Kidneys At the time of birth, the morphological and functional maturation of the kidney is not yet complete (Fig, 10-1), Weight, size and shape of the kidneys The weight and size of the kidneys in young children is relatively larger than in older children and adults, In « newborn, the weight of the kidneys is 1:100, and in adults it is 1:200 in relation to body weight. In children under 1 year of age, the upper and lower poles of each kidney are close together and it resembles « round organ, and later acquires « bean-shaped shape. Kidney topography The relatively large size of the kidneys and the shorter lumbar spine determine the low topographic location of the kidneys in children of the first years of life. Their upper pole is located at the level of the XI-XII thoracic vertebra, and the lower one is at the level of the upper edge of the IV lumbar vertebra, i.e. below the iliac crest, This Feature disappears by the age of 7. The difference in the position of the contralateral kidneys normally does not exceed the height of the body of one lumbar vertebra, The kidneys in young children are located almost parallel; at an elder age, their upper poles come closer together. Perinephric fiber In young children, the kidneys are more mobile than in adults, This is due to the poor development of their perirenal tissue, pre- and post-renal fascia, The formation of fixation mechanisms ends by 5-8 years, From this time on, the normal displacement of the kidneys during inspiration is not exceeds 1.8% of the child’s body length, Kidney structure In the first years of life, the kidneys have « lobular structure (disappearing by 2-5 years), the thickness of the medulla prevails over the thickness of the cortical layer (1:4, while in adults it is 1:2). In a full-term newborn, the amount312 repcedeutics of childheed dis (rounded orga more mobile than h w glomer supplied with bloodChapter 10, Urinary system 313 nephrons are the same as in adults (about 2 million), and only in very premature infants their new formation continues for some time after birth. The number of glomeruli per unit volume of tissue in newborns and infants is greater than in adults, Their diameter is much smaller. In children under two ears of age, the nephron is not sufficiently differentiated (Fig, 10-2) Morphological maturation of the cortex ends by 3-5 years, dd the kidneys a8 «whole by shes! ape Functional features of the kidneys From the moment ef birth, the kidneys begin te perform homeostatic Function, The filtration capacity of c newborn's kidneys is low. This is + Features of the histological structure of the visceral layer glomerular capsules (cuboidal epithelium); + small glomerular sizes (total filtering surface glomeruli are 5 times smaller than in adults); + low hydrostatic pressure (the volume of blood #lowing through the kidney every minute in an adult is 25% of the heart : significant release, in « newborn only 5%), ‘As the child grows, the velume of glomerular filtration increases and approaches the level ef an adult by the end of the 1st year of life, The processes of tubular reabsorption and secretion of various substances are Formed gradually; in newborns they have a number of differences: + tubular reabsorption of electrolytes and low-molecular substances is reduced, therefore, at this age, higher urinary excretion of amino acids, phosphates and bicarloonates is note + glucose reabsorption already in the first weeks ef life is equal to that of an adult or even exceeds it, which helps preserve energy « genetically necessary substance for « growing organism; + reabsorption of sodium ions eccurs intensively during exercise sodium chloride, the kidneys of newborns continue to recbserb sedium ions, while in adults their chserption i haste + newborns are not capable of adequate excretion of water and sodium chloride; their kidneys can excrete Fluid fractionally throughout the day and 4 one-time load may be accompanied by a lack of diuretic effect; reduced cbility to excrete ions of potassium, calcium, magnesium, ete es of requlctonof the acid-base state dont mature ct the time of birth: the child's kidneys secrete 2 times less per unit time; the pe314Chapter 10, Urinary system 315 more acid radicals; Due to the immaturity of the tubules and low enzyme activity, the production and secretion of hydrogen and ammonium ions is limited, and the base-saving mechanism practically dees not Function The concentration function of the kidneys in young children is low, which is due to insufficient formation of antidiuretic hormone (ADH), imperfect regulatory mechanisms, short length of +the nephron loop, functional inferiority ef the epithelium of the distal tubules, low glomerular Filtration (and, accordingly, low tubular filling), etc. Therefore, newborns are characterized by low specific gravity of urine, Children’s kidneys reach a concentrating ability similar to that of adults by 4-12 months, The kidneys of a newborn are cble to provide homeostasis only in conditions where the bedy is not subject to excessive stress, Optimal homeostatic kidney function is established by the age of 2 10-11 years, + Children's kidneys are not able to quickly and effectively normalize water end electrolyte disturbances due te imperfect esme- and volume regulation, They cannet vigorously remove water when there is an excess Pit or save fluid when there isc lack of it; they reabsorb sodium much more actively, which is deposited in the tissues of the body, This is why children easily experience swelling and dehydration, About This must be remembered when performing infusion therapy. + Malnutrition, early transfer to artificial Feeding due te low secretory capacity in the pestnatal period can have adverse consequences for the child; deviation in the concentration in +the blood ef one or another ion, which can acquire the picture of a certain symptom complex (hyper- or hypocalcemia, hyper - or hypokalemia, etc.), + The relatively lew and slow excretion of many substances bby children's kidneys must be taken into account when prescribing drugs (for example, antibiotics), saline solutions, etc. + When transferring 4 child to artificial Feeding, especially in ‘the first days of lif, the balance of acids and bases easily shifts +o the acidic side, which is the result of an increase in protein load and, consequently, the amount ef preducts te be remeved from the body under conditions of physiologically low glomerular filtration and the ability of the tubules to excrete hydrogen ions, + The immaturity ef the mechanisms of renal regulation of the acid-base state also leads to the rapid development of acidosis in young children with various diseases.316 Propaedeutics of childhood diseases Urinary tract The urinary tract in children of younger age groups is characterized by insufficient development of muscle and elastic tissue in their The renal pelvis is relatively wider than in adults, and in children under 5 years of age is located mainly intrarenal, since the renal sinus is poorly expressed, The ureters extend from them at right angles, The ureters are relatively longer, wider, hypotonic, have relatively low contractility, are more tortuous, and have kinks, The distal section of the ureter (lying directly in the wall and submucosal layer of the bladder) is very short; it lengthens with age, reaching maximum by 10-12 years, The bladder in infants is located higher than in adults (above the symphysis); with age, it gradually descends into the pelvis, Its anterior wall is not covered by peritoneum, but is adjacent to the anterior wall of the abdominal cavity, The bladder has an oval shape, its mucous membrane is thick, tender, loose, and well supplied with blood, The muscle fibers in the area of the ureteral orifices are poorly developed, so the ureteral orifices gape, The physiological capacity of the bladder in a newborn is about 50 ml, at the age of 1 year - 100 ml, at 5-4 years - 150-200 ml, at 12-14 years old ~300-400 ml The urethra (urethra) in girls at all ages is shorter and wider than in boys, Its curvature in infants is more pronounced than in adults, This must be taken into account when performing bladder catheteriaction and cystosceps Anatomical features of the urinary tract in young children age (relatively wide, hypotonic pelvis, tortuous, artic evers hater lear the bie chet ot right angle, greater kidney mobility than in adults) predispose to urodynamic disturbances, which may contribute to the subsequent addition of microbial-inflammatory press A short intravesical segment of the ureter, poor development of muscle fibers in the area of the ureteral orifices predispose to the development of vesicoureteral reflux, + The structural features of the urethra in girls, the proximity of the latter to the anus, create conditions for the penetration of infection from the periurethral region into the urinary tract.Chapter 10, Urinary system 317 Diuresis In healthy newborns, during the first 3 days of life, very little urine is excreted (transient oliguria) or none at all (in the first 12. hours), which is due to the low intake of Fluid into the body, its extrarenal losses and hemedynamic features, The absence of - urine output during the day suggests pathology, Subsequently, due to the intensity of metabolism and the uniqueness of the diet, children excrete relatively more urine than adults, The daily amount (Table 10-1) of urine in children under 10 years of age can be calculated using the formula: 600 + 100 x (n- 1), where nis age in years: 600 daily diuresis of « one-year-old child. When the ambient temperature is high, less urine is released, and when the ambient temperature is low, more urine is released, Table 10-1, Number of urinations per day Age Newborns (except the first days of life) 6 months-1 year ‘The act of urination Emptying the bladder occurs reflexively, In newborns, there isn voluntary urinary retention Conditioned retien inhibition of the urge to urinate is developed for some time in the process of raising « child, The ability to voluntarily regulate urination develops only towards the end of the child’s first year of life. In the second year of life, this ability becomes stable. However, with excitement, during exciting games, involuntary urination can be observed in children up to three years old, and in sleep - up to5 years old318 dldhood diseases RESEARCH METHODOLOGY An examination of the urinary system organs includes questioning the child and his parents, examination, palpation, percussion, laboratory and instrumental research methods. Questioning When questioning the child and his parents, possible complaints and health problems should be actively identified, + Pain in the abdomen, in the lumbar region, It should be noted that young children do not localize pain well, On the healthy side, pain may be reflexive in nature + Dysuric disorders: Frequent or rare urination, painful urination, urinary incontinence and incontinence, enuresis. + Swelling on the Face, legs. Often viewed by parents as quick third increase in the child's weight. + Increased blood pressure, sometimes accompanied by headache, dizziness pain, pain in the heart area, + Change in the appearance of urine (turbidity, sediment, change in color), - “Unmotivated” rises in temperature to febrile levels or prolonged low-grade fever, = Visual impairment, hearing impairment + Dyspeptic disorders (nausea, vomiting, loss of appetite, diarrhea), thirst, itchy skin, + Weakness, lethargu, increased Fatigue, malaise, adynamia, weight loss. It is also necessary to clarify the history of life, illness, family namnesis, You should find out: - when the complaints appeared; + results of the analyzes performed: the treatment performed and its effectiveness; + presence of diseases of the urinary system in close Inspection Examination reveals many pathological signs (Table 10-2).Chapter 10. Urinary sustem 319 Table ee Sweling (or pastiness) on the contours | oF the suprapubic end lumber | Stigma de Morphogenesis Changes child's behavior during a: = 10-2, Symptoms of urinary organ diseases ‘Appears due to spasm of arterioles er anemia, Waxy paller is characteristic of renal amyloidesis, Paleness with an icteric tint for uremia (you can notice scratching, ecchymeses on the skin, a coated dry tongue, smell ammonia. coming from the patient's mouth or skin) Swelling can be general - distributed throughout the body (anasarca): - with accumulation ef Fluid in cavities: abdominal (ascites), hymen oral (hydrothorax) and in the pericardial cavity (hydropericardium), In this case, you can see the puffiness of the Face, swelling of the eyelids, narrowing of the palpebral fissures (facies nephritica, Fig, 10-3), smoethness of the contours of the jeints (Fig. 10-4), lumbar lordosis, traces of pressure from clething, sheets (Fig, 10 ~5). If hidden edema is suspected, the following is performed: -McClure~Aldrich blister test: - weigh the child daily; 5 diuresis is measured daily The abdomen increases in volume with ascites - when the child is in an upright position, he looks drooping (cs Fluid Flows down) with « pretruding navel (due te increased intra-abdeminal pressure); - when horizontally spread out with bulging lateral sections (“Frog belly”, Fig. 10-6), Bulging in the suprapubic region due te bladder overflow is observed in acute urinary retention. Newborns and children in the First months of life are full. the bladder may protrude above the pubis Swelling of the lumbar region on the affected side observed with paranephritis Most often Found in children with genetic nephropathies, malformations of the kidneys and urinary tract Infants express pain when urinating by 2 crying during er immediately oPter In the hyporeflex form of neurogenic dysfunction, urine : cof the bledder, the act of urinction continues For « long time time, often in several stages, te Facilitate urinctien, children press with their hands on the anterior abdominal wall et320 Propaedeutics of childhood diseases Puc, 10-3, Nephi Rice, 10-4, Smoothness of joint os Rice, 10-5, Pressure marks from clething Rice, 10-6. <> Palpation This methed is used to detect edema and tissue pastiness (Fig, 10-7) The kidneys (usually the right one) can be palpated in children of the first 2 years of life (especially with low nutrition) due to their relatively large size and low location (Fig, 10-8). In older children, the kidneys are not normally palpable. Detection of kidneys during palpation in older children indicates their enlargement or displacement, Enlarged kidneys can be palpated due to hydronephrosis, tumor, vicarious hypertrophy of a single kidney, Sometimes it is possible to detect kidney prolapse (nephroptosis), c dystopic kidney, In the absence of kidney pathology, they can be palpated in case of abnormal development . of the muscles of the abdominal wall (aplasia, hypoplasia). Painful sensations on palpation of the kidneys occur with pyelonephritis, paranephritis 321/465a eee ee ee ee a 8 Pelpation of the abdemen is used te identify pain or sensitivity along the ureter, the projections of which on the anterior abdominal wall are the uoper and lever ureters points (Fig, 10-4), Pelpation of the bladder in the suprapubic region is carried cut with beth hands Before the test, the bladder must be emptied. The bladder, as an elastic, Fluctuating formation, the upper pole o which tdtaneousy sometimes reaches the navel, is polpated in acute and chronic urinary retention. A normally full bladder can be Felt in infants. Rice, 10-7. Methods for detecting : deme the ewer trom It is necessary to press with the Angers of your right hand in the area of the shin abeve the tibia Rice. 10-8, kidney palpation technique. ‘The child lies on his back with slightly bent lege, the examiner places bis eft hand under the patient's lower back, resting his fingers on the angle formed by the XII rib and the long back muscles; places his right hand on bis stomach and penetrates th right hypochondrium in Front outward from the rectus abdominis muscle, then tries dese your hands322 Propaedeutics of childhood diseases Rice, 10-4, Methodology for ‘The superior ureteric points are located at the intersection of s line drown ‘through the navel with the outer ‘edges of the rectus abdominis muscles, The lower ureteric points ave located at the intersection of the bispinal line with the outer edges of the rectus Rice, 10-10, Tapping the lumbar region The examiner places his left hand on the lumber region, first on one side, then en the other, and epplies short, net very strong blows to it with the ‘edge of the palm of his right hand. Percussion Tapping oF the lumbar region (modified Pasternatsky symptom, Fig. 10-10) is used to identify pain or discomfort, sometimes rediating te the leg or lower abdomen, smo ocr daring this study (in this case, the symptom is assessed as positive). A positive symptom of fFleurage ie determined by inflammatory processes ithe kidneys and perinephric tissue (pyelonephritis, paranephritis), urdithias' Percussion can be used to determine the height of the upper pele of the Filed bladder For this purpose, the plessis meter finger of the left hand is placed parallel te the pubis and percussed along ve the pubis the mid ofthe abdemen from the navel down until the sound 8 dul This metho is ued if acute rary retentions especie Percussion alse reveals the presence of Free fluid in the abdominal cavity (see the method in the chapter “Digestive system ‘Auscultation ‘auscultation of the abdomen is carried out in the projection of the renal vessels on both sides, Detection of a systolic murmur in the rene eres indicates possible damage to the renal arteries (congenital or acquired renal artery stenosis) cor the corta in this ares,324 Propaedeutics of childhood diseases General urine analysis A general urine test includes determination of the physical properties, chemical composition of urine and microscopy of its sediment (Table 10-3). Method of urine collection; examine freshly released morning urine (medium stream), collected after a thorough toilet of the external genitalia, In newberns and infants, urine collection perineum, of hematuria and leukecyturia, ¢ two-hundred-can sa A general urine test gives an approximate assessment of changes in urinary porenko's method of counting cellular elements in 1 ml of urine; « Addis Kakovsky test - counting of cellular elements in urine General urine test in children Norm Features ef urine in children m In the first week of ty (depends on t may be | P latter is the ureresein) nuclei ef which many purine and Pyrimidine bases are released; the fina product of their metcbelism is urinary Infants have lighter urin than elder children and , | lew to amber ye Like adultserm | (depending on water lead) up red blood cells 0-2 in the field c : 0-4 in the field DpH | pH and other | the Features of urine in children reaction in newborns is acidic (pH din premature inf its to « greater On the 2-4th day of life, the pH value increases Jing: - with breastfeed y, the pH is 6.4 (i.e 7.8; - with artificial 5, physiological acidosis is typica ren has the first weeks of urine of ch gravity during th joes not exceed 1,016-1 In newborns in the first days of life, transient used by the proteinuria may develop, tubules, and capillaries, In full-term m ars on the 410th day of lif ( mature infants) ; | amount of them in the urine of children is the sam | r\s are allowed up to 5-6 in the field of view nent is Formed due to excessive consumption of meat se, Fever, hunger slucocorttico use increased catabolism, Oxalates are present in urine due to excess consumption of foods rich ir 32526 Table 10-4, Results of quantitative tests in healthy children Sediment elements ‘The Nechyporenko method ‘Aszmple Until vrte [Red dae Unt 00 pt 20000 Bacteriological examination of urine ‘A.culture of morning urine collected in « sterile container is performed. After 24 hours, qualitative and quantitative assessment of the results is carried out, The type of pathogen and its sensitivity to antibacterial drugs ere identihed. Pathological bacteriuria is considered when more than 10 microbial bodies are detected in 1 ml of urine in newborns and young children and more than 0.5-1.0x10 in older children, Renal function tests Various renal function tests are presented The study of the Functional state of the kidneys allows us to judge localization and severity of structural damage te their parenchyma, ‘The value of glomerular Altration increases with infusion therapy drinking or taking large volumes of liquid orally, eating high-protein Foods; decreases under the influence of heavy physical activity, a change in body position from horizonta| te vertical, under the influence Table 10-5, Renal function tests Function under study Determination method + in newborns 30-50 ml/min/ 1.73 m>; + From year 80-120 mi/min/ 1.73 m2 leg of creatinine (medi fixed sample Reberg), i.e. by the amount a)Chapter 10. Urinary system fe Daily diuresis ina healthy child is 2/3-3/boF the daily To assess kidney function, the content of nitrogen- containing substances (urec, creatinine, uric acid), total protein and its Fractions, electrolytes, Using special tests, it is possible to examine the partial functions of individual parts of the nephron: te assess the function of proximal tubules, the clearance of free amino acid phosphates is examined, and renal capacity is examined to assess distal tubular Function, excrete hydrogen ions and electrolytes (sodium, potassium, chlorine ions, phosphorus, calcium, etc.). If necessary, an instrumental examination of the child is carried out ‘Allows you to evaluate the size (Fig. 10-12), shape, position formation, structure of the kidneys, renal blood Flow, Functional ‘Hate ofthe kidney, cenditon ofthe bade, detity stones inthe urinary system (Fig, 10-13), sweling in the body cavities (Fig, 10-14)328 Propaedeutics of childhood dis ind urinary tract, urodynam moniter the dynamics of the pathological process to determine the shai assess the amount of fur dlentify space-occupying Formations in the re } 4 Angiography | oftheren arteries B Fy the morphelegicel var anges in the of the kidney | te 08 the bledder, urethra, and you can identity vesicoureteral reflux (Fig, 10-16) [ inorder to study the uredynamics of th Itrasound ef the kidneys: « reduced size of the right kidney (wrinkled): 6 - the left kidney of the same child is of normal size 290/465+, Russian > — English330 Propsedeutics of childhood diseases, SEMIOTICS OF LESIONS OF THE URINARY ‘Anomalies of the development of the urinary system organs Kidney development abnormalities Quantity changes: accessory kidney; ble kidney (two pelvises in one mass of renal parenchyma) agenesis (complete absence of an organ, Fig. 10-18); (absence of an organ in the presence of a vascular pedicle) « horseshoe kidney (Formed when the lower or upper ends fusion) (Fig, 10- ¢, 10-17, Kidney duplication; a, 6 scheme of options, in ultrasound; d-urogram331 of both ends: ped kidney Location (Fig, 10-20), rotation hype + simple (decrease in the relative disruption of their structure), ional dysplasia is « grew with impaired differentiation ie Rice, 10-19, Horseshoe kidney; « - embryonic structures, diagram; 6 Uttrascund: in urogram 332/465332 Propaedeutics of childhood diseases Rice, 10-21, Kidney hypoplasia: «333 most common cause is stenosis of the ureteropelvic segment, the ted with imp in embryogenesis. Anomalies of the ureter place) of the ostia; retrocaval ureter, ladder abnormalities exstrophy (congenital cleft of the bladder « - diverticulum (Fig, 10-23). Rice, 10-22, Congenital! hydronephrosis Anomalies in the development of urination - atresia or stenosis (Fig. 10-24) the lower part of the lower wa! entire external opening opens in the area of the coronary on the lower surface of the of the urethra). Rice, 10-23, Multiple diverties334 Propaedeutics of childhood diseases Changes in urine tests Changes in urine are the most cad somtimas the only sign of damage to the urinary Urinary syndrome. Urinary syndrome is understood es the appearance of pathological changes in urine in the Form of proteinuria, hematuria, leukocyturia, cylindruria, the urinary sediment, These changes ‘Change in urine color, The color of urine changes in many pathelogical conditions, taking certain medications, and also in healthy children Rice. 10-24, Urethral efter ecting certain Feeds ewe (Fig, 10-25). Leukecyturia - an increase in the content of leukocytes in the urine above = Neutrophilic type of urine urecytegram is noted in microbial inflammatory diseases of the kidneys and urinary tract (pyelonephritis, cystitis, urethritis, tuberculosis and other infections), as wel asthe external genitalia = Mononuclear and lymphocytic types of urocytogram are characteristic of damage to the tubulointerstitial tissue of the kidneys in glomerulonephritis, interstitial and lupus nephritis, Hematuria (detection of more than 2 red blood cells in the field of view in the morning urine), According to the degree of severity, macro- and microhematuria are distinguished. renal and extrarenal in origin, Causes of hematuria in children, see Fig. 10-26. Other possible changes in urine are presented in table, 10-7,ckground336 Propaedeutics of childhoed diseases Hematuria Renal Glomerular eceurs -glomerulonephritis = (ccute, progressive, chronic) 1 A-nephropathy ~ diseases of thin membranes nephvitis + idiepathic mixed -lipopreteins, 8-globulins) glomerular when the properties of the glomerular basement membrane are damaged er changed; tua sir hi ipo nth ability of the kidney tubules to reabsorb protein From primary urine; + prerenal is caused by increased education loss of low molecular weight proteins (light chains of immunoglobulins, hemoglcbin, myoglobin), which are filtered by normal ‘glomeruli in quantities exceeding the capecity oF ‘tubules te reabsorption (preteinuria “ovrtow338 Propaedeutics of childhood diseases Table 10-7, Changes in urine tests Couser change Incomplete transparency of urine occurs whon ther The urine becomes cloudy due te the presence of bacteria and a large amount of salts in it, cloudy if there is drops of fot Ghange'in ‘An acidic urine reaction can occur in children after an urine reaction overload of meat Food, with glomerulonephritis, and diabetic An alkaline urine reaction is observed with a vegetable diet, consumption of alkaline mineral water, due to vomiting (due to loss of chlorine ions), with inflammatory diseases of the urinary tract, hypokalemia, in the presence of phosphate, with the disappearance of edema, with bacterial fermentation in the Change Relative density fluctuations below 1,010 hatig They indicate 4 violation of the concentration Function relative density | of the kidneys: this condition is called hypesthenuri, om The presence of a constant relative density of uri corresponding to the density of primary urine (1,008-1,010) is called isosthenurie, A decrease in the relative density of urine occurs when urine is diluted or its concentration : is impaired, which occurs in chronic glemerulonephritis with severe damage to tubulointorstitial tissue, interstitial nephritis, congenital and hereditary kidney diseases, chronic pyelonephritis in the stage of sclerosis ‘An increase in the relative density of urine, hypersthenuria (specific gravity above 1,030) is observed in the presence of sugar, protein, and salts in it Cylinder| | | Cylindruria is associated with protein precipitation in +the tubular lumen, Casts in the urine appear under hyaline casts during physical exertion, Fever, orthostatic proteinuria, nephretic syndrome, ete.; granular in severe degenerative lesions oF the tes; ving with lesions ef the tubular epithelium, nephrotic syndrome; er daeneratve changes in the tubes with glomerulonephritis, nephrotic syndrome; erythrocytes for hematuria of renal origin; leukocytes for leukocyturia oF renal originMay eccur with excess sugar consumption, infusion ‘theropy with glucose solutions, and dichetes, In the chsence of these Factors, glucosuria indicates « violation of glucose reabsorption in the proximal nephron (tubopathy, interstitial nephritis) Characteristic of acetonemic vomiting, diahetes Epithelial cells appear in large numbers in the urine under various pathological conditions: squamous epithelium (upper layer of the epithelium of the bladder) - in acute and chronic cystitis, columnar or ‘cuboidal epithelium (epithelium of the tubules, pelvis, ureter) - in inflammatory diseases, dysmetabolic A precipitate of uric acid and its salts is observed in children with urinary acid diathesis and in a number of kidney diseases leading to disruption of the Formation oF ammonia by the ‘tubular epithelium, Tripelphosphates and cmorphous phosphates ‘are Found in the urine in microbial inflammatory diseases oF ‘the kidneys and urinary tract, as welll as in primary and secondary ‘tubulepathies against the background of hyperphosphaturia ‘end impaired acidegenesis and ammonicgenesis, Oxalates are found in urine during extrarenal uid loss, in some tubulepathies, 65 well as in oxalosis (c hereditary disease characterized by impsired metabolism of oxalic acid precursors) Polyuria Increased daily mere diuresis. Convergence of edema. ‘than 2 times compared to the use of osmotic diuretics nd the norm of scluretics, (in older children, severe renal dysfunction (renal age, a Failure in the ee phase). 1500 ml/m? per dau) DiabetesMay be due to impaired renal function in patients with glomerulonephritis, limiting Fluid intake; increase in cardice edema Transient cliguria is observed in new born in the first 3 days of life Urine dees not enter the bladder due to a violation of its formation in the kidneys (true anuria) or due te obstruction oF the everying urinary tract. ‘True anuria can be a sign of acute renal failure, occur when the bloed supply to the kidneys is impaired (shock, acute blood loss), exposure to toxic Factors, acute inflammation of the renal parenchyma (acute glomerulonephritis) Occurs when there is a disturbance in the ‘the bladder, Ischuria can eccur acutely when nom traumatic rupture or stone obstruction of the urethra or persist For « long time with severe atony presence of residual urine) is ‘observed in the presence of an cbstruction at the level of the bladder neck or strictures of the urethra, stones ‘and tumers of the beer, ureterecele, etc,). For incomplete chronic delay intermittent urine stream, deed urinetien, urinction in 2 stages, which is mere ‘often observed with bladder diverticulum, urethrohydronephresis, vesicoureteral‘ 341 Causes | Kidney disorders, A tendency te nocturia is characteristic of various kidney s characteristic diseases, and noctur Edema is a common symptom of various kidney diseases, he development of edema may be due to concentration of proteins, mainly albumins, in the blood increased capillary permeability cs result of increased. activation of the renin-angiotensin-aldosterone system, which determines an increase in the reabsorption of sodium and water; » decreased glomerular filtration, Edema is observed in acute and chronic glomerulonephr tis, Nephrotic syndrome Nephrotic syndrome is a symptom complex including: + + severe proteinuria. (more than 50 mg/kg per day); hypopreteinemia. (hypoallbuminemia) hyperlipidemia Clinical forms of nephrotic syndrome: complete - the presence of the entire symptom complex incomplete in the absence of edema or one of the laboratory symptoms ptomov nephrotic syndrome; Rice, 10-27, Nephrotic syndrome (anasarca)342 Propaedeutics of childhood diseases + pure, net accompanied by hematuria or hypertension: + mixed with hematuria. or hypertension. Nephrotic syndrome can be primary or secondary (Table 1(0-4). Table 10-9, Causes of nephrotic syndrome in children Primary nephrotic syndrome Secondary nephrotic syndrome Congenital and infantile nephro- For intrauterine infections tic syndrome, (toxoplasmosis, cytomegalovirus For glomerulonephritis: infection, congenital syphilis, ~ sith winimal hongesin the ete). = For infectious diseases tuberculosis, = focal segmental glomerus ( hepatitis B and C, HIV. lesclerosis (hyalinosis): suphiis, ete) - membranous; For systemic diseases of connective “ mesangioproliferative; tissue and systemic vasculature, - meergiceplen ck - extracapillary with crescents; With structural dysembryogenesis ~ Hroplestic Kidney tue For metabolic diseases. For renal vein thrombosis, For hereditary diseases For chromosomal diseases Nephritic (acute nephritic) syndrome Nephritic syndrome is a symptom complex including: + extrarenal symptoms (edema, hypertension, possible changes in cardiovascular system, central nervous system); + rencl symptoms (oligurie, homcturie, proteinuri, cylindruria) The occurrence of acute nephritic syndrome is most typical for acute glomerulonephritis. It can also be observed during primary nal and secondary (for example, with SLE, Henoch-Schénlein disease, Wegener's granulomatosis, Goodpasture's syndrome) glomerulonephritis. Appearance nephritic syndrome clwcys indicates an increase in activity these diseces, Dysuric syndrome Dysuric syndrome is a syndrome ef impaired urination (Table 10-10), «sigh of pathology oF the lower urinary tract,Table 10-10, Urinary disorders ‘Observed in children with « hyperetlex bladder: with significant loss of Fluid due Increased urination May occur in healthy children during cooling (pollaiuria) denia. and when suimming in salt water. Pollakiuria in combination with pain during urination is a characteristic sign of cystitis: pollakiuria, more pronounced during the dey, aggravated by rmevements, is characteristic of stones in ‘the bladder; painless pollakiuria is observed with a hyperreflex bladder, In addition, pellckiuric cam occur with urethritis, prostatitis, with reflex effects rom the intestines (anal fissures, True urinary incontinence is characteristic incontinence are ectopia of the ureteric orifices into the urethra or vagina, Most often develops with pathology of the nervous system, with mental disorders, as well 4 pathelepy of the lever urinary tract,344 Propaedeutics of childhood diseases Pain syndrome Pain syndrome in kidney diseases can be caused by three main reasons: stretching of the kidney capsule, inflammatory sweling of the mucous membrane and/or stretching of the renal pelvis, spasm of the urinary tract. Stretching of the kidney capsule occurs in parenchymal kidney diseases (glomerulonephritis, amyloidosis, etc,) and in patients with congestive plethora in heart failure, The pain in this case is usually mild, dull, and constant, At the same time, with « kidney infarction, pain can occur acutely and be very pronounced, If * the pelvis is affected (pyelonephritis), the pain can be intense - mi growing, + Acute, paroxysmal, very intense pain in the lower back or along the ureter (renal colic) is characteristic of urolithiasis, Pain during urination in the lumbar region and in one of the hollows abdominal veins appear with vesicoureteral reflux, Pain in the bladder area is caused by its pathology and occurs with cystitis, the presence of 4 stone, or urinary retention, Pain in the area of the urethra can be caused by inflammation, ‘Arterial hypertension Hypertension in children with kidney disease develops quite often, When the renal parenchyma is damaged or vasoconstriction occurs, blood ircation in the kidneys is disrupted, which leeds to activation of the renin-angiotensin-aldosterone system, As a result, general peripheral vascular resistance increases, sodium and water ions are retained, which causes There is an increase in cardiac eutput and circulating blood volume, + Parenchymal renal hypertension occurs with diffuse damage to the renal parenchyma: with acute and chronic glomerulonephritis, interstitial nephritis, congenital kidney anomalies, amyloid dose, kidey tomer, kidrey injury, ee + Vasorenal hypertension is caused by renal artery stenosis, the presence of multiple renal arteries, anomalies of the renal veins, thrombosis or aneurysm of the renal artery or vein, aortoarteritis or juvenile polyarteritis with damage to the renal arteries, ete, Kidney failure Renal failure is a condition in which the kidneys reduce the ‘uaretion of various substances From the body: water, petessim fons, sodium, nitrogen-containing substances (creatinine and urea), medium molecular * 345/465Chapter 10. Urinary system 345 Clinically, renal failure is manifested by symptoms: + overbudretion; + hyperkalemia; The basis of renal failure is the interaction of three factors: + decreased blood perfusion through the renal vessels, + disruption and blockade of microcirculation in * them, replacement of renal structures with connective tissue. Partial transient renal failure is characterized by « significant ecrese nthe oaretonet abn (ay wee te kidneys, associated with « decrease in renal blood flow or impaired bloed flow through the renal glomeruli, This state of development - - hypovelemic conditions (high physical activity, diabetes rhea, vomiting, fever); - decreased pumping function of the heart; 5 vasoconstriction during hypertensive crises; . increcsed bled viscosity during parapreteinemia, Acute renal failure is « disorder of kidney function caused by Ee damage to nephrons, clinically characterized by cliguria, This condition develops with immune diseases, disseminated intravascular coagulation syndrome against the background of sepsis and severe infections, hemolysis, shock, burns, Frostbite, massive blood transfusions, etc., with thrombosis and thromboembolism of the renal vessels; exposure to nephrotoxic substances; in case of obstruction of the ureter. Chronic renal failure is « condition caused by irreversible loss of Functioning nephrons and ether kidney tissues, while diuresis depends on the stage of the disease and can be adequate, excessive, - and in the terminal stage olige- er enuria develeps, Chronic renal failure develeps with rapidly progressive and chronic glomerulonephritis, with chronic pyelonephritis against the background of abnormalities of the kidney structure, with nephritis in patients with systemic connective tissue diseases, amylcidesis, ete, Fragment of medical history When examining, pay attention to the color of the skin, the presence of stigmata of dysmorphogenesis, edema (pasty) of the eyelids, Face, torso, extremities, changes in the size and shape of the chdomen, the contours of the suprapubic, lumbar regions, the child's behavior during [ll urination time, Palpation reveals swelling (pasty) in the lower extremities, Blood pressure is measured,