Definition
VUR is the retrograde fow of urine from the bladder
to the ureter or kidney.
Etiology:
1-Primary: Congenital incompetence of the valvular
mechanism of vesicouretral junction,duplication of ureters,
etc.
2- secondary:
•Infammation: cystitis (transient VUR)
•Calculi
•increas intravesical pressure: posterior urethral valve,
neurogenic bladder.
•Bladder surgery.and injured the sphenector
🔹
Clinical manifestations
VUR is usually discovered during radiological evaluation of
urinary tract infection e.g. voiding cystourethrogram ARF is a clinical syndrom e in w hich a sudden deterioration in
🔹
(VCUG).Usually patient complain from recurrent UTI
VUR is classified in to 5 grades according to its severity and
Vesicouretral Refux
renal function results in the inability of the kidneys to maintain
fluid and electrolyte homeostasis.
🔹
Natural history
Grades I and II and 50% of grade lll: >80%
the degree of urethral dilatation and calyceal deformity. It characterized by:
– Oliguria or anuria
🔹
resolve spontaneously with maturation.
Grades IIll, IV, and V: only 15% resolve
spontaneously
– Electrolyte& acid base disturbances (hyperkalemia and
metabolic acidosis)
🔹 يعني نص حاالت الدرجة الثالثة تتعالجي لحالها و نص – Impaired excretion of substances such as creatinine ,urea and
phosphate
يدخل في مضاعفات
Etiology:
🔹
Consequences of VUR 🔷
🔹1) PRERENAL CAUSES:
🔹
Incomplete emptying of ureter and bladder
🔹Blood loss:acute hemorrhage
Plasma loss: burns
🔹Fluid loss: dehydration due to:ّ
predispose to urinary tract infection (UTI).
🔹 Renal scarring (reflux nephropathy)
Hypertension and/or end stage renal failure
(particularly with grades IV-V) ▪ Diarrhea خمس أيام وماتعالج أوعوض سوائل,
▪ vomiting, fever
Treatment
🔹 Grades I-III VUR+ normal nephrosonogram: 🔹
▪ Diabetic ketoacidosis
🔹Hypoalbuminemia
Give long term prophylactic antibiotic therapy (Co-
trimoxazole or nitrofurantoin once daily at dose of 🔹Septic shock,
🔹Heart failure
Hypoxia:
1/4-1/3 of dose treated UTI) + frequent urine
culture (every ▪ Pneumonia
🔹
1-3 months).
Prophylaxis is usually continued until reflux
▪ Respiratory distress syndrome
🔶
🔹
resolves
Surgical intervention is indicated for: Grades IV
🔷
🔹2)Glomerulonephritis:
INTRINSIC RENAL CAUSES: 🔹 A) Manifestations of the underlyingetiology:
1)Prerenal: dehydration, hypovolem ia, shock,heart
%V, and 50% of grade III (persistent refux or failure
of prophylaxis)
▪ Postinfectious / postsreptococcal
▪ Lupus erythematous
🔹
failure,etc.
2)Renal: acute glom erulonephritis, hem olytic-urem ic
▪ Henoch–schőnlein purpura 🔹
syndrom e etc.
3) Postrenal: congenital anom alies, tum
ors,calculi,stricture,hem aturia w ith clots, etc.
Urinary tract infections (UTI) are the most common genitourinary disease of 🔹
▪ Membranoproliferative
🔹Acute tubular necrosis
childhood.
🔹Cortical necrosis 🔶 B) Manifestations of acuterenal failure:
Prevalence of UTI: depends on age and sex:
Neonatal period: symptomatic UTI occur in 1.5/1000. Males are commonly 🔹
🔹
Hemolytic-uremic syndrome
Renal vein throm bosis
1-Decreased urine output:oliguria or anuria
2-Edema (due to salt and w ater retention) .
affected.
Thereafter: 🔹 Rhabdomyolysis
🔹Tumor lysis syndrome
Acute interstial nephritis Clinical manifestations
➢Manifestations of the underlying etiology
3-Pallor (due to anemia)
4-Hypertension (due to ↑ salt and w ater retention,and ↑ secretion
UTI can occur at any age, mostly in children < 3 years.
Clinical manifestations &classification of rennin) it m ay progress to hypertensive encephalopathy.
🔷
Girls: boys = 10: 1 (prerenal,renal or postrenal)
1. Pyelonephritis: 5-Uremic encephalopathy: lethargy, drowsiness
It characterized by any or all of the following:
- Abdominal or fank pain, fever, malaise, nausea and vomiting Toxic, shivering and
About 5% of girls have at least one UTI prior to puberty
At any time 1-2% of apparently healthy school girls have an active UTI 🔹
🔹
3) POSTRENAL:
Posterior urethral valve
➢Manifestations of acute renal failure
➢Manifestations of complications
6-GIT :anorexia,nausea,vomiting.
7- Acidotic breathing.(deep rapid)
voiding
-Acute pyelonephritis may result in renal injury, which is termed pyelonephritic
🔹 Predisposing factors Acute Renal Failure 🔹
🔹
Uretropelvic junction obstruction
Uretrovesicular junction obstruction
8- Manifestations of electrolyte disturbances:
• Hyperkalemia: weakness, paraesthesia.
scarring. Some newborns and infants may show non specific symptoms such as
(poor feeding, fever, jaundice, irritability, weight loss and diarrhea)
•Female, wiping from back to front
•Uncircumcised males 🔹
🔹
Ureterocele
Tumor
• Hypocalcemia : tetany,convulsions
• Hyponatremia : convulsions (dilutional hyponatrem ia)
•Vesicoureteral reflux
•Toilet training
Renal disease 2 🔹 Urolithiasis
🔹Neurogenic bladder 🔶
Hemorrhagic cystitis
2.Cystitis: •Voiding dysfunction C) Manifestations ofcomplications of ARF:
indicates that there is bladder involvement. Symptoms include: •Obstructive uropathy – Congestive heart failure and pulmonary edema (due to
Dysuria, urgency, frequency, suprapubic pain, incontinence and malodorous urine •Pinworm infestation Albendazole أول ما نعالج الطفل يتحسن volume overload)Hemorrhage
•Urgency and frequncy common in female , so when we see it in male that's mean – Gastrointestinal hemorrhages (due to stress ulcers or
there is complication or abnormalites •Constipation
•Congenital abnormalities gastritis)
3. Asymptomatic bacteriuria: 🔹 Chemicales •الي تعمل مي و صابون و تدخل الجاهل تخليهم يبلط؟ – Arrhythmias (ventricular fibrillation→death)Hyperalemia
Refers to individuals who have a positive urine culture without any manifestations
of infection and occur almost exclusively in girls, the condition is benign and does
🔹 Routes of infection:
-Ascending : (commonest routes)In chidren
– Behavioral changes ,seizure ,coma
not cause renal injury. 2-Nutrition
Large proportion of children with UTI are Asymptomatic 🔹
-Hemotogenous: (common in neonatal period)
Causative organisms:
•In girls: Escherichia coli, klebsiella,proteus.
3-
Hyperkalemia
•In boys: Escherichia coli, proteus, staph.Saprophyticus
🔥 most common is E.coli سؤال هدية من الدكتوره االم الماضي لذلك نركزعليه
🔹Pathogenesis قالت اقرءوه قرايه III. Treatment of specific problems :
🔷 1-Fluid therapy:
1🔹Rapid screening tests for UTI: 🔹
For patient with oliguria + normal intravascular volume: (Not have hypervolemia)
🔹 Restrict fluid : daily intake =volum e of urine of previous 24hours +insensible w ater loss (400 m l/m 2/24hours)
a.Dipstick nitrite test: detects nitrites produced by reduction of
urinary nitrates by bacteria. A positive test = bacteruria .False negative results may occur 🔹IfFluid
there is fever add another 75 m l/m 2/each degree centigraderise
is given as 10-30 % glucose solution (without electrolytes ) given slowly IV or orally (if tolerated)
• M 2 = √ high in cm ×body weigh in kg/3600
B.dipstick leukocyte esterase test : it detect the presence of WBCs not bacteria
Investigations
2 🔹Urine analysis:
•color : may be reddish if blood is present
1.Complete blood picture:
• Anemia :dilutional ,or HA.
عشان√ •نوجد المتر المربع3600 يعني تحت الجذر التربيعي للطول بالسم والوزن بالكجم قسمه
✳️
(For patient with oliguria or anuria + fluid overload there is no insensible loss and urin not changed )
🔷2-Nutrition
More severe restriction of fluids Daily intake =losses in urine ,stools and vomitus only
•Aspect: turbidity due to pyuria (turbidity persists if urine is warmed and acidifed ) • Leukopenia (in SLE nephritis )
•Odor : strong coliform odor • Throm bocytopenia (in SLE ,HUS, renal veinthrom bosis Management of ARF
🔷3- Hyperkalemia
•Proteins : mild proteinuria
•Sediment :
2.Renal function parameters:
• Blood urea nitrogen (B U N ):
I. Hospitalization and monitoring
II.Treatment of the etiologicfactor:
|||. Treatment of specific problems
🔷4- Sever acidosis ( PH <7.15 & bicarbonate<12 mEq /liter):
↑• Serum creatinine: • Sodium bicarbonate IV Its reduce the ionized calcium to ↑ arterial pH to7.20 (or ↑sod. bicarb.to 12 m Eq/liter)
🔸
Pyuria (5 or more WBCs/HPF in the sediment of centrifuged
urine sample or 10 or more WBCs/ mm3 of uncentrifuged
urine ,using counting chamber)
↑• Serum U ric acid :↑ All uria and creatinine and urea
nirogen increased due to decreased renal excretion
🔶 A- Prerenal Causes: By I.V line urgent correction of hypovolemia, hypotension
using the following formula:
If less than 12m Eq We just Partialy corrected up to 12m Eq But if its more than 12 we don't corrected (mEqN
Pyuria is not diagnostic, it may be absent in active UTI, on the
other hand, it can be present with febrile illnesses or dehydration or with glomerulonephritis Presence 3. Serum electrolytes:
🔸If after correction there is still no voiding, give N .saline 20 ml /kg/ over 30 min. voiding
and/or hypoxia
HCO3 required = 0.3X Wt (in kg) X (12 – HCO3[mEq/l] )
• Rapid correction → tetany and vol.overload
of bacteria in fresh uncentrifuged sample (one organism/HPF represents 10' colonies/ml) • Serum sodium :↓ due dilutional hyponatremia
🔹
3 Urine culture ,colony count and anitbiotic sensitivity testing :
• Serum potassium :↑due decreased excretion and increased K
+ from cells and acidosis
➢If NO voiding occurs in spite of good hydration: (Use furosemide ± Mannitol) as
follows
Furosemide: 2m g/kg at a rate of 4m g/m inutes (onset of action m ay be delayed for
🔷 5- Hypocalcemia + hyperphosphatemia:
↓
Hypocalcaem ia treated by serum phosphorus using "phosphate-binding calcium carbonate antacid " Excrete the
a. Sample obtained by sterile suprapubic puncture or sterile catheter:
• Serum phosphates : ↑due decreased excretion
🔷
The finding of any number of bacteria indicates infections several hours ) phosphorus which Is the cause of hypocalcemia ,Calcum Take by mouth except in case of tetany
b. Voiding sample (properly obtained and promptly cultured): Diagnosis of UTI • Serum calcium : ↓Secondary to increased phosphate ➢If No response we can give a second dose 10 m g/kg (once only ) 6- Hyponatremia :dilutional hyponatremia Fluid restriction will manage most cases
•A count of >100,000(more or equal)colonies/ml of single organism =significant bacteruria &indicates Diagnosis of UTI is made by finding significant bacteruria in a properly collected 4 .Blood PH: metabolic acidosis Mannitol (single dose of 0.5 g/kg of a 20% solution ,IV over 30 m inutes )in addition to or • If serum N a <120 m Eq/liter :give 3 % sodium chloride to↑ serum Na to 125 m Eq/liter: We corrected if less than 125m
UTI urine sample. 5 Urine: may contain RBCs,protines,casts in intrinsic renal ARF in place of furosemide Eq
6 ECG: evidence of electrolyte disturbances (hyperkalemia or
🔶
•A count of less than 10,000 colonies/ml indicates contamination of urine by urethral, periurthral, Urine should be cultured with in ١/٢ hour or kept refrigerated at 4c not more • Normal value of Na+ 135-145mEq mEq Nacl required = 0.6 X BW (kg) X (125-serum Na[ mEq /L] )
arrhythmias)
🔷
vaginal,or perineal skin fora. than 24 hours B- For urinary tract infection: antibiotics (better avoid antibiotics secreted by
•A count between 10.000 and 100.000 /ml: you should repeat sampling by catheter or suprapupic 7.chest radiogram: pulm onary congestion, cardiom kidney,if used,their doseshould be adjusted based of renal function). 7- gastrointestinal bleeding: like stress ulcer
aspiration and repeat culture How can we obtain a clean properly collected urine sample for Urinary tract infections
egaly,pulm onary edem a.
8.Studies for detection of underlying cause:
🔶 C- Post renal causes: surgical interference to remove obstruction, nephrostomy, – Prevention :by calcium carbonate antacids
1 Localization of the site of UTl:
examination and culture ?
First wash the perineum and genitalia with soap and water then steriized by
• Renal ultrasonography :to show size of kidney (shrunken ,
enlarged,etc..)
etc.
🔷
– IV cim etidine 5-10m g/kg/12 hour
🔷 8 Hypertension: See treatm ent of acute postsreptococcal GN .
12- indications of peritoneal or hemodialysis:
it is an upper (pyelonephritis ) or lower ( cystitis) UTI? This is
nornal saline Or sterling water • IVP & Radionuclide scan (after recovery) 🔷 9 Circulatory congestion and heart failure: See treatm ent of APS GN
10 Seizures:
🔹
usually difficult However •the following are in favour of upper UTI (pyelonephritis): 🔹
Voiding sample:
🔹 Urinary bladder catheterization:or bag, must be certain numbers of bacteria
• Cystoscopy,VCUG , and retrograde pyelography. – Correction of the cause :as hyponatremia, hypocalcemia ,etc
🔹
🔹
1.High fever and toxic look
2.Renal angle tenderness
suprapubic bladder aspiration (in neonates & young infants): Any number of
bacteria is positive infection 🔷
– Diazepam (0.1 - 0.3 mg/kg/dose,IV )
11- Anemia:
🔹
🔹
3.Leukocytosis
4.Bacteremia
• Mild dilutional anemia ( Hb 9-11g/dl) requires no treatment If we corrected the fluids the anemia will corrected
• Blood loss from active bleeding should be replaced by fresh blood.
🔹 5.Urinary white cell casts
6.High ESR
•Blood culture:
• Hemolytic anemia with H b <7g/dl: fresh packed red cells (10m l/kg). لوعملنا كل هذه العالجات والزال ماتحسن المري ض واليوريا
والكرياتينين عاليين هنا •بيدخل بغسيل كلوي
Done for neonates and young infants *due hematogenous transmission
•Renal function studies :
🔹
In acute pyelonephritis:may be mild increase of blood urea and serum creatinine
7- Imaging studies
•Renal & bladder ultrasonography
•Voiding cystourethrography (VCUG) is done after treatment in all males and for females
under 5 years of age or having UTI for the 2nd time
•Renal scintigrphy with dimercaptosuccinic acid (DMSA) for demonstrating scarring.
*It show if the infection Acute or chronic, Necessary in Asymptomatic patients, in acute
disease show decrease absorbtion of dye While in chronic show scarring in kidney tissue
""طبعًا مش موجود عندنا
DMSA The right kidney show
scarring That indicates the chronic disease
Antibiotic therapy:
- For newborns : 10-14 days parenteral antibiotics
-For older children with cystitis: oral antibiotic for 1 week (Amoxicillin or Co-
trimoxazole)
- For older children with suspicious pyelonephritis :
•Start with parenteral broad- spectrum antibiotics until high fever and toxicity
disappear then
•Continue with an oral antibiotic( according to results of culture) to complete
14 days
prophylactic antibiotics:
Co-trimoxazole bactrim drug (% of therapeutic dose) should given if recurrences
are frequent or if imaging studies prove the presence of VUR
1-General supportive measures
Hydration,alkinazation of urine with oral sodium Citrate or bicarbonate, prevent Treatment
residual urine, symptomatic treatment of fever and pain,treatment of 1.Antibiotics
by fatema okoff hypertension andlor renal failure (if present)
2-Follow -up evaluation of the urinary tract
2.General supportive measures
3.Follow_up evaluation of urinary tract
-Repeated urine culture. 4.treatment of predisposing factors (if any )
-Radiological evaluation.
-Renal ultrasonography.
1 Treatment of predisposing factors (if any):
as VUR, calculi, obstructive lesions, etc
Prognosis of UTI
Long term prognosis for promptly & adequately treated UTI is
excellent.
Chronic or recurrent UTI can occur in the presence of predisposing
🔹
factors: Inadquate therapy for the acute attack of UTI"
🔹 Presence of vesicoureteral reflux.
🔹
🔹
Presence of congenital or acquired urinary tract obstruction.
Foreign bodies or indwelling catheter
🔹
🔹
Urinary schistosomiasis.
Neurogenic dysfunction of bladder.
Individual susceptibility of uroepithelial cells to adherence of E
coli.
VUR is the retrograde fow of urine from the bladder
to the ureter or kidney.
Etiology:
1-Primary: Congenital incompetence of the valvular
mechanism of vesicouretral junction,duplication of ureters,
etc.
2- secondary:
•Infammation: cystitis (transient VUR)
•Calculi
•increas intravesical pressure: posterior urethral valve,
neurogenic bladder.
•Bladder surgery.and injured the sphenector
🔹
Clinical manifestations
VUR is usually discovered during radiological evaluation of
urinary tract infection e.g. voiding cystourethrogram ARF is a clinical syndrom e in w hich a sudden deterioration in
🔹
(VCUG).Usually patient complain from recurrent UTI
VUR is classified in to 5 grades according to its severity and
Vesicouretral Refux
renal function results in the inability of the kidneys to maintain
fluid and electrolyte homeostasis.
🔹
Natural history
Grades I and II and 50% of grade lll: >80%
the degree of urethral dilatation and calyceal deformity. It characterized by:
– Oliguria or anuria
🔹
resolve spontaneously with maturation.
Grades IIll, IV, and V: only 15% resolve
spontaneously
– Electrolyte& acid base disturbances (hyperkalemia and
metabolic acidosis)
🔹 يعني نص حاالت الدرجة الثالثة تتعالجي لحالها و نص – Impaired excretion of substances such as creatinine ,urea and
phosphate
يدخل في مضاعفات
Etiology:
🔹
Consequences of VUR 🔷
🔹1) PRERENAL CAUSES:
🔹
Incomplete emptying of ureter and bladder
🔹Blood loss:acute hemorrhage
Plasma loss: burns
🔹Fluid loss: dehydration due to:ّ
predispose to urinary tract infection (UTI).
🔹 Renal scarring (reflux nephropathy)
Hypertension and/or end stage renal failure
(particularly with grades IV-V) ▪ Diarrhea خمس أيام وماتعالج أوعوض سوائل,
▪ vomiting, fever
Treatment
🔹 Grades I-III VUR+ normal nephrosonogram: 🔹
▪ Diabetic ketoacidosis
🔹Hypoalbuminemia
Give long term prophylactic antibiotic therapy (Co-
trimoxazole or nitrofurantoin once daily at dose of 🔹Septic shock,
🔹Heart failure
Hypoxia:
1/4-1/3 of dose treated UTI) + frequent urine
culture (every ▪ Pneumonia
🔹
1-3 months).
Prophylaxis is usually continued until reflux
▪ Respiratory distress syndrome
🔶
🔹
resolves
Surgical intervention is indicated for: Grades IV
🔷
🔹2)Glomerulonephritis:
INTRINSIC RENAL CAUSES: 🔹 A) Manifestations of the underlyingetiology:
1)Prerenal: dehydration, hypovolem ia, shock,heart
%V, and 50% of grade III (persistent refux or failure
of prophylaxis)
▪ Postinfectious / postsreptococcal
▪ Lupus erythematous
🔹
failure,etc.
2)Renal: acute glom erulonephritis, hem olytic-urem ic
▪ Henoch–schőnlein purpura 🔹
syndrom e etc.
3) Postrenal: congenital anom alies, tum
ors,calculi,stricture,hem aturia w ith clots, etc.
Urinary tract infections (UTI) are the most common genitourinary disease of 🔹
▪ Membranoproliferative
🔹Acute tubular necrosis
childhood.
🔹Cortical necrosis 🔶 B) Manifestations of acuterenal failure:
Prevalence of UTI: depends on age and sex:
Neonatal period: symptomatic UTI occur in 1.5/1000. Males are commonly 🔹
🔹
Hemolytic-uremic syndrome
Renal vein throm bosis
1-Decreased urine output:oliguria or anuria
2-Edema (due to salt and w ater retention) .
affected.
Thereafter: 🔹 Rhabdomyolysis
🔹Tumor lysis syndrome
Acute interstial nephritis Clinical manifestations
➢Manifestations of the underlying etiology
3-Pallor (due to anemia)
4-Hypertension (due to ↑ salt and w ater retention,and ↑ secretion
UTI can occur at any age, mostly in children < 3 years.
Clinical manifestations &classification of rennin) it m ay progress to hypertensive encephalopathy.
🔷
Girls: boys = 10: 1 (prerenal,renal or postrenal)
1. Pyelonephritis: 5-Uremic encephalopathy: lethargy, drowsiness
It characterized by any or all of the following:
- Abdominal or fank pain, fever, malaise, nausea and vomiting Toxic, shivering and
About 5% of girls have at least one UTI prior to puberty
At any time 1-2% of apparently healthy school girls have an active UTI 🔹
🔹
3) POSTRENAL:
Posterior urethral valve
➢Manifestations of acute renal failure
➢Manifestations of complications
6-GIT :anorexia,nausea,vomiting.
7- Acidotic breathing.(deep rapid)
voiding
-Acute pyelonephritis may result in renal injury, which is termed pyelonephritic
🔹 Predisposing factors Acute Renal Failure 🔹
🔹
Uretropelvic junction obstruction
Uretrovesicular junction obstruction
8- Manifestations of electrolyte disturbances:
• Hyperkalemia: weakness, paraesthesia.
scarring. Some newborns and infants may show non specific symptoms such as
(poor feeding, fever, jaundice, irritability, weight loss and diarrhea)
•Female, wiping from back to front
•Uncircumcised males 🔹
🔹
Ureterocele
Tumor
• Hypocalcemia : tetany,convulsions
• Hyponatremia : convulsions (dilutional hyponatrem ia)
•Vesicoureteral reflux
•Toilet training
Renal disease 2 🔹 Urolithiasis
🔹Neurogenic bladder 🔶
Hemorrhagic cystitis
2.Cystitis: •Voiding dysfunction C) Manifestations ofcomplications of ARF:
indicates that there is bladder involvement. Symptoms include: •Obstructive uropathy – Congestive heart failure and pulmonary edema (due to
Dysuria, urgency, frequency, suprapubic pain, incontinence and malodorous urine •Pinworm infestation Albendazole أول ما نعالج الطفل يتحسن volume overload)Hemorrhage
•Urgency and frequncy common in female , so when we see it in male that's mean – Gastrointestinal hemorrhages (due to stress ulcers or
there is complication or abnormalites •Constipation
•Congenital abnormalities gastritis)
3. Asymptomatic bacteriuria: 🔹 Chemicales •الي تعمل مي و صابون و تدخل الجاهل تخليهم يبلط؟ – Arrhythmias (ventricular fibrillation→death)Hyperalemia
Refers to individuals who have a positive urine culture without any manifestations
of infection and occur almost exclusively in girls, the condition is benign and does
🔹 Routes of infection:
-Ascending : (commonest routes)In chidren
– Behavioral changes ,seizure ,coma
not cause renal injury. 2-Nutrition
Large proportion of children with UTI are Asymptomatic 🔹
-Hemotogenous: (common in neonatal period)
Causative organisms:
•In girls: Escherichia coli, klebsiella,proteus.
3-
Hyperkalemia
•In boys: Escherichia coli, proteus, staph.Saprophyticus
🔥 most common is E.coli سؤال هدية من الدكتوره االم الماضي لذلك نركزعليه
🔹Pathogenesis قالت اقرءوه قرايه III. Treatment of specific problems :
🔷 1-Fluid therapy:
1🔹Rapid screening tests for UTI: 🔹
For patient with oliguria + normal intravascular volume: (Not have hypervolemia)
🔹 Restrict fluid : daily intake =volum e of urine of previous 24hours +insensible w ater loss (400 m l/m 2/24hours)
a.Dipstick nitrite test: detects nitrites produced by reduction of
urinary nitrates by bacteria. A positive test = bacteruria .False negative results may occur 🔹IfFluid
there is fever add another 75 m l/m 2/each degree centigraderise
is given as 10-30 % glucose solution (without electrolytes ) given slowly IV or orally (if tolerated)
• M 2 = √ high in cm ×body weigh in kg/3600
B.dipstick leukocyte esterase test : it detect the presence of WBCs not bacteria
Investigations
2 🔹Urine analysis:
•color : may be reddish if blood is present
1.Complete blood picture:
• Anemia :dilutional ,or HA.
عشان√ •نوجد المتر المربع3600 يعني تحت الجذر التربيعي للطول بالسم والوزن بالكجم قسمه
✳️
(For patient with oliguria or anuria + fluid overload there is no insensible loss and urin not changed )
🔷2-Nutrition
More severe restriction of fluids Daily intake =losses in urine ,stools and vomitus only
•Aspect: turbidity due to pyuria (turbidity persists if urine is warmed and acidifed ) • Leukopenia (in SLE nephritis )
•Odor : strong coliform odor • Throm bocytopenia (in SLE ,HUS, renal veinthrom bosis Management of ARF
🔷3- Hyperkalemia
•Proteins : mild proteinuria
•Sediment :
2.Renal function parameters:
• Blood urea nitrogen (B U N ):
I. Hospitalization and monitoring
II.Treatment of the etiologicfactor:
|||. Treatment of specific problems
🔷4- Sever acidosis ( PH <7.15 & bicarbonate<12 mEq /liter):
↑• Serum creatinine: • Sodium bicarbonate IV Its reduce the ionized calcium to ↑ arterial pH to7.20 (or ↑sod. bicarb.to 12 m Eq/liter)
🔸
Pyuria (5 or more WBCs/HPF in the sediment of centrifuged
urine sample or 10 or more WBCs/ mm3 of uncentrifuged
urine ,using counting chamber)
↑• Serum U ric acid :↑ All uria and creatinine and urea
nirogen increased due to decreased renal excretion
🔶 A- Prerenal Causes: By I.V line urgent correction of hypovolemia, hypotension
using the following formula:
If less than 12m Eq We just Partialy corrected up to 12m Eq But if its more than 12 we don't corrected (mEqN
Pyuria is not diagnostic, it may be absent in active UTI, on the
other hand, it can be present with febrile illnesses or dehydration or with glomerulonephritis Presence 3. Serum electrolytes:
🔸If after correction there is still no voiding, give N .saline 20 ml /kg/ over 30 min. voiding
and/or hypoxia
HCO3 required = 0.3X Wt (in kg) X (12 – HCO3[mEq/l] )
• Rapid correction → tetany and vol.overload
of bacteria in fresh uncentrifuged sample (one organism/HPF represents 10' colonies/ml) • Serum sodium :↓ due dilutional hyponatremia
🔹
3 Urine culture ,colony count and anitbiotic sensitivity testing :
• Serum potassium :↑due decreased excretion and increased K
+ from cells and acidosis
➢If NO voiding occurs in spite of good hydration: (Use furosemide ± Mannitol) as
follows
Furosemide: 2m g/kg at a rate of 4m g/m inutes (onset of action m ay be delayed for
🔷 5- Hypocalcemia + hyperphosphatemia:
↓
Hypocalcaem ia treated by serum phosphorus using "phosphate-binding calcium carbonate antacid " Excrete the
a. Sample obtained by sterile suprapubic puncture or sterile catheter:
• Serum phosphates : ↑due decreased excretion
🔷
The finding of any number of bacteria indicates infections several hours ) phosphorus which Is the cause of hypocalcemia ,Calcum Take by mouth except in case of tetany
b. Voiding sample (properly obtained and promptly cultured): Diagnosis of UTI • Serum calcium : ↓Secondary to increased phosphate ➢If No response we can give a second dose 10 m g/kg (once only ) 6- Hyponatremia :dilutional hyponatremia Fluid restriction will manage most cases
•A count of >100,000(more or equal)colonies/ml of single organism =significant bacteruria &indicates Diagnosis of UTI is made by finding significant bacteruria in a properly collected 4 .Blood PH: metabolic acidosis Mannitol (single dose of 0.5 g/kg of a 20% solution ,IV over 30 m inutes )in addition to or • If serum N a <120 m Eq/liter :give 3 % sodium chloride to↑ serum Na to 125 m Eq/liter: We corrected if less than 125m
UTI urine sample. 5 Urine: may contain RBCs,protines,casts in intrinsic renal ARF in place of furosemide Eq
6 ECG: evidence of electrolyte disturbances (hyperkalemia or
🔶
•A count of less than 10,000 colonies/ml indicates contamination of urine by urethral, periurthral, Urine should be cultured with in ١/٢ hour or kept refrigerated at 4c not more • Normal value of Na+ 135-145mEq mEq Nacl required = 0.6 X BW (kg) X (125-serum Na[ mEq /L] )
arrhythmias)
🔷
vaginal,or perineal skin fora. than 24 hours B- For urinary tract infection: antibiotics (better avoid antibiotics secreted by
•A count between 10.000 and 100.000 /ml: you should repeat sampling by catheter or suprapupic 7.chest radiogram: pulm onary congestion, cardiom kidney,if used,their doseshould be adjusted based of renal function). 7- gastrointestinal bleeding: like stress ulcer
aspiration and repeat culture How can we obtain a clean properly collected urine sample for Urinary tract infections
egaly,pulm onary edem a.
8.Studies for detection of underlying cause:
🔶 C- Post renal causes: surgical interference to remove obstruction, nephrostomy, – Prevention :by calcium carbonate antacids
1 Localization of the site of UTl:
examination and culture ?
First wash the perineum and genitalia with soap and water then steriized by
• Renal ultrasonography :to show size of kidney (shrunken ,
enlarged,etc..)
etc.
🔷
– IV cim etidine 5-10m g/kg/12 hour
🔷 8 Hypertension: See treatm ent of acute postsreptococcal GN .
12- indications of peritoneal or hemodialysis:
it is an upper (pyelonephritis ) or lower ( cystitis) UTI? This is
nornal saline Or sterling water • IVP & Radionuclide scan (after recovery) 🔷 9 Circulatory congestion and heart failure: See treatm ent of APS GN
10 Seizures:
🔹
usually difficult However •the following are in favour of upper UTI (pyelonephritis): 🔹
Voiding sample:
🔹 Urinary bladder catheterization:or bag, must be certain numbers of bacteria
• Cystoscopy,VCUG , and retrograde pyelography. – Correction of the cause :as hyponatremia, hypocalcemia ,etc
🔹
🔹
1.High fever and toxic look
2.Renal angle tenderness
suprapubic bladder aspiration (in neonates & young infants): Any number of
bacteria is positive infection 🔷
– Diazepam (0.1 - 0.3 mg/kg/dose,IV )
11- Anemia:
🔹
🔹
3.Leukocytosis
4.Bacteremia
• Mild dilutional anemia ( Hb 9-11g/dl) requires no treatment If we corrected the fluids the anemia will corrected
• Blood loss from active bleeding should be replaced by fresh blood.
🔹 5.Urinary white cell casts
6.High ESR
•Blood culture:
• Hemolytic anemia with H b <7g/dl: fresh packed red cells (10m l/kg). لوعملنا كل هذه العالجات والزال ماتحسن المري ض واليوريا
والكرياتينين عاليين هنا •بيدخل بغسيل كلوي
Done for neonates and young infants *due hematogenous transmission
•Renal function studies :
🔹
In acute pyelonephritis:may be mild increase of blood urea and serum creatinine
7- Imaging studies
•Renal & bladder ultrasonography
•Voiding cystourethrography (VCUG) is done after treatment in all males and for females
under 5 years of age or having UTI for the 2nd time
•Renal scintigrphy with dimercaptosuccinic acid (DMSA) for demonstrating scarring.
*It show if the infection Acute or chronic, Necessary in Asymptomatic patients, in acute
disease show decrease absorbtion of dye While in chronic show scarring in kidney tissue
""طبعًا مش موجود عندنا
DMSA The right kidney show
scarring That indicates the chronic disease
Antibiotic therapy:
- For newborns : 10-14 days parenteral antibiotics
-For older children with cystitis: oral antibiotic for 1 week (Amoxicillin or Co-
trimoxazole)
- For older children with suspicious pyelonephritis :
•Start with parenteral broad- spectrum antibiotics until high fever and toxicity
disappear then
•Continue with an oral antibiotic( according to results of culture) to complete
14 days
prophylactic antibiotics:
Co-trimoxazole bactrim drug (% of therapeutic dose) should given if recurrences
are frequent or if imaging studies prove the presence of VUR
1-General supportive measures
Hydration,alkinazation of urine with oral sodium Citrate or bicarbonate, prevent Treatment
residual urine, symptomatic treatment of fever and pain,treatment of 1.Antibiotics
by fatema okoff hypertension andlor renal failure (if present)
2-Follow -up evaluation of the urinary tract
2.General supportive measures
3.Follow_up evaluation of urinary tract
-Repeated urine culture. 4.treatment of predisposing factors (if any )
-Radiological evaluation.
-Renal ultrasonography.
1 Treatment of predisposing factors (if any):
as VUR, calculi, obstructive lesions, etc
Prognosis of UTI
Long term prognosis for promptly & adequately treated UTI is
excellent.
Chronic or recurrent UTI can occur in the presence of predisposing
🔹
factors: Inadquate therapy for the acute attack of UTI"
🔹 Presence of vesicoureteral reflux.
🔹
🔹
Presence of congenital or acquired urinary tract obstruction.
Foreign bodies or indwelling catheter
🔹
🔹
Urinary schistosomiasis.
Neurogenic dysfunction of bladder.
Individual susceptibility of uroepithelial cells to adherence of E
coli.
