuria,
  moderate proteinuria, edemas.