CKD due to PUV with Complicated UTI

1. Clinical Meeting
Dr. Abdullahel Amaan
Resident (Phase-A,Neonatology),
Current Placement: Pediatric Nephrology.

2. Particulars of the patient
 Name : Fahim
 Age :5 ½ years
 Sex : Male
 Address :Bongshal,dhaka
 Date of admission : 19/09/16
 Date of examination : 19/09/16
 Informant : Mother

3. Presenting complaints
 Fever for 5 days.
 Retention of urine for 10 hours.

4. The History of Present Illness
According to the statement of informant mother, Fahim had
developed fever 5 days back. It was high grade,
intermittent in nature, not associated with chill or rigor. It
was treated with paracetamol and an antibiotis which was
given earlier episode of illness. About 10 hours back, he
had developed sudden retention of urine. It was
associated with lower abdominal pain and occassional
dribbling.

5. History of Present Illness (Contd...)
 The mother also informed that, Fahim had been suffering
from several urinary problem like dribbling, straining while
micturation and lower abdominal pain, along with
occassional fever for last 6 months. Before that, he didn’t
have any of such problems. He had no H/O trauma or
genital instrumentation before. Due to such complaints, he
was circumcised about 4 months back, but the condition
didn't improve. 5

6. History of Present Illness (Contd...)
With the above mentioned complaints, he was
admitted in BSMMU for further evaluation and
management.

7. Birth History
 Antenatal History: Mother was under regular
antenatal check-up and her antenatal period
was uneventful.
 Natal History: He was born by NVD at term at
home.
 Postnatal History: postnatal period was
uneventful.

8.  Developmental History: His development is age
appropriate .
 Past Illness History: There is no previous history of
such type of illness.
 Immunization: He is immunized as per EPI
schedule.

9.  Feeding History:
 Weight in 50th : 20kg, so daily requirement is 2000 kcal.
 Daily intake:
1 glass milk in the morning (160kcal)+
1 cup rice (120), 1 cup dal (50), meat/fish (50)  220kcal+
1 glass milk in evening (160) +
1 cup rice (120), 1 cup dal (50), meat/fish (50)  220kcal
So, total intake = 780 kcal.
So daily deficit was = 1220 kcal.
 Travel History: Nothing contributory.

10. Family History
He is the only issue of his non-consanguineous
parents.
 Other family members are in good health.

11. Social and Personal History
They belong to a below average socioeconomic
family. His father is a shopkeeper and mother
is a housewife.

12. Drug History
He was treated locally by paracetamol and
cefixim.

13. PHYSICAL
EXAMINATION

14.  Appearance : Ill looking, toxic.
 Pallor : Moderately pale.
 Jaundice
 Cyanosis
 Dehydration Absent
 Clubbing
 Koilonychia
 Leukonychia
 Oedema
General Examination

15.  BCG mark : Present
 Skin survey : NAD.
 Lymph nodes : not palpable.
 Bony tenderness: Absent
 Eyes & ENT: No abnormality detected
 JVP not raised
 No sign of meningeal irritation
 BSUA: Nil.
General Examination(contd..)

16.  Vital signs :
Pulse : 124 beats/min
BP : 120 / 70mm Hg (Both 95 th - 99th centile)
Temp : 102° F
R/R : 32 breaths / min

17. ANTHROPOMETRY
 Height – 105 cm, Lies on 5th centile
 Weight – 14 kg
Lies below 3rd centile.
Z score: - 2.36
 BSA - 0.61 m2
17

18. SYSTEMIC
EXAMINATION

19. GENITOURINARY SYSTEM
Inspection :
: Lower abdomen is mildly distended , flanks not full ,
umbilicus centrally placed & inverted. External genitalia
normal.
Palpation :
Kidneys not Ballotable.
Bladder was palpable above the level of umbilicus.
Renal angle tenderness absent.
Fluid thrill – Absent.

20. Percussion :
Shifting dullness – absent.
Auscultation :
Renal bruits absent.
19/04/2011 20

21. GASTROINTESTINAL SYSTEM
Oral cavity : Healthy .
Abdomen proper :
Inspection :
Lower abdomen is mildly distended , flanks not full ,
umbilicus centrally placed & inverted.
Palpation :
Abdomen is soft, non-tender. Bladder was palpable
above the level of umbilicus. There was no other
organomegaly.
Fluid thrill - Absent
21

22. Contd----
Percussion :
shifting dullness absent.
Auscultation :
Bowel sound present.
22

23. Pulse- 124 b/min, regular, normal volume and
character.
JVP- not raised
Precordium- No visible pulsation, engorged vein,
deformity. Apex beat is situated in left 5th Intercostal
space along mid-clavicular line. 1st and 2nd heart
sounds are audible in 4 cardiac areas, no added
sound.
Cardiovascular System

24. Respiratory System
 Inspection :
Respiratory rate : 32 breaths/min
Shape of the chest : Normal
Movement : Symmetrical .
No visible vein or pulsation .
Intercostal and subcostal recession : Absent .
 Palpation :
Trachea centrally placed .
Apex beat in left 5th intercostal space along the
mid - clavicular line .
Vocal fremitus : Normal.

25. Contd..
 Percussion :
Resonant
 Auscultation:
Breath sound vesicular , no added sound

26. Locomotor System
Inspection: No limb or joint deformity.
Palpation: Bulk- normal
Tone- normal
Muscle power- Grade 5
Joint tenderness- Absent

27. Nervous System
 Higher psychic function: Intact
 Motor function: Normal
 Reflexes: Intact.
 Sensory: Intact
 Cranial Nerves: Intact
 Gait: Normal

28. Salient Feature
Fahim, 5 ½ years old boy, only issue of his non-
consanguineous parents, hailing from Dhaka was
admitted in BSMMU with complaints of high grade,
intermittent fever for last 5 days and acute retention of
urine along with lower abdominal pain and occassional
dribbling for about 10 hours.

29. Salient features contd---
He had been suffering from dribbling, straining & lower
abdominal pain during micturation along with occassional
fever for last 6 months.
There was no history of respiratory distress, convulsion,
vomiting, dysuria or any trauma.
29

30. On examination, child was ill looking, toxic, febrile, temp-
102°F, Pulse-124 b/min, R/R- 32/min, BP- 120/70 mm Hg
systolic & diastolic both 95th - 99th centile, Height – 105
cm(Lies on 5th centile),Weight – 14 kg (Lies <3rd centile),
BSA-0.61m2, BSUA- nil. Abdominal examination revealed
palpable urinary bladder above the level of umbilicus. Other
systemic examination reveals nothing abnormality.
Salient Feature (contd..)

31. Provisional Diagnosis

32. Provisional Diagnosis
Obstructive Uropathy (probably due to PUV) with
Complicated UTI with
Failure to Thrive (FTT).

33. Points in favour
History
 Acute retention of urine.
 H/O dribbling, straining,
 L/A pain, occassional fever.
.
O/E
o Palpable urinary bladder.
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Obstructive Nephropathy

34. Points in favour
History
 High grade fever.
 Features of Obstuctive uropathy.
.
O/E
o Ill looking, toxic, febrile.
19/04/2011 34
Complicated UTI

35. CKD with
Obstructive Uropathy (PUV) with
Complicated UTI.
 Points in favour of CKD:
1. Features of urinary obstruction for > 3 months,
2. Moderate pallor,
3. Hypertension.
Differential diagnosis

36. INVESTIGATION
 Urine R/M/E & C/S with colony count:
Protein - trace
Pus cells - plenty /HPF
RBC - 1-3 / HPF
 CBC Hb - 6.5 g/dl
ESR - 74 mm in 1st hour
TC - 13,000 /cu mm,
DC - N- 87%, L - 09%
Platelets -2,70,000 /cu mm.
MCV-75 fl, MCH- 28pg,
RDW- 14.6%. 36

37. Investigation contd----
Serum creatinine : 3.47 mg/dl
S.Electrolytes :
Na : 128 mmol/l,
k : 3.3 mmol/l
Cl : 104 mmol/l,
TCO2 : 13 mmol/l.
37

38. .
S. Calcium : 9.9 mg/dl
iP : 5.94 mg/dl.
PTH : 96 pg/ml
X-Ray lumbosacral spine: Normal.
USG of KUB: bilateral moderate hydronephrosis.
19/04/2011 38

39. FINAL DIAGNOSIS
CKD with Obstructive Nephropathy
with Complicated UTI.
39

40. MANAGEMENT
 General management:Salt restriction.
 Fluid restriction (PDO + insesible loss).
 Management of HTN:
Tab. Prozosin (0.25mg/kg/D)
Nifedipine gel (SOS).
 Inj. Ceftriaxon (75 mg/kg/D).
 Calcium, Vit-D3, Folic acid, Zinc.
 Sodium bi carbonate.
 Bladder evacuation: alternate hot & cold compression.
40

41. Follow up on 2nd day of hosp.
41
subjective Objective Assessment Plan
• Intermittent U
retention.
• Fever.
 Ill looking,
 Toxic.
 Moderately pale
 Temp-99°F
 BP 118/70 mmHg
(>99th/ 95-99th )
 BSUA – nil
Weight – 14 kg
Intake – 1000ml
Output – 700ml
U Retention,
fever &
uncontrolled
HTN,
Anemia.
• Continuous
catheterization.
• Sublingual
Nifedipin.
• PRBC.
Action:
• Catheterzation.
• PRBC (5ml/kg)
• SL Nifedipin.

42. Follow up on 3rd day of hosp.
42
subjective Objective Assessment Plan
• Fever.
 Ill looking,
 Moderately pale.
 Toxic.
 Temp-100°F
 BP 120/70 mmHg
(>99th/ 95-99th )
 BSUA – nil
Weight – 13.7 kg
Intake – 500ml
Output – 350ml
fever &
uncontrolled
HTN,
Anemia.
 Increase
Prazosine
dosage
 Sublingual
Nifedipin.
 PRBC (another
unit).

43. Follow up on 4th day of hosp.
43
subjective Objective Assessm
ent
Plan
• Fever.
• Urine C/S
report: +ve for
E coli.
• Sensitive to-
Meropenem,
Amikacin,
Netilmicin,
Cotrimoxazole,
Nitrofurantoin.
 Ill looking,
 Moderately pale.
 Toxic.
 Temp-101°F
 BP 110/70 mmHg
(95-99th )
 BSUA – nil
Weight – 13.4 kg
Intake – 1000ml
Output – 1350ml
fever  Change the
antibiotic.
 PRBC (another
unit).
Action:
 Meropenem.
 PRBC given.

44. On 8th day of hospitalization
 Plan: Repeat S creatinin & USG.
 Results:
 S creatinin: 0.63 mg/dl. (previously 3.47mg/dl).
 USG: Size of the kidneys (85x41 & 88x39)mm with
slightly increased cortical ecogenicity with reduced
CMD. PC system was mildly dilated on the right side.
19/04/2011 44

45. On 9th day of hospitalization
 Plan: MCUG.
 Results: Narrowing in membranous urethral area,
dilated posterior urethra, irregular surface of bladder
with trabeculation.
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48. .