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Course: Pediatric Nursing

Topic: Care of Child with Genitourinary Disorder Part II

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Module Goals

Learners will be able to:

Define hydronephrosis, nephrotic syndrome and glomerulonephritis.
Identify signs and symptoms of these disorders in children.
Explain related diagnostic procedures.
Discuss evidence-based management of these disorders in children.
Describe nurse’s role in management of these disorders in children.

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Hydronephrosis

Swelling of kidneys due to abnormal buildup of urine caused by:

Blockage between

Kidney and ureter- Ureteropelvic junction obstruction
Ureter and bladder- Ureterovesical junction obstruction
In boys, posterior urethral valve obstruct urine flow to urethra

Bladder to ureter backward flow of urine- Vesicoureteral reflux

Signs/symptoms:

Pain in abdomen or flank pains
May have hematuria
Nausea/vomiting
Signs/symptoms of urinary tract infection

University of Missouri, n.d.

UNC School of Medicine- Urology, n.d.

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Hydronephrosis

Swelling of kidneys due to abnormal buildup of urine caused by:

Blockage between

Kidney and ureter- Ureteropelvic junction obstruction
Ureter and bladder- Ureterovesical junction obstruction
In boys, posterior urethral valve obstruct urine flow to urethra

Bladder to ureter backward flow of urine- Vesicoureteral reflux

Signs/symptoms:

Pain in abdomen or flank pains
May have hematuria
Nausea/vomiting
Signs/symptoms of urinary tract infection

University of Missouri, n.d.

UNC School of Medicine- Urology, n.d.

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Hydronephrosis: Diagnostics

Prenatal Hydronephrosis:

Often identified during routine prenatal ultrasound

Post-natal Hydronephrosis:

Identified through further investigations after child shows clinical signs/symptoms

Other diagnostic tests that may be performed:

Renal scan
X-ray
Voiding cystourethrogram (VCUG)

UNC School of Medicine- Urology, n.d.

Healthwise staff, 2021

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Hydronephrosis: Management

For many infants, condition resolves just before or after birth
Child with hydronephrosis may be prescribed prophylactic antibiotic
Mild to moderate hydronephrosis may not need intervention but is continuously monitored
May require surgical interventions for severe hydronephrosis putting kidney function at risk

Type of surgery depends on the where the obstruction is in the urinary system

UNC School of Medicine- Urology, n.d.

Healthwise staff, 2021

Healthwise Staff, 2020a

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Critical Thinking Question

Which of the following are sign/symptoms of hydronephrosis? (Select all that apply)

Nausea and vomiting
Fever
Tea colored urine
Frequent urge to urinate
Bedwetting

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Nephrotic Syndrome (NS)

A condition that causes kidneys to leak large amounts of protein into urine, usually due to damage to glomeruli
May occur at any age, usually first diagnosed in children between age 2 to 5 years old
Signs and symptoms:

Swelling around eye is most common
Swelling in other parts of the body
Foamy urine
Fatigue
Lesson common: hematuria, loss of appetite, muscle cramps, diarrhea or nausea

NHS UK, 2019

NIDDK, 2021

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NS in Children: Causes

Primary NS (affecting only the kidney)

Minimal change disease (MCD):

Most common cause of NS in young children
Very little change to glomeruli or nearby kidney tissue
Cause unknown

Focal segmental glomerulosclerosis (FSGS):

Kidney glomeruli become scarred
Due to genetic variants or changes in genes at birth

Membranous nephropathy (MN):

Autoimmune disease causes proteins to build up in the glomerular basement membrane

NIDDK, 2021

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NS in Children: Causes (Continued)

Secondary NS (develops due to infections, medicines, or conditions that affect other parts of the body)

Systemic diseases like IgA vasculitis and lupus
Infections like hepatitis B and C, HIV, malaria
Leukemia, lymphoma, sickle cell disease
Some medicines and drugs, such as nonsteroidal anti-inflammatory drugs, and some medicines used to treat mood disorders, bone loss, or cancer

NIDDK, 2021

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NS in Children: Complications

NIDDK, 2021

Losing too much protein in the urine can lead to many complications, including:

Higher risk of infection
Blood clots
Hypertension
High cholesterol
Brief or long-lasting kidney problems

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NS in Children: Assessment

Medical and family history
Edema - principal presenting feature:

Mild to moderate periorbital, scrotal or labial swelling
Severe: gross scrotal/labial or limb swelling, ascites, increased respiratory effort/distress
Weight gain: measuring height and weight

Vital signs
Clinical assessment & diagnostic testing of acute complications if signs/symptoms present:

Intravascular volume depletion
Infection
Thrombosis

NIDDK, 2021

Perths Children’s Hospital, 2021

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NS in Children: Diagnostics

Immunization status, recent exposure to vaccine preventable diseases- Streptococcus pneumoniae and varicella exposure
Urinalysis:

Urine protein: creatinine ratio (ideally first morning urine)
MCS if febrile
±Urine sodium (intravascular volume depletion)

Blood tests, to test kidney function and underlying diseases

FBP, UEC, LFTs, calcium, phosphate, magnesium
Initial presentation only: Streptococcal serology, complement levels (C3, C4), antinuclear antibody
Blood cultures if febrile/septic

Perths Children’s Hospital, 2021

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NS in Children: Assessment and Diagnostics (Continued)

Imaging (if concerned about thromboembolism)
Kidney ultrasound
Genetic testing
Kidney biopsy for children with complex disease, low kidney function, or are 12 years old or older

NIDDK, 2021

Perths Children’s Hospital, 2021

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Critical Thinking Question

Which of the following information is true regarding nephrotic syndrome in children? (Select all that apply)

Edema is the principal presenting feature
Weight loss may be masked by edema
There is a higher risk of deep vein thrombosis
Sample from the second void is preferred for urine protein creatinine ratio test
Child’s immunization status should be reviewed

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NS in Children: Pharmacological Management

Hospitalization required for initial therapy
Prednisone or prednisolone, is the mainstay treatment for primary NS

Before initiating corticosteroid therapy concomitant acute infections should be treated

Active tuberculosis should be ruled out, or treated

Internationally accepted dosage:

First four weeks: 60mg/m²/day, once daily orally

(maximum of 60mg/day)

Next four weeks: 40mg/m²/day, every other day orally

NS that do not respond to corticosteroids, more likely to progress to end-stage kidney disease

NIDDK, 2021

Perths Children’s Hospital, 2021

Pasini et al., 2017

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NS in Children: Pharmacological Management

Primary NS (continued):

Other immuno-suppressant prescribed alone or in adjunct to low dose corticosteroid (corticosteroid not effective or cause harm)
Medicine to manage symptoms and complications:

Anti-hypertensives, diuretics, statins, anticoagulants, antibiotics
Diuretics should be stopped immediately if child is hypovolemic

Management of Secondary NS depends on the cause of NS

Antibiotics for infections
Might need to stop medications for treatment of HIV, lupus, diabetes

NIDDK, 2021

Perths Children’s Hospital, 2021

Pasini et al., 2017

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NS in Children: Non-pharmacological Interventions

Vaccination:

Unimmunized children should receive pneumococcal vaccine
Live vaccines contraindicated while on or within 1 month of completion of steroid therapy
Varicella recommended three months after steroid discontinuation

Daily weight, urinalysis or urine protein to creatinine ratio (UPCR)
Albumin infusion

Observe for respiratory distress, hypertension, congestive heart failure
Contraindicated in pulmonary edema

Dietary changes for sodium, fluid, saturated/cholesterol restrictions

NIDDK, 2021

Perths Children’s Hospital, 2021

Pasini et al., 2017

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Special Nursing Consideration for Children with NS

Monitoring daily weight, fluid intake/output
Carrying out daily lab tests as required
Monitoring and immediate management of complications
Child/Parent education:

Safe restrictions on dietary salt, fluids, saturated fats
About prescribed medications
Signs and symptoms of possible complications associated to NS and prescribed treatments, when to seek medical advice
Need of vaccines, contraindications related to live vaccine
Measures to prevent infections in children while on immunosuppressants

NIDDK, 2021

Perths Children’s Hospital, 2021

Pasini et al., 2017

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What Would the Nurse Do?

Which of the following nursing interventions are appropriate for the nurse to undertake while caring for 1 year old child with nephrotic syndrome being treated with prednisolone and intravenous albumin 20% ? (Select all that apply)

Document amount all fluid intake
Inform parents to immunize the child with varicella vaccine
Monitor lung sounds
Monitor vital signs
Monitor child’s weight
Refer to dietician to counsel parent on low salt diet

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Answer: a, c, d, e, f

Monitoring and documenting fluid intake output, vital signs, and weight gain are all important nursing care for child with nephrotic syndrome.

Since the child is on prednisolone, nurse should inform the parents that live-vaccines, like varicella, should not be administered during prednisolone treatment. Nurse should also inform that child is at greater risk for vaccine preventable infections, thus should consult doctor for safe time for different vaccines.

Children provided with intravenous 20% albumin are at risk of pulmonary edema, which is a life threatening situation. Listening to the lung sounds, crackling sounds, is one of the assessments made for pulmonary edema.

Parents should be counselled by dietician for appropriate diet that are low on salt, fats, and fluids.

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Glomerulonephritis in Children

Inflammation of glomerular apparatus of the kidney due damage caused by body’s own immune system or certain medicines
Acute glomerulonephritis happens few weeks after an infection
Chronic/progressive glomerulonephritis characterized by irreversible and progressive glomerular and tubulointerstitial fibrosis
Causes:

Usually secondary to previous streptococcal infection
Follows pharyngitis or otitis by 1-3 weeks
Lag time after skin infections is variable (can be up to 3 weeks)

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care, 2013

Healthwise staff, 2020b

Bettercare Learning Programmes, n.d.

National Kidney Foundation, n.d

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Glomerulonephritis in Children: Signs/Symptoms

Acute glomerulonephritis:

Hematuria, Proteinuria
Oliguria or anuria in severe case
Edema of face (especially morning), feet (especially evening)
Hypertension

Kidney failure due to chronic glomerulonephritis:

Lack of appetite
Nausea and vomiting
Tiredness
Difficulty sleeping
Dry and itchy skin
Nighttime muscle cramps

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care, 2013

Bettercare Learning Programmes, n.d.

National Kidney Foundation, n.d

Contact info: info@nursesinternational.org

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Glomerulonephritis in Children: Complications

Glomerulonephritis in Children: Diagnostics

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care, 2013

Urinalysis (hematuria, proteinuria)
Complete blood Count (hemoglobin, white blood cell count)
Recent throat swab positive for Streptococcus A infection

Acute renal failure Congestive heart failure Pulmonary edema Sepsis	Hyperkalemia Severe hypertension Chronic renal failure

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Glomerulonephritis in Children: Management

Healthwise staff, 2020b

Bettercare Learning Programmes, n.d.

Antibiotics for streptococcal infection
Fluid restriction
Daily weight to assess fluid status
Low sodium and low protein diet until urine output increases

Bread, jam, rice, fruit and vegetables with no added salt

Diuretic to increase urine output
Treat hypertension and monitor blood pressure
Immunosuppressants for inflammation
Evaluate serum urea, creatinine, and electrolytes for renal failure

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Special Nursing Consideration for Glomerulonephritis in Children

Monitor fluid restrictions, input/output, daily weight

Be aware of sign/symptoms for pulmonary edema or heart failure due to fluid overload

Administer prescribed medications for infection, hypertension, diuresis, immunosuppression

Monitor for and manage associated side-effects and complications

Provide client/parent education:

Need for fluid restriction
About prescribed medications
Signs of infection for early treatment to prevent Glomerulonephritis

Healthwise staff, 2020b

Bettercare Learning Programmes, n.d.

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Critical Thinking Question

Which of the following nursing interventions is appropriate for a nurse to undertake when caring for a child with glomerulonephritis? (Select all that apply)

Administer antibiotics
Monitor fluid intake and output
Record daily weight
Monitor blood pressure
Assess for signs for congestive heart failure
Assess for signs of pulmonary edema

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (con.):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References:

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care (2013). Government of Canada. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care/chapter-13-genitourinary-system.html#a21

Bettercare Learning Programmes. (n.d.). Child Healthcare/ 13. Serious illnesses- Acute Glomerulonephritis. https://bettercare.co.za/learn/child-healthcare/text/13.html#acute-glomerulonephritis

Healthwise Staff. (2020a, December 17). Learning About Hydronephrosis. [Review of article Learning About Hydronephrosis by J.Pope, A.Husney, & P.Anderson]. MyHealth.Alberta.ca. https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=abr7742

Healthwise Staff. (2020b, December 17). Glomerulonephritis in Children: Care Instructions. [Review of article Glomerulonephritis in Children: Care Instructions by A. Husney, E.G. Thompson, & K. Romito]. MyHealth.Alberta.ca. https://myhealth.alberta.ca/health/AfterCareInformation/pages/conditions.aspx?hwid=ug5368&

Contact info: info@nursesinternational.org

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References:

Healthwise Staff. (2021, February 10). Learning About Fetal Hydronephrosis. [Review of article Learning About Fetal Hydronephrosis by J.Pope, A.Husney, & P.Anderson]. MyHealth.Alberta.ca. https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=abq4741

National Kidney Foundation. (n.d.). What is Glomerulonephritis?. https://www.kidney.org/atoz/content/glomerul#what-causes-chronic-glomerulonephritis

NHS UK. (2019, February 28). Nephrotic syndrome in children. https://www.nhs.uk/conditions/nephrotic-syndrome/

NIDDK. (2021, October). Nephrotic Syndrome in Children. National Institute of Health, U.S Department of Health and Human Services. https://www.niddk.nih.gov/health-information/kidney-disease/children/nephrotic-syndrome-children

Contact info: info@nursesinternational.org

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References:

Pasini, A., Benetti, E., Conti, G. et al. (2017). The Italian Society for Pediatric Nephrology (SINePe) consensus document on the management of nephrotic syndrome in children: Part I - Diagnosis and treatment of the first episode and the first relapse. Italian Journal of Pediatrics, 43 (41) (2017). https://doi.org/10.1186/s13052-017-0356-x

Perth Children’s Hospital. (2021, October). Nephrotic Syndrome Management. Government of Western Australia , Child and Adolescent Health Services. https://pch.health.wa.gov.au/For-health-professionals/Clinical-Practice-Guidelines/Nephrotic-Syndrome-Management

UNC School of Medicine- Urology. (n.d.). Hydronephrosis. https://www.med.unc.edu/urology/pediatrics/pediatric-conditions/hydronephrosis/

University of Missouri Health Care. (n.d.). Pediatric Hydronephrosis. https://www.muhealth.org/conditions-treatments/pediatrics/pediatric-urology/hydronephrosis

Contact info: info@nursesinternational.org

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