2.
37 years old male patient
Not diabetic nor hypertensive
Admitted at ER with elevated kidney function in
routine investigation.
3. Past HX
Hx HD for 2 years followed by kidney transplant in 7/2016 hx of stricture
in ureter with double J insertion w removed 30 days after operation
KFT returned to normal
Immune suppressive medications(prograf 3*2 ,myofortic 180mg 3*2,solupred
20mg)
3m later presented with fever,rigor admitted to hospital in w he
was diagnosed as acute pyelonephritis and received antibiotics and
discharged with also normal kidney functions
3month later (in feb/2017) he became oliguric ,had vomiting,edema lower
limb kidney biopsy was taken and 3 sessions of plasmapharesis was done
before the result of biopsy followed by 4 session of hemodialysis upon
indications the urine improved and he disharged with basal
creatinine 3.5 urology consultations was done ureteric stricture
was detected and repair operation was done after operation VCUG was
done and patient was diagnosed as VUR grade 3 with recurrent UTI and
prophylactic antibiotic was prescribed
5.
General patient looks healthy not toxic,oriented to
time,place,person with avearge intelligence, no fever no
rigor
Head, neck no puffiness in eyelid, no congested
neck veins ,no enlarged L.N??
Chest clear, no enlarged axillary L.N??
Abd. Lax ,no tender graft,no palpable L.N
LL No edema LL,no sensory or motor
abnormality????.
Vital signs (bp 170/80, HR 88, Temp 37, RR 16b/min)??
examination
6.
Creatinine 7.9
Urea 165
Na 140
K 3.3???
Ca 9.2
ABG 7.18/13???
Urine pus 30-40
Sonar atrophied native kidneys, transplanted
kidney 11*5cm, grade 1 nephropathy, Good CMD, mild
back pressure with dilated upper ureter
investigations
7.
Rejection B-Cell mediated???
T-Cell mediated???
Vascular?? Duplex normal with R.I less than
0.7
Drug toxicity fk level+biopsy
pyelonephritis associated with VUR urine analysis+
culture,sensitivity.
No hx of vomiting so dehydrations is less likely but we can start small
amount of parenteral fluids.
DD of aki
13. Improvement of KFT creat 4.5
Urine output more than 2liter/day
Urine c,s follow up pus 1,2 with no colony growth
Ttt in discharge
Continue on antibiotics for howlong??
Prophalactic antibiotic???
Immunesuppressive modification????(creat 4.5+tubular injery)
Surgical correction of VUR ???
Iron profile
Bone mineral disease
A-v shunt????
Dry body weight recording???
Progression
14.
VUR,PV
Post.valve(abn.bladder)
abnormal congenital
obstructing membrane that
is located within the
posterior male urethra; this
valve is the most common
cause of bladder outlet
obstruction in male children
Vesicoureteral
reflux
(VUR) is characterized
by the retrograde flow of
urine from the bladder
to the kidneys
C/P
• Infection :in infants
can manifest as
failure to thrive, with
or without fever;
other features
include vomiting,
diarrhea, anorexia,
and lethargy
• abdominal pain
rather than as the
classic flank pain and
tenderness observed
in adults
• hypertension or with
uremic symptoms
from renal failure
15.
Renal ultrasonography (RUS)
voiding cystourethrography (VCUG)
Voiding urosongraphy(VUS)
IVP.
DMSA renal isotope scan Nuclear medicine renal scanning with a cortical
imaging agent (eg, technetium-99m [99m Tc] dimercaptosuccinic acid) is a
better means of detecting and identifying renal scarring than is
ultrasonography.
Computed tomography (CT) scanning is not indicated in the evaluation of
reflux nephropathy because of radiation dose, the need for intravenously
administered contrast material, and the potential need for patient sedation.
Although CT scans can demonstrate renal scarring and hydronephrosis,
they cannot demonstrate VUR.
Magnetic resonance imaging (MRI) is not routinely indicated in the
evaluation of reflux nephropathy because MRI can demonstrate renal
scarring and hydronephrosis, but not VUR. [4]
diagnosis
16.
Grade I - Reflux into nondilated ureter
Grade II - Reflux into renal pelvis and calyces
without dilation
Grade III - Reflux with mild-to-moderate dilation
and minimal blunting of fornices
Grade IV - Reflux with moderate ureteral tortuosity
and dilation of pelvis and calyces
Grade V - Reflux with gross dilation of ureter, pelvis,
and calyces, loss of papillary impressions, and
ureteral tortuosity
grading
17. DMSA SCAN (dimercaptosuccinic acid)
Gamma rays are one type of ionising radiation, a form of energy. At high levels, they
can be dangerous to humans because they can damage cells, the living parts of the body.
We are all exposed to ionising radiation – in our homes and workplaces (it is in some
construction materials and it seeps from the ground into buildings), when we eat
certain foods, and when we take a flight. However, this is at very low levels.
Are DMSA scans harmful?
A DMSA scan gives the same amount of radiation (dose) that we would be exposed to
in between 6 months and one year. The radioisotope that is injected into your child’s
body becomes inactive after a few hours and is passed out of his or her body in urine or
faeces (poo).
How to prepare your child??
Your child does not usually need to do anything to prepare for this test.
Mothers may be asked if they are pregnant or if they could be pregnant. This is because
ionising radiation from X rays may harm an unborn baby. Sometimes your child may be
asked to go to the toilet just before the scan to make sure his or her bladder is empty.
Your child may be able to meet with a play specialist, who can use dolls and other toys
to help him or her prepare for the test.
What happens
The DMSA scan takes place in the nuclear medicine department of your hospital. A
radiographer or a technician, a specialist trained in imaging tests, performs the test.
18.
Imaging after the first UTI is indicated in all children younger than 5
years, children of any age with febrile UTI, and boys of any age with
UTI.
All children with a history of febrile UTI should undergo kidney and
bladder ultrasonography.
the Society for Pediatric Urology continued to recommend that both
ultrasonography and cystography be performed.
Although the traditional approach in children with UTI has been
evaluation for VUR with VCUG ,some authorities have advocated a
"top-down" approach for children with UTI. [10] In this algorithm, a
child with a history of febrile UTI undergoes a dimercaptosuccinic acid
(DMSA) renal scan to assess for evidence of kidney involvement,
kidney scarring, or both. Negative DMSA scan findings suggest that
clinically significant VUR is unlikely, obviating the need for VCUG.
However, if DMSA scan findings are positive, VCUG is recommended.
AAP guidelines
19.
VUR patient is candidate for transplant or
not??
repair before transplant or not???
22.
Definitions
Bacteriuria :bacteria are established and multiplying within the
urinary tract. “Significant bacteriuria” is defined as the presence of 105
or more of the same organism per ml of urine.accuracy is enhanced by
presence of pyuria, defined as more than 10 WBC per mm3 of unspun
urine.
Asymptomatic bacteriuria :It is frequently detected during routine
investigations. Bacterial counts of ≥ 105 CFU/ml in two consecutive
clean-catch urine samples, permit to differentiate between
asymptomatic UTI and contamination (< 105 CFU/ml). A lower cut-off
level of ≥ 104 CFU/ml is accepted in case of infection with S.
saprophyticus and Candida. Asymptomatic bacteriuria should not be
treated except if complicated.
Symptomatic abacteriuria :Bacterial infection with low counts of
uropathogens may present as the so called ‘urethral syndrome’.
Aetiology includes - renal abscess formation without drainage into
urinary tract, complete ureteral obstruction, urinary tract tuberculosis
UTI
23.
It is of two types – re-infection and relapse.
Relapse: Occurrence of bacteriuria with the same organism
within three weeks of completing treatment. It can be diagnosed
by urine culture done before, during and between 10 and 21 days
after treatment or on recurrence of symptoms. Relapse indicates
failure to eradicate, which, most often occurs in association with
renal scars, stones, cystic diseases, or prostatitis, in patients with
chronic interstitial nephritis or in those who are
immunocompromised.
Re-infection is defined as eradication of bacteriuria by
appropriate treatment, followed by infection with a different
organism after 7 to 10 days.
Recurrent infection
24.
lower UTI: are afebrile and do not have elevation in
acute phase reactants
upper UTI are febrile and develop leucocytosis and
increased C-reactive protein
Lower Vs upper UTI :
25.
Complicated if:
Disorders of urine transport
Anatomical
Neurogenic
Associated diseases :
Polycystic kidney diseases
Analgesic abuse
Immunosuppression
Diabetes mellitus
Miscellaneous :
Pregnancy
male
Prostatitis
Indwelling urinary catheter
Uncomplicated Vs
Complicated UTI
(duration,ttt or not if asym??)
