Approach to Polyuria in Children... Dr.Padmesh

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Approach to Polyuria in children

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Approach to Polyuria in Children... Dr.Padmesh

  1. 1. APPROACH TO POLYURIA Dr.Padmesh.V
  2. 2. Dr.Padmesh. V Definition of Polyuria: Urine output > 5 ml/kg/hr Or > 2 L/m2/day Definition of Oliguria: Urine output < 0.5 – 1 ml/kg/hr Or < 300 ml/m2/day
  3. 3. Dr.Padmesh. V Surface area = Ht (cm) X Wt (kg) 3600( Daily insensible water loss = 300-400 ml/m2 )
  4. 4. Dr.Padmesh. V CAUSES OF POLYURIA: 1. INCREASED FLUID INTAKE 2. INCREASED URINARY SOLUTE EXCRETION 3. IMPAIRED URINARY CONCENTRATION
  5. 5.  CAUSES OF POLYURIA: Dr.Padmesh. V 1. INCREASED FLUID INTAKE 1.Iatrogenic 2.Compulsive water drinking (Psychogenic polydipsia) 2. INCREASED URINARY SOLUTE EXCRETION OSMOTIC DIURESIS: 1.Diabetes mellitus 2.Mannitol treatment SALT LOSS: 1.Adrenal insufficiency 2.Diuretics 3.Cerebral salt wasting 4.Aldosterone resistance 3. IMPAIRED URINARY CONCENTRATION INEFFICIENT ADH ACTION: (DIABETES INSIPIDUS): 1.CENTRAL (NEUROGENIC) DIABETES INSIPIDUS: 2.NEPHROGENIC DIABETES INSIPIDUS: RENAL DISORDERS: 1.Renal Tubular acidosis 2.Bartter Syndrome 3.Gitelman Syndrome
  6. 6. Dr.Padmesh. V CAUSES OF POLYURIA: 1. INCREASED FLUID INTAKE: Iatrogenic Compulsive water drinking (Psychogenic polydipsia)
  7. 7. Dr.Padmesh. V CAUSES OF POLYURIA: 2. INCREASED URINARY SOLUTE EXCRETION: OSMOTIC DIURESIS: 1.Diabetes mellitus 2.Mannitol treatment SALT LOSS: 1.Adrenal insufficiency 2.Diuretics 3.Cerebral salt wasting 4.Aldosterone resistance
  8. 8. Dr.Padmesh. V CAUSES OF POLYURIA: 3. IMPAIRED URINARY CONCENTRATION: INEFFICIENT ADH ACTION: (DIABETES INSIPIDUS): 1.CENTRAL (NEUROGENIC) DIABETES INSIPIDUS: 2.NEPHROGENIC DIABETES INSIPIDUS: RENAL DISORDERS: 1.Renal Tubular acidosis 2.Bartter Syndrome 3.Gitelman Syndrome
  9. 9. Dr.Padmesh. V CAUSES OF POLYURIA: 3. IMPAIRED URINARY CONCENTRATION: INEFFICIENT ADH ACTION: (DIABETES INSIPIDUS): 1.CENTRAL (NEUROGENIC) DIABETES INSIPIDUS: -Genetic defects: AR, AD, Wolfram DIDMOAD Synd. -Malformations: Septo-optic dysplasia, Holoprosencephaly,Anencephaly. -Neurological insults: Head trauma, Neurosurgery, Infection,Brain death. -Infiltrative disorders: Sarcoidosis, Histiocytosis. -CNS tumors: Craniopharyngioma, Germinoma, Pinealoma
  10. 10. Dr.Padmesh. V CAUSES OF POLYURIA: 3. IMPAIRED URINARY CONCENTRATION: INEFFICIENT ADH ACTION: (DIABETES INSIPIDUS): 2.NEPHROGENIC DIABETES INSIPIDUS: -Genetic: XL (V2 receptor defect), AR, AD (Aquaporin defect) -Acquired: Hypokalemia, Hypercalcemia, Obstructive uropathy, Nephrocalcinosis.
  11. 11. Dr.Padmesh. VAPPROACH TO POLYURIA: 1.HISTORY 2.CLINICAL EXAMINATION 3.INVESTIGATIONS
  12. 12. Dr.Padmesh. V HISTORY: Age of onset: Congenital / Acquired H/O fever: UTI Failure to thrive: DM, Nephrogenic D.I, RTA, CAH, Bartter H/O head trauma,neurosurgery: Central D.I H/O meningitis: Central D.I
  13. 13. Dr.Padmesh. V HISTORY: contd… H/O weight loss: DM, RTA H/O rash,seborrhea: Histiocytosis H/O muscle weakness: Hypokalemia- RTA, Bartter H/O drug intake: Mannitol, Diuretics, out-dated Tetracyclines.
  14. 14. Dr.Padmesh. V HISTORY: contd… Symptoms of increased ICT: CNS tumors H/O polyuria, shock in newborn period: CAH H/O constipation,paresthesia: Hypercalcemia H/O psychological problems: Psychogenic polydipsia H/O abdominal cramps, arthralgia, etc: Sickle cell anemia
  15. 15. Dr.Padmesh. V CLINICAL EXAMINATION: Anthropometry: To r/o Failure to thrive : DM, DI, RTA, CAH Fever: UTI Mental retardation: CNS malformations Neurological deficits: CNS pathologies
  16. 16. Dr.Padmesh. V CLINICAL EXAMINATION: Genital ambiguity: CAH Mid line defects: Central D.I Features of Rickets: Renal Tubular Acidosis, Renal failure Acidotic breathing: RTA
  17. 17. Dr.Padmesh. V CLINICAL EXAMINATION: Rash, Seborrhea, ear discharge: Histiocytosis Hyperpigmentation: Adrenal insufficiency Muscle weakness,neck flop: Hypokalemia: RTA, Bartter Also look for signs of dehydration, shock..
  18. 18. Dr.Padmesh. V INVESTIGATIONS: 24 hour urine output >5ml/kg/hr or >2L/m2/day POLYURIA Further investigations
  19. 19. Dr.Padmesh. V INVESTIGATIONS: Contd… Urine examination for: WBCs: UTI Sugar: D.M Specific gravity: <1.005 – D.I Urine Osmolality: <300 mOsm/kg- D.I
  20. 20. Dr.Padmesh. V INVESTIGATIONS: Contd… Urea, Creatinine Serum Electrolytes Calcium Blood gas analysis Blood glucose Plasma Osmolality
  21. 21. Dr.Padmesh. V INVESTIGATIONS: Contd… High Plasma Osmolality >300 mOsm/kg Low Urine Osmolality <300 mOsm /kg Urine Sp.gravity < 1.005 Serum Sodium > 145 mmol/L Serum Osmolality <270 Urine Osmolality >600 mOsm/kg Urine Sp.gravity >1.010
  22. 22. Dr.Padmesh. V INVESTIGATIONS: Contd… High Plasma Osmolality >300 mOsm/kg Low Urine Osmolality <300 mOsm /kg Urine Sp.gravity < 1.005 Serum Sodium > 145 mmol/L Serum Osmolality <270 Urine Osmolality >600 mOsm/kg Urine Sp.gravity >1.010
  23. 23. Dr.Padmesh. V INVESTIGATIONS: Contd… High Plasma Osmolality <300 mOsm/kg WATER DEPRIVATION TEST Serum Osmolality >270
  24. 24. Dr.Padmesh. V WATER DEPRIVATION TEST-Determines ability of kidneys to concentrate urine.-Useful in the diagnosis of DI.-Requires careful supervision because dehydration and hypernatremia may occur.
  25. 25. Dr.Padmesh. VWATER DEPRIVATION TEST : Method: Begin the test after a 24-hr period of adequate hydration & stable weight. Obtain a baseline weight after bladder emptying. Restrict fluids for 7 hours. Measure body weight and urine specific gravity and volume hourly. Check serum Na+ and urine and serum osmolality every 2 hr. Terminate the test if weight loss approaches 5%.
  26. 26. Dr.Padmesh. VWATER DEPRIVATION TEST: Interpretation: Normal individuals & Psychogenic DI: Central or Nephrogenic DI: When water is deprivedWill concentrate urine (to 500-1400 mOsm/L) Urine osmolality remains <150-300 mOsm/LPlasma osmolality will be 288-291 mOsm Plasma Osmolality > 300 mOsmUrine specific gravity rises to at least 1.010 Urine Specific gravity remains <1.005 Urine volume decreases significantly No significant reduction of urine volumeThere will be no appreciable weight loss. Weight loss of up to 5% usually occurs
  27. 27. Dr.Padmesh. V VASOPRESSIN RESPONSE TEST:To differentiate CENTRAL D.I from NEPHROGENIC D.I Baseline Urine osmolality is recorded Vasopressin injection given Urine Osmolality measured at 1 hr & 4 hrs after injection Increase in urine osmolality>50% increase from baseline <50% increase from baseline CENTRAL D.I NEPHROGENIC D.I
  28. 28. Dr.Padmesh. V OTHER TESTS: Central D.I: MRI of hypothalamic-pituitary region Nephrogenic D.I: Renal imaging Genetic Studies as required.
  29. 29. Dr.Padmesh. V

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