renal system samah suleiman 20/4/2006. urinary tract infections is the inflammatory process...
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Urinary tract infections is the inflammatory process resulting from bacterial invasion into urinary sterile urinary tract Epithelial cells that line the urinary tract respond quickly to bacterial invasion, producing pathogen- destroying leukocytesTRANSCRIPT
Renal System
Samah Suleiman20/4/2006
Urinary tract infections
is the inflammatory process resulting from bacterial invasion into urinary sterile urinary tract
Epithelial cells that line the urinary tract respond quickly to bacterial invasion, producing pathogen-destroying leukocytes
Diagnosis of UTI is confirmed by pyuria-white blood cells, and bacteriuria-bacteria in the urine
Prevalence: Childhood bacterial UTI is the second after upper respiratory tract infections
UTI affect 3-5% of all girls and 1% of boys by the age 11years
Escherichia coli which found in the GI tract is the responsible bacteria for 80% of pediatric UTI
Risk factors
Anatomic factors such as short and strait female urethra, situated close to rectum
Female infants are specially vulnerable as a result from fecal soiling
Congenital anomalies In male: UTI is associated with
prostate problems
UTI is also documented with bowel dysfunction: this believed to be due to pressure of the distended rectal segment and colonic seeding bacteria via the heamatogenic route
Host factors include reduced immune response, bacterial adherence
male found to have greater immune system immaturity and decreased resistance to pyelonephritis and septicemia
uncircumcised male infants has elevated colonization, more risk for UTI for the first 6 months of age
breast feeding offer protective benefits against UTI
Pathophysiology
The kidneys are essentially regulatory organs which maintain the volume and composition of body fluid by filtration of the blood and selective reabsorption or secretion of filtered solutes.
the kidneys are retroperitoneal organs (ie located behind the peritoneum) situated on the posterior wall of the abdomen on each side of the vertebral column, at about the level of the twelfth rib. The left kidney is lightly higher in the abdomen than the right, due to the presence of the liver pushing the right kidney down.
The kidneys take their blood supply directly from the aorta via the renal arteries; blood is returned to the inferior vena cava via the renal veins. Urine (the filtered product containing waste materials and water) excreted from the kidneys passes down the fibro muscular ureters and collects in the bladder
The bladder muscle (the detrusor muscle) is capable of distending to accept urine without increasing the pressure inside; this means that large volumes can be collected (700-1000ml) without high-pressure damage to the renal system occuring.
When urine is passed, the urethral sphincter at the base of the bladder relaxes, the detrusor contracts, and urine is voided via the urethra.
urinary tract is a sterile system, the slightly acidic urine creates hostile environment for most alkaline microorganisms
first line of defense is expulsion via bladder flushing or voiding-increase frequent voiding
immune response start and leukocytes flood the area
affected tissue become inflamed and edematous
bacteria release toxin that is alkaline in nature
nerve endings responds with painful bladder spasm to flush out the pathogen
mucosal infiltration produce hemorrhagic areas
ureterovesicle junction (UVJ) may be become incompetent
transient reflux permits the infection to ascend into the kidneys- pyelonephritis result and may cause irreversible renal involvement (renal parenchymal scarring with loss of glomeruli)
infants acquire pyelonephritis have mote extensive renal damage than children older than 4 years old- have 30% UTI recurrence after the first infection
risk of future hypertension or renal compromise in adulthood
gram-negative septic shock may result from the pyelonephritis due to bacterial endotoxins-life threatening condition
child may experience seizures, hypertension, fever and loss of consciousness
Assessments
Lower tract infections usually presented by increase urinary frequency, urgency, dysuria, hematuria, starngeuria (stopping and starting the urinary stream)
Urine may appear cloudy, blood-tinged Incontinence, mild fever, and
suprapupic pain are common
High fever->39C, flank pain, vomiting, lethargy, and genaralised malaise point to pyelonephritis
Vomiting, diarrhea, irritable cry, poor feeding, slow weight gain or weight loss, diaper rash should raise suspicion of UTI
Diagnostic tests
Collecting urine sample: Midstream urine sample: depends on
the child ability to void Adhesive urine-collection bag: from
non-toilet trained child High incidence of contamination
Recover urine from diaper via aspiration technique: do not recover urine from diapers containing gelling materials for specific gravidity, pH, or protein
Catheterization: inserting polyurethane catheter into the bladder by sterile technique
Suprapupic aspiration: with a syringe withdraw urine directly from the bladder
Blood and protein in the urine confirm UTI
Leukocyte esterase is an enzyme released during WBC destruction
Leukocyte esterase and nitrate testing are often negative because of frequent voiding and lower levels of esterase in the child’s blood
Interventions
Symptomatic relief Arrest the spread of infections Eliminate systemic infiltration of
bacteria Combined antibiotic therapy, increased
fluid intake, and frequent voiding
Urinary evaluation and monitoring for recurrence
Antibiotic therapy for lower UTI include combined sulfamethoxazole, nitrofurantoin, penicillins, and cephalosporins orally for 7-10 days
These may altered after culture results
Repeated urine specimen should be collected 48-72hours after initiation of medication
Increased fluid intake: up to 1000 cc for the older child to dilute and washed out endotoxins and tissue debris
Bladder irritants such as chocolate and caffeine rich should be avoided
Give mild analgesic such as acetaminophen
IV therapy: nursing care directed toward V/S, level of discomfort, intake and output monitoring
Child and family teaching include aspects of disease progression and management, handling of medication
Discuss the risk factors for reinfection and recommended prevention technique
Females whose first UTI before age 5 years and all males should have renal ultrasound, voiding cystourethrogram (VCUG), and intravenous pyelogram (IVP)
Glomerulonephritis
The glomeruli are the structures of the kidneys that supply blood flow to the small units (nephrons) in the kidneys that filter urine.
In glomerulonephritis, the glomeruli become inflamed and impair the kidney's ability to filter urine.
Causes systemic immune disease such as
systemic lupus erythematosus (SLE, or lupus)
Henoch-Schönlein purpura - A disease usually seen in children that is associated with purpura (small or large purple lesions on the skin and internally on the organs) and involves multiple organ systems.
Anti-Glomerular Basement Membrane Disease (Goodpasture's
syndrome)
Is a clinical group of glomerulonephritis and pulmonary hemorrhage, mediated by an anti-glomerular basement membrane antibody which also reacts with the basement membrane of pulmonary capillaries.
Antibody response is directed toward a normal antigen present in the GBM
Goodpasture's syndrome and anti-GBM disease are classic examples of autoimmune disorders.
Clinical Course
Goodpasture's syndrome may occur at any time, but peaks in the spring and summer months are common.
It frequently begins with a flu-like illness with evidence of pulmonary compromise. Progressive dyspnea, hemoptysis and occasionally ventilatory failure occur.
Urinalysis reveals hematuria with red blood cell casts and variable proteinuria.
Patients with Goodpasture's syndrome require immediate institution of plasma exchange and immunosuppressive therapy.
Patients with an initial serum creatinine less than 7 mg/dl have a greater responding favorably to therapy.
Post-Infectious Glomerulonephritis
It is the most common form of glomerulonephritis in children
A common cause is from a streptococcal infection, such as upper respiratory infection. Usually from group A beta-hemolytic streptococci.
usually occurs more than one week after an infection and referred to as acute post-streptococcal glomerulonephritis, APSGN
The post-streptococcal glomerulonephritis is primarily a disease of children, 6 to 7 years of age
The onset is usually abrupt, with a latent period of 7 to 21 days between infection and the development of nephritis
Common initial clinical manifestations of post-
streptococcal glomerulonephritis
Hematuria Edema Hypertension Oliguria In most patients hematuria disappears
by 6 months but proteinuria may persist for two years in a third of patients
The prognosis for complete recovery is excellent in children even accompanied by initial impairment in renal function, persistent proteinuria and the nephrotic syndrome
Children prostacycline and prostaglandin E promote the maintenance of glomerular filtration
It is evidenced that they reduced by the reduction of their output in the stage of chronic renal failure.
The growth of renin and antidiuretic hormone synthesis in children suffering from nephrotic glomerulonephritis is not accompanied by the increase of the output of prostaglandin E, their renal antagonist,
This lead to the development of the edematous syndrome
Generally, Symptoms may include
Dark brown-colored urine (from blood and protein)
Sore throat Diminished urine
output Fatigue
Lethargy Increased
breathing effort Headache High blood
pressure Joint pain
Seizures (may occur as a result of high blood pressure)
Pale skin color Fluid
accumulation in the tissues (edema)
Diagnosis
Thorough physical examination
Complete medical history
Throat culture Urine tests
Blood tests Electrocardiogra
m (ECG) - to detects heart muscle damage.
Renal ultrasound - to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.
Chest x-ray - to produce images of internal tissues, and organs onto film.
Renal biopsy - kidney tissue is sent for special testing to determine the specific disease.
Treatment
Specific treatment will be determined based on:
Child's age, overall health, and medical history
The extent of the disease Child's tolerance for specific
medications, procedures, or therapies
Expectations for the course of the disease
Family preference If glomerulonephritis is caused by a
streptococcal infection, then treatment will be focused on curing the infection and treating the symptoms associated with the infection.
Other different reason cannot be cured, so treatments focus on slowing the progression of the disease and preventing complications.
Treatment
Fluid restriction Decreased protein diet Decreased salt and potassium diet Medication, such as diuretics, blood
pressure medications, phosphate binders - medications to decrease the amount of the mineral phosphorus in the blood. immunosuppressive agents
Dialysis: used for short-term or long-term therapy to remove wastes and additional fluid from the blood after the kidneys have stopped functioning.
If glomerulonephritis does not resolve, long-term kidney failure may need to be addressed.
Acute renal failure
Develop rapidly over days or weeks and classified according to the site of injury to the kidney:
Prerenal: result from impared blood flow to or oxygenation of the kidneys
Usuallu cured with early supportive treatment
Renal or parenchymal: injury or malformation of the kidney tissue-Need dialysis
Postrenal: obstruction of the urinary flow at some level between the kidney and the urinary meatus –require surgical removal of the obstruction