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Morning Report

Lindsey Gakenheimer-Smith MD PGY3

History - HPI
• 2m ex-35 week twin male presenting with poor
weight gain
• Regained birth weight at 4 weeks but has not gained
weight since then
• Frequent NBNB emesis/reflux
• Started on ranitidine 2 weeks ago without
• Feeds include breast + bottle q1.5-2h (21-24 oz/day)
• Stools 3-4x/day, creamy yellow color
• No fevers, no rashes, no jaundice, no fatigue with
feeds but does seem more tired than twin
• Birth and Medical Hx: born at 35 weeks via SVD,
spent 48h in NICU for respiratory distress; no
home O2 or NG need
• Meds: ranitidine 15mg BID
• Allergies: no known food or drug allergies
• FHx: twin sister is healthy with normal weight
• Social Hx: lives with parents, twin sibling, 2 older
• VS: T 37.1C HR 160 RR 20 BP 83/52
• Ht 54 cm (19th %ile), Wt 3.12 kg (15th %ile) OFC 37.5 cm (5th
• Birth weight 5lbs 9oz (53rd %ile)
• General: nontoxic, small for age
• HEENT: AFOSF, MMM, no adenopathy
• CV: RRR, normal S1 and S2, no murmurs or gallops, brachial
and femoral pulses 2+
• RESP: LCAB, normal work of breathing, no adventitious sounds
• GI: soft, NTND, no hepatosplenomegaly
• MSK: no abnormalities
• GU: Male Tanner Stage 1, bilateral descended testes
• SKIN: no rashes or jaundice
• NEURO: awake, alert, normal tone and strength
Differential Diagnosis
• GI • Inborn error of metabolism
o Malrotation • Plmonary
o Swallowing Dysfunction o CF
o Esophagitis o Other chronic lung diseases
o Pyloric Stenosis
o Malabsorption
• Nutritional
o o Inadequate intake
Chronic liver disease
• Infection • Primary immunodeficiency
o Gastroenteritis • Renal
o Meningitis o AKI
o Botulism o RTA
• Congenital heart disease
• Malignancy
• Congenital adrenal

• Anion Gap – 11
• ESR 62 CRP 0.1
What next?
• Diagnostics
o Labs
o Imaging

• Treatment
o Fix electrolytes and acidosis
• What type of fluids?
• Is he volume deplete as well?
• Frequency of lab monitoring?
• Urine studies
o Cath UA – large Hgb 6 RBCs, Large LCE, neg nitrite, 10 WBCs, trace glucose, 1+
protein, neg bacteria
o Urine Na - <20
o Urine Cl – 24
o Urine Cr – 7.2
o Urine K – 12.7
o Urine urea nitrogen - 118
o Urine Osm – 116 (low) (serum Osm normal at 286)

o FENa ~ 4.1%
o FE Urea 53.6%
o Urine anion gap – (Na + K – Cl) =~8

• Serum aldosterone 196 (high)

• Random Cortisol 3.6

• What next?
• By the way, you just got a page – nurses required
multiple attempts to cath him

• And family just remembered – he had

hydronephrosis on 2nd trimester US, improved but
was still present on postnatal US; was supposed
to follow-up with PCH nephrology in 2 weeks

• Would you like to change your differential?

• Complete retroperitoneal ultrasound
o Grade 4 left hydroureteronephrosis with marked cortical
thinning; tortuous dilated ureter along entire course
o Grade 2 right hydronephrosis
o Thickened bladder urinary wall
o Hyperechogenicin bilateral renal parenchyma suggesting
medical renal disease
o UTD classification - P3 (high risk)
Prenatal Urinary Tract Dilation (UTD)
• Common Causes
o Transient Hydronephrosis (50-70%)
o Ureteropelvic obstruction (10-30%)
o Ureterovesical junction obstruction/megaureter (5-15%)
o Vesicoureteral reflux (10-40%)
o Multicystic dysplastic kidney (2-5%)
o Posterior Urethral Valves (1-5%)
o Ureterocele, ectopic ureter, Prune belly syndrome,
polycystic kidney disease, cysts (all rare)
UTD Classifications
Antenatal Postnatal

Both antenatal and postnatal US repeated at least

Follow-Up – Prenatal US
Follow-Up - Postnatal US
Next Steps
• Page Urology for consult and foley placement
o If any concern for GU obstruction, place foley ASAP
o Don’t try too hard – page urology for placement if struggling

• Imaging
o VCUG (to evaluate for VUR and any bladder outlet obstruction)
o Diuretic renography (Mag 3 Lasix renal scan) to diagnose urinary tract
• Can help identify level of renal function and any obstruction
• May not be required if VCUG is diagnostic

• Antibiotic Prophylaxis for UTI

o If severe urinary tract dilation, consider if moderate
Long-Term Management
• Urologic interventions to relieve obstruction
• Close monitoring of renal function
• Maintain normal electrolyte and acid-base status,
adequate caloric intake
o Restriction and/or supplementation of electrolytes, bicarb, fluids
o Breastmilk is best
• Low solute load, including low Phos
• Alternative – Similac PM 60/40
• Consider fortification, g-tube
• Prevent UTIs
o Antibiotics
o Circumcision

• Monitor for complications

• CKD, renal failure
• Hypertension
• Anemia
• Poor feeding
• Growth failure, frequent fractures
• Dyslipidemia
• Neurocognitive delay
• Frequent UTIs – continued renal scarring
Patient Outcome
• Diagnosed with megaureter, bilateral
ureterostomy tubes placed
• CKD Stage 5 with peritoneal dialysis and polyuria
• Has hypertension, poor feeding, growth failure,
requires multiple nutritional supplements
• Frequent hospitalizations for electrolyte
• Undergoing evaluation for renal transplant
• Nguyen HT, Benson CB, et al. “Multidisciplinary
consensus on the classification of prenatal and postnatal
urinary tract dilation (UTD classification system). Journal
of Pediatric Urology Dec. 2014(10)6:982-998.
• Cadogan M. “Hyponatremia.” Life in the Fast Lane. Last
updated 5/18/2016. Accessed online 11/4/2018
• Sommers MJ, Traum AZ. “Hyponatremia in children.”
UpToDate. Last updated 11/11/2016. Accessed online
• Srivastava T, Warady BW. “Overview of the management
of chronic kidney disease in children.” UpToDate. Last
updated 9/10/2018. Accessed online 11/4/2018.