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Hydronephrosis Case Study

Physical Exam

Question 2

Question 1

Sources

Hydronephrosis

Labs

Clinical Course

PubMed

Problem List

Admission

Differencial Diagnosis

UVA Nursing Seminar III GNUR 6626Sydney Stryker RN, BSN, C-ELBW, RNC-NIC, RNC-LRN, N-NNIC

Maternal History

Cranial nerves intact; motor strength appropriate in upper and lower extremities, reflexes normal in upper and lower extremities sensation is normal. Tone is normal.

HENNT Normocephalic Anterior Fontanelle open and flat Flat symmetric face Pupils equal, round, and reactive to light Ears normally formed and in line with the outer canthus of the eye Palate intact by palpation Nares patent Symmetric facial movements

Cardiac:

  • Regular rate and rhythm with no murmurs, rubs or gallops.
  • Pulses full (2+) and symmetric in all extremities.

Chest/Respiratory:

  • Clear to auscultation bilaterally
  • Mild intermittent comfortable tachypnea and mild subcostal retractions, increased with agitation
  • Chest cage symmetric without pectus deformity
  • Nipples normally formed and equally spaced

GI:

  • Soft, nondistended, nontender.
  • No hepatosplenomegaly or masses
  • No discoloration
  • Bowel sounds present
  • Vesicostomy site celan and intact, non-reddened

Extremities

  • Normal appearance
  • Symmetric movements of all extremities
  • Hips: Negative Barlow & Ortolani, with no clicks/clunks

Back: Spine normal with no sacral tufts or dimples

Skin:

  • No areas of hyper or hypopigmentation
  • No café-au-lait macules
  • No visible telangiectasias on skin or mucous membranes
  • No rashes
  • No thinned/translucent skin
  • No striae/abnormal scars.

GU:

  • Descended testes bilaterally
  • Circumcision site healing

RFPDOL 6DOL 7DOL 8DOL 9DOL10NA142142141142138K3.74.04.24.24.1CL10810410010093CO22021273031BUN8275645546CREAT2.22.32.21.92.0CA9.39.69.910.510.8PHOS5.24.54.84.84.4GLU8483758476

GU:

  • Descended testes bilaterally
  • Circumcision site healing

Clinical Characteristics

Hydronephrosis in newborns often presents with no outward symptoms. This is because the blockage or reflux may be mild and not cause significant impairment to kidney function. However, in some cases, there can be some physical signs or symptoms that indicate a more serious condition. Here's a list of some clinical characteristics of hydronephrosis in a newborn:

  • Abdominal swelling: This can be a sign of a severe blockage in the urinary tract that is causing urine to back up into the kidneys.
  • Urinary tract infection (UTI): Newborns with hydronephrosis may be more susceptible to UTIs, which can cause fever, poor feeding, vomiting, and lethargy.
  • Mass in the abdomen: In some cases, a hydronephrotic kidney can be felt as a mass in the abdomen during a physical examination.

Lab Trends

Age: 11 days at PMA 37w1d

  • RFP
  • CBC
  • BC

Diagnosis/Testing

  • Prenatal US
  • Obstruction --> Oligohydraminos --> lung development
  • Voiding Cystourethrogram (VCUG): uses x-rays to show how urine flows through the bladder and urethra
  • Radionuclide Scan: creates images of the urinary tract as a radioactive substance passes through

  • SVD
  • 35w4d
  • Cord clamping was delayed for 60 seconds
  • Clear Fluid
  • APGAR 8 and 9 at 1 and 5 minutes
  • Resuscitation included: Stimulation and bulb suction
  • Admitted to the NICU for further workup for hydronephrosis and possible posterior valves
  • Admission Measurements

Admission

FEN

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FEN

  • Premature infant of 35 weeks gestaion
  • Hydronephrosis, bilateral s/p cutaneous-vesicostomy
  • Posterior urethral valves (PUV)
  • Newborn affected by oligohydraminios
  • LGA Infant
  • Posterior urethral valve determined by voiding cystourethrography (VCUG)
  • Pulmonary artery stenosis of peripheral branch
  • E. coli UTI

Current Problem List

Management of Antenatal Hydronephrosis

Key summary points

  • Antenatal hydronephrosis is the most frequently detected abnormality by prenatal US and its outcome depends on the underlying etiology.
  • There is still no consensus for the evaluation and management of patients with AHN.
  • Mild isolated AHN represents up to 80% of the cases and generally regarded as a self-limited condition.
  • Conservative approach with careful close follow up for patients with asymptomatic VUR and UPJO is generally recommended in recent years.

Yalçınkaya, F., & Özçakar, Z. B. (2020). Management of antenatal hydronephrosis. Pediatric nephrology (Berlin, Germany), 35(12), 2231–2239. https://doi.org/10.1007/s00467-019-04420-6

Differencial Diagnosis

  • Ureteropelvic junction (UPJ) obstruction: This occurs when there is a blockage at the point where the ureter meets the renal pelvis. It can be due to intrinsic narrowing or extrinsic compression.
  • Vesicoureteral reflux (VUR): In VUR, urine flows backward from the bladder into the ureters and sometimes up to the kidneys, which can lead to dilation of the renal pelvis and ureters.
  • Posterior urethral valves (PUV): PUV is a condition where flaps of tissue in the urethra obstruct urine flow, leading to bladder outlet obstruction and subsequent hydronephrosis.
  • Megaureter: This is an abnormal dilation of the ureter, which can be congenital or acquired. It may result from abnormal peristalsis or a functional obstruction.
  • Multicystic dysplastic kidney (MCDK): This congenital condition involves abnormal development of the kidney, leading to the formation of multiple cysts and non-functional renal tissue. Hydronephrosis can occur due to the dilation of cysts.
  • Duplex kidney: In this condition, there is a duplicated collecting system, leading to two ureters draining a single kidney or each draining a separate portion of the kidney. Obstruction in one or both of the ureters can cause hydronephrosis.
  • Prune belly syndrome: This rare congenital disorder involves underdeveloped abdominal muscles, urinary tract abnormalities, and often, bilateral hydronephrosis.
  • Neurogenic bladder: Conditions such as spinal cord abnormalities or spinal dysraphism can lead to neurogenic bladder dysfunction, causing urinary retention and subsequent hydronephrosis.

Nguyen HT, Benson CB, Bromley B, et al. Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). Journal of Pediatric Urology. 2014;10(6):982–998.[Al-Salem AH. Chapter 2: Hydronephrosis in infants and children. In: An Illustrated Guide to Pediatric Urology. Cham, Switzerland: Springer International Publishing, 2017. 43–69.Baskin LS. Overview of fetal hydronephrosis. UpToDate website. www.uptodate.com/contents/overview-of-fetal-hydronephrosis External link. Updated December 20, 2018. Accessed January 15, 2019Yalçınkaya F, Özçakar ZB. Management of antenatal hydronephrosis. Pediatr Nephrol. 2020 Dec;35(12):2231-2239. doi: 10.1007/s00467-019-04420-6. Epub 2019 Dec 6. PMID: 31811536.

  • FEN
  • Urology/Nephrology
  • Respiratory
  • Cardiovascular
  • Infecious Disease
  • Pain and Sedation

Pertient Systems

Management

  • Prophylactic Antibiotics
  • Foley for strict I&Os
  • Wait and See
  • Surgical Mangement:
    • Vesicostomy: small opening, or stoma, is created in the bladder wall to provide an alternative route for urine drainage.
      • Typically performed in cases where there is severe bladder outlet obstruction, such as posterior urethral valves (PUV).

What is hydronephrosis in newborns?Hydronephrosis in newborns is enlargement, or dilation, of the renal pelvis—the basin in the central part of the kidney where urine collects. Hydronephrosis can occur in one or both kidneys. This condition is often diagnosed before birth during a prenatal ultrasound.In some cases, hydronephrosis is mild and goes away on its own without treatment. In other cases, hydronephrosis may be a sign of a blockage in the urinary tract or reflux—or back up—of urine from the bladder to the kidney that needs treatment.Males are about twice as likely as females to have hydronephrosis.In 1 or 2 out of every 100 pregnancies, the fetus is diagnosed with hydronephrosis. In about half of these cases, the hydronephrosis goes away by the time the infant is born.

FEN

  • History of emeis and inability to tolerate feeds, likely dysomotility complicated by uremia.
  • No malrotation noted on 3/10 upper GI. Now tolerating feeds with slow advance, no recent emesis.
  • PICC TPN/IL +Carnitine TF 150ml/kg/day
  • MHM/DHM 45ml/kg/day PO/NG
  • Continue decrease protien at 2gm/kg per nephrology due to elvated BUN

  • Prenatal US dignosed hydronephrosis and possible PUV
  • Oligohydraminos
  • Prenatal Labs
  • Betamethasone x2

32 y.o. G4P1112

Maternal History

  • Nuero
  • HEENT
  • Neck
  • Chest
  • CV
  • Abdomen
  • Back
  • GU
  • Extremities
  • Skin

By Systems

Physical Exam