CHAPTER 24: THE CHILD WITH RENAL

DYSFUNCTION b. Renin
- in response to reduced
RENAL STRUCTURE AND FUNCTION blood volume, decreased
blood pressure, or
Kidney’s increased secretion of
1. Primary responsibility catecholamines
➔ to maintain the composition and - stimulates the production of
volume of the body fluids in the angiotensins, which
equilibrium. produce arteriolar
❖ To maintain this constant internal constriction and
environment, the kidney must respond - an elevation in blood
appropriately to alterations in the pressure and
internal environment caused by - stimulate the production of
variations in aldosterone by the adrenal
a. dietary intake cortex.
b. extrarenal losses of water and
solutes. RENAL PHYSIOLOGY
➢ accomplished by the formation of
urine (the product of glomerular
filtration), tubular reabsorption, Nephron
and tubular secretion. - structural and functional unit of the kidney
❖ Reabsorption is the transport of a
substance from the tubular lumen to the Contains a complex system of:
blood in surrounding vessels. ● Tubules
❖ Secretion is transport in the opposite ● Arterioles
direction (i.e., from the blood to the ● Venules
lumen). ● Capillaries
➢ These processes are either active
or passive. Consists of the:
● Bowman capsule
❖ Excretion is the elimination of a - which encloses a tuft of
substance from the body, in this case capillaries and is joined
urine. successively to the
proximal convoluted tubule
2. Secondary function ● the loop of Henle
➔ production of certain humoral ● distal convoluted tubule
substances. ● straight or collecting duct

a. Erythropoietin-stimulating factor
(or erythrogenin)
- which acts on a plasma
globulin to form
erythropoietin, which in turn
stimulates erythropoiesis in
the bone marrow.
- Its production increases in
the presence of hypoxia
and androgens.
❖ Few red blood cells form in the
absence of erythropoietin
- anemia associated with
advanced kidney disease

Collecting tubules join larger ducts
all the larger collecting ducts of one renal
pyramid join to form a single duct that opens into
a minor calyx
number of calyces empty into one of several
major calyces that converge into the renal pelvis
renal pelvis narrows after it leaves the kidney and
forms what then becomes a ureter through which
urine drains into the
urinary bladder
❖ blood supply to the kidneys constitutes
approximately one fifth of the total cardiac
output; therefore profuse bleeding can
accompany renal trauma.
Afferent arteriole
- separates into capillary loops that
constitute the glomerular tuft, supplying
each nephron.
- deliver blood to the glomerulus
Efferent arteriole
- carry blood away from the glomerulus
- efferent arterioles branch into a
peritubular capillary network and
hairpin loops called the vasa recta,
which parallel the loops of Henle and
collecting ducts.
❖ total surface area of the renal capillaries is
approximately = to the total surface area
of the tubules
Bowman Capsule
Two cellular layers that separate the blood from
the glomerular filtrate
1. capillary endothelium
2. a layer of tubular epithelial lining cells
❖ Situated between these layers is the
basal lamina, or basement membrane.
❖ The glomerular membrane is permeable
because the capillary endothelium is
fenestrated with pores, or fenestrae.
❖ The outer surface of the glomerular
epithelium consists of fingerlike
projections (pseudopodia, or podocytes)
that cover the entire surface to form slits
called slit pores.
❖ Basement membrane has no visible
openings but behaves as though it
contains pores or channels.
❖ glomerular filtrate (which has essentially
the same composition as plasma
except for the large protein molecules
and cellular elements) passes through
these three layers at a rapid rate.
❖ The structure of these layers becomes
altered in kidney disease.
Glomerular Filtration
➢ governed by the same mechanism as
filtration across other capillaries in the
body
● size of the capillary bed
● permeability of the capillaries
● hydrostatic and osmotic pressure
gradients across the capillaries
The filtration capacity of the glomerulus is the
product of permeability of the glomerular
capillaries and three pressure forces:
1. glomerular hydrostatic pressure
2. colloidal osmotic (oncotic) pressure (COP)
3. intracapsular pressure
➢ Blood enters the nephron at a substantial
pressure (def: the action of a force
against an opposing force)
➢ hydrostatic pressure forces plasma fluid
and solutes through the capillary
membrane and into the unit’s collecting
apparatus.
➢ water and solutes are selectively
reabsorbed back into the vascular
compartment
➢ not reabsorbed is excreted as urine
➢ Filtration takes place as long as
hydrostatic pressure within the
glomerular capillaries exceeds the
opposing COP of the plasma proteins.
 ➢ If the pressure becomes equal through
decreased hydrostatic pressure or
decreased COP, no further filtration
takes place.
In a state of dehydration
➢ more water is reabsorbed
➢ when water intake is increased, more is
excreted as urine
Def:
Osmotic diuresis
➔ when large solutes, such as
glucose, are filtered through the
capillaries in such excessive
amounts that they cannot be
reabsorbed
In conditions that produce osmotic diuresis
➢ the osmotic attraction of the solute causes
less water to be reabsorbed, resulting in
water being excreted in the urine with the
solute.
Tubular Function
Function of the renal tubules
➔ is to modify the glomerular filtrate.
❖ Tubular cells may add more of a
substance to the filtrate (tubular
secretion)
❖ remove some or all of a substance from
the filtrate (tubular reabsorption), or
both.
❖ The reabsorption is selective and
discriminating for substances essential to
body processes and equilibrium, whereas
nonessential substances are eliminated
as waste.
❖ The substances are secreted or
reabsorbed in the tubules by
➢ Osmosis
➢ Passive movement down a
chemical or electric gradient, or
➢ actively transported against these
gradients.
Active transport mechanisms
- move vital substances both inward
and outward from the tubular
filtrate.
➢ Ex. the proximal tubule
reabsorbs essential
substances such as
glucose, amino acids, and
sodium ions and returns
them directly to the blood.
- have a limited capacity, or
threshold, for moving the solute.
- When the maximum of the
transport mechanism is
reached, no more substance is
reabsorbed, and the remainder is
excreted in the urine.
➢ For example, when blood
glucose concentrations
exceed their transport
capacity, the surplus
remains in the filtrate to be
excreted in the urine
(glycosuria).
- When two substances share a
common transport mechanism, the
first substance may be blocked by
the addition of a second substance
(selective inhibition).
- The effect of many therapeutic
agents (e.g., diuretics) depends on
this process.
Electrolytes
- are moved by both active transport and
diffusion
- the transport of certain electrolytes,
particularly sodium, has important
effects on other substances.
➢ For example, sodium is actively
transported from all parts of the
nephron.
➢ The movement of sodium ions
produces both an electric and an
osmotic gradient, which causes
chloride ions and water to
diffuse from the tubules in an
effort to establish equilibrium.
➢ There is a limit to the concentration
gradient against which sodium can
be transported out; therefore when
larger than normal amounts of
sodium ions remain in the
tubules, water is obliged to remain
with the sodium.

Under normal conditions the kidneys are:
➔ able to adjust the urine and solute
excretion in response to the requirements
for body water and electrolyte balance.
➔ able to excrete or conserve both water
and most electrolytes in addition to
excreting the end products of protein
metabolism, principally urea.
➔ The volume of urine excreted by the
kidneys in a given period depends on the
water balance (including intravascular
filtration pressure), the quantity of
solutes presented to the kidneys, and the
capacity of the kidneys to dilute or
concentrate the filtrate.
Renal Development and Function in Early
Infancy
within the first weeks of embryonic life
➔ development of the kidney begins
➔ but is not completed until about the end
of the first year after birth
34 to 46 weeks of gestation
➔ nephrons increase in number and
➔ reach their full complement
● at this point they are immature
and less efficient
❖ glomeruli enlarge considerably after birth.
❖ In infant,
➢ Glomerular filtration and absorption
are relatively low
❖ between 1 and 2 years of age
➢ Glomerular filtration and absorption
reach adult values
❖ Newborn
➢ unable to dispose of excess water
and solutes rapidly or efficiently
tubular length of nephrons = highly variable
Glomerular size = less variable
❖ Juxtaglomerular nephrons show more
advanced development than the cortical
nephrons.
Loop of Henle
- the site of the urine-concentrating
mechanism
- short in the newborn, which reduces the
ability to reabsorb sodium and water
and therefore produces very dilute
urine.
- newborn pituitary gland secretes adequate
amounts of antidiuretic hormone.
Third month of life
- length of tubules gradually increases
until concentrating ability reaches adult
levels
- urea synthesis and excretion are slower
during this time
First weeks of life
- newborn retains large quantities of
nitrogen and essential electrolytes to
meet the needs for growth
- the excretory burden is minimized
principal end product of nitrogen metabolism
➔ urea
❖ The lower concentration of urea also
reduces concentrating capacity because it
contributes to the concentration
mechanism.
Newborn infants
➔ unable to excrete a water load at rates
similar to those of older persons
➔ Hydrogen ion excretion is reduced
➔ acid secretion is lower for the first year of
life
➔ plasma bicarbonate levels are low
❖ Because of these inadequacies of the
kidney and because of less efficient blood
buffers
➢ the newborn is more liable to
develop severe metabolic
acidosis
❖ Sodium excretion is reduced in the
immediate newborn period, and the
kidneys are less able to adapt to sodium
deficiencies and excesses.
 Ex. An isotonic saline infusion may
produce edema because of impaired
ability to eliminate excess sodium.
❖ inadequate reabsorption of sodium from
the tubules may increase sodium losses in
disorders such as vomiting or diarrhea.
❖ Infants
➢ have a diminished capacity to
reabsorb glucose and, during the
first few days,
➢ to produce ammonium ions.
❖ Kidney functions during fetal life and
produces urine that contributes to the
amniotic fluid volume.
❖ 24-hour urine volume is low at birth
❖ rapidly increases in the neonatal period
❖ steadily increases with normal growth
❖ Kidneys continue to grow in size until
body growth is complete in adolescence.
RENAL PELVIS AND URETERS: STRUCTURE
AND FUNCTION
Renal Pelvis
- a funnel-shaped structure that originates
at the major calyces and terminates in the
funnel-shaped ureteropelvic junction.
Ureter
- a thin mucomuscular tube that extends
from the ureteropelvic to the
ureterovesical junction in the base of the
bladder.
- allow the passage of urine from the upper
urinary tracts while preventing backflow of
urine from the bladder to the ureters
Principal function of the renal pelvis and
ureter
➔ the transport of urine from the kidney to
the bladder
● Urine
○ moved via a process called
peristalsis
○ whereby muscular movements
originating in the renal pelvis
propel a bolus of urine toward the
urinary bladder for storage and
eventual evacuation when the child
urinates.
● Renal Pelvis
○ stores only a relatively small
volume of urine (approximately 15
ml in adults) before a contraction
is triggered that pushes the urine
toward the bladder.
Efflux
- forward movement of urine from the
kidney to the bladder
Reflux
- abnormal (or backward) urine
movement
❖ mechanical stretching, neurogenic and
hormonal factors modulate ureteral
peristalsis.
Ureterovesical junction
- joins the ureters and bladder
- made up of three principal components:
1. the lowest segment of the ureter
2. the trigone muscle, and
3. the adjacent bladder wall
During bladder filling
➔ intravesical pressure remains relatively
low and the
➔ detrusor muscle remains in a relaxed
state
❖ peristaltic contraction of the ureter
propels urine into the bladder.
Micturition
- The action of urinating.
During micturition
➔ there is an increase in intravesical
pressure as the detrusor muscle
contracts
◆ this raises the potential for harmful
reflux into the upper urinary
tracts.
❖ The normal ureterovesical junction has
several mechanisms to prevent reflux.
❖ The terminal (intravesical) ureteral
segment tunnels through the bladder wall
at an oblique angle.

During bladder contraction
➔ tension in the detrusor muscle squeezes
the intravesical ureter closed.
➔ The trigone muscle that surrounds the
ureteral orifice of the terminal ureter
enhances this process.
➔ longitudinally arranged muscle of the
intravesical ureter contracts, providing
further resistance to reflux.
➔ Anatomic defects of the ureterovesical
junction, such as:
● lateral displacement of the ureter
● reduced length of the intravesical
ureter
➢ predispose the child to
primary reflux.
➔ Secondary reflux
➢ can result from high pressure in
the bladder causing failure of the
ureteral vesical junction to close
during bladder contraction.
There is a recognized correlation between lower
urinary tract dysfunction and persistent reflux
and evidence suggesting that reflux in older
children with lower urinary tract dysfunction is
secondary rather than primary.
URETHROVESICAL UNIT: STRUCTURE AND
FUNCTION
Urethrovesical unit consists of the
● Bladder
● Urethra
● Pelvic muscle
Additional information:
Kidneys & ureters - upper urinary tract
Bladder & Urethra - lower urinary tract
Urinary bladder
- a muscle-lined sac that stores and
empties itself of urine
In the Infant
➔ bladder lies entirely in the
abdomen
❖ bladder assumes its place in the true
pelvis shortly before puberty
❖ This change in position is due to the
maturation of the pelvic bone rather
than migration of the bladder and urethra.
The bladder has:
● two inlets (the ureteral orifices)
● a single outlet (the urethral orifice)
❖ The base of the bladder is a relatively
➢ fixed, triangular area consisting
of the:
● bladder neck
● trigone.
❖ The body of the bladder is distensible
➔ tetrahedron (four-sided shape)
when relatively empty
➔ to a nearly spherical shape as the
bladder fills.
❖ One of the four layers of the bladder wall
consists of smooth muscle bundles that
promote bladder evacuation via
micturition.
❖ muscular tunic is called the detrusor.
➢ also contains collagen
Collagen
- a tough, nonelastic substance that
maintains the integrity of the
bladder wall while also preventing
overdistention.
Pathologic factors:
a. denervation of the bladder
b. obstruction of the outlet
➢ may cause an overabundance of
collagen in the detrusor muscle
➢ Causes:
○ loss of bladder compliance
(distensibility)
○ abnormally high filling pressures
○ trabeculation (irregularity) of the
bladder wall
Urethra
- a mucomuscular tube that connects the
external meatus and the bladder
Male Urethra
 - originates at the bladder neck, 3. competence of the urethral sphincter
piercing the prostate and pelvic mechanism
floor before tunneling through the —must function normally for an individual to
posterior portion of the penis achieve and maintain continence.
and terminating at the glans penis.
- proximal portion of the urethra ❖ Detrusor control requires successful
comprises the sphincter integration of neurologic structures in
mechanism the:
- distal portion serves as a conduit ➢ Brain
for the passage of urine or semen ➢ spinal cord, and
- urethral meatus is a vertical slit ➢ peripheral nervous
located: at the summit of the glans systems.
penis.
Brain
Female Urethra - influences bladder function via its
- follows a relatively short, straight inhibitory role on detrusor contractions.
course compared with the male. - The stable detrusor contracts only when
- It originates at the bladder base its owner gives permission and several
and terminates at an external areas of the brain work together to control
meatus located immediately detrusor stability.
superior to the vaginal orifice.
- The distal two-thirds of the female ❖ A pathologic condition of one of these
urethra are fused with the vaginal areas may produce detrusor
wall. overactivity, or the loss of control over
detrusor contractions.
Primary responsibilities of the bladder
➔ to store urine manufactured by the Spinal cord
kidneys and to evacuate this urine at - influences lower urinary tract function
regular intervals via the process of because it transmits messages between
micturition. the brain and the target organ.
- Two areas in the spinal cord are
During infancy the bladder particularly significant.
➔ expected to empty spontaneously
➔ by the fourth year of life (or earlier) ➢ The thoracolumbar cord (spinal
◆ the child is expected to gain levels T10–L2)
control of detrusor and urethral - influences bladder and
sphincter function urethral sphincter function.
- Sympathetic impulses
Urinary continence. from the brain travel to the
- control of the urethrovesical unit bladder body and smooth
muscle of the urethra,
Continent individuals are expected to: causing relaxation of the
● hold their urine for at least 2 hours while detrusor muscle and
awake. contraction of urethral
● During sleeping hours smooth muscle.
○ may arise once to urinate - This combination of actions
○ many children and young adults promotes bladder filling
sleep for 8 hours or more without and storage of urine.
interruption. ➢ The sacral spinal cord (spinal
segments S2–S4)
Three factors - influences the bladder
1. anatomic integrity of the lower urinary tract muscle, promoting
2. detrusor control, and micturition.
 - Parasympathetic
impulses travel from these
nuclei, causing contraction
of the detrusor muscle and
indirectly promoting
relaxation of smooth
muscle in the urethra.
❖ Two peripheral nerve plexuses directly
influence control of the detrusor muscle.
1. pelvic plexus
- provides parasympathetic
innervation to the bladder
and urethra, and
2. inferior hypogastric plexus
- provides sympathetic
innervation
Urethral sphincter mechanism
- final mechanism
- responsible for the attainment and
maintenance of continence
➢ Traditionally two sphincters are
described.
1. Internal sphincter
- consists of the smooth
muscle of the bladder and
proximal urethra, and
2. External sphincter
- consists of the periurethral
striated muscle.
However, it is better to describe a single
mechanism consisting of elements of
compression and elements of tension.
❖ Elements of compression are necessary
for the urethra to form a watertight seal
between episodes of urination.
- The softness (collapsibility) of
the urethral wall is important for
continence, particularly when a
catheter alters urethral integrity.
- The mucus
➢ produced by the epithelium
➢ further enhances the
watertight seal of the
urethra.
➢ reduces surface tension,
promoting collapse of the
walls and sealing the
microscopic fissures
against urinary leakage.
❖ The vascular cushion
- also acts as an element of
compression (in addition to
producing tension), contributing to
urethral closure during physical
stress.
- The vascular cushion, or
network of the arterioles,
venules, and arteriovenous
communications in the urethra,
promotes urethral compression
by transmitting pressure from the
muscles surrounding the urethra
and those intrinsic to its walls.
- contributes to urethral closure
pressure because it is filled with
an incompressible fluid that has
its own intrinsic pressure.
❖ The elements of tension in the urethral
sphincter mechanism consist of the:
➢ vascular cushion
➢ intrinsic smooth and skeletal
muscles
➢ periurethral striated muscle
- These muscles are specially innervated
to maintain the tension needed for urethral
closure between episodes of micturition
and to provide an extra measure of
urethral tension, which is needed when
significant physical exertion stresses
sphincter closure.
❖ The pelvic muscles
- receive somatic innervation,
➢ which allows voluntary
interruption of the urinary
stream and provides
added protection against
precipitous rises in
abdominal pressure.
Clinical Manifestations
➔ incidence and type of kidney or urinary
tract dysfunction change with the age
and maturation of the child.
Example:
1. a complaint of enuresis
 - has greater significance at 8 years ● Dehydration
old than at 4 years old ● Enlarged kidneys or bladder
2. In newborns, renal abnormalities may be
associated with a number of other
malformations
Ex. 3. Childhood (2 to 14 Years)
➢ obvious neural tube ● Poor appetite
defects to the subtle ● Vomiting
abnormal shape or ● Growth failure
position of the outer ear. ● Excessive thirst
➢ Failure to thrive in children ● Enuresis, incontinence, frequent
may be a sign of impaired urination
renal function. ● Painful urination
● Swelling of face
➔ Obtain further information from the child’s ● Seizures
● History ● Pallor
● family history ● Fatigue
● and laboratory studies ● Blood in urine
- as part of a complete ● Abdominal or back pain
physical examination. ● Edema
● Hypertension
Signs and Symptoms of Urinary Tract ● Tetany
Disorders or Disease
Suspected renal disease can be further evaluated
1. Neonatal Period (Birth to 1 Month) by means of laboratory tests, radiographic
● Poor feeding studies, and renal biopsy.
● Vomiting
● Failure to gain weight Laboratory Tests
● Rapid respiration (acidosis)
● Respiratory distress Detection of renal problems
● Spontaneous pneumothorax or ➔ Both urine and blood studies contribute
pneumomediastinum vital information.
● Frequent urination
● Screaming on urination Routine urinalysis
● Poor urinary stream - single most important test is probably.
● Jaundice
● Seizures ➢ Specific urine and blood tests provide
● Dehydration additional information.
● Other anomalies or stigmata
● Enlarged kidneys or bladder Glomerular filtration rate (GFR)
- is generally accepted as the best overall
2. Infancy (1 to 24 Months) index of kidney function.
● Poor feeding - Though the gold standard for
● Vomiting measurement of GFR has been the
● Failure to gain weight filtration of the small carbohydrate inulin
● Excessive thirst this is not a practical test clinically.
● Frequent urination
● Straining or screaming on urination ➢ The kidney handles creatinine,
● Foul-smelling urine - an end product of protein
● Pallor metabolism in muscle, in a
● Fever similar way so that its plasma
● Persistent diaper rash concentration can be used to
● Seizures (with or without fever) estimate GFR.
 - Creatinine clearance tends to
slightly overestimate GFR.
- Serum creatinine is a function of
both creatinine excretion and
production, so it varies, depending
on muscle mass.

❖ Equations have been developed to

estimate kidney function using serum
creatinine and variables such as:
● Age
● Sex
● Race
● body size.

➢ In the past, 12- or 24-hour urine

collections have been used routinely to
measure creatinine clearance, and
therefore GFR, but studies have shown
these difficult to obtain urine collections do
not provide a better estimate of GFR
than the equations
➢ In the case where a 24-hour urine
collection is indicated, the nurse is
responsible for assisting in obtaining a
complete and accurate collection.
Table 24.1 outlines the major urine and blood tests.
Radiologic and other tests of urinary system function are described in Table 24.2.
Blood tests of renal function are outlined in Table 24.3.