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Glomerulonephritis Case Presentation
- 1. Paediatrics Case Presentations “When one teaches, two learn” -Robert Heinlein Rhea Marcano~
- 2. RENAL Case 4
- 3. History 10 year old boy 3/7 day complaint of “brown urine” Patient known from birth No major illnesses or injuries Active in a band & Cross-country Track Denies drug use & Sexual activity
- 4. History (cont’d) 2/52 weeks ago, he had 2/7 day of fever & sore throat improved spontaneously, has been well since R.O.S remarkable ONLY for puffy eyes (attributed to late night studying)
- 5. Physical Examination Afebrile BP 135/90 active & non-toxic in appearance peri orbital edema present urine dipstick:- Specific gravity 1.035 2+ Bloods 2+ Proteins RBC cast by microscopy
- 6. Quick Review
- 7. AnatomyKidney Urethra Bladder Sphincter Ureter Renal Capsule Renal Cortex Renal Medulla Pyramid Ureter Renal Artery & Vein Calyx Interlobar Arteries
- 8. Physiology Of the Renal System
- 10. Differentials Rhabdomyolitis secondary to Post viral infection Urinary Tract Infection Pyelonephritis Nephrotic Syndrome
- 11. RhabdomyolitisHow to diagnose? Tests to determine muscle and kidney health may include determining levels of: • Creatine kinase, which is an enzyme found in the skeletal muscles, the brain, and the heart. • Myoglobin in blood and urine, which is a protein that’s a byproduct of muscle breakdown. • Potassium, which is another important mineral that may leak from injured bone and muscles. • Creatinine in blood and urine, which is a breakdown product created by muscle that’s normally removed from the body by the kidneys. Elevated levels of these substances are signs of muscle damage. Learn More about Rhabdomyolitis http://www.healthline.com/health/rhabdomyolysis#causes3
- 12. Urinary Tract Infection How to diagnose? Analyze a urine sample Urine Culture CT or MRI (frequent infections) Cystoscopy Learn more about UTI’s: http://www.mayoclinic.org/diseases- conditions/urinary-tract-infection/basics/tests-diagnosis/con- 20037892
- 13. Pyelonephritis How to diagnose? Urinalysis Urine Culture Ultrasound Computerized tomography (CT) Dimercaptosuccinic acid (DSMA) scintigraphy Learn more about Pyelonephritis: https://www.niddk.nih.gov/health- information/kidney-disease/kidney-infection-pyelonephritis
- 14. Nephrotic Syndrome How to diagnose? Urinalysis Blood Test Biopsy Learn more about nephrotic syndrome: http://www.mayoclinic.org/diseases- conditions/nephrotic-syndrome/basics/tests- diagnosis/con-20033385
- 15. Nephrotic Syndrome Nephrotic Syndrome is a kidney disorder that causes your body to excrete too much protein in the urine. It is usually caused by damage to the small blood vessels of the Glomeruli that filters blood. It causes oedema in the periorbital area, ankles and feet first and can lead to Anasarca if not properly managed. Nephrotic Syndrome can lead to serious long term health problems and must be managed seriously.
- 16. Brown Urine Hx. of URTI Fever UTI Pyelo Cross Country Track Rhabdo Fever Resolved Not ill appearing No nitrites on dipstick Periorbital Oedema Nephrotic Syndrome Dipstick protein <3 ?Specific gravity elevated Normal BP elevated specific gravity (1.035) Urine dipstick protein 2+ Afebrile Active & non-toxic Presence of Cast
- 17. Rhabdomyolitis
- 18. Laboratory Test to support Diagnosis Elevated Creatinine Kinase >600 (usuaully markedly elevated, can reach up to the 100,000 depending on the extent. Myoglobin in the urine and blood Elevated Potassium (leaked minerals bone and muscle)(Normal 3.6 - 5.2 mmol/L) Creatinine in blood or urine
- 19. Prognosis Paediatric patients tend to have a better prognosis than adult Have Heme in the urine < 2+ is also associated with a better prognosis (>2+ associated with Acute Renal Failure) 20% of person in the study with heme >2+ had acute renal failure 30-40% of patients in another study developed renal failure, therefore it is safe to say between 1/5 to 2/5 of patients.
- 20. Signs of Renal Failure Peak CK level higher than 6000 IU/L Dehydration (hematocrit >50, serum sodium level >150 mEq/L, orthostasis, pulmonary wedge pressure < 5 mm Hg, urinary fractional excretion of sodium < 1%) Sepsis Hyperkalemia or hyperphosphatemia on admission Hypoalbuminemia
- 21. Follow up Care after Diagnosis ABC’s is always first Fluid Resuscitation ( IV fluids should be started immediately with added bicarbonate) with strict input/output charting Place a large bore needle Start with >400ml/hr then titrate till urine output is aleast 200ml/hr (adults), 20ml/kg children, 1-2L/h adolescence, subsequently 2-3 times the maintenance is also a good average Medication (diuretics, bicarbs, underlying illness if one ) ECG if clinical cardiac symptoms/signs present (can be due to electrolyte abnormality)
- 22. Follow up (cont’d) Dialysis ( last line if Acute Renal Failure occurs or person has impaired kidney function from before) Monitor for Disseminated intravascular coagulation, compartment syndrome, renal failure & hyperkalemia Trend bloods (CK q6-12hrly, LFT, Potassium levels)
- 23. References 1. http://www.mayoclinic.org/diseases-conditions/urinary-tract- infection/basics/tests-diagnosis/con-20037892 2. http://www.healthline.com/health/rhabdomyolysis#causes3 3. https://www.niddk.nih.gov/health-information/kidney-disease/kidney- infection-pyelonephritis 4. http://www.mayoclinic.org/diseases-conditions/nephrotic- syndrome/basics/tests-diagnosis/con-20033385 5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043460/ 6. http://www.aafp.org/afp/2009/1115/p1129.html
Editor's Notes
- Associated with Low specific gravity Normal range 1.005- 1.030 This patient had 1.035
- • creatine kinase, which is an enzyme found in the skeletal muscles, the brain, and the heart • myoglobin in blood and urine, which is a protein that’s a byproduct of muscle breakdown • potassium, which is another important mineral that may leak from injured bone and muscles • creatinine in blood and urine, which is a breakdown product created by muscle that’s normally removed from the body by the kidneys
- Your long-term outlook depends on the degree of kidney damage. If rhabdomyolysis is caught early, you may be able to avoid major complications and return to normal health in a few weeks. Even then, however, you may still have some lingering weakness and pain in your muscles. If major kidney damage occurs, your kidneys may be permanently damaged. Several of the symptoms and complications of rhabdomyolysis are serious and may result in death if you don’t get treatment for them. American Academy of Pediatrics Rebekah Mannix, Mei Lin Tan, Robert Wright, Marc Baskin RESULTS. Two hundred ten patients were studied. One hundred ninety-one patients met study eligibility (128 male and 63 female), with a median age of 11 years. The most common documented symptoms were muscle pain (45%), fever (40%), and symptoms of viral infection (39%). The most common causes of pediatric rhabdomyolysis were viral myositis (38%), trauma (26%), and connective tissue disease (5%). Six of 37 patients with creatinine kinase levels of ≥6000 IU/L had previously undiagnosed dermatomyositis or hereditary metabolic disease, compared with 10 of 154 patients with creatinine kinase levels of 1000 to 5999 IU/L. Nine of 191 patients developed acute renal failure. None of 99 patients with initial urinary heme dipstick results of <2+ developed acute renal failure, compared with 9 of 44 patients with urinary heme dipstick results of ≥2+. Higher initial creatinine kinase levels and higher fluid administration rates were associated with higher maximal creatinine levels. CONCLUSIONS. The cause of acute pediatric rhabdomyolysis is different from that of adult rhabdomyolysis. The risk of acute renal failure in children is much less than the risk reported for adults. http://pediatrics.aappublications.org/content/118/5/2119?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token
- Treatments options for rhabdomyolysis If discovered early in its progression, rhabdomyolysis can be successfully treated without long-term damage to the kidneys. Fluid recovery Getting enough fluid into your body is the first and most important treatment. They must start IV fluids quickly. This fluid should contain bicarbonate, which helps flush the myoglobin out of your kidneys. Medications Your doctor may prescribe medications such as bicarbonate and certain kinds of diuretics to help keep your kidneys functioning. They can also treat high potassium levels in the blood, or hyperkalemia, and low blood calcium levels, or hypocalcemia, with appropriate IV fluids. Dialysis If kidney damage and acute renal failure have already started, you may need to receive dialysis. During dialysis, blood is taken out of the body and cleaned in a special machine in order to remove waste products. Home remedies In mild cases of rhabdomyolysis, home treatment can help aid in the recovery process. The goals of at-home treatment include resting the body so muscles can recover and rehydration to help prevent further kidney damage. When you’re feeling fatigued, recline in a comfortable position and try to relax. Drink plenty of water and other clear liquids, such as light broth and sports drinks.
- Serial physical examinations and laboratory studies are indicated to monitor for compartment syndrome, hyperkalemia, acute oliguric or nonoliguric renal failure, and disseminated intravascular coagulation (DIC). Compartment syndrome necessitates immediate orthopedic consultation for fasciotomy. DIC should be treated with fresh frozen plasma, cryoprecipitate, and platelet transfusions. Monitor cardiac function. Monitor creatine kinase (CK) levels to show resolution of rhabdomyolysis.