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Pediatric Renal Diseases

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Pediatric Renal Diseases Glomerular Diseases Acute Glomerulonephritis (AGN ... – PowerPoint PPT presentation

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Title: Pediatric Renal Diseases


1
Pediatric Renal Diseases
2
Developmental and Physiological Aspects 1.
Urine volume Newborns 13 ml/kg/h
310 d 100300 ml/d 2 m
250400 ml/d 1 y 400500
ml/d
3
3 y 500600 ml/d 5 y
600800 ml/d 8 y 6001000
ml/d 14 y 8001400 ml/d gt14 y
10001600 ml/d
4
?Oliguria (low urine output) Newborns
lt 1ml/kg/h Infant infancy
lt200ml/m2/d Pre-school age lt300ml/m2/d
School age lt400ml/m2/d ?Anuria
lt 50 ml/m2/d (newborns lt
0.5 ml/kg/h)
5
2. Routine urine test 2.1. Urine
color--normally yellow, color changes may
be normal or abnormal 2.2. PH normal
range 57 2.3. Specific gravity
newborns 1.0061.008 , gt1 year old
1.0111.025
6
2.4. Urine analysis freshly collected and
centrifugal urine ? RBC lt 3/hpf ? WBC lt
5/hpf ? Castscellular (RBC, WBC) and
granular casts are abnormal, hyaline
casts can be normal
7
  • ? Crystals phosphate and
  • urate crystals may be normal
  • ? Protein(Pro) negative
  • ? Sugar (Glu)
  • ? Ketones (Ket)
  • ? Urobilinogen (Uro)
  • ? Bilirubin (Bil)

8
3. Addis count RBC lt 50,0000, WBC
lt1,000,000, Casts lt 5000 4. 24h total urinary
protein

less than 100 mg/m2/d, or lt4 mg/m2/h,
or lt100 mg/L, or lt150
mg/d

9
5. Renal function tests BUN, Cr 6. Imaging
procedures X-ray, Ultrasound, VCUG,
Nuclear medicine (99mTc DMSA,

99mTc
DTPA), IVP etc. 7. Renal Biopsy
10
Glomerular
Diseases

11
Classify ?Clinical classify
1. Primary glomerular diseases 1.1.
Glomerulonephritis (Nephritis)
?Acute glomerulonephritis
12
  ?Rapidly progressive glomerulo-
nephritis (RPGN)   ?Persistent
glomerulonephritis ?Chronic
glomerulonephritis
13
  ?Rapidly progressive glomerulo-
nephritis (RPGN)   ?Persistent
glomerulonephritis ?Chronic
glomerulonephritis
14
1.2. Nephrotic syndrome (NS)
?Simple tape NS
?Nephritic tape NS
15
1.3. Asymptomatic (isolated)
hematuria or proteinuria
1.4. Familial nephritis 2. Secondary
glomerular diseases it is part of mul-
tisystem disorder, e.g.
16
2.1. Hepatitis B virus related
glomerulonephritis (HBV-GN) 2.2. Purpuric
nephritis 2.3. Lupus nephritis (LN) ?
Pathologic classify ?Immunopathology classify
17
Acute
Glomerulonephritis (AGN)
18
Definition
Glomerulonephritis is a various group of
diseases acute nephritic syndrome. ?Acute
poststreptococcal glomerulonephritis, APSGN
(acute nephritis)
19
? Incidence age in 5 14 years old ? peak age
37 years old ? Boys gt girls 21

? Incidence peak Jan.
Feb. Sep. and Oct.
20
Etiology Pathogenesis ? Bacterial
? group Aß- hemolytic
streptococci, Staphylococci, Pneumococci,
G bacilli
21
? Viral influenza virus, mumps virus ,
Coxsackie virus, ECHO virus and
EBV ? Other pathogens fungi etc.
22
The immunoreaction caused by group Aß-
hemolytic strep- tococci-nephritogenic strans
23
          Circulating
immunecomplexes
(CIC) Antigensantibodies   In situ
immunecomplexes
24
?deposited on glomerular capillaries ?
complement system activated?immune
mediators and inflammatory mediators
25
Pathology 1. The feature of
pathological changes Diffus, exudative
and proliferative inflammation of
the glomerulus
26
2. Chief variety Endothelial and mesangial
cells proliferation with leukocyte
infiltration immunofluorescence shows
granular IgG C3 deposits
27
Electron microscopy ?Hump-like electron dense
deposits on epithelial side of GBM
Pathophysiology (Figure)
28
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29
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31
Infection of
streptococci Immune
complexes Local immune
inflammation in
glomerular capillaries Stenosis of blood
Glomerular filtration
capillary cavity membrane
injury GFR ?
Hematuria
Proteinuria
Oliguria
Cylindruria Blood volume?
Venous pressure? Edema
Circulatory load?
Hypertension
32
Clinical Manifestations ? Prodromal
infections pharyngitis, scarlet fever,
Angina, and pyoderma ? Incubation period about
10 days for pharyngitis, 1420 days for
skin infection
33
1. Typical findings (general case)
1.1. Ordinary symptoms low grade fever,
nausea, debility, malaise, anorexia
and vomiting, etc.
34
1.2 Principal symptoms
(nephric
signs) a. Edema (nonpiting
edema, nephritic edema) Edema is the
most common initial sign Periorbital
edema Oliguria may be present
35
b. Hematuria Microscopic (most of
cases) gt5/hpf, Gross (1/31/2 cases)
usually tea or cola colored (brownish)
urine, continue 12 w

36
????
37
c.Hypertension 1/32/3 cases Pre-school
agegt120/80mmHg School agegt130/90 mmHg
Headache may be
present d. Proteinuria lt3
38
2. Severe findings (Severe case) Appear the
following symp- toms within 2 w of the onset.
39
a. Circulatory congestion RR?, HR?, fidget
, hepa- tomegaly??dyspnea, jugular
phlebectasia, pulmonary edema, gallop
rhythm and cardiac dilation
40
Chest X-ray Enlarged cardiac silhouette,
lung markings coarsen (pulmonary vascular
congestion)
41
b. Hypertensive encepha- lopathy
BP??brain hypoxia and edema
42
Smart headache, nausea,

vomiting and diplopia or transient
blindness ? convulsion, coma ?Hypertensive crisis
43
c. Acute renal insufficiency Severe
oliguria or anuria? temporary azotemia,
distur- bance of electrolytes and
metabolic acidosis
44
3. Atypical findings (Atypical case)
?Extrarenal symptomatic
nephritis ? Acute nephritis with neph-
rotic manifestation
?
Asymptomatic AGN
45
Laboratory investigations 1. Routine
urinalysis RBC?, 2 3, gt 5/hpf, protein
1 3, may occur hyaline (or granular or
red cell) casts, /- WBC
46
2. Blood exam 2.1. Hemogram initial
mild anemia ( due to
hemodilution), WBC? or normal 2.2.
ESR? 3. Renal functions BUN and Cr
are normal or slight increase
47
4. Immunologic exam Evidence of recent
streptococcal
infection 4.1. ASO? 7080 of
patients, 1014 days after infected,
incidence peak at 35w , normal after 36 m
48
4.2. ADNase-B positive rate is high
(more than 90 cases ) 4.3. ADPNase
4.4. Ahase
49
5. Serum complement 8090 cases low
CH50 and low C3 (within 2 w of the
onset), normalized in 68 w ?If C3
still low after 8 w other etiology?
50
Course Prognosis ?Course About 2 w
?Routine urine test returns
to normal within 46 w ?ESR returns to normal
within 23 m
51
? Addis count 48 m ? Microscopic hematuria
may

persist for 6 m 1 y ?
Prognosis most children (95)have a
complete recover, recurrences are rare

52
Diagnosis Clinical diagnosis
Acute Nephritic Syndrome ? Diagnostic
point 1. Prodromal infections,
evidence of streptococcal
infection
53
2. Urine exam RBC, protein and
casts 3. Low C3
54
Differential Diagnosis 1.Other AGN e.g.
MPGN , IgA nephropathy ( IgAN) 2. Acute
exacerbation of chronic nephritis



55
3. Rapidly progressive GN
4. Nephrotic syndrome
5. Secondary GN, e.g. HSP nephritis
56
Therapy There is no
specific treatment for typical cases.
1. General measures 1.1. Frequent measurement
of BP
57
1.2. Rest treatment Bed rest within 2 w of
onset Slight activities edema sub-
sided, BP be normal and gross hematuria
disappeared
58
Continue to attend school ESR
returns to normal Normal activities 3 m after
the routine urine test be normal
59
1.3. Diet ? Edema, hypertension re-
strict sodium low salt diet (sodium
chloride 60 mg/kg/d ), or salt-free diet

60
? Azotemia proteins 0.5 g/ kg/d ?
Severe oliguria, BP?or
circulatory congestion re- stricting fluid
intake, chart to record intake and output

61
2. Antibiotics Object to eradicate
remnant bacteria in the focuses, but
does not alter natural history of AGN

PG im , for 10 14 days
62
3. Symptomatic treatment 3.1. Diuretics
HCT 12 mg/kg/d, Lasix 12 mg/kg/time
, q68 h (prn)
63
3.2. Antihypertensive medica -tion
Systolic pressuregt140 mmHg Diastolic
pressuregt90 mmHg ?Nifedipine 0.20.3
mg/kg/d (Max. 1 mg/kg/d ), bidtid,
po/sublingual
64
?Reserpine 0.07 mg/kg/time,
po/im , (Max. 1.52 mg/time) ?0.02
mg/kg/d , po ?Captopril 0.30.5 mg/kg/d,
po, (Max. 56 mg/kg/d), bid or tid
65
4. Deal with serious symptoms 4.1. Hypertensive
encephalo- pathy ?Treatment must be given
promptly
66
Use sodium nitroprusside infusion- 510
mg10GS 100ml(50100 ug/ml) , 1ug/


kg/min, ?8 ug/kg/min


Attention Survey BP
67
4.2. Serious circulatory congestion a.
Restrict the intake of water and
sodium b. Treatment of hypertension
c. Diuretics
68
4.3. Acute renal insufficiency
Lasix 5 mg/kg/time, Fluid
400ml/m2/24h, Dialytic treatment 5.
Follow-up measure BP, blood test (C3,
BUN, Cr) , urine test
69
Prevention Proper
treatment of pharyngitis and skin
infections less crowded living conditions.


70
    
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