Pediatric Kidney Conditions: Pyelonephritis, Cystitis, Nephrotic Syndrome, PSGN

Pyelonephritis: Diagnosis and Treatment

Diagnostic Criteria:

1. Fever >38°C
2. Pyuria (>5-10 WBC)
3. Bacteriuria >10⁵ CFU/ml
4. Signs of bacterial infection in blood test (leukocytosis, CRP >20mg/l)
5. Abdominal or flank tenderness
6. Abnormalities in kidney ultrasound

Treatment:

1. Gentamicin 7 days (not longer). After antibacterial sensitivity testing, other antibiotics should be continued for 10-14 days.
2. Cefuroxime (second generation cephalosporin) 10-14 days.
3. Amoxicillin alone is not recommended.
4. If the fever has not settled in 48 to 72 hours or the child has not improved, the antibiotic sensitivity should be reviewed and the antibiotic changed appropriately.
5. Septic patient – Third generation cephalosporins or second generation cephalosporins + gentamicin, after antibacterial sensitivity testing, other antibiotics should be continued for 14 days.

Cystitis: Diagnosis and Treatment

Diagnostic Criteria:

1. Frequency, dysuria
2. Leukocyturia or hematuria
3. Bacteriuria 10⁵ CFU/ml (not always)
4. ESR < 20 mm/h, CRP < 20 mg/l
5. Low grade fever

Treatment:

Cystitis treatment for 3-5 days (trimethoprim or nitrofurantoin) is sufficient.

Single-dose or 1-day treatment of cystitis is not recommended.

Minimal Change Disease (Nephrotic Syndrome)

General:

• #1 Cause of Nephrotic Syndrome in Children!
• After Infection
• Tumor (Hodgkin’s)

Clinical Features:

1. Pallor
2. Fatigue
3. Severe edema (abnormal accumulation of fluid within the interstitial space)
4. Abdominal pain
5. Dyspnea
6. Decrease of diuresis (hypovolemia)

Diagnosis:

1. Nephrotic characteristics
2. Blood: ESR High + thrombocytosis
3. Biopsy
   • LM = NO CHANGE
   • EM = Effacement of Foot processes!

Treatment:

1. Steroid therapy (prednisolone) 3-4 months
   • Initial dose – 2mg/kg/per day (max 60mg/day) – 4 – 6 weeks.
   • If proteinuria disappears, prednisolone is switched to alternate day therapy 1.5 mg/kg for 4 weeks.
2. Relapse – proteinuria 3 g/day (or 40mg/m²/h.)
3. Prolonged or repeated steroid ADR (obesity, osteoporosis, cataracts)
4. Cyclophosphamide (2mg/day 8-12 weeks) or Cyclosporine (5 mg/kg/day)

Post-Streptococcal Glomerulonephritis (PSGN)

General (Nephritic):

• After Infection With Streptococci!
• In Children, it is Most commonly: Streptococcal Tonsillopharyngitis + Impetigo!
• PSGN presents as Nephritic Syndrome (Hematuria/ Mild Proteinuria/ Edema + HBP)
• HEMATURIA ALWAYS PRESENT

Pathophysiology:

Immune complex containing Streptococcal antigen with Glomerular BM ———-> Complement(+) and Damage of Glomeruli! ———> Nephritic syndrome!

Etiology:

1. 10–30 days following an acute infection
2. Organism:
   • group A beta-hemolytic streptococci (infection of Mouth, Pharynx, Tonsillitis) [GABHS]
   • Osteomyelitis
   • Sometimes endocarditis / Abscess (Less common)

Clinical Features:

1. Nephritic:
   • Hematuria: tea- or cola-colored urine (100% HEMATURIA In ALL CASES)
   • Hypertension: can lead to headaches
   • Edema
   • Dyspnea in pulmonary edema
   • Neurologic symptoms in cerebral edema (e.g., seizures)
2. Oliguria
3. Influenza-like symptoms
4. Flank pain

Diagnosis:

1. Laboratory tests
   • Normocytic, normochromic anemia
   • Possibly elevated BUN and creatinine (often transient)
   • Antistreptolysin titer (ASO)
   • Anti-DNase B antibody (ADB)
   • C3 complement
2. Urinalysis: nephritic sediment
3. Ultrasound: enlarged kidneys
4. Renal biopsy (not performed in most cases)
   • Indication: suspected rapidly progressive glomerulonephritis

Treatment:

1. Self-limiting in most cases
   • Only supportive, this includes:
2. Monitor Electrolyte, Renal Function Parameters + BP
3. For edema
   • Low Na / Low Prt / Loop Diuretics!
4. For HBP
   • ACE(-) / Ca channel Blockers
5. Persistent Streptococcal Infection
   • Antibiotics (Penicillin B/ Benzathine)
6. Severe Cases
   • GCD