Pediatric nephrology in developing world

23/05/2019

case #4
Ans1= D/Ds
a)PSGN
b)Atypical nephrotic syndrome
After initial stabilsation in ER his following Baselne workup was done i e.
Complete Urine = protienuria 2+, heamaturia 3+ with RBCs cast & pus cells + epithelal cells
24hrs uinary protiens = >4gm
Complete Blood counts, WBC 14.2 e Neut 80% HB =9
S=ca =6.4, S=po4 = 5.8, S=k= 5.2, S= po4=6.4
Serum C3 level was low= 0.05,C4=Normal
Blood Urea = 178
s-creatinin=5.4
S-Albumin 3.3, Hco3= 17.9
A*O titer was raised i e 328
AntiHcv & HbsAb was neg.
UOP= 1-2ml/kg/hr with cola colored
ANS=3, after giving broad spectrum antibiotic IV Pencilline. along with diuretics,Pt was planned for hemodialysis, because his GFR was

21/05/2019

Case 4=A 12yr old boy having wt of 40kg, previously healthy, vaccinated, presented to us in Emergency with complain of periorbital puffiness for 2 weeks that extend gradually in cephalocaudal direction, along with abdomial distention for 1 week. pt had history of upper respiratory tract infecton 3 weeks back which was treated by local doctor. pt had c/o decrease urine output for 2-3days with cola color & association of dysuria, burning micturation, mild pelvic region pain, 2-3 episodes of vommiting On examination in ER fascial puffiness, abdominal ascites was present,but no pedal oedema, cardiovascular & repratory system examination was unremarkable with no evidence of pericardial & pleural effusion was present at that time, CNS was intact, while his
BP was = 160/110
HR 120/min
Temp 98f.
Q1= Enlist your step to approach this pt? D/Ds?
Q2 most im ivestigations youll go for?
Q3 management plan?

21/03/2019

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05/03/2019

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04/02/2019

case #3
Question (1): (A)
This child requires a urinalysis and blood culture immediately. Bacterial infection usually with Pneumococcus or haemophilus influenzae is common and serious in untreated nephrotic syndrome in young children, who are dependent on opsonins for splenic processing of these encapsulated organisms. Opsonins and immunoglobulins as well as albumin are lost in the urine of nephrotic children. While the other investigations listed are useful, the results do not usually change the immediate management.
Question (2: (D)
The child should receive intravenous antibiotics (usually penicillin) to treat the child’s periorbital cellulitis and also commence oral prednisolone without delay. However, intravenous methylprednisolone might be considered if the child does not tolerate oral medications. Intravenous albumin (1gm/kg infused over 4 hours) with frusemide (1mg/kg intravenously after 2 hours of infusion and at the end of the infusion) may be required in very edematous children with gross ascites and scrotal/penile or labial edema.

03/02/2019

case #3
A three-year-old boy is brought to the emergency department because of swelling around his eyes, which has been
present for two weeks. In the past 24 hours, the periorbital
swelling has become more marked with increasing redness
and the child has a fever to 38 degrees Celsius. The child’s
family doctor had diagnosed conjunctivitis and prescribed
some antibiotic eye drops. On examination in the emergency
department, the boy is noted to be irritable when examined
and to have edema of his legs extending to the thighs with
sacral edema and ascites. The cardiovascular and respiratory examinations are within normal limits with no evidence
of pleural effusions. The child’s weight is 15 kg (50th percentile) while his height is 88 cm (3rd percentile). His blood
pressure is 115/70.

(1) What are the most important two investigations to be
carried out immediately?
(A) Blood culture and urinalysis for blood and protein.
(B) Serum albumin and creatinine, urea and electrolytes.
(C) Full blood count and blood culture.
(D) Urinalysis for blood and protein and serum albumin.
(E) Creatinine, urea and electrolytes and serum cholesterol.

(2) What should be the first treatment given to this child?
(A) Intravenous antibiotics.
(B) Oral prednisolone.
(C) Intravenous albumin with frusemide.
(D) Intravenous antibiotics and oral prednisolone.
(E) Intravenous methylprednisolone or dexamethasone.

19/01/2019

case #2 cotd….
we managed this case accordingly
1) proptup position
2) high flow oxygen
3)managed hyperkalemia 1st acc to protocol.
4)after taking high risk informed concent, shifted the pt to heamodialysis section, done heamodialysis for 4 hrs with ultrafiltraton of 1500ml successfully.pt's saturaton improved upto 80%.repeat the session after 24hrs with same UF and settings for 3&half hrs. pts saturation was upto 98%, electrolytes imbalance were settled. ECG improved. And pt survived Alhummdulillah.next day pt was oral free, O2 free, lying in the bed comfortably. it shows how an adequate dialysis sessson on your immediate dicision is life saving. your pt can live a rewarding life on dialysis.
underlying Xray was done after completion of firt session.

15/01/2019

case #2
17yrs Old male diagnosed case of CKD due to obstructive uropathy (PUV since birth), was on regular session of heamodialysis twice a week. He missed his session and was presented to us in severe respiratoy distress, On cardiac monitor his oxygen saturation was 60%, ECG showing picture of hyperkalemia with tall tented T wave and absent P wave, Chest Xray AP view showing BL Bat wing appearance of pulmonary oedema, with underlying consolidation patch.
Organize your steps of management?

01/01/2019

case #1..contd
This was case of posterior reversible nephropathy (PRES) syndrome, a relatively uncommon and underdiagnosed condition. Several predusposing factors including drug intake especialy cyclosporin, HTN, Acute kidnry injury,CKD, leukemia, lymphoma and thrombocytopenia have been blamed but most likely etiologies are hypertension and renal failure. Clinical manifdstations are headache, seizures depressed concious level loss of vision, may be homonymous hemianopia and cortical blindness. Early diagnosis and managment of HTN, seizures and raised ICP can lead ti complete neurological recovery. One need to keep high index of suspicion dx n manage early

30/12/2018

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28/12/2018

case #1 contd..
Correct option is C
This patient improved with good urine out put, DTPA scan revealed obstructive pattern on both sides with GFR of 15 ml on right side and 12 ml on left side. His BP ranged between normal to grade 2 HTN. He was operated for left pelbuc stone aiming to relieve obstruction. Recovery was smooth with optimal fluid electrolyte managmrnt. He started complaining of headache on day 3, followed by nausea his concious level started deteriorating, threw a clonic fit on left side n became unconcious .he regained some concious level after 1 hour but could not see, he could only have some light perception his sighns of meningeal irritation were negative , no cranial nerve palsies abd he was afebrile. CT scan brain showed hypidense finger like projections in right parieto occipital region
What is most likely diagnosis?

26/12/2018

case #1
Eleven years old boy was brought to us through E/R in gasping state, criticaly ill and in volume overload. His pulse rare was 108/min, BP of 125/80 mmHg, mild pedal edema, borderline clinical cardiomegaly and bilateral creputations especialy at basis. He had hepatomegaly of 2 cm below costal margin. When history was inquired frim parents it was found that actualy he was ill for last 1 year, he would often c/o lumber pain without clear radiation to any site. His parents had concern of his poor growth, poor apettite off and on fever and vomiting. His wt n height are below erd percentile.his HB was 6 gm/dl, bkoid urea 200mg/dl and serun creatinine was 9mg, had low serum calcium, high phosphorus 7.2 mg and iPTH of 860, s.bicarb was 6 meq , serum sodium of 132 n K of 4.8meq. Urine output was 0.7 ml/kg/hour. Ultrasound revealed multiple calculi in both kidneys severe hydronephrosis, left kidney measurex 22 cm and obstruction at left pelvis due to 2.t cm stone at lt pelvis. Rt kudney again 11.4 cm with multiple stones , thete was partial obstruction at rt pelvis due to stone of size of 1.6 cm
After initial stabilization
What should be appropriate managment?
A) Acute PD?
B)hemodialysis?
C)Dialysis followed by PCN(percutanous nephrostomy) of most obstruted kidney?