PEDIA 3A – NEPHRO GN - DR.

MATHEUS (SAMPLEX)
(Sabayan nyo ng trans to. Gamit ko yung 3B trans. Pero paulit ulit lang naman yung mga
tanong. At madaming cases.Napaghalo ko yung majors and shiftings. Pero umuulit lang  HSP
talaga yung mga tanong. STUDY AT YOUR OWN RISK.) - IgA deposits in mesangial cells of glomerulus WITH systemic
manifestations
Mga clue lang from samplex dahil nalilito din ako dito:  HUS
- Microangiopathic haemolytic anemia
 UTI - Hemoglobinuria
- imaging: ultrasound of kidneys and urinary bladder - tea colored urine (yung PIGN and IgA nephro may tea colored
- confirm: urine culture and sensitivity din pero meron silang edema and URTI respectively)
- better sensitivity: pyuria and nitrite test and wbc esterase test  Hemorrhagic cystitis
- to diagnose: do a urine culture - bright red urine with blood clots
- neonates: sepsis syndrome MAJOR EXAMS AND SHIFTINGS
- infant: fever
- lower UTI: Amoxicillin
 Nephrotic syndrome
HEMATURIA IS GLOMERULAR
- hematuria  Urinalysis is positive for significant hematuria and proteinuria
- massive protein loss in the urine
- initial diagnostic study: urinalysis MICROSCOPIC HEMATURIA
- DOC: prednisone  Isolated microscopic hematuria: Long term follow up is necessary to
- pag may sinabing varicella sa case: give varicella immune globulin rule out progressive renal disease
- pag vaccine tas naka steroid si patient: conjugate pneumococcal  Isolated microscopic hematuria: correlates with best renal prognosis
- to determine presence of nephrotic range proteinuria: urine  Case: 10y/o female. Microscopic hematuria from 10-20 rbc/hpf on 3
protein/creatinine ratio diff occasions. No complaints by the patient. PE findings were
- manifestation is caused by: hyperalbuminemia
normal. Next step: repeat urinalysis and observe
 PIGN
 Alport's syndrome: initially presents with microscopic hematuria
- edema, swelling
- confirm: urinalysis, complement 3, ASO titer, creatinine without systemic manifestations in vhildren but may persist in
- strengthen diagnosis: latent period adulthood with associated sensorineural loss
 Glomerulonephritis  CASE: 11 y/o male consulted due to isolated microscopic hematuria
- Cardinal manifestation: hematuria ranging from 10-20 RBC/Hpf on 3 separate occasions. There are no
- Lab exam to diagnose: Urinalysis complaints by the patient and PE findings were essentially normal.
- GN is considered when: urinalysis has significant hematuria and As part of hx taking it is important to ask for: Family hx of chronic
proteinuria kidney dse
- Complication: hypertension  CASE: On a routine examination done for school entrants, a 6 y/o
 IgA nephropathy male was found to have microscopic hematuria ranging from 10-
- IgA deposition WITHOUT systemic disease
20rbc/hpf and proteinuria of +2. The patient was asymptomatic.
- assoc with URTI
What would you ask if you are thinking of glomerulonephritis?:
history of previous infection

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UTI
 In children: >40,000 CFU from a suprapubic sample
 In children: Initial renal imaging: ultrasound of the kidneys and
urinary bladder
 Case: 2y/o girl, had 2 eps of UTI in the past 4mos. Urine culture was
E. coli >100,000 CFU/ml. Renal imaging study: ultrasound of the
kidneys and urinary bladder
 Neonates: Sepsis is the most common manifestation of UTI; sepsis
syndrome
 Highest possibility that UTI is present: positive test for WBC esterase
and nitrite test
 Better sensitivity for diagnosing true UTI: pyuria, +nitrite test, +WBC
esterase test, bacteriuria
 Case: 3y/o, abd pain, fever, pain on urination, lower abdominal
tenderness, right sided costo-vertebral angle tenderness. To
confirm diagnosis: urine culture and sensitivity
 Case: 3 month old boy, high grade fever for one day. Urinalysis was
done and revealed Dark colored urine with pus cell of 50-60/hpf,
nitrite test+3 and WBC esterase test +2. Next step: do a urine
culture (used to diagnose)
 In infant: seen as fever
 Suprapubic aspiration: any number of colonies
 Catheterized urine: >/= 10,000 colonies
 Clean catch urine: >/= 100,000 single colony
 Urine bag urine specimen: > 100,000 2 or more organisms
 Lower UTI: Amoxicillin
 For a case of UTI, in what situation would you advice advanced renal
imaging?: Patients with midline anomalies at the lumar area
 Least reliable indicator for the presence of UTI: pus cells
 Usual organism isolated for UTI in children: E. coli
NEPHROTIC SYNDROME
 Main event that leads to cascade of manifestations: massive protein
loss in urine
 Minimal Change Nephrotic Syndrome (MCNS): male, 2-6 years old,
most steroid-responsive
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 Proteinuria: greater than 40 mg/m2/hr
 Minimum: 40 mg/m2/hr
 Minimum duration of tx with high dose steroid prior tapering: 4
weeks
 Patients diagnosed with nephrotic syndrome should be started with
prednisone: 60 mg/m2/day (sagot sa iba ay 20 mg/m2/day, di ko
alam kung alin ang tama. Pero feeling ko yung 60 yung tama.
Hahaha. Walang sisihan ah)
 Adult nephrotic syndrome: Membranous GN
 Case: 8y/o girl, new onset swelling around the eyes. Periorbital,
sacral, pretibial edema. BP is 96/64. Most appropriate initial dx
study: urinalysis
 Case: 2y/o male, pale looking, generalized edema. Urinalysis
showed Albumin of +4. Serum albumin was 2.2 gm/dL. Cholesterol
was 2x above normal. 24 hr urine protein was 44 mg/m2/hr. ASO
titer was <200 IU. Start the patient on: Prednisone (DOC)
 Case: 6y/o male, severe abd pain. 10 days PTC, sudden onset of
facial edema. Edema persisted, gradually involved LE with distention
of abdomen. UO decreased, no change in urine color. Lab exam:
Urinalysis
 (Above case) cause of severe abd pain: primary peritoneal infection
 (Above case) strenghten diagnosis: presence of massive proteinuria
 Case: 5y/o girl with generalized swelling (edema). Urine protein
400mg/dL (heavy proteinuria, coz >200), Albumin 1.6 g/dL
(hypoalbuminemia, coz <2.5g/dL), Cholesterol 360 mg/dL
(hypercholesterolemia). Dx: Nephrotic Syndrome
 Case: 3y/o male, in relapse, on steroid therapy exposed to a cousin
with variclella 2 days PTC. Next step: give varicella immune globulin
immediately
 Immunocompromised because: serum albumin level is low;
immunoglobulins are lost in urine
 Part of management: provide adequate amount of protein intake
for growth
 Diagnosed Nephrotic syndrome, initial duration of prednisone tx
based on APN: 12 weeks
  True of the APN protocol: associated with a longer remission period
and fewer relapses
 Diagnosed Nephrotic syndrome, initial duartion of prednisone tx
based on ISKDC: 8 weeks
 ISKDC criteria: heavy proteinemia, edema, hyperlipidemia. Except:
hyperalbuminuria
 Vaccine given in nephrotic patients on steroid therapy: conjugate
pneumococcal
 CASE: 7 month old male infant is suspected to have nephrotic
syndrome, since timed urine collection is difficult to do. The next
best thing to determine presence of nephrotic range proteinuria is
to request for a: urine protein/creatinine ratio
 The clinical manifestation of nephrotic syndrome is primarily caused
by: hyperalbuminemia
POST STREP GN/POST INFECTIOUS GN
 Average latent period: 10-14 days
 Case: 6y/o, sustained wound 16 days PTA. 12 days PTA, wound got
infected, no meds taken. 2 days PTC, had puffy eyelids, pedal
edema, gross hematuria. Latent period is: 10 days
 Case: 6y/o male, facial edema. 5 days PTC, there's sudden onset of
facial edema, distention of abdomen, edema of LE + tea colored
urine, oliguria, headache, vomiting. On PE, facial edema, positive
fluid wave, decreased breath sounds on both lung fields, grade 2
pitting edema. Lab exams to confirm dx: urinalysis, complement 3,
ASO titer
 Case: 7y/o female, (same as above patient, pinalitan lang yung age
and sex): urinalysis, CBC, creatinine, complement 3, ASO titer
 Case: patient had sore throat 15 days ago, not treated. 4 days PTA,
puffiness of eyelids. Progressed to facial and pedal edema. Latent
period: 11 days
 Case: 5y/o male, 12 days PTA, empty milk can was thrown at him
on his right leg resulting to a shallow abrasion. 9 days PTA, abrasion
have erythematous borders with some purulent discharge. 2 days
PTA, puffiness of eyelids then few hours developed generalized
seizures. Latent period for this case: 7 days
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 Case: 4y/o boy sustained shallow wound from protruding nail 16
days PTA. 12 days PTC, wound got infected. 4 days PTC, puffy
eyelids with gross hematuria and pedal edema. Latent period for
this case: 8 days
 Is an immune complex dse. Injury to kidney is due to: deposition of
circulating immune complex in the kidneys
 TRUE: antibiotic tx is mandatory regardless of the etiology, most
viral causes have a shorter latent period, prognosis of acute post
strep GN is very good (NOT TRUE: a complicated course is
anticipated for post-viral GN)
 APGN: associated with hypertension; trace back 10 days for history
of previous infection; formation of immune complex (antigen-
antibody reaction)
 PIGN: prognosis of APGN is very good; high blood pressure
 AGN with NORMAL creatinine: hypertension, pulmonary
congestion, edema
 AGN with ABNORMAL creatinine: hematuria
 To strengthen the diagnosis of post-GN, establish presence of:
latent period
 Complications: hypertensive crisis, volume overload, renal failure.
Except: edema
 CASE: A 3 y/o boy has been coming back regularly for the past 6
months due to microscopic examination, repeated urinalysis done in
the past revealed only significant hematuria. There is no family
history of renal dse. PE is normal what is your course of action in the
mgnt of the case?: continue to monitor the patient and not any
signs of renal progression before doing more intense work up
 (Clue: Actually di ko alam kung pano nakukuha yung latent period.
Pero ang napansin ko lang, ima-minus mo lang yung last 2 numbers
na ‘PTC or PTA’ okaya kung dalawa lang yung given na ‘PTC or PTA’
sa case, saka mo makukuha yung latent period. Haha. Di na ko nag-
abalang maghanap ng ratio at di ko pa din to naaaral. O baka ako
lang may hindi alam kung pano yun nalalaman?! Hahaha. Sarreh.
Basahing mabuti yung tanong. Minsan in word nakalagay yung
numbers. #testtaking)
GLOMERULONEPHRITIS
 Cardinal manifestation: hematuria
 Lab exam to diagnose: Urinalysis (5th case in post infectious GN ^)
 Complication that could have caused seizure: hypertension (5th
case in post infectious GN ^)
 GN is considered when: urinalysis has significant hematuria and
proteinuria
 Complication: hypertension
ASO TITER
 Strep infection, increase after: 2 weeks
 Sensitivity is lower for strep pyodermas
PROTEINURIA
 Significant protein in the urine: 24 hour urine protein/albumin
determination
 Case: previously healthy 8y/o boy, abrupt onset of facial swelling,
edema, periorbital and facial swelling, urine is normal except for
presence of protein. Normal BUN and creatinine. Next step in
management: give oral prednisone (DOC: prednisone or
prednisolone)
IGA NEPHROPATHY
 Case: 9y/o male, tea colored urine, cough, colds, low grade fever,
urinalysis showed too many to count rbc with low grade proteinuria,
happened before patient had acute upper respiratory tract infection
 Recurrence of gross hematuria whenever patient suffers an URTI
 IgA deposition WITHOUT systemic disease
 Poor renal prognosis: progressive and heavy proteinuria, persistent
hypertension, diminished renal function
 Indicator of prognosis: development of proteinuria
HENOCH SCHONLEIN PURPURA NEPHRITIS/HSP
 abdominal pain, arthritis, purpura rash on LE and GN are suggestive
of: HSP
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 IgA deposits in mesangial cells of glomerulus WITH systemic
manifestations
WILM'S TUMOR
 Case: 7y/o male, abdominal mass. 2mos PTA, had hard mass on
superior part of the left kidney. 3 days PTA, complains of vague
abdominal pain. On CT scan, abdomen showed large left renal mass
probably Wilm's tumor with lymph nodes on periaortic area.
Classification of the patient: Stage 3
 Case: wilm's tumor patient had nephrectomy. All tumor infiltrates at
operative area not removed. No metastasis in other organ system:
Stage 3
 (Above patient) tumor weighed 650g. There's hyperchromatism and
anaplasia of cells. Has poor prognosis based on: stage of patient,
size and wt of tumor, unfavorable histo type(AOTA)
 Renal malformation associated: Duplicating renal collecting system
 Seen in the bone: Stage 4
 Case: Condition did not improve despite intensive measures. Urine
is cola colored with bulging on left side
 Bilateral: Stage 5
 Not treated with radiation: Stage 1
 Associated with wilm’s tumor except: reflux (kasama yung:
hypoplastic kidney, hydronephrosis, ectopic kidney)
RISK FACTOR IN THE DEVELOPMENT OF RENAL VENOUS THROMBOSIS
 Dehydration
 Respiratory distress syndrome (RDS)
 Renal venous thrombosis: pathophy involves microangiopathic
hemolytic anemia
HEMOLYTIC UREMIC SYNDROME (HUS)
 Anemia, gross hematuria, renal failure, history of diarrhea
 Microangiopathic haemolytic anemia
 Case: 1y/o male, tea colored urine 3 days duration. Hx of diarrhea,
sudden onset of pallor, decreased UO for more than 24hrs.
Urinalysis showed tea colored +4 for blood protein is trace and rbc
 of 5-6/hpf. Bun and creatinine were 4x above normal. Impression: 24 HOUR URINE CREATININE CLEARANCE
HUS  Most sensitive tool to assess renal function in a stable state
 Hemoglobinuria
24 HOUR URINE ALBUMIN DETERMINATION
PENICILLIN  One way to distinguish tubular vs. glomerular proteinuria
 Significant hematuria and proteinuria with low C3 and +ASO titer.
Start penicillin. TRUE OR FALSE
 For primary peritonitis secondary to nephrotic syndrome 1. Postinfectious glomerulonephritis is antibody dependent
cytotoxicity. FALSE (immune mediated)
PRIMARY PERITONITIS 2. Microscopic hematuria is not indicative of postinfectious GN. FALSE
 Severe abdominal pain, periumbilical in location with some (gross or microscopic hematuria)
abdominal guarding associated with fever 3. Hematuria is the hallmark of nephrotic syndrome. FALSE (edema)
4. Steroid treatment for nephrotic syndrome is 10-week regimen.
CYSTITIS, HEMORRHAGIC FALSE (12 weeks)
 Case: 7y/o male, dysuria. Recent cough, colds, no fever. Gross 5. Steroid sensitive NS can lead to peritonitis and the most common
hematuria, bright red urine with blood clots. Normal PE and VS causative agent of which is Staph aureus. FALSE (Strep. pneumo)
 Hematuria may be related to prior viral infection 6. Prognosis is said to be guarded for MPGN. TRUE
 Infection of the urinary bladder 7. IgA nephropathy is the most common chronic glomerular disease
worldwide. TRUE
INTERSTITIAL NEPHRITIS 8. IgA nephropathy will have an elevated serum elevated levels of C3.
 Glomerular injury associated with hypersensitivity reactions FALSE (normal)
especially to drugs 9. An uncommon manifestation of Henoch Schonlein Purpura is
 Caused by: Allergic reactions ureteritis. TRUE
10. Wilm's tumor is the second most common malignant abdominal
PERITONITIS AND SEPTICIMIA tumor in chlidhood. TRUE
 Most common agent: S. pneumoniae
MATCHING TYPE (please double check. Di ko alam kung tama mga sagot sa
VESICO URETHERAL REFLUX samplex eh)
 diagnosed by void cystourethrogram  Post-infectious GN – hematuria with clinical signs
 Benign familial hematuria – Asymptomatic hematuria without
LUMBOSACRAL MENINGOCOELE abnormalities
 renal imaging studies aside for an ultrasound is performed  Urolithiasis – hematuria with clinical signs
 Hemorrhagic cystitis – gross hematuria
VOIDING CYSTOGRAM  Exercise hematuria – Asymptomatic hematuria without
 Reflux up to ureter only: Grade 1 abnormalities
 Urinary tract infection – gross hematuria

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  Acute kidney injury-failure – asymptomatic hematuria with  VCUG – vesicoureteral reflux
proteinuria Alternative drugs for nephrotic syndrome
 Cyclophosphamide – alopecia
MATCHING TYPE  Chlorambucil – hematologic malignancy
Clinical condition  Cyclosporine – gingival hypertrophy
 Nephrotic syndrome – hypervolemic hyponatremia Acute GN urinary findings
 Hypoaldosteronism – hypovolemic hyponatremia  Gross hematuria – 2-3 weeks
 Use of loop diuretics – hypovolemic hyponatremia  Microscopic hematuria – 12-18 months
 Congenital heart failure – hypervolemic hyponatremia  Proteinuria – 3-6 months
 Diabetes insipidus – NOTA
Intervention in hyperkalemia
 Calcium gluconate administration – protects the myocardium from
arrhythmia formation
 Inuslin glucose combination – shift potassium from the extracellular
fluid compartment to the intracellular compartment
 Hydration of the patient – dilutes serum potassium
 Kayexalate enema – gains sodium and excretes potassium at the GIT
 Diuretics – removes potassium from the body thus decreases total
body potassium stores
 Dialysis – removes potassium from the body thus decreases total
body potassium stores
 B2 agonist administration – shift potassium from the extracellular
fluid compartment to the intracellular compartment

MATCHING TYPE
Glomerular disease
 IgA nephropathy – recurrent gross hematuria without extrarenal
manifestation
 HSP nephritis – recurrent gross hematuria with extrarenal
manifestation
 Alport syndrome – persistent hematuria with sensorineural hearing
loss REFERENCE: Sandamakmak na
Imaging studies samplex. Plus Winstons compilation
 DMSA – renal scarring and Ayesha notes Goodluck and God
 DTPA – obstructive uropathy bless!

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