Kidney disease in children

1. Prepared by: Areej nawara
Supervisor: Dr Hamaza Abdeljawad
The nursing care of children
with renal & urinary disorder

2. Renal structure and function
• Maintaining the composition and volume of the body fluids
in equilibrium
• Production of certain hormonal substance (e.g.,
erythropoietin)
• Remove wastes from bloodstream
• The nephrons Increase in number throughout gestation and
reach their full complement by birth but still Immature and
less effective

3. Renal structure and function
• Glomerular filtration and absorption are relatively low at
birth and do not reach adult values until 1-2 years
• Loop of Henle (site of the urine concentrating mechanism) is
short in the newborn which reduces the ability of the
newborn to reabsorb sodium and water. Concentrating ability
reaches adult levels by around 3rd month of age
• Amount of urine excreted In 24 hours depends on : fluid
Intake, state of kidney health, and age

4. Diagnostic tests
• Urine Culture (suprapubic aspiration)
Glomerular filtration rate: measured by the creatinine clearance test
(100ml/
BUN:
Is used to measure the amount of urea nitrogen in the blood
Tests glomerular function (N=5-20 mg/100ml)
Serum creatinine: 0.7-1.5 mg/100ml
Sonography & MRI

5. Diagnostic tests
• To visualize the sizes of kidneys, ureters
• Differentiate between solid or cystic masses.
• X-ray: KUB
• IVP: intravenous pyelogram
• CT scan: size & density of kidneys, adequacy of urine flow
• Cystoscopy: evaluate stenosis

6. Diagnostic tests
• Voiding Cystourethrogram (VCUG): (Is a technique for
visualizing person's urethra and urinary bladder while the
person urinates (voids) consists of catheterizing the person in
order to fill the bladder with a typically cystografin). evaluate
reflux In ureter
• Renal biopsy

7. Chief concern:
• Strong urine odor
• Diaper rash
• Family history (Renal disease)
• Pregnancy history(Nephrotoxic
drugs)
• Past illnesses (Recurrent UTI)
• Burning or cries during urination
• Blood in urine/ Frequency of
urination
• Abdominal pain/ Flank pain
• Enuresis
• Periorbital edema
• Poor appetite

8. Urinary Tract Infection (UTI)
• UTI is the presence of significant numbers of microorganisms
anywhere within the urinary tract
• May present without clinical manifestations
• Peak incidence between 2-6 years of age Female has greater risk
of developing UTI

9. Urinary Tract Infection (UTI)
• The likelihood of reoccurrence In female is 50%
• Prevalence of UTI In infants Is 3.7% in boys and 2% In girls
• Escherichia coli (80% of cases) and other gram-negative enteric-
organisms are most commonly causative agents

10. A number of factors contribute to the
development of UTI including:
• Anatomy of UT
• Physical properties of UT
• Chemical conditions properties of the host's urinary tract

11. Factors contributing to UTI
• Shorter urethra in females
• Uncircumcised males
• Incomplete bladder emptying (reflux, stenosis)
• Altered urine and bladder chemistry/ sterility
• Adequate fluid intake promote urine sterility Use of cranberry
juice Increased urine acidity and so prevent UTI

12. Extrinsic factors:
• Poor hygiene, use of bubble bath, hot tubs
• Bladder neck obstruction, chronic constipation, tight
clothing/diapers
• Altered Normal. Flora: antimicrobial agents
• Catheters

13. UTI: Assessment
• Any child with fever, dysuria, urgency should be evaluated for
UTI
• Clean-catch urine for culture & sensitivity
• UTI, urine Is positive for proteinuria due to bacterial growth
• Hematuria due to mucosal Irritation
• Increase WBC
• Urine pH is more alkaline (>7)

14. Clinical Manifestations of Urinary Tract Disorders
Neonatal Period (Birth to 1 Month Old)
• Poor feeding
• Vomiting
• Failure to gain weight
• Rapid respiration (acidosis)
• Respiratory distress
• Spontaneous pneumothorax or
pneumomediastinum Frequent
urination
• Screaming on urination
• Poor urine stream
• Jaundice
• Seizures
• Dehydration
• Other anomalies or stigmata
• Enlarged kidneys or bladder

15. Clinical Manifestations of Urinary Tract Disorders
Infancy (1 to 24 Months Old)
• Poor feeding
• Vomiting
• Failure to gain weight
• Excessive thirst or Frequent
urination
• Straining or screaming on urination
• Foul-smelling urine
• Pallor
• Fever
• Persistent diaper rash
• Seizures (with or without fever)
• Dehydration
• Enlarged kidneys or bladder

16. Clinical Manifestations of Urinary Tract Disorders
Childhood (2 to 14 Years Old)
• Poor appetite
• Vomiting
• Growth failure
• Excessive thirst
• Enuresis, incontinence, frequent
urination
• Swelling of face
• Seizure
• Pallor
• Fatigue
• Blood in urine
• Abdominal or back pain
• Edema
• Hypertensin
• Tetany
• Painful urination

17. DIAGNOSTIC EVALUATION
Urine culture
First morning urine specimen
• Clean catch mid stream
• Specimen
• Collection bag
Supra pubic aspiration
Bladder catheterization

18. DIAGNOSTIC EVALUATION
Urinalysis
• Increased number of RBC
• Nitrate test positive
• Significant bacteriuria

19. Renal ultrasound
• USG
• VCUG
• GU anatomy
• IVP
• GU tract anatomy
• Pelvi calceal dilatation
• Hydronephrosis Renal scarring
• Dipstick tests

20. Uti classification
Classification of UTIs
Level of
complex
Sit of
Infection
Type of
Infection
Symptoms of
Infection
Uncomplicated
Complicated
Lower Tract
Infection
Upper Tract
Infection
Acute
Infection
Chronic
Infection
Asymptomatic
Symptomatic

21. UTIS Classification (Cont.)
Lower UTI:
• Cystitis
• Prostatitis
• Urethritis
Upper UTI:
• Acute pyelonephritis
• Chronic pyelonephritis
• Interstitial pyelonephritis
• Renal abscess
• Perirenal abscess.
Both upper & lower UTI are
further divided into complicated and
uncomplicated.

23. UTI: Management
Identify contributing factors to
Eliminate the infection
Reduce the risk of recurrence
Prevent urosepsis
Preserve renal function
7-10 days antibiotics matching organism sensitivity
(penicillins, sulfonamide, cephalosporins, tetracyclines)

24. UTI: Management
Mild analgesics/ antipyretics
Increase fluid intake: flush out Infection
Clean-catch urine after 72 hrs to assess effectiveness
For recurrent UTI, prophylactic antibiotics for 6 months.

25. Nursing Care
Education regarding prevention & treatment
 Instruct parents to observe for clues that suggest UTI
Incontinence in a toilet-trained child Strong-smelling
urine

26. Frequency
Preventive Strategies for Urinary Tract Infections
Provide education to parents about strategies to reduce the
risk for urinary tract Infections, including the following:
Teach proper perineal hygiene. Girls should always wipe
the perineum from front to back after voiding
Encourage the child to drink plenty of fluids and avoid long
periods of holding urine

27. Frequency
Caution against tight underwear; children should wear cotton
rather than nylon underwear.
 Encourage the child to void more frequently and to fully
empty the bladder.
 Discourage bubble baths and hot tubs, which can imitate the
urethra
• Encourage abstinence of sexual activity. However, il girls are
sexually active, Instruct them to void before and after sexual
Intercourse to prevent urinary stasis and flush out bacteria
introduced during Intercourse

28. Acute Glomerulonephritis (AGN)
Inflammation of the Glomeruli occurs as
an immune complex disease after infection
Common in school age children
1-2 weeks After Streptococcal Infection
(sore throat) antibodies are formed, an
immune complex reaction is then occurs
after a period of time which become
trapped in the glomerular capillary loop

29. Types of Glomerulonephritis
Most are postinfectious
 Pneumococcal, streptococcal, or viral
May be distinct entity or May be a manifestation of a systemic
Disorder
SLE
Sickle cell disease
Others

30. Acute Poststreptococcal Glomerulonephritis (APSG)
• Is a noninfectious renal disease (autoimmune)
• Onset 5 to 12 days after other type of
• Infection
• Often group Aẞ-hemolytic streptococc Most common in
children 6 to 7 years old
• Uncommon in children younger than 2 years old
• Can occur at any age

31. Clinical manifestations
• Tea-colored urine
• Anorexia
• Joint stiffness & pain
• Lab Results
• Urine analysis: ↑ WBC, epithelial cells, RBC casts
• Proteinuria
• Serum ↑ BUN, creatinine, ESR, decreased Hgb
• Hypoalbuminemia
• Serum ASO titers may be elevated

32. Acute Glomerulonephritis Classical
Symptoms:
•Fluid retention
•Periorbital edema
•Diminished unrinary output
•Dark tea-colored urine
•Elevated blood pressure.

33. Management
• Usually resolves spontaneously, treatment is focused on relief of
symptoms.
• Antibiotics, such as penicillin to destroy any streptococcal bacteria
that remain in the body
• Antihypertensive medications and diuretic medications to control
swelling and high BP
• Dietary salt restriction may be necessary to control swelling and
high blood pressure
• >90% recover from AGN

34. Complications
•Acute/chronic renal failure
•Hyperkalemia
•Nephrotic syndrome
•Chronic glomerulonephritis
•Hypertension
• Congestive heart failure or pulmonary edema (inspiratory
crackles)

35. Nursing Diagnosis
•Fluid volume excess r/t decreased U.O.
•Risk for impaired skin integrity r/t edema and decreased
activity
• Anxiety r/t hospitalization, knowledge deficit of
• Disease

36. Prognosis
•95%-rapid improvement to complete recovery
•5% to 15%-chronic glomerulonephritis
• 1%-irreversible damage

37. Management
•No added salt diet & Fluid restriction
•Q4h BP & Daily weights
•I&O

38. Nephrotic syndrome
INTRODUCTION:
•Nephrotic syndrome is a group of symptoms which is
seen in any condition that seriously damages the
glomerular capillary membrane, causing increased
glomerular permeability with loss of protein in urine.

39. Nephrotic syndrome
INTRODUCTION:
•Nephrotic syndrome is a group of symptoms which is
seen in any condition that seriously damages the
glomerular capillary membrane, causing increased
glomerular permeability with loss of protein in urine.

40. Nephrotic syndrome
INTRODUCTION:

41. DEFINITION:
• Nephrotic syndrome is a
group of symptoms
characterized by
proteinuria (>3.5 grams
per day), low blood
protein levels, high
cholesterol levels, and
edema.

42. INCIDENCE:
• All ages can be affected.
• Most common during 2 to 6 years.
• Affects male more than female.

43. Forms of NS
• Minimal Change Nephrotic Syndrome
(MCNS)
• Idiopathic
• 80% of all cases
• Good prognosis
• Secondary to another disorder
• Congenital: autosomal recessive gene

44. PATHOPHISIOLOGY:
• The glomerular basement membrane is negatively charged layer.
• Due to antibody attack or other causes, this property is lost which
allows proteins especially albumin to pass through glomerular
membrane.

45. PATHOPHISIOLOGY:

46. CLINICAL FEATURES:
• Excessive weight gain, edema – peri-orbital initially, then in
extremities, increases in the morning.
• Ascites
• Scrotal/labial swelling may be present.

47. CLINICAL FEATURES:
• Urine changes;
 decreased volume
 Frothy and pallor
• Edema of intestinal mucosa may lead to loss
• Of appetite, poor intestinal absorption.

48. Contd..
• Fatigue, lethargic, irritability. Blood pressure may be normal or
slightly Decreased due to decreased intravascular Volume
• Susceptibility to infection increases Dyspnea may be seen due to
pleural effusion, Ascites and other type of fluid.

49. DIAGNOSIS:
•HISTORY TAKING:
• Family history
• Birth history
• Antenatal history

50. PHYSICAL EXAMINATION:
INVESTIGATIONS:
•Urinalysis
•Serum tests
•Hematology
•Kidney biopsy
•KUB X-ray
•USG
•Edema can be seen
•INVESTIGATION AND
FINDINGS:

51. Urinalysis:
•Shows marked proteinuria, cast, few RBCs, increased
urine specific gravity
•24 hrs. urinary protein excretion: >50 mg/kg/day

52. Serum:
• Markedly decreased
serum protein (albumin)
• High cholesterol (450-
1500 mg/dl)
• Hyponatremia
CONTD:
• Hematology
• Normal or increased hemoglobin level
• High platelet count
• Kidney biopsy
• Done if there is recurrent relapses, non
responsive to treatment

53. COMPLICATIONS:
• Blood clots / venous thrombosis
• Poor nutrition
• High blood pressure
• Acute kidney failure
• Chronic kidney failure
• Infections

54. TREATMENT:
Goals of management:
• Reduce urinary protein excretion.
• Reduce fluid retention.
• Prevent infections and complications.
• Pharmacological treatment:
• Diuretics : Frusemide, spironolactone
• Corticosteroids : Prednisolon

55. TREATMENT:
Goals of management:
Albumin Infusion :
• Immune suppressant therapy: For child who continue to have
proteinuria (+2 or more) after 8 weeks of steroid therapy are
treated with immune suppresant therapy such as
cyclophosphamide.

56. Nursing managements:
Monitor edema urine characteristics, albumin, I/O , abdominal girth,
daily weight, etc.
Administer medications such as diuretics. Antibiotics and
corticosteroid as ordered.
Improve nutritional status.
Low sodium diet
High calorie and high protein diet
Small and frequent feeding

57. Nursing managements:
Contd..
• Encourage activities and exercise.
• Maintain skin integrity
• Provide skin care.
• Change position every 2 hrs.
• Check for skin break down.
• Prevent and manage side effects of steroid therapy.

58. Discharge plan and home care teaching.
• Cut down on salt. This can reduce the amount of water your body
retains.
• Follow your doctor's advice for the amounts of protein and
potassium you need in your diet.
• Wash your hands often, especially before eating and after being in
public places.
• Avoid people who are sick.
• Use mild soaps, such as Dove or Cetaphil.
• Use moisturizing lotion after you bathe. You can use it more often
if your skin is dry. Choose a lotion with no alcohol.

59. Acute Kidney Injury (AKI): Definition
• Formerly referred to as acute renal failure (ARF).
• Defined as an "sudden deterioration in kidney function results in
the inability to maintain fluid and electrolyte homeostasis"

60. ETIOLOGY
•Pre renal
•Intrinsic or renal
• Post renal
• Both pre and post renal aki are potentially reversible in early
stages but if prolonged can cause renal parenchymal damage.
•Pathagansis

62. Clinical manifestations
•Azotemia: accumulation of nitrogenous waste (Blood
Urea Nitrogen (BUN)) within
•The blood
•Circulatory congestion/ hypervolemia

63. Electrolytes abnormalities:
•Increased K(potassium level > 7mEq/L) & phosphate
•Decreased Na+ (seizures) & calcium
•Metabolic acidosis, hypertension
•Oliguria: output < 1ml/kg/hr; Anuria: no urinary output in
24 hours
•Nausea, Vomiting, Drowsiness

64. PHYSICAL EXAMINATION :
Obtaining a thorough physical examination is extremely
important. Clues may be found in any of the following –
•Skin
•Eyes
•Ear
•Respiratory system Cardiovascular system
•Abdomen

65. PHYSICAL EXAMINATION :
•Ear Hearing loss – Alport disease and aminoglycoside
toxicity
•Mucosal or cartilaginous ulcerations – Wegener's
•Granulomatosis
•Respiratory system :- rapid and deep breathing – met.
•Basal creps – volume overload

66. PHYSICAL EXAMINATION :
• Acidosis
• Cardiovascular examination:
• Pericardial friction rub – Uremic pericarditis
• Increased JVP, Gallop rhythm, pitting edema – CHF due to volume overload.
• Abdomen:
• Renal angle tenderness – nephrolithiasis, papillary necrosis, renal artery or vein
thrombosis.
• Distended bladder – urinary obstruction.
• Chronic liver disease with ascites with prerenal aki – hepatorenal syndrome

67. PHYSICAL EXAMINATION :
• Ultrasound of KUB
• Evaluates renal size, able to detect masses, obstruction, stones
• Chest x-ray DTPA DMSA BENAL BIOPSY Indicated in
• Patient in whom the etiology is not identified.
Unremitting AKI lasting longer then 2-3 wks or in *assessing the extent of renal damage
and outcome.
Suspected drug induced AKI in a patient receiving therapy with a potentially nephrotoxic
drugs.

68. Acute Renal Failure (ARF):
Management
• Treat the underlying disease
• Management of the complications
• Provision of supportive therapy
• Strictly monitor intake and output (weight, urine output, insensible losses, IVF) &
monitor serum electrolytes
• Adjust medication dosages according to GFR

69. Nutrition
• Provide adequate caloric intake
• Limit protein intake to control increases in BUN
• Minimize potassium and phosphorus intake
• Limit fluid intake
• If adequate caloric intake can not be achieved due to fluid limitations,
some form of dialysis should be considered

70. PREVENTION OF AKI
• Important measures includes prompt rehydration therapy in acute
diarrhea, avoidance or judicious use of nephrotoxic drugs.
• Maintenance of proper hydration for patients undergoing diagnostic
procedures with radio contrast media.
• Forced diuresis along with the use of allopurinol is effective
preventing AKI in patient.

71. PREVENTION OF AKI
• CHRONIC RENAL FAILURE
• *CRF: refers to irreversible renal dysfunction as manifested by the
ability of the kidneys to excrete sufficient fluid and wastes products
from the body to maintain health.
• *CRF is fatal if it is not treated.
• CRF is a progressive process, stages are defined by categorizing how
much renal function remains.

72. ETIOLOGY:
• Under 5 yr. (most commonly Congenital abnormalities)
• Renal Hypoplasia
• Renal Dysplasia
• Obstructive Uropathy
• Congenital Nephrotic Syndrome
• Prune Belly Syndrome
• Cortical Necrosis
• Polycystic Kidney
• Renal Vein Thrombosis

73. ETIOLOGY:
• Hemolytic Uremic Syndrome
• AFTER 5 YRS (ACQUIRED AND INHERITED DISORDERS)
• Glomerulonephritis
• Nephronophthisis
• Alport Syndrome
• Polycystic Kidney Disease
• Throughout Childhood years
• Cystinosis
• Hyperoxaluria

74. PHYSICAL EXAMINATION
• Pallor & sallow appearance
• Short stature
• Bony abnormality of renal osteodystrophy
• Edema

75. LABORATORY FINDINGS
• Elevated BUN and creatinine
• Hyperkalemia
• Hyponatremia
• Acidosis
• Disadvantages
• Systemic anticoagulation (except citrate) Frequent filter clotting
Vascular access in infants

76. LABORATORY FINDINGS
• Hypocalcemia
• Hyperphosphatemia
• Elevated uric acid
• Hypoproteinemia (if proteinuria) Normocytic, normochromic
anemia
• Elevated serum cholesterol and triglyceride
• Hematuria & Proteinuria(glomerulonephritis)
• Hypertension

77. NUTRITION
• Progressive restriction of various dietary components
• Dietary restriction of phosphorus, potassium and sodium
• RDA of caloric intake for age
• Protein intake 2.5g/kg/day
• High biologic value protein (egg, milk, meat, fish, fowl) *
Supplement carbohydrate, fat (MCT) and protein (pro-Mod)

78. NUTRITION
• Nasogastric, gastrostomy, or gastrojunal tube feeding Continuous
overnight infusions
• Water soluble vitamins, routinely supplied
• Zinc and iron only if deficiency
• Supplement with fat soluble vitamins – usually not required

79. Types Of Dialysis
• Peritoneal Dialysis
• Acute Intermittent Hemodialysis
• Continuous Hemofiltration

80. Advantages (Peritoneal Dialysis)
• Simple to set up & perform.
• Easy to use in infants
• Hemodynamic stability
• No anti-coagulation
• Bedside peritoneal access
• Treat severe hypothermia or hyperthermia

81. Disadvantages (Peritoneal Dialysis)
• Unreliable ultrafiltration
• Slow fluid & solute removal
• Drainage failure & leakage
• Catheter obstruction
• Respiratory compromise
• Hyperglycemia
• Peritonitis
• Not good for hyperammonemia or
intoxication with dialyzable poisons

82. Intermittent hemodialysis
Advantages
• Maximum solute clearance of 3
modalities
• Best therapy for severe
hyperkalemia
• Limited anti-coagulation
• Time
• Bedside vascular access can be
used
Disadvantages
• Hemodynamic instability
• Hypoxemia
• Rapid fluid and electrolyte shifts
• Complex equipment
• Specialized personnel
• Difficult in small Infants

83. Intermittent hemodialysis
Advantages
• Easy to use In PICU
• Rapid electrolyte correction
• Excellent solute clearances
• Rapid acid/base correction
Advantages
• Controllable fluid balance
• Tolerated by unstable pts.
• Early use of TTP
• Bedside vascular access
• Routine

84. Intermittent hemodialysis
Disadvantages
• Systemic anticoagulation (except citrate)
• Frequent filter clotting
• Vascular access in Infants

85. Prevalence of pediatrics dialysis in Palestine
Prevalence of pediatric dialysis among pediatric age group is about
23/2500.000, mean age of patients is 12.4, 60.9% are males, 34.8% are
from Nablus, 11 on HD, 54.5% of HD patients have CVC. 90.9% of HD
patients uses heparin during dialysis, 36.4% of them complains of
hypotension during sessions, 12 patients are on PD, 25% of them
complains from abdominal pain during sessions, 8.3% (N-1) of PD
transfer to peritoneal from CVC because it is cost effective, 45.5% of PD
transfer to peritoneal from CVC because it is more comfortable, 18.8%
of HD transfer to shunt from CVC because it is more comfortable, 27%
of HD transfer to shunt from CVC because it is obstructed,

86. Prevalence of pediatrics dialysis in Palestine
Congenital nephrotic syndrome is the cause of ESRD in 30% of our sample, 56.5%
diagnosed of their disease at infancy period between (0-1) year old, mean age of
onset of dialysis: 10 years old, 43.5% of patients have chronic comorbidities, 60.9%
of patients have been admitted to the hospital since they started dialysis, 17.4%
(n=4) of patients have four family member with history of congenital kidney
disease, 56.5% (n=13) their school performance was affected because of dialysis,
52% of patients parents believe in and used alternative medicine, 50% of those
patients who tried alternative medicine had improvement in their life and energy,
61% of the patient's parents had primary education and 39% had secondary
education, 66% of patients who tried and believed in alternative medicine had
primary education and 34% of them had secondary education.

87. Reference
Keenan-Lindsay, L., Sams, C., O'Connor, C. L., Perry, S. E., Hockenberry, M. J.,
Lowdermilk, D. L., & Wilson, D. (2021). Maternal Child Nursing Care in
Canada-E-Book. Elsevier Health Sciences.
Misra, O., Prabhu, S., & Singh, S. (2016). Nelson Essentials of Pediatrics:
First South Asia Edition. Pbl Elsevier Health Sciences, 804.
leifer, G., ( 2018) . introduction to maternity and pediatrics nursing - E-Book
Hockenberry, M. et al (2018). Wong's essentials of pediatric nursing, 10
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