May.Yvette.Allain.Cristina.Ralph.Sheryl.Bart.Heinrich.Pipoy.KC.Jam.Cecille.Denesse.Mike.Hoops.Ces.Christian.Elaine.Riza.Kristel.Ezra.Goldi.

Buf
f.Mona.AM.Maan.Adi.KC.Peng.Karla.Alphe.Aaron.Kyth.Anne.Eisa.Kring.Candy.Isay.Marco.Joshua.Fars.Rain.Jassie.Mika.Shar.Erika.Macky.Viki.Joan
.Precious.Kate.Katrina.Ams.Hannah. Memay.Pau.Rachelle.Esther.Joel.Glenn.Toni

PEDIATRICS 2 07-july-08
THE URINARY SYSTEM and URINARY TRACT INFECTIONS
Dr. Victor S. Doctor
Trans grUp: Goldie and Her Invisible Frends!!!

THE NORMAL KIDNEY

ANATOMY PHYSIOLOGY

Kidneys of Newborn Infant

Notes from Nelson:
relatively large and can usually be palpated through
the anterior abdominal wall
mean combined weight of both kidneys at birth: Glomerular Filtration - net result of opposing forces across
at 6 mos = 24 grams
the capillary wall. The force for ultrafiltration (glomerular
at 12 mos = 70 grams capillary hydrostatic pressure) is a result of systemic arterial
at 6 y/o = 140 grams pressure, modified by the tone of the afferent and efferent
adult weight approx. 300 grams arterioles. The major force opposing ultrafiltration is the
Nephron glomerular capillary oncotic pressure, which is created by the
structural and functional unit of the renal parenchyma gradient between the high concentration of plasma proteins
within the capillary and the almost protein-free ultrafiltrate in
36 week of gestation, nephrogenesis stops and each
th
Bowman's space. Filtration may be modified by the rate of
kidney has 850,000-1M nephrons
glomerular plasma flow, the hydrostatic pressure within
each nephron consists of a glomerulus and its tubules
Bowman's space, and the permeability of the glomerular
for urine formation, acid-base balance, secretion of
certain substances capillary wall.

 each glomerulus is a rete of capillary tufts enclosed The GFR may be estimated by measurement of the serum
in Bowman’s capsule creatinine level. Creatinine is derived from muscle
 capillary tufts consist of loops bound together in a metabolism. Its production is relatively constant, and its
central area called Mesangium excretion is primarily through glomerular filtration, although
 mesangium is composed of cytoplasmic matrix and tubular secretion may become important in renal insufficiency.
cells (mesangial or capillary); it is usually the FIRST In contrast to the concentration of blood urea nitrogen, which
TO REACT IN THE EVENT OF GLOMERULAR INSULT is affected by state of hydration and nitrogen balance, the
 3 Fixed cells of the Glomerulus:
serum creatinine level is primarily influenced by the level of
•endothelial or intracapillary cell
glomerular function. The serum creatinine is of value only in
•mesangial cell
estimating the GFR in the steady state. A patient may have a
•epithelial or extracapillary cell
normal creatinine level without effective renal function very
shortly after the onset of acute renal failure with anuria. In this
Notes from Nelson: clinical setting, serum creatinine may be an insensitive
measure of decreased renal function because its level does not
rise above normal until the GFR falls by 30–40%.
Each kidney contains approximately 1 million
nephrons (glomeruli and associated tubules). In 3 Principal Kidney Functions
humans, formation of nephrons is complete at 1. maintain constancy of internal environment by
birth, but functional maturation with tubular adjusting volume, concentration and composition of
growth and elongation continues during the first body fluids
decade of life. Because new nephrons cannot be 2. elimination of metabolic wastes such as urea &
formed after birth, progressive loss of nephrons creatinine
may lead to renal insufficiency. Decreased 3. elaborate the hormones rennin, erythropoietin,
nephron number at birth may be associated with prostaglandins, kallikrein-kinin
hypertension in adulthood, presumably related to
hyperfiltration and “premature” sclerosis of
overworked nephron units. This provocative Urine Formation
hypothesis, if proven, could identify a major risk 1. initiated by elaboration of a large volume of protein-
factor for hypertension and its associated free plasma ultrainfiltrate thru glomerular filtration
cardiovascular complications in the newborn 2. concentration and alteration of filtrate composition in
the tubules (thru tubular reabsorption of essential
period.
substances and elimination of waste products)

>space< >space< >space< >space< Proximal Tubule

- reabsorbs 80% of filtrate volume and sodium
- all the glucose and amino acids (small portion)
and much of the filtered phosphate, minute amt
of protein that pass thru the glomeruli
- primary active process is sodium reabsorption
May.Yvette.Allain.Cristina.Ralph.Sheryl.Bart.Heinrich.Pipoy.KC.Jam.Cecille.Denesse.Mike.Hoops.Ces.Christian.Elaine.Riza.Kristel.Ezra.Goldi.Buf
f.Mona.AM.Maan.Adi.KC.Peng.Karla.Alphe.Aaron.Kyth.Anne.Eisa.Kring.Candy.Isay.Marco.Joshua.Fars.Rain.Jassie.Mika.Shar.Erika.Macky.Viki.Joan
.Precious.Kate.Katrina.Ams.Hannah. Memay.Pau.Rachelle.Esther.Joel.Glenn.Toni

- followed by passive reabsorption of chloride and  there is diluted urine d/t failure to concentrate
water by diffusion  glomerulus is not affected so filtration is not affected
- volume is greatly reduced but Na and Cl- not  creatinine clearance – for kidney function test
altered
3. Loss of Renal Function
 decreased number of nephrons
Loop of Henle
 water is reabsorbed in the descending limb nephron hypertrophy  early aging 
 sodium is reabsorbed in the ascending limb hyperfiltration  nephrosclerosis  eventual
result is an environment in the interstitial tissue of destruction (proteinuria and HPN)  renal
insufficiency  renal failure
medulla that is hypertonic to plasma thus  urine
concentration takes place in the adjacent collecting
4. Necrosis of Renal Parenchyma
ducts
 tubule and surrounding intersitium are inflamed
 fluid at end of loop is Hypertonic.
 destruction of the growth of functional cells (growth
Distal Tubules factors, vit D, erythropoietin, prostaglandins,
hormones)
 fluid initially hypotonic to plasma d/t large amt of
sodium reabsorbed in the ascending limb  tubule destroyed, glomerulus obliterates
 more sodium reabsorbed d/t aldosterone  area replaced by non-functional scar TISSUE
 potassium is secreted  # of nephrons are reduced
 acidification takes place  remaining nephrons are overworked

Collecting Ducts Notes from Nelson:

- final concentration mediated by vasopressin (ADH)
acting on the lining cells of the duct making them more
permeable to water The 3 basic forms of UTI are pyelonephritis, cystitis, and
asymptomatic bacteriuria.

Now we come to Doctor Doctor’s lecture.. Have fun.. Clinical pyelonephritis is characterized by any or all of the
following: abdominal or flank pain, fever, malaise, nausea,
URINARY TRACT INFECTIONS vomiting, and, occasionally, diarrhea. Newborns may show
- there is bacterial invasion and multiplication nonspecific symptoms such as poor feeding, irritability, and weight
- inflammation and host reaction
loss. Pyelonephritis is the most common serious bacterial infection
- loss of normal renal function
in infants <24 mo of age who have fever without a focus. These
- necrosis of renal tissue
symptoms are an indication that there is bacterial involvement of
1. Bacterial Invasion and Multiplication the upper urinary tract. Involvement of the renal parenchyma is
 bacteria from stools termed acute pyelonephritis, whereas if there is no parenchymal
 proximity of urethra involvement, the condition may be termed pyelitis. Acute
 adherence of e.coli that resists urine flow pyelonephritis may result in renal injury, termed pyelonephritic
 ascends from urethra to bladder (cystitis; lower UTI) scarring.
 ascends from bladder to ureters ( reflux)
 ascends from ureters to kidneys (pyelonephritis: Cystitis indicates that there is bladder involvement; symptoms
Upper UTI) include dysuria, urgency, frequency, suprapubic pain, incontinence,
 low to negative bacterial growth by culture & and malodorous urine. Cystitis does not cause fever and does not
sensitivity result in renal injury. Malodorous urine, however, is not specific
 short bladder time: newborn & infants
for a UTI.Asymptomatic bacteriuria refers to a condition that
 acidic urine
results in a positive urine culture without any manifestations of
 low dose antibiotics
infection. It is most common in girls. The incidence is 1–2% in
 wrong culture media
preschool and school-age girls and 0.03% in boys. The incidence
2. Inflammation and Host Reaction declines with increasing age. This condition is benign and does not
 Urethritis – dysuria, burning sensation cause renal injury, except in pregnant women, in whom
asymptomatic bacteriuria, if left untreated, can result in a
Cystitis – dysuria, bladder tenderness, frequent symptomatic UTI. Some girls are mistakenly identified as having
urination with fever; on ultrasound: thickened asymptomatic bacteriuria, whereas they actually are symptomatic,
bladder wall experiencing day or night incontinence or perineal discomfort.
Pyelonephritis – systemic SSx

 bladder irritation – hypercontracted bladder wall  Normal Urinary Tract

frequent small amt of urine  vesicoureteric junction does not allow retrograde
 to diagnose bladder infxn: ultrasound will show flow of urine from the bladder to the kidney
bladder walls thickened than normal
Vesico-ureteral Reflux
 inflammation  edema  thickening of walls  phenomenon of backward-upward flow of urine
 WBC during inflammation
May.Yvette.Allain.Cristina.Ralph.Sheryl.Bart.Heinrich.Pipoy.KC.Jam.Cecille.Denesse.Mike.Hoops.Ces.Christian.Elaine.Riza.Kristel.Ezra.Goldi.Buf
f.Mona.AM.Maan.Adi.KC.Peng.Karla.Alphe.Aaron.Kyth.Anne.Eisa.Kring.Candy.Isay.Marco.Joshua.Fars.Rain.Jassie.Mika.Shar.Erika.Macky.Viki.Joan
.Precious.Kate.Katrina.Ams.Hannah. Memay.Pau.Rachelle.Esther.Joel.Glenn.Toni

 permits transport of urine from bladder to the - most common type and most common post-
kidney infectious form
 may be unilateral or bilateral - peak age at 7 y/o
 demonstrated and graded by Voiding - an immune-complex meadiated dse d/t prior
Cystourethrogram (VCUG) infection with the nephritogenic strains of
Group A beta-hemolytic strep
(post-strep  AGN  inflamed glomerulus
(immunologic)
*yan po ung part na me example c doc ng past,
present at future..

- low volume urine w/ high sp. gravity

Notes from Nelson: - RBC PREDOMINANCE (gross hematuria)
- tubules unaffected
- glomerulus is congested
Retrograde flow of urine from the bladder to the ureter and - essential elements: edema, oliguria, hematuria,
renal pelvis is referred to as vesicoureteral reflux. The hypertension
ureter normally is attached to the bladder in an oblique - Tx:
direction, perforating the bladder muscle (detrusor) laterally a. anemia from hematuria is insignificant
and proceeding between the bladder mucosa and detrusor b. oliguria / edema – osmotic diuretics; 
muscle, creating a flap-valve mechanism that prevents water intake and  salt intake
reflux. Reflux occurs when the submucosal tunnel between c. for HPN – rapid-acting anti-HPN
the mucosa and detrusor muscle is short or absent. Reflux
usually is congenital, occurs in families, and affects UTI –
Notes WBC
from Nelson:
approximately 1% of children. NephroticRBC
AGN – syndrome is primarily a pediatric disorder and is
15Nephrotic
times more Syndrome
common in children than adults. The incidence
– urine should not contain WBC nor RBC; no
Reflux predisposes to renal infection (pyelonephritis) by is 2-3/100,000 children per year; and the majority of affected
hematuria; no pyuria
facilitating the transport of bacteria from the bladder to the children will have steroid-sensitive minimal change disease.
– contains massive amount of protein
upper urinary tract. The inflammatory reaction caused by a The characteristic
–
features of nephrotic syndrome are heavy
excessive protein excretion
pyelonephritic infection may result in renal injury or proteinuria (>3.5 g/24 hr in adults or 40 mg/m2/hr in children),
scarring, also termed reflux nephropathy. Extensive renal – hypoalbuminemia
hypoalbuminemia d/t massive
(<2.5 2g/dL), edema, proteinuria
and hyperlipidemia.
scarring impairs renal function and may result in renin- ( > 1 g / m / 24 hrs)
ETIOLOGY: Most children (90%) with nephrotic syndrome
del aMundo
have form of–the
2gidiopathic nephrotic syndrome. Causes of
mediated hypertension. renal insufficiency or end-stage
Harisson – 3.5
idiopathic nephroticg syndrome include minimal change
renal disease, impaired somatic growth, and morbidity
during pregnancy. Reflux nephropathy once accounted for disease (85%), mesangial proliferation (5%), and focal
as much as 15–20% of end-stage renal disease in children segmental glomerulosclerosis (10%). The remaining 10% of
and young adults. With greater attention to the management children with nephrotic syndrome have secondary nephrotic
of urinary tract infections (UTIs) and a better understanding syndrome related to syste-mic ( Table 527-1 ) or glomerular
of reflux, end-stage renal disease secondary to reflux diseases such as membranous nephropathy or
nephropathy is uncommon. Reflux nephropathy remains membranoproliferative glomerulonephritis
one of the most common causes of hypertension in
children. Reflux in the absence of infection or elevated PATHOPHYSIOLOGY: The underlying abnormality in
bladder pressure does not cause renal injury. nephrotic syndrome is an increase in permeability of the
glomerular capillary wall, which leads to massive proteinuria
and hypoalbuminemia. The cause of the increased
Components of Urinalysis permeability is not well understood. In minimal change
• color disease, it is possible that T-cell dysfunction leads to alteration
• volume of cytokines, which causes a loss of negatively charged
• consistency (cloudy or not) glycoproteins within the glomerular capillary wall. In focal
• sp. gravity segmental glomerulosclerosis, a plasma factor, perhaps
• RBCs, WBCs, casts, crystals produced by lymphocytes, may be responsible for the increase
• pH (varies normally with food intake) in capillary wall permeability. Alternately, mutations in
• blood chemistry podocyte proteins (podocin, α-actinin 4) are associated with
• creatinine focal segmental glomerulosclerosis ( Table 527-3 ). Steroid-
• uric acid / other metabolic products
resistant nephrotic syndrome is associated with mutations in
NPHS2 (podocin) and WT1 genes.
 if with acidosis, but kidneys are normal
 urine will be acidic Although the mechanism of edema formation in nephrotic
 if blood is acidic, urine is alkaline syndrome is incompletely understood, it seems likely that, in
 kidneys are non-functional most instances, massive urinary protein loss leads to
 if with high Na in blood, kidneys are normal hypoalbuminemia, which causes a decrease in the plasma
 there will be  Na in urine oncotic pressure and transudation of fluid from the
intravascular compartment to the interstitial space. The
Post-Streptococcal Acute Glomerulonephritis (PSAGN) reduction in intravascular volume decreases renal perfusion
pressure, activating the renin-angiotensin-aldosterone system,
which stimulates tubular reabsorption of sodium. The reduced
intravascular volume also stimulates the release of antidiuretic
hormone, which enhances the reabsorption of water in the
collecting duct.
May.Yvette.Allain.Cristina.Ralph.Sheryl.Bart.Heinrich.Pipoy.KC.Jam.Cecille.Denesse.Mike.Hoops.Ces.Christian.Elaine.Riza.Kristel.Ezra.Goldi.Buf
f.Mona.AM.Maan.Adi.KC.Peng.Karla.Alphe.Aaron.Kyth.Anne.Eisa.Kring.Candy.Isay.Marco.Joshua.Fars.Rain.Jassie.Mika.Shar.Erika.Macky.Viki.Joan
.Precious.Kate.Katrina.Ams.Hannah. Memay.Pau.Rachelle.Esther.Joel.Glenn.Toni

Assignment ni doc.. kinuha ko n lng ulit sa del Mundo..

 What are the alternative methods for collecting 24-
hr urine? Figure 1: ze urineri zystem

A freshly voided urine specimen collected early in the

morning is preferable for routine urinalysis. The
specimen should be examined immediately to avoid
disintegration of formed elements. Water or softdrinks to
hasten collection of a specimen should be avoided as
these results in dilute urine, red cell lysis, and
undergraded qualitative protein testing.

Methods:
1. PEREZ REFLEX - Stimulation of urination by running
tap water or stroking the spinal column upward or
downward (recommended)
2. Plastic (U- or wee_ bags and sterile vials may be used
to collect samples after proper cleansing of the genitalia
*bags should be discarded and changed if no
urine is voided w/in 3 hrs
3. Aseptic catheterization using French 8 or 10 catheter
(or French 5 C-32 feeding tube) and suprapubic bladder
tap may be done when indicated

Figure 2: zis is e nefron

mga words of wisdom ni doc..

1. if the function of ur legs is to walk and it is severed,

what will happen? answer: you cannot walk..  akalain
mo un, nabago pananaw ko sa buhay dahil dito..
2. Know what is normal…  bawal kontrahin to..

PASENSYA NA AT MAGULO UNG TRANS.. CNUBUKAN

NAMIN KUNIN ANG PANIG NI NELSON EH..
UNFORTUNATELY, MAHIRAP CYA ISINGIT SA LEC SO
NAKA BOX NALNG CYA.. SANA MAKATULONG.. LAM KO
KULANG, ALANGAN NAMAN ILAGAY KO LAHAT DB..
HEHE.. ANYWAY, KNG MAY TNUNG, PLS REFER TO THE
FIGURES BELOW.. YAN NA MISMO UNG LEC NATIN.. UH
HUH!! UH HUH!!

Figure 3: This iz e cast