Ch. 44 - Renal Conditions

glomerulonephritis therapeutic management

- A 10-day course of antibiotic therapy may be required - Children with acute renal failure should be hospitalized to allow for fluid and electrolyte management until their renal function has stabilized - Antihypertensive therapy usually is necessary (limit sodium intake, fluid intake, diuretic use, and possible antihypertensives) - Excellent prognosis for children with acute poststreptococcal glomerulonephritis - low salt diet - possible fluid restrictions

glomerulonephritis diagnostic evaluation

- Blood chemistry values usually within normal range - If renal insufficiency is severe, BUN and creatinine levels are elevated - Electrolyte disturbances, such as high serum potassium and low serum bicarbonate levels, can result from inadequate glomerular filtration - An antistreptolysin (ASO) titer, which indicates presence of antibodies to streptococcal bacteria, or a Streptozyme test, can be elevated - Protein, erythrocytes, leukocytes, and glucose may be found in urine

Nephrotic Syndrome Etiology and Incidence

- Cause of primary nephrotic syndrome is not fully understood, but success in controlling the disease by use of immunosuppressive drugs suggests possibility of an immunologic component. - Minimal alterations of glomerulus are seen on histologic examination. - Most common cause of primary nephrotic syndrome in children is idiopathic - Nephrosis can develop as a result of focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, or mesangial proliferation. Incidence is slightly higher in males and occurs most frequently during early childhood.

Nephrotic Syndrome Therapeutic Management

- Corticosteroids are first line therapy. - Parents are educated about disease process and home care. - Before treatment begins, child is tested for exposure to TB and varicella because treatment suppresses immune system. - Corticosteroid therapy is continued until child is in remission—defined as <1+ urine protein for 3-7 consecutive days. - Steroids usually are continued at same daily dose for 4-6 weeks. - After initial treatment, child's dose is decreased and changed to an alternate-day schedule and then slowly tapered. - low salt diet - prevent infection and skin breakdown

Wilms Tumor Diagnostic Evaluation

- Diagnosis can be suspected from data in child's history. - Abdominal ultrasonography is initial study done to detect a solid intrarenal mass. - Abdominal CT or MRI, chest radiography, and chest CT are performed to further evaluate extent of disease. - Laboratory tests include CBC, electrolyte levels, liver and kidney function tests, and urinalysis. - Definitive diagnosis is made at time of surgery on basis of pathologic findings.

CHD management - medications

- Diuretics - Antihypertensives - Sodium bicarbonate (maintain acid-base balance) - Synthetic, active vitamin D, and phosphorus-binding medications Dialysis: May be used depending on severity of the patient's symptoms.

Nephrotic Syndrome Manifestations

- Frothy urine (severe proteinuria) - Edema - insidious onset, massive edema from shift of fluid into interstitial spaces, worsens during the day - Anorexia - Fatigue - Abdominal pain - Respiratory infection - Increased weight - normotensive or hypotensive - hypovolemia - pallor, fatigue Toddler or preschool-aged child Unlike the child with glomerulonephritis, the child with nephrotic syndrome usually has normal blood pressure. Edema is usually first noted in the periorbital spaces and dependent areas of the body; its onset is often insidious.

glomerulonephritis manifestations

- Hematuria (cardinal sign; can be microscopic to gross, evidenced by smoky or tea-colored urine) - Edema, which is worse in the morning, affects primarily eyelids, hands, and feet (abrupt onset, mild periorbital or lower extremity) - Oliguria - Flank pain - Hypertension - Headache Usually young school-age children

CKD Etiology and Incidence

- Most common causes, especially in younger children, are congenital anomalies such as obstruction, vesicoureteral reflux (VUR), and renal dysplasia. - CKD can develop in children from diseases such as glomerulonephritis, pyelonephritis, and HUS. - In general, secondary causes of ESRD, such as diabetes and high blood pressure, are not seen in children. - Incidence of CKD with ESRD among children <19 years of age is approximately 18 in 1 million - Incidence is higher in white adolescent males.

Nephrotic Syndrome Diagnostic Evaluation

- Nephrotic syndrome can be diagnosed on the basis of clinical presentation, age of child, and laboratory results. - Urinalysis demonstrates protein (3+ to 4+), and urine appears dark and frothy. - Microscopic hematuria may be present. - Serum cholesterol, triglycerides, hematocrit, and hemoglobin values are elevated. - Serum albumin is markedly decreased (<2.5 g/dL). - Child has normal electrolyte levels and a negative ASO titer or Streptozyme test. - Hypoalbuminemia (<2.5 g/dL), elevated cholesterol and triglyceride, hemoglobin, hematocrit, and platelet levels - normal serum electrolytes, complement levels, ASO titer

glomerulonephritis etiology and incidence

- Occurs as immune reaction to group A beta-hemolytic streptococcal infection of throat or skin - Streptococcal infection needs to be substantiated for diagnosis - Occurs most frequently in young children of preschool or early school age - Clinical symptoms usually develop 1-2 weeks after streptococcal pharyngitis or 3-6 weeks after streptococcal skin infection (pyoderma) (Pan & Avner, 2016)

AKI Pathophysiology

- Prerenal AKI is the result of conditions that decrease perfusion of the kidney causing ischemia and subsequent cellular inflammation, injury, and possible cell death. - Intrinsic AKI is the result of actual damage to kidney tissue from certain diseases, many with inflammatory, hypoxic, or ischemic components. - Postrenal AKI result of obstruction of urine outflow

Nephrotic Syndrome Pathophysiology

- Primary nephrotic syndrome, or minimal change nephrotic syndrome (MCNS), occurs from an insult to the glomerular basement membrane. - Damage to membrane causes increased permeability. - Proteins, particularly albumin, are cleared at an increased rate, resulting in loss of plasma proteins and in proteinuria. - Blood albumin values are low (hypoalbuminemia) because of loss of albumin through the defective glomerulus and liver's inability to synthesize proteins to balance the loss.

glomerulonephritis laboratory findings

- RBCs, casts, small amount of protein in urine (0 to 3+) - Normal serum albumin, cholesterol, and triglyceride levels; decreased or normal hemoglobin and hematocrit values - Altered electrolytes, elevated blood urea nitrogen, or creatinine levels - Elevated ASO titer or Streptozyme, decreased complement levels

AKI Diagnostic evaluations

- Serum creatinine and BUN levels are increased - BUN level, an end product of protein catabolism, may reflect child's nutritional status - Metabolic acidosis can occur, as indicated by low serum bicarbonate level - Serum potassium level may be increased - Serum sodium level may be increased or decreased, depending on fluid volume status Renal ultrasonography may help with the diagnosis of obstruction and postrenal AKI. A renal scan can be helpful in determining the cause of all AKI types. It can assess blood flow, kidney function, and obstruction.

glomerulonephritis pathophysiology

- Thought to occur due to an immunologic response following streptococcal infection - Body responds to bacteria by forming antibodies, which combine with bacterial antigens to form immune complexes - As antigen-antibody complexes travel through the circulation, they become trapped in the glomerulus and activate an inflammatory response in the glomerular basement membrane

Which combined clinical evidence should best warrant dialysis in the AKI patient?

BUN >120 mg/dL Increasing BUN >120 mg/dL suggests renal insufficiency and dialysis is required. Severe hypertension Hypertension, together with other indicators, leads to the requirement for dialysis. Patient has fluid overload Edema can be caused by fluid overload. Kidneys cannot compensate and fluid needs to be removed by other methods. Pulmonary crackles that do not clear with a cough Pulmonary crackles that do not clear with a cough indicate pulmonary edema. Pulmonary edema can form from fluid overload and congestive heart failure. Blood pH is low and not responsive to intervention Metabolic acidosis that does not respond to treatment is an indication for dialysis.

Chronic Kidney Disease and End Stage Renal Disease

CKD is an irreversible loss of kidney function that usually occurs over months to years. It can be managed conservatively with medications and diet restrictions. CKD progresses to end-stage renal disease (ESRD), which is the permanent, irreversible loss of kidney function such that conservative treatment alone can no longer sustain the child's health and life. ESRD usually is diagnosed when the glomerular filtration rate (GFR) decreases to 10 percent.

CKD Diagnostic Evaluation

CKD may manifest nonspecifically. - Physical examination may reveal short stature and failure to thrive. - Rising serum creatinine and BUN levels suggest ESRD. - Creatinine clearance testing - As renal function deteriorates, creatinine clearance decreases. - Bone radiographs diagnose renal osteodystrophy. - Diagnosis of ESRD is made by monitoring serum creatinine levels, glomerular filtration rate (GFR), and the quality of the child's life. - Dialysis or kidney transplantation is required once ESRD is diagnosed with only 5%-10% of kidney function remaining.

Causes of Prerenal Failure

Dehydration Perinatal asphyxia Hypotension Shock Renal artery obstruction

After eating hamburgers at the state fair, a patient develops bloody diarrhea. At the emergency department they are given IV antibiotics and fluids. During hospitalization, the nurse notes the patient is oliguric. Within a few days, the patient has copious amounts of dilute urine. Which is the most important complication for the nurse to assess for?

Dehydration and electrolyte imbalance due to slow nephron tubule recovery The increase in GFR exceeds the tubular recovery and therefore copious, dilute urine is produced. When reabsorption and secretion do not occur normally, electrolyte imbalance is a concern.

Dialysis

Dialysis is a process of removing waste products and excess body fluids and regulating electrolytes and minerals. It is sometimes necessary in acute renal failure. When chronic kidney disease progresses to end-stage renal disease (ESRD), dialysis or kidney transplantation is required. The two principle types of dialysis are hemodialysis and peritoneal dialysis.

CKD Management - Diet

Diet: Individualized and modified to regulate fluids, electrolytes, minerals, and waste products. - Reductions in sodium and fluid intake - Phosphorus is restricted to manage bone disease - Potassium restriction - Protein intake is regulated to decrease accumulation of waste products

Which statements help to clarify the main differences between peritoneal dialysis and hemodialysis?

Efficiency of dialysis Hemodialysis is more efficient than peritoneal dialysis. Time required for dialysis Hemodialysis requires less time than peritoneal dialysis. Location of catheterization Hemodialysis requires direct vascular access. Peritoneal dialysis requires catheterization of the abdomen. The risk for infection at access site in hemodialysis is higher. Caregiver involvement in dialysis treatment Peritoneal dialysis typically requires parents/caregivers to be actively involved in the dialysis treatment. Hemodialysis is performed in hospital or clinical settings.

AKI Manifestations

Electrolyte abnormalities Fluid volume shifts Increased BUN and serum creatinine levels Acid-base imbalances Nonspecific symptoms as seen in HUS Hypertension Edema Respiratory distress due to fluid overload

HUS Clinical Manifestations

Electrolyte abnormalities Fluid volume shifts Increased BUN and serum creatinine levels Acid-base imbalances Nonspecific symptoms include: Poor feeding Decreased appetite Vomiting Seizures

CKD Manifestations

Electrolyte abnormalities Fluid volume shifts (dehydration or fluid overload) Acid-base imbalances Renal osteodystrophy (rickets) Anemia Poor growth Hypertension Fatigue Decreased appetite Poor feeding Nausea and vomiting Neurologic symptoms from accumulation of wastes in the blood

A patient has returned for a follow-up appointment for pharyngitis. The child now has altered electrolytes and an elevated ASO titer. The nurse notes facial edema and hypertension. Which finding confirms a diagnosis of acute poststreptococcal glomerulonephritis?

Elevated ASO titer Elevated ASO titer provides evidence for acute poststreptococcal glomerulonephritis as it indicates a confirmation for strep infection.

CKD Pathophysiology

Exact mechanisms are unclear. Factors that contribute to development of ESRD include: - Continuing immunologic injury - Congenital obstructive uropathies - Hyperfiltration (overwork of the remaining nephrons) - High dietary phosphorus intake - Persistent proteinuria - Hypertension

Which 3 factors need to be considered when planning care for a patient diagnosed with ESRD?

GFR GFR ≤10% indicates significant reduction in nephron functionality. Quality of life A child's quality of life is considered in the diagnosis of ESRD. Once a child is diagnosed with ESRD, dialysis or kidney transplant is required. Serum creatinine and BUN levels Increasing creatinine and BUN levels are indications of declining renal function.

HUS Etiology and Incidence

HUS is one of the most frequent causes of acute kidney injury (AKI) in children. HUS is often associated with Shiga toxin-producing Escherichia coli (STEC) infection that results from improperly cooked meat or contaminated dairy products.

Which manifestations should the nurse likely anticipate for a patient diagnosed with HUS?

Hematuria Hematuria is a symptom often associated with HUS, and therefore the nurse will need to manage this symptom. Hemolytic anemia This is a symptom that is expected in a patient with HUS, therefore the nurse will need to treat this symptom. Thrombocytopenia Thrombocytopenia is expected in this patient with HUS, and therefore the nurse will need to implement care to manage this patient. Stool culture that is positive for E. coli This is a finding that will often appear in patients with HUS, and therefore this symptom will need to be managed by the nurse.

Hemodialysis

Hemodialysis cleanses the blood by circulating it through a special filter called an artificial kidney. Blood is pumped through the artificial kidney and returned to the body. Hemodialysis occurs through a surgically placed, vascular access, such as a double-lumen central line or an arteriovenous fistula or shunt. Children who receive long-term dialysis usually receive treatments three times per week for 3-4 hours each time. Considerations - The major complications of hemodialysis include access infection and access obstruction. - School, social, and family lives may be disrupted because of the treatment schedule. - Children treated with hemodialysis in a specialized pediatric unit can thrive. - School-age and adolescent patients can receive a more permanent access site so they can return to daily activities. - Hemodialysis is technically more difficult for infants and small children related to more pronounced fluid and electrolyte shifts. - Hemodialysis is more efficient and requires less time than peritoneal dialysis.

Both nephrotic syndrome and glomerulonephritis have similar clinical manifestations. What evidence can be used to distinguish between the two disease states?

Hypertension In glomerulonephritis the patient is hypertensive. In nephrotic syndrome the patient may be normo- or hypo-tensive. Gross hematuria Gross hematuria is evident in glomerulonephritis. Microscopic hematuria may be present in nephrotic syndrome. Normal serum albumin levels Normal serum albumin levels are found in glomerulonephritis. Hypoalbuminemia is a symptom of nephrotic syndrome. Normal serum electrolyte levels Normal serum electrolyte levels are seen in nephrotic syndrome. Altered electrolyte levels are found in glomerulonephritis.

Which explanation describes the rationale for immunizing children prior to receiving a kidney transplant?

Immunosuppression that is required after transplant increases the risk for infections. Immunizations will initiate an immune response that is specific for the antigens of the inoculation. This will provide future protection.

A family brings their toddler to the clinic because of frothy urine and a swollen face. Serum analysis confirms hypoalbuminemia and elevated hematocrit levels. The child is normotensive. Based on this clinical data, what care measure should the nurse anticipate in managing this patient?

Immunosuppression with corticosteroids For the child with nephrotic syndrome, corticosteroids are continued until child is in remission—defined as <1+ urine protein for 3-7 consecutive days. Steroids are typically continued at the same daily dose for 4-6 weeks.

Peritoneal Dialysis

In peritoneal dialysis, fluid enters the peritoneal cavity through a catheter that is placed in the child's abdomen, at the bedside or in the operating room. The dialysis fluid remains in the cavity for a prescribed time (dwell time), during which waste products, chemicals, and fluid pass through the peritoneal membrane into the fluid. The fluid is then drained out of the body, and the process is repeated. Peritoneal dialysis should be used in patients who are hemodynamically unstable.

In which situation should peritoneal dialysis be favored over hemodialysis?

Infants who are hemodynamically unstable Peritoneal dialysis is a slower process and therefore prevents dramatic shifts in fluid and electrolytes.

Kidney Transplant Considerations

Kidneys come from either living donors or cadaveric donors. A living donor is often someone in the child's family, such as a parent, older sibling, or grandparent, although persons without a biologic relation may also donate a kidney. The donor must be in good health and have healthy kidneys. Rejection by the child's immunologic system of the transplanted kidney is the most common complication. Immunosuppressive medications are taken to prevent rejection. These include: - Cyclosporine (Gengraf or Neoral), - prednisone, tacrolimus (Prograf), - mycophenolate (CellCept or Myfortic). Note: When the immune system is suppressed, risk of infection is increased related to the body's decreased ability to fight infection. Children with renal transplants should be monitored for infection and may take antiinfective medications routinely.

Hemolytic uremic syndrome (HUS)

Most children affected with hemolytic uremic syndrome (HUS) have an associated prodrome of gastrointestinal symptoms, including bloody diarrhea, which suggests that an infectious agent may be the cause of HUS.

HUS Diagnostic Evaluation

Necessary to ascertain any recent history of bloody diarrhea that might suggest HUS, as history often gives an indication of underlying cause of the AKI.

Nephrotic Syndrome

Nephrotic syndrome refers to a kidney disorder characterized by proteinuria, hypoalbuminemia, hypercholesterolemia, and edema. Nephrotic syndrome can be classified as primary or secondary.

Causes of intrinsic renal failure

Nephrotoxins (e.g., aminoglycosides, contrast dye) Lupus erythematosus Hemolytic uremic syndrome (HUS) Glomerulonephritis Pyelonephritis

Wilms Tumors - Etiology & Incidence

Occurs in children with no unusual physical features and no family history of the disease. Cause of Wilms tumor is unknown. Has been associated with: - Aniridia (absence of the irises) - Hemihypertrophy - Cryptorchidism - Hypospadias About 8:1 million children <15 years of age are diagnosed annually, representing 6% of childhood cancers Most children are diagnosed between the ages of 2 to 5 years; however, it is seen in neonates, adolescents, and adults. Bilateral Wilms tumors rare

Why is it important to understand blood proteins in a patient with nephrotic syndrome?

Proteins are filtered in the glomerulus and lost in the urine. Increased permeability in the glomerulus causes proteinuria in nephrotic syndrome. Synthesis of liver proteins cannot keep up with need and patient develops hypoalbuminemia. As proteins are lost in the urine, the liver works to maintain normal levels of blood proteins. Liver metabolism cannot synthesize proteins fast enough to compensate for loss.

Glomerulonephritis

Refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Infection or a systemic disease process, such as lupus erythematosus or Schönlein-Henoch purpura (an autoimmune vasculitis), can cause glomerular inflammation.

Secondary nephrotic syndrome

Secondary nephrotic syndrome is the result of a systemic disease, such as hepatitis, systemic lupus erythematosus, heavy metal poisoning, or cancer.

Indications for Dialysis for AKI

Some patients with AKI develop the need for dialysis. Changes in fluid retention, electrolyte imbalance, and increasing waste products indicate the need for dialysis. Indications for dialysis in acute kidney injury (AKI): - Severe fluid overload - Pulmonary edema or congestive heart failure caused by fluid overload - Severe hypertension - Metabolic acidosis not responsive to medications - Hyperkalemia not responsive to medications - Blood urea nitrogen (BUN) level >120 mg/dL

A patient presents with sudden onset of gross hematuria, proteinuria and hypertension. In assessing this patient, what statement best supports the importance for the nurse to assess the presence of throat discomfort over the past two weeks?

Streptococcal pharyngitis can induce glomerulonephritis. Acute poststreptococcal glomerulonephritis occurs as an immune reaction to a group A beta-hemolytic streptococcal infection of the throat or skin. Clinical symptoms usually develop 1-2 weeks after a streptococcal pharyngitis.

AKI Therapeutic Management

Supportive treatment includes establishing and maintaining euvolemia (normal fluid balance), electrolyte repletion, and corticosteroids. - Most children with AKI have high serum potassium level - Potassium is restricted and interventions to remove potassium are utilized - If treatments for hyperkalemia are not effective, dialysis is recommended - Decreased sodium level due to fluid overload - As underlying problem is treated, GFR returns to normal quickly and child voids large amounts of dilute urine - Risk for dehydration related to fluid loss - In most cases, renal function progressively returns to normal

Wilms Tumor Manifestations

The most common clinical presentation is an asymptomatic, immobile, abdominal mass discovered by the parent or other caregiver while bathing the child or by a primary care provider during a routine physical examination. Additional manifestations include: - Microscopic or gross hematuria - Hypertension - Abdominal pain - Constipation - Nausea/vomiting - Fatigue - Anemia - Fever WAGR: Wilms tumor, Aniridia, Genitourinary anomalies, and Retardation

A 1-year-old child presents to the clinic with an abnormal abdominal bulge. The parents state the patient has been asymptomatic and the mass has not grown in size. The mass is also immobile. Upon close observation the child also has unusual appearing eyes. Why are both an ophthalmology and renal referral necessary in this patient?

The unusual appearing eyes, with missing or partial iris, are suggestive of Wilms tumor. Aniridia, missing or partial iris, can be a sign of Wilms tumor. This is a genetic disorder that is related to Wilms tumor. Renal referral is required because the large, immobile, abdominal mass in such a young child is indicative of Wilms tumor. The large, immobile mass in the abdomen is suggestive of Wilms tumor, which affects the kidney.

HUS Therapeutic Treatment

Therapeutic treatments are focused on: - Fluid loss - Eliminating causative bacteria - Increasing thrombocyte and erythrocyte levels - Increasing GFR

Therapeutic Treatment

Therapeutic treatments are focused on: - Fluid loss - Eliminating causative bacteria - Increasing thrombocyte and erythrocyte levels - Increasing GFR

What is the significance of thrombocytopenia in a patient with HUS?

Thrombocytopenia potentiates small vessel occlusion and development of thrombi. Thrombocytopenia results from nonimmunologic platelet destruction. Small thrombi are found throughout the body. Anemia can also result from the capture of RBCs in the clots. Thrombocytopenia develops as platelets occlude vessels and then decreases blood flow and GFR. As platelets occlude vessels, including in the kidney, blood flow decreases and there is a reduction in GFR.

Kidney Transplant

Transplantation is the therapeutic goal for most children with ESRD; it offers the best opportunity for relatively normal lives and continued growth and development. Unfortunately, transplantation is not a cure. Children with kidney transplants must continue to take immunosuppressive medications daily, have frequent blood tests, and attend regular clinic appointments.

Wilm's Tumor Therapeutic Management

Treatment for Wilms tumor consists of surgery and chemotherapy alone or combination with radiation therapy. Depending on the tumor stage and histology, 4-year survival rates range from 55% to 99%.

HUS Pathophysiology

Two important characteristics of O157:H7 strain of E. coli contribute to development of HUS. - Bacterium attaches to intestinal mucosa allowing bacteria to grow and multiply - Bacteria produce a toxin that damages endothelial cells of capillary walls - Subsequent inflammatory response results in occlusion of capillaries - Can lead to AKI - Vascular process seen in HUS can affect any organ - Anemia results from fragmentation of erythrocytes and hemoglobinuria results from hemolysis - Thrombocytopenia occurs as platelets get trapped impairing blood flow throughout body

Causes of postrenal failure

Ureteropelvic junction obstruction Neurogenic bladder Outlet obstruction by stones, tumor, or edema

Wilms Tumor Pathophysiology

Wilms tumor arises from renal parenchyma of the kidney. Categories of Wilms tumor are based on favorable and unfavorable histologic findings. - Children with favorable histologic findings (the majority) have a better prognosis At initial diagnosis, disease is usually local, but metastasis to other organs occasionally occurs. Lungs are most common site of metastasis. As with other tumors, a staging system directs treatment.

Wilms Tumor

Wilms tumor is the most common renal tumor in children. NURSING QUALITY ALERT: Assessing the Child with a Wilms Tumor The tumor mass should not be palpated during the assessment because of the risk of rupturing the protective capsule. Excessive manipulation can cause seeding of the tumor and spread of cancerous cells.

membranoproliferative glomerulonephritis

a chronic form of glomerulonephritis, characterized by mesangial cell proliferation, irregular thickening of glomerular capillary walls, thickening of the mesangial matrix, and low serum levels of complement.

Acute glomerulonephritis

refers to disorders that occur suddenly, are self-limiting, and resolve completely. Acute poststreptococcal glomerulonephritis, the most common type, is characterized by sudden onset of hematuria, proteinuria, hypertension, edema, and renal insufficiency

Acute Kidney Injury

the sudden, severe loss of kidney function In AKI, the kidneys can no longer filter waste products, regulate fluid volume, or maintain chemical balance. Most children with AKI regain renal function depending on the underlying cause. Children with AKI are cared for in acute care units. Principles of nursing care include (1) monitoring and maintaining fluid, electrolyte, and acid-base balances (2) preventing infection (3) providing adequate nutrition (4) reducing parent and child anxiety (5) teaching about the disease process, treatment, and dialysis.