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  • Parthraj Jadeja
    Parthraj Jadeja
    03 Mar 2020 08:32:11 PM

    Good evening sir... it is a Nicely prepared data. And an interesting case too.

    I would want to know pathology on right side. Is it an hypoplastic kidney? Hydronephrosis on either side? 
    Two issues to deal with-
    1. Recurrent UTI
    2. CKD and it's complications.
    Grade 4 VUR on left side will need either reimplant or nephroureterectomy depneding upon the ERPF or GFR of both kidneys .
    I am not sure about deflux at this age but correcting source of sepsis is must before going for transplant and immunosuppression.
    So My answer is 
    1.treat the active sepsis 
    2.manage hypertensive crisis and cardiac function( differentiate between flash pulmonary eedema and cardiomyopathy of CKD)
    3. Removal of source of sepsis with reimplant or nephroureterectomy
    4. Continue treatmnt for CKD
    5. Transplant as early as feasible.

  • Ravindra Sabnis
    Ravindra Sabnis
    03 Mar 2020 11:05:23 PM

    Recurrent UTI can be controlled with chemo prophylaxis.  She is never given medication so far. So it has to be tried.  

    Nephrologists should think from pre-emptive tx. point of view. 
    Fitness, cardiac problems - nephrologists should assess.  
    There is no question of recovery of function. when albinuria , retarded growth - already last stage of ckd.  

  • Dr. Anil Takvani
    Dr. Anil Takvani
    04 Mar 2020 07:28:50 AM

    My understanding:

    1. DMSA scan is not representative of bilateral FTI relates scarring.
    2. Left side DMSA represents global reduction in parenchymal mass suggestive of dyplasia related to high grade reflux(very rarely seen entity in female child).
    3. Hypertention may be a renal origin has damaged the right renal function.
    4.Is there any voiding dysfunction, constipation? She is 6 year, it is easy to get history of incontinence, frequency, lazy voider, holding patterns and constipation. If present do further work-up.
    5. Put the patient on AB prophylaxis and also treat bowel bladder dysfunction if present.
    6. If they are willing for transplant do left nephroureterectomy, if not then do left reimplantation. Left reimplantation will reduce chances of FUTI though it will not  improve renal function.
    Thanks for very interesting case...

  • shriram joshi
    shriram joshi
    04 Mar 2020 07:07:02 PM

    Dysplasia with vur Gr 4/5 occurs around 6th week of intraurterine life. Dysplasia can be global or patchy and is accompanied by small kidneys and poor function. I am not aware of gender bias in such a case. Gender should not matter as it is the grade and timing of VUR in intrauterine life matters.

    This child is in CKD 3/4. Continued infection inspite of antibiotic prophylaxis could be an indication for a nephroureterectomy on the left side. If one is planning for pre-emtive renal transplant (preferred renal replacement therapy in this child) nephrouretrectomy can be planned with the renal TxP. Pop up reflux on the right is a possibility, but with no scars on DMSA, and no dilated ureter on the right side, it is unlikely. 
    Prashant your history sheet does not detail clinical signs and symptoms of bladder bowel dysfunction. If you can provide this then Anil's querry can be answered.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    05 Mar 2020 10:12:07 AM

    @ Prof. S S Joshi Sir,

    Sir, When we see case of unilateral HUN with smaller kidney antenatal, we perform VCUG as a postnatal work-up. 
    Generally VCUG shows high grade reflux and DMSA shows global shrinkage or multiple phtophenic generalized areas with reduction in cortical mass. We categorize these change as congenital nephropathy.
    This is seen more commonly in male patients, in female it is senn in less than 1%.
    Attaching few slides with representative VCUG and DMSA scans.
    Will upload appropriate article soon.

    View Document

  • Amilal Bhat
    Amilal Bhat
    05 Mar 2020 10:16:15 AM

    1.Detailed review history both for Bladder and Bowel

    2. Antibiotics and conservative management for CRF in consultation with Nephrologist
    3. More chances of Dysplastic 
    4. Review with response of conservative tt and then plan 

  • shriram joshi
    shriram joshi
    05 Mar 2020 04:10:31 PM

    Dear Anil,

    I am not familiar with term congenital nephropathy. But if you were to section these kidneys after nephrectomy, you will find dysplasia. Since dyspasia requires histopathological confirmation, clinically one can  say is a hypoplastic kidney with poor function. 

  • Uday Sankar Chatterjee
    Uday Sankar Chatterjee
    05 Mar 2020 06:17:46 PM

     1. I think UDS is necessary to exclude elevated Detrussor pressure, if present,  before surgical intervention.

    2. Regarding Renal Tx... Survival of Tx kidney is ~10-12 years. 
    We have to delay ESRD and Tx by reducing bladder pressure, (if elevated), infection by excluding VUJO (if present along with VUR)

    3. In this situation, , this ESRD would be due to TIN.. ( interstitial ) on refluxing side. So water loss would be adequate during ESRD. By which she (if not endowed economically) might evade RRT for longer time. 

    4. So refluxing unit better be preserved.

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    15 Mar 2020 12:39:48 PM

    Sorry for delayed post. There is no BBD.

    I am of the firm opinion that the child should be offerred pre-emptive transplant given the growth lag.
    Unfortunately the parents were not convinced and did not buy that idea.
    Lost to follow up

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