Assessment of the renal system

Nursing assessment is a key component of nursing practice, which forms the foundation for planning and provision of patient‐ and family‐centred care. The Nursing and Midwifery Council (NMC) (2015) states that nurses must ‘make sure that people’s physical, social and psychological needs are assessed and responded to’. It is therefore really important when undertaking a holistic nursing assessment that criteria relating to the renal system are taken into account (see Table 13.2).

Commonly, infants, children and young people who present with symptoms of a urinary tract disorder will be required to undergo further tests to confirm the diagnosis. These tests may include the following;

• blood tests to assess renal function
  
• renal ultrasound, which provides a non‐invasive assessment of urinary tract anatomy
  
• CT (computed tomography) scan – this type of X‐ray uses a computer to produce detailed images of many structures inside the body, including the internal organs, blood vessels and bones
  
• DMSA (dimercaptosuccinic acid) scan – a type of radioisotope scan that shows which areas of the kidneys are working normally and which areas have been damaged (usually following kidney infections)
  
• intravenous urogram to show detailed anatomy of the renal calyces or ureter
  
• micturating cystourethrogram (MCUG) uses X‐rays that show the bladder and urethra while the child is passing urine. It identifies whether or not the urine goes from the bladder back up to the kidneys instead of out through the urethra, known as vesicoureteric reflux (VUR)
  
• MAG3 scan – MAG is an abbreviation for a chemical called mercaptoacetyltriglycine (MAG3 or MAG III), which is injected to perform this test. It shows how well each kidney is working, how well urine is draining from the kidneys, and can help to identify if there is any blockage that affects the flow of urine from kidneys
  
• kidney biopsy – this involves the removal of small samples of kidney tissue, which are then examined under high‐powered microscopes to find out more about the kidneys.

For a successful outcome to these specialist investigations, the child and family need full preparation, explanation and, where required, provide informed consent. The Great Ormond Street Hospital Manual of Children’s Nursing Practices, Chap. 14 (Macqueen, Bruce & Gibson, 2012), provides a comprehensive account of the nursing implications for these investigations as does infoKID, a web resource for parents and carers of children with renal disorders (www.infokid.org.uk).

In summary, while this section has focused on renal‐specific assessment skills, these should form part of the full holistic assessment of all infants, children and young people for whom you care.

Medical disorders of the upper urinary tract

Glomerulonephritis

Glomerulonephritis is a type of kidney disease that involves the glomeruli, which sit in the Bowman’s capsule in the nephron (Fig. 13.3). During glomerulonephritis, the glomeruli become inflamed, which impacts on the kidney’s ability to filter urine normally. There are many causes of glomerulonephritis, for example:

• acute glomerulonephritis is a common condition in children following a streptococcal infection, often referred to as post‐streptococcal glomerulonephritis (PSGN);
  
• systemic immune disease, such as systemic lupus erythematosus (SLE or lupus) – very rare in children;
  
• other systemic diseases which are also rare in children: polyarteritis nodosa and Wegener vasculitis, which are inflammatory diseases of the arteries, and Henoch–Schönlein purpura;
  
• Alport syndrome, which is an inherited disease.

Children who present with glomerulonephritis can have a wide variety of signs and symptoms. The most common are listed in Table 13.4.

Haematuria and proteinuria	Urine looks dark brown in colour
Fluid overloaded	Hypertensive Increase in body weight Oedema Headaches Seizures Reduced urine output (oliguria) Increased respiratory rate
Changes in physical appearance	Pale skin colour Skin rash, especially over the buttocks and legs Lethargic
Other	Sore throat Decreased appetite

Diagnosis is made on the history and physical examination, supported by a variety of tests, which may include the following;

• Urinalysis – laboratory examination of urine to assess for infection, and to accurately measure the amount of protein in the urine. In the case of haematuria, to count the number and types of blood cells.
  
• Blood tests, as well as a full blood count and urea and electrolytes tests, will be undertaken to look for antibodies and measure complement levels, which will provide information linked to infections. An estimation of the eGFR (estimated glomerular filtration rate) will also be performed.
  
• Renal ultrasound scan to look at the shape and size of the kidneys.
  
• Chest X‐ray, especially if the child presents with breathing problems.

The management and nursing care of children with glomerulonephritis is very much dependent upon the presenting symptoms and the underlying cause. Some children may need to have some dietary restrictions, for example, a no added salt diet, or a fluid restriction. Others may need to take medication, for example, antibiotics, antihypertensives and diuretics. On rare occasions children may be prescribed immunosuppressive drugs, and in even rarer cases may require dialysis.

In summary, there are several causes of glomerulonephritis, the most common of which is associated with a streptococcal infection of the throat. For the majority of children the disease is mild, responds well to treatment and does not cause any long‐term renal disease.

Henoch–Schönlein purpura

Henoch–Schönlein purpura (HSP) is a condition that can affect people of all ages; however, it is most often seen in children between the ages of 3 and 10 years, and is twice as common in boys. It is more common during the winter months and is frequently preceded by an upper respiratory tract infection.

Children with HSP often present with a fever, and have a rash that is characteristically symmetrically distributed over the buttocks, feet and ankles, backs of legs, lower back and arms. Children with HSP also commonly complain of pain in their joints and abdominal colic‐like pain. Intussusception (see Chapter 14) can occur. Although renal involvement is common, it is not usually the first symptom (Lissaur & Clayden, 2007).

Most children with HSP do not need special treatment, and many will be monitored as outpatients. The mainstay of treatment is symptom management, i.e., analgesia for joint pain. After several days or a few weeks, the majority of children begin to feel better and the rash and other symptoms disappear. HSP sometimes comes back, usually within a few months, and may need further treatment. A few children have long‐term problems, especially when their kidneys are affected. They will need to be monitored and may need specialist paediatric nephrology follow‐up.

Haematuria

Haematuria indicates the presence of red blood cells in the urine. Urine does not normally contain red blood cells because these are too large to pass through the tiny holes (fenestrae) in the kidney filters. However, the glomeruli can be damaged in renal disease, which allows blood to pass into the urine. Microscopic haematuria means that the blood can only be detected during microscopy. Gross haematuria means the urine appears red in colour. Microscopic haematuria in healthy children does not usually need to be investigated unless it is present in at least three urine tests over several months. However, if a child has other symptoms, for example, hypertension or proteinuria, further investigations are warranted.

Haematuria is a common finding in children and has many causes, which include the following:

• abnormal structures in the urinary tract (renal cysts)
  
• inherited diseases (Alport syndrome)
  
• mineral imbalances in the urine (hypercalciuria causing renal stones – calculi)
  
• glomerulonephritis
  
• idiopathic, where no cause of haematuria is found.

In summary, care and management of children with haematuria may be minimal to complex depending on the underlying cause.

Chronic kidney disease

Chronic kidney disease (CKD) is characterised by permanent deterioration of renal function that gradually progresses to end‐stage renal disease (ESRD). Congenital disorders, including congenital anomalies of the kidney and urinary tract, are responsible for about 66% of all cases of CKD in children in developed countries. All data on CKD in adults and children is reported to the UK Renal Registry by the specialist renal units across the UK and Ireland. An annual report is published by the UK Renal Registry, a section being dedicated to an analysis of CKD data in children. The last UK Renal Registry (2015) reported that a total of 917 children and young people under 18 years with established renal failure (ERF) were receiving treatment at paediatric nephrology centres in 2014. This clearly demonstrates that CKD is very rare in children and out of these, 79.3% had a functioning kidney transplant, 11.2% were receiving haemodialysis, and 9.5% were receiving peritoneal dialysis (UK Renal Registry, 2015). There are a variety of causes of CKD (Table 13.5), the most common primary renal diagnosis being renal dysplasia with reflux.

Understanding normal renal function (Peate & Gormley‐Fleming, 2015) will enable you to appreciate the physiological consequences of CKD (Table 13.6), and to recognise the need for multidisciplinary specialist paediatric nephrology services. CKD is classified into five stages (Table 13.6), which are defined by the GFR. The GFR measures the volume in millilitres (mL) filtered by the kidneys each minute (min), which is an indication of kidney function. This is adjusted for children against a standard adult body size, which has a surface area of 1.73 square metres (m²).

Table 13.7 describes the stages of CKD and GFR.

Unfortunately there is no cure for CKD. Treatment options include the following:

• Peritoneal dialysis (PD) (Fig. 13.4)
  
  
  
  • A treatment that uses the peritoneal membrane as a filter to remove waste and fluid. The peritoneal cavity is filled with dialysate fluid, which sits in the cavity for several hours allowing the peritoneum to filter the blood. The dialysate fluid is then drained out into a waste bag and fresh dialysate is replaced into the peritoneal cavity. PD is done at home either several times a day or overnight.
  
  
• Haemodialysis (HD) (Fig. 13.5)
  
  
  
  • Blood is pumped out of the body and into a haemodialysis filter (dialyser), often referred to as an ‘artificial kidney’, either by a central venous catheter or via an arteriovenous fistula; the blood is then returned to the body. This filter removes waste products and excess water. Each dialysis session takes 3–4 hours, and is done three or more times a week. It is commonly done in a specialist children’s haemodialysis unit; however, some older children are able to do haemodialysis at home.
  
  
• Renal transplantation (Fig. 13.6)
  
  
  
  • This treatment is considered the best for children as it allows them to return to a much more normal way of life without the constraints of dialysis.
    
    
    
    • Types of transplantation:
      
      
      
      • Deceased donor transplant or a cadaveric transplant, where the deceased person has consented to organ donation.
        
      • Living donor is a living person (an adult) who agrees to give one of his or her two healthy kidneys to a recipient. The living donor is usually related to the child.
        
      • Altruistic donation, in this situation the donor does not usually know the recipient. An altruistic donor is a living donor.
  
  
• Supportive treatment
  
  
  
  • Unfortunately, in some cases the right option for the child and family is the decision not to have dialysis or a transplant. The child and family will be offered supportive treatment with the aim being to treat and control the symptoms of CKD focusing on family‐centered care, which includes medical, psychological and practical support.

In summary, CKD is rare in children. It has many causes, the most common of which is associated with structural congenital malformations, which require the support of a specialist paediatric renal team to provide holistic family‐centred care. There is no cure for CKD; however, with dialysis and transplantation many children with CKD now find themselves being transferred to adult renal units in their late teens.