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UTI in children (urinary tract infection).pptx

The document provides a comprehensive overview of the interpretation of urine tests, including key findings such as urine color, turbidity, odor, specific gravity, pH, and the presence of various substances like glucose and ketones, highlighting their clinical significance and implications for diagnosing urinary tract infections (UTIs). It outlines symptoms and signs for UTI diagnosis in children, the recommended use of imaging tests, and the distinctions between atypical and recurrent UTIs, alongside protocols for follow-up care and management based on test results. The document also details the use of nuclear scans in assessing renal conditions and the preparation required for accurate results.

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Urinary Tract Infection, Nuclear Scans, MCUG Dr Muhammad Umer Razaq MBBS, FCPS (Paeds Medicine), FCPS (Paeds Nephrology) European Board Pediatric Nephrology Certificate in Health Professional Education Consultant Pediatric Nephrologist
Interpretation of urine report
Significance of urine test • ‘’The ghosts of dead patients that haunt us do not ask why we did not employ the latest fad of clinical investigation. They ask us, why did you not test my urine?’’—Sir Robert Grieve Hutchison (1871–1960)
Urine report interpretation • Dipstick findings • Microscopic examination
Urine color Normal value: Pale • Pale yellow to amber: Concentration • Red or tea colored urine: Blood, hemoglobin, myoglobin, porphyrin, non- pathologic pigments (beets, food color) or medication. • Brown color: Prolonged contact between blood in the urinary tract and acidic urine causes the heme pigment to become oxidized to a methaem derivative. • Blue to green: Presence of biliverdin or pseudomonas infection.
Urine Turbidity Normal value: Clear • The urine is normally clear but can be cloudy in the presence of leukocytes, epithelial cells, bacteria, or precipitation of amorphous phosphate or amorphous urate.
Urine odor • Infection with urea-splitting organisms including Ureaplasma urealyticum, Proteus, Staphylococcus, Klebsiella, Providentia, and Pseudomonas species may generate an ammonia like smell. • Unusual urine odor can lead to the diagnosis of rare metabolic disorders such as maple syrup urine disease (maple syrup odor), phenylketonuria (musty odor) or hypermethioninemia (fishy odor).
Specific gravity Normal value: 1.010-1.025 • Specific gravity reflects the urinary concentrating and diluting capability of the kidney. Distinguishing pre-renal states from intrinsic renal disease. Dehydration Concentrated urine SIADH Over hydration Concentration defect Diabetes insipidus
Urinary pH Normal value: 5.0 to 8.0 • Early morning sample. Precise measurements by pH meter. Disease monitoring Proximal RTA Drugs ammonium chloride Acidosis Fasting state Distal RTA Drugs: Sodium bicarbonate Alkalosis Urea-splitting organism After meal
Glucose Normal value: Nil • Isolated renal glucosuria • Proximal tubular disorder such as Fanconi syndrome. • Overt hyperglycemia: Diabetes, iatrogenic
Ketones Normal value: Nil • Ketone bodies are formed during the catabolism of fatty acids and include acetoacetic acid, beta hydroxybutyric acid, and acetone. • DKA, Infection • Stress, Fasting • Burn, Exercise, Pregnancy • Fever, Hyperthyroidism
Leukocyte esterase Normal value: Negative • Strip tests detect leukocyte esterase, an enzyme found in neutrophils. • Samples should be processed rapidly to avoid degradation of esterases and false negative results. • A positive urinalysis for leucocytes is suggestive of bacteriuria or urinary tract infection (UTI) If positive then a further confirmatory urine culture is required.
Nitrite Normal value: Negative • Nitrites indicate the presence of bacteria capable of reducing dietary nitrate such as Escherichia coli, Enterobacter, Citrobacter, Klebsiella, and Proteus species. • Not reliable in small infants. • The test has a high specificity but a low sensitivity for the diagnosis of UTI • A positive urinalysis for nitrite is suggestive of bacteriuria or urinary tract infection (UTI) If positive then a further confirmatory urine culture is required.
Protein Normal value: Nil Albumin is better detected than other urinary proteins including globulins, tubular proteins. • True proteinuria: Nephrotic, nephritic, UTI • Orthostatic proteinuria: First morning samples • Transient proteinuria: Fever, exertion, acute illness
•Concentrated urine •Alkaline urine •Gross hematuria, pyuria, bacteriuria •Dipstick left in urine too long or delay in reading •Contamination and drugs •Antiseptics: chlorhexidine, benzalkonium False positive proteinuria •Dilute urine •Acidic urine False negative proteinuria
Blood Normal value: Nil • Reagent strips detect RBC, myoglobin, and hemoglobin. • The supernatant of a centrifuged urine containing red blood cells will be clear yellow as opposed to being pink if the urine contains hemoglobin or myoglobin.
Microscopic evaluation
Microscopic examination • Microscopic evaluation of fresh urine is extremely valuable in the evaluation of renal disease. The presence of casts, cells, and crystals should be sought. Although hyaline and granular casts can be seen in normal states, cellular casts are pathologic. Red blood cell casts are pathognomonic of glomerular disease and white blood cell casts can be seen with pyelonephritis or postinfectious glomerulonephritis.
RBC Normal value: Nil • More than 5 red blood cells/high power field in uncentrifuged urine or more than three red blood cells/high-power field in the centrifuged sediment from 10 ml of freshly voided midstream urine. • Help determine their origin. • Presence of dysmorphic red blood cells suggests glomerular hematuria.
False-positive hematuria; alternative causes of red urine • Foods: beetroot, berries containing anthocyanins, and food dyes • Hemoglobinuria: intravascular hemolysis Myoglobinuria, rhabdomyolysis • Urate crystals: pink discoloration of nappies • Drugs: rifampicin, phenothiazines, desferrioxamine, phenindione • Inborn errors of metabolism: porphyria and alkaptonuria
False negative hematuria • The presence of reducing agents, such as ascorbic acid in the urine, may cause a false-negative result. • Urine dipsticks detect the presence of hemoglobin in the urine through its ability to catalyze a reaction between hydrogen peroxide and o-tolidine
Crystals • Crystals are rarely seen in fresh urine but appear after the urine stands for a period of time. • Uric acid, calcium oxalate, amorphous urate, cystine, tyrosine, leucine, and cholesterol are usually found in acid urine. • Triple phosphate, calcium carbonate, ammonium biurate, amorphous phosphates and calcium phosphate crystals are usually found in alkaline urine..
Significance of urinary crystals • Calcium carbonate and amorphous phosphate are of no clinical significance • Cystine, tyrosine, leucine, and cholesterol crystals are always relevant. • Cystine crystals: cystinuria, • Leucine crystals: maple syrup urine disease, methionine malabsorption syndrome. • Tyrosine crystals: liver disease, tyrosinosis, and methionine malabsorption syndrome. • The presence of cholesterol crystals can indicate excessive tissue breakdown.
Urinary eosinophil Normal value: Negative • Acute interstitial nephritis (AIN):diagnostic • Eosinophiluria may be seen in prostatitis, cystitis, and glomerulonephritis also,
Urinary tract infection in under 16s: diagnosis and management NICE guideline [NG224] Published: 27 July 2022
Symptoms and signs that increase the likelihood that a urinary tract infection (UTI) is present Symptoms and signs that decrease the likelihood that a UTI is present •Painful urination (dysuria) •More frequent urination •New bedwetting •Foul smelling (malodorous) urine •Darker urine •Cloudy urine •Frank haematuria (visible blood in urine) •Reduced fluid intake •Fever •Shivering •Abdominal pain •Loin tenderness or suprapubic tenderness •Capillary refill longer than 3 seconds •Previous history of confirmed urinary tract infection •Absence of painful urination (dysuria) •Nappy rash •Breathing difficulties •Abnormal chest sounds •Abnormal ear examination •Fever with known alte
Microscopy results Interpretation Pyuria and bacteriuria are both positive Assume the baby or child has a urinary tract infection (UTI) Pyuria is positive and bacteriuria is negative Start antibiotic treatment if the baby or child has symptoms or signs of a UTI Pyuria is negative and bacteriuria is positive Assume the baby or child has a UTI Pyuria and bacteriuria are both negative Assume the baby or child does not have a UTI
Urine dipstick test result Strategy Leukocyte esterase and nitrite are both positive Assume the child has a urinary tract infection (UTI) and give them antibiotics. If the child has a high or intermediate risk of serious illness or a history of previous UTI, send a urine sample for culture. Leukocyte esterase is negative and nitrite is positive Give the child antibiotics if the urine test was carried out on a fresh urine sample. Send a urine sample for culture. Subsequent management will depend on the result of urine culture. Leukocyte esterase is positive and nitrite is negative Send a urine sample for microscopy and culture. Do not give the child antibiotics unless there is good clinical evidence of a UTI (for example, obvious urinary symptoms). A positive leukocyte esterase result may indicate an infection outside the urinary tract that may need to be managed differently. Leukocyte esterase and nitrite are both negative Assume the child does not have a UTI. Do not give the child antibiotics for a UTI or send a urine sample for culture. Explore other possible causes of the child's illness.
Imaging tests for localising UTI • Do not routinely use imaging to localise UTI. • In rare instances when it is clinically important to confirm or exclude acute upper UTI, use either: • power doppler ultrasound or • a dimercaptosuccinic acid (DMSA) scintigraphy scan if power doppler ultrasound is not available or the diagnosis has not been confirmed.
Imaging tests (ultrasound) • Send babies and children with atypical UTI for a urinary tract ultrasound during the acute infection, to identify structural abnormalities such as obstruction and to ensure prompt management. • Send babies younger than 6 months with first-time UTI that responds to treatment for ultrasound within 6 weeks of the UTI. • Do not routinely send babies and children over 6 months with first-time UTI who respond to treatment for an ultrasound, unless they have atypical UTI. • In a baby with a non-E. coli urinary tract infection that is responding well to antibiotics and has no other features of atypical infection, a non-urgent ultrasound can be requested, to happen within 6 weeks.
Imaging • Use a DMSA scan 4 to 6 months after the acute infection to detect renal parenchymal defects in babies and children • If the baby or child has a subsequent UTI while waiting for a DMSA scan, review the timing of the scan and consider doing it sooner. • Do not routinely use imaging to identify VUR in babies and children who have had a UTI, except in specific circumstances
Definitions of atypical and recurrent urinary tract infection (UTI) Atypical UTI includes: • Seriously ill • Poor urine flow • Abdominal or bladder mass • Raised creatinine • Septicaemia • Failure to respond to treatment with suitable antibiotics within 48 hours • Infection with non-E. coli organisms Recurrent UTI: • Two or more episodes of UTI with acute upper UTI (acute pyelonephritis), or • One episode of UTI with acute upper UTI plus 1 or more episodes of UTI with lower UTI (cystitis), or • Three or more episodes of UTI with lower UTI
Recommended imaging schedule for babies younger than 6 months Test Responds well to treatment within 48 hours Atypical urinary tract infection Recurrent urinary tract infection Ultrasound during the acute infection No Yes Yes Ultrasound within 6 weeks Yes If abnormal consider micturating cystourethrogram (MCUG) No No Dimercaptosuccinic acid scintigraphy scan 4 to 6 months after the acute infection No Yes Yes Micturating cystourethrogram No Yes Yes
Recommended imaging schedule for babies and children between 6 months to under 3 years Test Responds well to treatment within 48 hours Atypical urinary tract infection Recurrent urinary tract infection Ultrasound during the acute infection No Yes No Ultrasound within 6 weeks No No Yes Dimercaptosuccinic acid scintigraphy scan 4 to 6 months after the acute infection No Yes Yes Micturating cystourethrogram No No No
Recommended imaging schedule for children 3 years or older Test Responds well to treatment within 48 hours Atypical urinary tract infection Recurrent urinary tract infection Ultrasound during the acute infection No Yes No Ultrasound within 6 weeks No No Yes Dimercaptosuccinic acid scintigraphy scan 4 to 6 months after the acute infection No No Yes Micturating cystourethrogram No No No
Follow up • Do not routinely follow up babies and children who have not had imaging investigations. • Refer babies and children who have recurrent UTI or abnormal imaging results for assessment. • When assessing babies and children with renal parenchymal defects, include height, weight, blood pressure and routine testing for proteinuria. • Do not offer long-term follow up to babies and children with minor, unilateral renal parenchymal defects, unless they have recurrent UTI, family history or lifestyle risk factors for hypertension. • Babies and children who have bilateral renal abnormalities, impaired kidney function, raised blood pressure or proteinuria should have monitoring and appropriate management by a paediatric nephrologist to slow the progression of chronic kidney disease.
Nuclear Scans DTPA Scan (Diuretic scan) DMSA Scan (Static scan) Mag -3 Scan Captopril Scan
Nuclear Scans • The nuclear renal scan, also known as renal scintigraphy, is an imaging method that uses radiopharmaceuticals/radiotracers to evaluate renal anatomy, physiology, and pathology. The various injected radiotracers are extracted from the blood by the kidneys and emit radiation, particularly gamma radiation, that is detected by gamma cameras.
Indications • Reno-vascular hypertension • Obstructive uropathy • Renal anomalies • Renal transplant • Renal parenchymal infections particularly pyelonephritis and postinfectious scarring
Preparation • The patients undergoing renal scanning should be well hydrated so as to minimize the radiation dose to the bladder wall which would be increased with a collapsed bladder. • Dehydration can delay renal excretion and interfere with the study results. • Most renal scintigraphy requires no premedication or dietary restriction. • NSAIDs are therefore avoided on the day of study. NSAID decrease prostaglandin synthesis and result in decreased renal perfusion as well as glomerular filtration which thereby affects glomerular filtration rate. NSAID also affects ureteric contraction and delays excretion.
• Patients are instructed to void just before their renal scan since a full bladder delays upper urinary tract emptying and interferes with the study results reliability especially when working up a case of obstructive uropathy. Occasionally foley catheterization is used to keep the bladder empty.
Technetium-99m diethylene triamine penta-acetic acid (Tc-99m DTPA) • Primarily cleared by glomerular filtration and therefore useful to measure GFR and to evaluate flow through the pyelocalyceal system through the ureter and into the bladder.
Technetium-99m dimercaptosuccinic acid (Tc-99m DMSA) • This agent predominantly binds to renal tubular cells in the renal cortex allowing cortical imaging. • Because it is bound to the cortex for a long time, it is primarily used for cortical anatomy and assessment of pathologies such as renal ectopia or renal scarring after recurrent UTI.
DMSA scan in pyelonephritis • DMSA renography is highly sensitive and has proven more helpful than ultrasonography for the early diagnosis of pyelonephritis in children over 5 years of age. Early detection and timely treatment of pyelonephritis are important in preventing complications such as cortical scarring and its associated loss of renal function. • The methodology is chosen in children to decrease radiation exposure compared to a CT scan. • Imaging findings of acute pyelonephritis include defects in cortical uptake of 99mTc- DMSA which can be focal or multifocal. Sometimes acute pyelonephritis presents as diffusely decreased activity due to renal edema. A bulging cortex may be noted in diffuse acute pyelonephritis
Normal DMSA scan
Technetium-99m mercaptoacetyl triglycine (Tc-99m MAG3) • his agent is secreted predominantly by proximal renal tubules with a small component (approximately 5%) of it filtered by the glomeruli. • Tc-99m MAG3 is extracted from plasma with greater efficiency resulting in retained parenchymal activity and allowing renal parenchyma evaluation. • MAG3 studies also allow for the assessment of urine flow through the pyelocalyceal system and bladder. More reliable in obstructive uropathy. • It has 40% more plasma clearance than that of Tc-99m DTPA improving imaging. • Investigation of choice in neonates and infants with obstructive uropathy.
• A bolus of radionuclide placed in an antecubital vein typically reaches the renal arteries from the aorta within 1 second. • For renal blood flow evaluation, serial dynamic images are acquired every 1 to 2 seconds for up to a minute. The kidneys are usually seen by 5 to 6 seconds from injection and show maximal activity in normal patients by 30 to 60 seconds. • Images are acquired at 15-60 seconds intervals for a period of 3-5 minutes when using 99mTc-DTPA and for 20-30 minutes when using 99mTc-MAG3. This phase allows for the best imaging of renal anatomy via parenchymal uptake. • Radiotracer activity usually starts appearing in the collecting system or urinary bladder by 4-8 minutes. Collecting system evaluation is accomplished after ambulating to promote pyelocalyceal system drainage or after a diuretic
Three phases of renogram • The first phase is known as the vascular transit phase which represents radiotracer entering the kidneys. It usually lasts about 30 to 60 seconds. • The second phase is known as the tubular concentration phase or parenchymal transit phase normally lasts 1 to 5 minutes when radiotracer appears in the tubules. It is represented by a peak in the renogram. • The third phase is noted by a downslope in the renogram indicating excretion of the radiotracer from the kidneys and clearance from the collecting system. It usually starts at 4-8 minutes after radiotracer injection.
Normal 99Tcm-Mag3 renal scan: There is symmetrical uptake of the radiotracer bilaterally with normal excretion indicated by radioactivity in the ureter and bladder. (red arrow= left kidney, green arrow=right kidney, yellow arrow=left ureter and black arrow=bladder).
9Tcm-Mag3 renal scan: Time activity determined for each kidney, separately. Upper portion of diagram shows parenchymal and pyelocalyceal (excretion) activity; lowest portion shows cortical activity. Parenchymal and pyelocalyceal (PC) activity of the right kidney (RK) (green line); left kidney (LK) (dashed red line). Cortical activity, alone, RK (broken green line) and LK (dot&dashed red line). Upstroke (curved yellow arrow) within first 30 seconds post Mag3 injection indicates normal renal vascular flow. Peaks (green & red curved arrows) represent normal parenchymal transit from cortex to PC system. Gradual downsloping (yellow arrowhead) indicates radiotracer excretion from parenchyma to collecting system phase. After diuretic administration there is rapid downsloping of RK and LK parenchymal and PC activity indicating normal excretion. Bottom of graph, 2 sets of lines representing RK and LK activity in the renal cortices only. Upstroke (blue arrow= normal perfusion).
• 9Tcm-Mag3 renal scan: Left kidney (LK) obstruction. A: Posteriorly acquired images of kidneys obtained every 30 seconds after radiotracer injection. Blue arrow=LK, yellow arrow=RK. Both kidneys are present. Renal parenchyma is seen bilaterally. Over exam course, there is normal emptying (disappearance of radiotracer) from the RK but no excretion from the LK (red arrow). B: Abnormal LK time activity curve: Green line=RK curve, Broken red line=LK curve. Normal RK upstroke (curved green arrow) to a peak, and normal downsloping. Broken red line=abnormal LK parenchymal transit seen as lack of peak, no excretion into the renal pelvis or ureter seen as lack of downsloping (curved red arrow).
Mag-3 in obstructive uropathy • When radiotracer excretion increases after the diuretic, the exam is interpreted as non- obstructive dilation. If after given a diuretic excretion is unaffected or shows little change, the diagnosis is obstructive uropathy. In obstructive uropathy, the renogram demonstrates continuous rising and little or no downsloping during the excretion phase. • A renogram may be flattened at the perfusion phase in cases of high grade-long standing obstruction which often leads to a decrease in renal perfusion. • A T1/2 calculation obtained from the renogram represents radiotracer activity falling to 50% of its maximum value. A clearance half time of more than 20 minutes usually indicates obstruction.
A: Normal renal perfusion curve (60 sec). B: Time activity curve over 30 minutes -. (Red line in the graph) shows persistent parenchymal activity without down sloping at 30 minutes indicating no radiotracer excretion
MCUG
MCUG • study of choice for diagnosing VUR and assessing the anatomy of the bladder and urethra. • Indications include UTI, antenatally or postnatally diagnosed hydronephrosis, and suspected PUV. • Images of the bladder that will allow for assessment of its wall characteristics and detection of structural abnormalities such as diverticula, ureteroceles or urachal abnormalities. These images should demonstrate whether there is any reflux into the ureters.
Contraindication • Active urinary tract infection should be excluded before doing this invasive • investigation.
• A catheter is placed via the urethra into the bladder using aseptic technique. • The bladder is filled with water soluble contrast under the pressure of gravity. • The amount of contrast used will vary according to the patient’s age and bladder capacity. • Bladder capacity for age [<2 y: weight × 7 ml, >2 y (age +2) × 30 ml)]
Cyclic VCUG • At some institutions a single cycle of filling and voiding is performed. At others, two or three cycles are the routine. • This latter method, termed cyclic VCUG, has demonstrated greater sensitivity in detecting reflux, but results in a higher radiation dose compared to the single cycle method. • In all cases, care is given to minimizing the dose of ionizing radiation
Technique • Oblique or lateral fi lm without the catheter is necessary to detect posterior urethral valves. • Films during filling phase are used to document bladder pathology and low pressure vesicoureteric reflux. • Early filling films should be obtained to identify a ureterocele, which may become compressed, on filling of the bladder. • If the child is unable to void, warm water applied to the perineum can induce voiding. Some children will not void on the fluoroscopy table despite a variety of maneuvers. In these cases, the micturition phase of the study is not possible and the sensitivity of the study to detect reflux is diminished.
UTI in children (urinary tract infection).pptx
UTI in children (urinary tract infection).pptx
UTI in children (urinary tract infection).pptx
UTI in children (urinary tract infection).pptx
UTI in children (urinary tract infection).pptx

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UTI in children (urinary tract infection).pptx

  • 1.
    Urinary Tract Infection, NuclearScans, MCUG Dr Muhammad Umer Razaq MBBS, FCPS (Paeds Medicine), FCPS (Paeds Nephrology) European Board Pediatric Nephrology Certificate in Health Professional Education Consultant Pediatric Nephrologist
  • 2.
  • 3.
    Significance of urinetest • ‘’The ghosts of dead patients that haunt us do not ask why we did not employ the latest fad of clinical investigation. They ask us, why did you not test my urine?’’—Sir Robert Grieve Hutchison (1871–1960)
  • 4.
    Urine report interpretation •Dipstick findings • Microscopic examination
  • 6.
    Urine color Normal value:Pale • Pale yellow to amber: Concentration • Red or tea colored urine: Blood, hemoglobin, myoglobin, porphyrin, non- pathologic pigments (beets, food color) or medication. • Brown color: Prolonged contact between blood in the urinary tract and acidic urine causes the heme pigment to become oxidized to a methaem derivative. • Blue to green: Presence of biliverdin or pseudomonas infection.
  • 8.
    Urine Turbidity Normal value:Clear • The urine is normally clear but can be cloudy in the presence of leukocytes, epithelial cells, bacteria, or precipitation of amorphous phosphate or amorphous urate.
  • 10.
    Urine odor • Infectionwith urea-splitting organisms including Ureaplasma urealyticum, Proteus, Staphylococcus, Klebsiella, Providentia, and Pseudomonas species may generate an ammonia like smell. • Unusual urine odor can lead to the diagnosis of rare metabolic disorders such as maple syrup urine disease (maple syrup odor), phenylketonuria (musty odor) or hypermethioninemia (fishy odor).
  • 11.
    Specific gravity Normal value:1.010-1.025 • Specific gravity reflects the urinary concentrating and diluting capability of the kidney. Distinguishing pre-renal states from intrinsic renal disease. Dehydration Concentrated urine SIADH Over hydration Concentration defect Diabetes insipidus
  • 13.
    Urinary pH Normal value:5.0 to 8.0 • Early morning sample. Precise measurements by pH meter. Disease monitoring Proximal RTA Drugs ammonium chloride Acidosis Fasting state Distal RTA Drugs: Sodium bicarbonate Alkalosis Urea-splitting organism After meal
  • 14.
    Glucose Normal value: Nil •Isolated renal glucosuria • Proximal tubular disorder such as Fanconi syndrome. • Overt hyperglycemia: Diabetes, iatrogenic
  • 15.
    Ketones Normal value: Nil •Ketone bodies are formed during the catabolism of fatty acids and include acetoacetic acid, beta hydroxybutyric acid, and acetone. • DKA, Infection • Stress, Fasting • Burn, Exercise, Pregnancy • Fever, Hyperthyroidism
  • 16.
    Leukocyte esterase Normal value:Negative • Strip tests detect leukocyte esterase, an enzyme found in neutrophils. • Samples should be processed rapidly to avoid degradation of esterases and false negative results. • A positive urinalysis for leucocytes is suggestive of bacteriuria or urinary tract infection (UTI) If positive then a further confirmatory urine culture is required.
  • 17.
    Nitrite Normal value: Negative •Nitrites indicate the presence of bacteria capable of reducing dietary nitrate such as Escherichia coli, Enterobacter, Citrobacter, Klebsiella, and Proteus species. • Not reliable in small infants. • The test has a high specificity but a low sensitivity for the diagnosis of UTI • A positive urinalysis for nitrite is suggestive of bacteriuria or urinary tract infection (UTI) If positive then a further confirmatory urine culture is required.
  • 18.
    Protein Normal value: Nil Albuminis better detected than other urinary proteins including globulins, tubular proteins. • True proteinuria: Nephrotic, nephritic, UTI • Orthostatic proteinuria: First morning samples • Transient proteinuria: Fever, exertion, acute illness
  • 19.
    •Concentrated urine •Alkaline urine •Grosshematuria, pyuria, bacteriuria •Dipstick left in urine too long or delay in reading •Contamination and drugs •Antiseptics: chlorhexidine, benzalkonium False positive proteinuria •Dilute urine •Acidic urine False negative proteinuria
  • 20.
    Blood Normal value: Nil •Reagent strips detect RBC, myoglobin, and hemoglobin. • The supernatant of a centrifuged urine containing red blood cells will be clear yellow as opposed to being pink if the urine contains hemoglobin or myoglobin.
  • 21.
  • 22.
    Microscopic examination • Microscopicevaluation of fresh urine is extremely valuable in the evaluation of renal disease. The presence of casts, cells, and crystals should be sought. Although hyaline and granular casts can be seen in normal states, cellular casts are pathologic. Red blood cell casts are pathognomonic of glomerular disease and white blood cell casts can be seen with pyelonephritis or postinfectious glomerulonephritis.
  • 23.
    RBC Normal value: Nil •More than 5 red blood cells/high power field in uncentrifuged urine or more than three red blood cells/high-power field in the centrifuged sediment from 10 ml of freshly voided midstream urine. • Help determine their origin. • Presence of dysmorphic red blood cells suggests glomerular hematuria.
  • 24.
    False-positive hematuria; alternativecauses of red urine • Foods: beetroot, berries containing anthocyanins, and food dyes • Hemoglobinuria: intravascular hemolysis Myoglobinuria, rhabdomyolysis • Urate crystals: pink discoloration of nappies • Drugs: rifampicin, phenothiazines, desferrioxamine, phenindione • Inborn errors of metabolism: porphyria and alkaptonuria
  • 25.
    False negative hematuria •The presence of reducing agents, such as ascorbic acid in the urine, may cause a false-negative result. • Urine dipsticks detect the presence of hemoglobin in the urine through its ability to catalyze a reaction between hydrogen peroxide and o-tolidine
  • 26.
    Crystals • Crystals arerarely seen in fresh urine but appear after the urine stands for a period of time. • Uric acid, calcium oxalate, amorphous urate, cystine, tyrosine, leucine, and cholesterol are usually found in acid urine. • Triple phosphate, calcium carbonate, ammonium biurate, amorphous phosphates and calcium phosphate crystals are usually found in alkaline urine..
  • 27.
    Significance of urinarycrystals • Calcium carbonate and amorphous phosphate are of no clinical significance • Cystine, tyrosine, leucine, and cholesterol crystals are always relevant. • Cystine crystals: cystinuria, • Leucine crystals: maple syrup urine disease, methionine malabsorption syndrome. • Tyrosine crystals: liver disease, tyrosinosis, and methionine malabsorption syndrome. • The presence of cholesterol crystals can indicate excessive tissue breakdown.
  • 29.
    Urinary eosinophil Normal value:Negative • Acute interstitial nephritis (AIN):diagnostic • Eosinophiluria may be seen in prostatitis, cystitis, and glomerulonephritis also,
  • 30.
    Urinary tract infectionin under 16s: diagnosis and management NICE guideline [NG224] Published: 27 July 2022
  • 31.
    Symptoms and signsthat increase the likelihood that a urinary tract infection (UTI) is present Symptoms and signs that decrease the likelihood that a UTI is present •Painful urination (dysuria) •More frequent urination •New bedwetting •Foul smelling (malodorous) urine •Darker urine •Cloudy urine •Frank haematuria (visible blood in urine) •Reduced fluid intake •Fever •Shivering •Abdominal pain •Loin tenderness or suprapubic tenderness •Capillary refill longer than 3 seconds •Previous history of confirmed urinary tract infection •Absence of painful urination (dysuria) •Nappy rash •Breathing difficulties •Abnormal chest sounds •Abnormal ear examination •Fever with known alte
  • 32.
    Microscopy results Interpretation Pyuriaand bacteriuria are both positive Assume the baby or child has a urinary tract infection (UTI) Pyuria is positive and bacteriuria is negative Start antibiotic treatment if the baby or child has symptoms or signs of a UTI Pyuria is negative and bacteriuria is positive Assume the baby or child has a UTI Pyuria and bacteriuria are both negative Assume the baby or child does not have a UTI
  • 33.
    Urine dipstick testresult Strategy Leukocyte esterase and nitrite are both positive Assume the child has a urinary tract infection (UTI) and give them antibiotics. If the child has a high or intermediate risk of serious illness or a history of previous UTI, send a urine sample for culture. Leukocyte esterase is negative and nitrite is positive Give the child antibiotics if the urine test was carried out on a fresh urine sample. Send a urine sample for culture. Subsequent management will depend on the result of urine culture. Leukocyte esterase is positive and nitrite is negative Send a urine sample for microscopy and culture. Do not give the child antibiotics unless there is good clinical evidence of a UTI (for example, obvious urinary symptoms). A positive leukocyte esterase result may indicate an infection outside the urinary tract that may need to be managed differently. Leukocyte esterase and nitrite are both negative Assume the child does not have a UTI. Do not give the child antibiotics for a UTI or send a urine sample for culture. Explore other possible causes of the child's illness.
  • 34.
    Imaging tests forlocalising UTI • Do not routinely use imaging to localise UTI. • In rare instances when it is clinically important to confirm or exclude acute upper UTI, use either: • power doppler ultrasound or • a dimercaptosuccinic acid (DMSA) scintigraphy scan if power doppler ultrasound is not available or the diagnosis has not been confirmed.
  • 35.
    Imaging tests (ultrasound) •Send babies and children with atypical UTI for a urinary tract ultrasound during the acute infection, to identify structural abnormalities such as obstruction and to ensure prompt management. • Send babies younger than 6 months with first-time UTI that responds to treatment for ultrasound within 6 weeks of the UTI. • Do not routinely send babies and children over 6 months with first-time UTI who respond to treatment for an ultrasound, unless they have atypical UTI. • In a baby with a non-E. coli urinary tract infection that is responding well to antibiotics and has no other features of atypical infection, a non-urgent ultrasound can be requested, to happen within 6 weeks.
  • 36.
    Imaging • Use aDMSA scan 4 to 6 months after the acute infection to detect renal parenchymal defects in babies and children • If the baby or child has a subsequent UTI while waiting for a DMSA scan, review the timing of the scan and consider doing it sooner. • Do not routinely use imaging to identify VUR in babies and children who have had a UTI, except in specific circumstances
  • 37.
    Definitions of atypicaland recurrent urinary tract infection (UTI) Atypical UTI includes: • Seriously ill • Poor urine flow • Abdominal or bladder mass • Raised creatinine • Septicaemia • Failure to respond to treatment with suitable antibiotics within 48 hours • Infection with non-E. coli organisms Recurrent UTI: • Two or more episodes of UTI with acute upper UTI (acute pyelonephritis), or • One episode of UTI with acute upper UTI plus 1 or more episodes of UTI with lower UTI (cystitis), or • Three or more episodes of UTI with lower UTI
  • 38.
    Recommended imaging schedulefor babies younger than 6 months Test Responds well to treatment within 48 hours Atypical urinary tract infection Recurrent urinary tract infection Ultrasound during the acute infection No Yes Yes Ultrasound within 6 weeks Yes If abnormal consider micturating cystourethrogram (MCUG) No No Dimercaptosuccinic acid scintigraphy scan 4 to 6 months after the acute infection No Yes Yes Micturating cystourethrogram No Yes Yes
  • 39.
    Recommended imaging schedulefor babies and children between 6 months to under 3 years Test Responds well to treatment within 48 hours Atypical urinary tract infection Recurrent urinary tract infection Ultrasound during the acute infection No Yes No Ultrasound within 6 weeks No No Yes Dimercaptosuccinic acid scintigraphy scan 4 to 6 months after the acute infection No Yes Yes Micturating cystourethrogram No No No
  • 40.
    Recommended imaging schedulefor children 3 years or older Test Responds well to treatment within 48 hours Atypical urinary tract infection Recurrent urinary tract infection Ultrasound during the acute infection No Yes No Ultrasound within 6 weeks No No Yes Dimercaptosuccinic acid scintigraphy scan 4 to 6 months after the acute infection No No Yes Micturating cystourethrogram No No No
  • 41.
    Follow up • Donot routinely follow up babies and children who have not had imaging investigations. • Refer babies and children who have recurrent UTI or abnormal imaging results for assessment. • When assessing babies and children with renal parenchymal defects, include height, weight, blood pressure and routine testing for proteinuria. • Do not offer long-term follow up to babies and children with minor, unilateral renal parenchymal defects, unless they have recurrent UTI, family history or lifestyle risk factors for hypertension. • Babies and children who have bilateral renal abnormalities, impaired kidney function, raised blood pressure or proteinuria should have monitoring and appropriate management by a paediatric nephrologist to slow the progression of chronic kidney disease.
  • 42.
    Nuclear Scans DTPA Scan(Diuretic scan) DMSA Scan (Static scan) Mag -3 Scan Captopril Scan
  • 43.
    Nuclear Scans • Thenuclear renal scan, also known as renal scintigraphy, is an imaging method that uses radiopharmaceuticals/radiotracers to evaluate renal anatomy, physiology, and pathology. The various injected radiotracers are extracted from the blood by the kidneys and emit radiation, particularly gamma radiation, that is detected by gamma cameras.
  • 44.
    Indications • Reno-vascular hypertension •Obstructive uropathy • Renal anomalies • Renal transplant • Renal parenchymal infections particularly pyelonephritis and postinfectious scarring
  • 45.
    Preparation • The patientsundergoing renal scanning should be well hydrated so as to minimize the radiation dose to the bladder wall which would be increased with a collapsed bladder. • Dehydration can delay renal excretion and interfere with the study results. • Most renal scintigraphy requires no premedication or dietary restriction. • NSAIDs are therefore avoided on the day of study. NSAID decrease prostaglandin synthesis and result in decreased renal perfusion as well as glomerular filtration which thereby affects glomerular filtration rate. NSAID also affects ureteric contraction and delays excretion.
  • 46.
    • Patients areinstructed to void just before their renal scan since a full bladder delays upper urinary tract emptying and interferes with the study results reliability especially when working up a case of obstructive uropathy. Occasionally foley catheterization is used to keep the bladder empty.
  • 47.
    Technetium-99m diethylene triaminepenta-acetic acid (Tc-99m DTPA) • Primarily cleared by glomerular filtration and therefore useful to measure GFR and to evaluate flow through the pyelocalyceal system through the ureter and into the bladder.
  • 48.
    Technetium-99m dimercaptosuccinic acid (Tc-99mDMSA) • This agent predominantly binds to renal tubular cells in the renal cortex allowing cortical imaging. • Because it is bound to the cortex for a long time, it is primarily used for cortical anatomy and assessment of pathologies such as renal ectopia or renal scarring after recurrent UTI.
  • 49.
    DMSA scan inpyelonephritis • DMSA renography is highly sensitive and has proven more helpful than ultrasonography for the early diagnosis of pyelonephritis in children over 5 years of age. Early detection and timely treatment of pyelonephritis are important in preventing complications such as cortical scarring and its associated loss of renal function. • The methodology is chosen in children to decrease radiation exposure compared to a CT scan. • Imaging findings of acute pyelonephritis include defects in cortical uptake of 99mTc- DMSA which can be focal or multifocal. Sometimes acute pyelonephritis presents as diffusely decreased activity due to renal edema. A bulging cortex may be noted in diffuse acute pyelonephritis
  • 50.
  • 52.
    Technetium-99m mercaptoacetyl triglycine (Tc-99mMAG3) • his agent is secreted predominantly by proximal renal tubules with a small component (approximately 5%) of it filtered by the glomeruli. • Tc-99m MAG3 is extracted from plasma with greater efficiency resulting in retained parenchymal activity and allowing renal parenchyma evaluation. • MAG3 studies also allow for the assessment of urine flow through the pyelocalyceal system and bladder. More reliable in obstructive uropathy. • It has 40% more plasma clearance than that of Tc-99m DTPA improving imaging. • Investigation of choice in neonates and infants with obstructive uropathy.
  • 53.
    • A bolusof radionuclide placed in an antecubital vein typically reaches the renal arteries from the aorta within 1 second. • For renal blood flow evaluation, serial dynamic images are acquired every 1 to 2 seconds for up to a minute. The kidneys are usually seen by 5 to 6 seconds from injection and show maximal activity in normal patients by 30 to 60 seconds. • Images are acquired at 15-60 seconds intervals for a period of 3-5 minutes when using 99mTc-DTPA and for 20-30 minutes when using 99mTc-MAG3. This phase allows for the best imaging of renal anatomy via parenchymal uptake. • Radiotracer activity usually starts appearing in the collecting system or urinary bladder by 4-8 minutes. Collecting system evaluation is accomplished after ambulating to promote pyelocalyceal system drainage or after a diuretic
  • 54.
    Three phases ofrenogram • The first phase is known as the vascular transit phase which represents radiotracer entering the kidneys. It usually lasts about 30 to 60 seconds. • The second phase is known as the tubular concentration phase or parenchymal transit phase normally lasts 1 to 5 minutes when radiotracer appears in the tubules. It is represented by a peak in the renogram. • The third phase is noted by a downslope in the renogram indicating excretion of the radiotracer from the kidneys and clearance from the collecting system. It usually starts at 4-8 minutes after radiotracer injection.
  • 55.
    Normal 99Tcm-Mag3 renalscan: There is symmetrical uptake of the radiotracer bilaterally with normal excretion indicated by radioactivity in the ureter and bladder. (red arrow= left kidney, green arrow=right kidney, yellow arrow=left ureter and black arrow=bladder).
  • 56.
    9Tcm-Mag3 renal scan:Time activity determined for each kidney, separately. Upper portion of diagram shows parenchymal and pyelocalyceal (excretion) activity; lowest portion shows cortical activity. Parenchymal and pyelocalyceal (PC) activity of the right kidney (RK) (green line); left kidney (LK) (dashed red line). Cortical activity, alone, RK (broken green line) and LK (dot&dashed red line). Upstroke (curved yellow arrow) within first 30 seconds post Mag3 injection indicates normal renal vascular flow. Peaks (green & red curved arrows) represent normal parenchymal transit from cortex to PC system. Gradual downsloping (yellow arrowhead) indicates radiotracer excretion from parenchyma to collecting system phase. After diuretic administration there is rapid downsloping of RK and LK parenchymal and PC activity indicating normal excretion. Bottom of graph, 2 sets of lines representing RK and LK activity in the renal cortices only. Upstroke (blue arrow= normal perfusion).
  • 58.
    • 9Tcm-Mag3 renalscan: Left kidney (LK) obstruction. A: Posteriorly acquired images of kidneys obtained every 30 seconds after radiotracer injection. Blue arrow=LK, yellow arrow=RK. Both kidneys are present. Renal parenchyma is seen bilaterally. Over exam course, there is normal emptying (disappearance of radiotracer) from the RK but no excretion from the LK (red arrow). B: Abnormal LK time activity curve: Green line=RK curve, Broken red line=LK curve. Normal RK upstroke (curved green arrow) to a peak, and normal downsloping. Broken red line=abnormal LK parenchymal transit seen as lack of peak, no excretion into the renal pelvis or ureter seen as lack of downsloping (curved red arrow).
  • 59.
    Mag-3 in obstructiveuropathy • When radiotracer excretion increases after the diuretic, the exam is interpreted as non- obstructive dilation. If after given a diuretic excretion is unaffected or shows little change, the diagnosis is obstructive uropathy. In obstructive uropathy, the renogram demonstrates continuous rising and little or no downsloping during the excretion phase. • A renogram may be flattened at the perfusion phase in cases of high grade-long standing obstruction which often leads to a decrease in renal perfusion. • A T1/2 calculation obtained from the renogram represents radiotracer activity falling to 50% of its maximum value. A clearance half time of more than 20 minutes usually indicates obstruction.
  • 60.
    A: Normal renal perfusioncurve (60 sec). B: Time activity curve over 30 minutes -. (Red line in the graph) shows persistent parenchymal activity without down sloping at 30 minutes indicating no radiotracer excretion
  • 62.
  • 63.
    MCUG • study ofchoice for diagnosing VUR and assessing the anatomy of the bladder and urethra. • Indications include UTI, antenatally or postnatally diagnosed hydronephrosis, and suspected PUV. • Images of the bladder that will allow for assessment of its wall characteristics and detection of structural abnormalities such as diverticula, ureteroceles or urachal abnormalities. These images should demonstrate whether there is any reflux into the ureters.
  • 64.
    Contraindication • Active urinarytract infection should be excluded before doing this invasive • investigation.
  • 65.
    • A catheteris placed via the urethra into the bladder using aseptic technique. • The bladder is filled with water soluble contrast under the pressure of gravity. • The amount of contrast used will vary according to the patient’s age and bladder capacity. • Bladder capacity for age [<2 y: weight × 7 ml, >2 y (age +2) × 30 ml)]
  • 66.
    Cyclic VCUG • Atsome institutions a single cycle of filling and voiding is performed. At others, two or three cycles are the routine. • This latter method, termed cyclic VCUG, has demonstrated greater sensitivity in detecting reflux, but results in a higher radiation dose compared to the single cycle method. • In all cases, care is given to minimizing the dose of ionizing radiation
  • 67.
    Technique • Oblique orlateral fi lm without the catheter is necessary to detect posterior urethral valves. • Films during filling phase are used to document bladder pathology and low pressure vesicoureteric reflux. • Early filling films should be obtained to identify a ureterocele, which may become compressed, on filling of the bladder. • If the child is unable to void, warm water applied to the perineum can induce voiding. Some children will not void on the fluoroscopy table despite a variety of maneuvers. In these cases, the micturition phase of the study is not possible and the sensitivity of the study to detect reflux is diminished.