Follow-Up -Duplex Kidney

Yesterday we went to see Dr. Chao again to decode the DMSA scanning report done 2 weeks back.

well, good news.. both her kidney are functioning normally. as in the percentage aded from both kidney's fucntion is appx 100% , just like any normal person without any duplex kidney problem. But her left kidney has two portion, one additional portion function at 1/3 of the whole kidney's function-- duplex kidney, and the other normal kidney function at 2/3 of the whole left kidney fucntion..

so, we are so relief to hear the result of the scanning. Dr Chao said we can stop the antibiotics and see her only after 4 months later.. so finger cros no more recurrent UTI.

Antibiotics Study

There are 3 antibioctics that im interested.
1. Cephalexin
2. Nitrofurantoin
3. cotrimoxazole

All the above are antobiotics to treat UTI, especially E.coli bacteria.

Bb's been taking Cephalexin since she was discharged in April. 3 doses per day for 2 weeks. then once a day for 7 weeks.

In between, we switched to Nitrofurantoin as advised by Dr Chao Xin ming ( the nephrology specialist we are seeing now in KKH private children clinic )

So, this antibiotics is a mild antibioctics which is oral administered that does not achieve significant blood and tissue levels but is excreted in the actuve form in the urine. It is therefore only used for the treatment of uncomplicated lower urinary tract infection due to mosy gram positive or gram-negative bactiria.


extracted from website
Nitrofurantoin.
Nitrofurantoin is an anti-bacterial drug that is used to treat urinary tract infections caused by many gram-negative and some gram-positive bacteria. (Nitrofurantoin was approved by the FDA in 1953.) There are three forms of nitrofurantoin available: a microcrystalline form (Furadantin), a macrocrystalline form (Macrodantin), and a sustained release, macrocrystalline form used twice daily (Macrobid).
Nitrofurantoin can cause acute and chronic liver disease. Most commonly, nitrofurantoin causes mild and reversible elevations in blood levels of liver enzymes without symptoms. In rare instances, nitrofurantoin can cause hepatitis.
Symptoms of nitrofurantoin hepatitis include:
• fatigue,
• fever,
• muscle and joint aches,
• poor appetite,
• nausea,
• weight loss,
• vomiting,
• jaundice, and
• sometimes itching.
Some patients with hepatitis also have a rash, enlarged lymph glands, and nitrofurantoin-induced pneumonia (with symptoms of cough and shortness of breath). Blood tests usually show elevated liver enzymes and bilirubin. Recovery from hepatitis and other skin, joint, and lung symptoms is usually rapid once the drug is stopped. Serious liver disease such as acute liver failure and chronic hepatitis with cirrhosis mostly occur in patients who continue the drug despite developing hepatitis.

so far bb does not exhibit any side effect from the once daily antibiotics. it is rather worrying with the long term side effect to the liver. But i guess doctor must have reason for the continuing oral antibioctics. she said to prevent UTI till she is 1 year old.

The alternative antibiotics that bb can take is cotrimoxazole ( trimethoprim + Sulhamethoxazole), this is also to treat UTI. it active against a broad spectrum of gram-negative and gram-positive bacteria. This combination is used to treat gram-negative UTI Side effect is skin rashes inclusing Stevens-Johnson Syndrome.

bb does not like the taste of Nitrofurantoin, but due to the stronger side effect from cotrimoxazole, i rather continue with nitrofurantoine than switching over to cotrix.

So, shall seek doc advise when see her again in July.

DMSA (Renal cortical scintigraphy)

Another medical term we need to familiarise with, this is the last scan we are doing to check the functions of the kidney and to detect if any scarring..

Gotten this from a website:

What is a DMSA scan?
A DMSA scan evaluates the size, shape and position of the kidneys. It is also used to detect any scarring in the kidneys caused by frequent infections.

This exam requires the use of a radiopharmaceutical through an IV catheter.


What should you do prior to the exam?

This test does not permit any movement. Your child will need to hold still for about an hour. You may want to practice with your child.

If your child requires sedation you will receive additional instructions to follow.

Dress your child comfortably, in clothes that are easily removed. Your child may be given a gown to change into for the procedure.

We have a large variety of video entertainment to choose from, however, your child can also bring along his/her favorite video or DVD to watch during the exam.

You may want to bring a snack or drink for your child to have after the exam.

Note: Parents will be allowed to accompany the child into the exam room. It may be helpful to make other arrangements for siblings.

What should you expect during the exam?

A technologist or nurse will place an IV in your child for the radiopharmaceutical (tracer) injection needed for this exam. This IV tube will be placed in the child’s arm, hand, or foot. Your child will only feel a little discomfort, like a mild pinch. Once the child has proper IV access, the procedure can begin.

The technologist will ask why the DMSA scan is being done, and explain the study to you and your child. The technologist will inject the tracer through the IV line.

Your child is then allowed to take a break. During the break, you and your child may leave the Nuclear Medicine department if you wish. The technologist will tell you what time you need to return to the department for the imaging portion of the test.

The set of delayed images will begin anywhere from 2 to 4 hours after the tracer is given. Upon return your child will be placed on the table on their stomach, with the camera above. Five pictures will be taken, lasting 10 minutes each. Your child must lie absolutely still or images may be unreadable. The nuclear medicine physician may then require additional imaging, after viewing the initial images.

Sedation is an option for the delayed imaging portion of the test for young patients and those unable to hold still.

MCU ( Micturating Cystourethrogram)

New term for me & LGG.. But we learnt as it is now part of the vocab to be familiarised for bb's condition..

Gotten this from a abstract from internet:

MCU is a pne of the most commonly performed fluoroscopic onvestigations in any pediatric radiology department. It is the essentila and a primary tool for diagnosis and evaluation of infants and young children with many genitourinary disorders.

The MCU demonstrates anatomy of both the bladder and urethra and the presence or absense of vesicouretral reflux (VUR). it also provides information about the fucntion and co-ordination of the bladder and urethral sphincter. The MCU is indicated in the investigation of patients with wide variety of clinical conditions including UTI

Method:
Prior to starting this procedure, it shoudl eb ensured that the child should has received the appropriate dose of antibiotic. The procedure should not be performed if the child has active UTI. The procedure should be performed under fluoroscopic guidance with the child awake. The nurse will lay the child on the fluoroscopic table and the parent is asked to stand at the top of the table and hold the child's hand. Urethral catheterization should be done on the table using strict aseptic technique, after proper cleaning if the interlabial area. the gel is applied to the tib of the catheter in all children .

the catheter is not advanced any further than 1-2cm, the nurse will fill the bladder with dye awhile the catheter is still in. VUR can be detected if any. detecting the grade of reflux is of vital importance to plan appropriate treatment. The fluoroscopy should be kept to minimum and low-dose technique whenever possible. The gonodal radiation dose received by children undergoing MCU can be as high as 309mRad in boys and 1,900mRad in girls. The risk of developing leukemia at this radiation does is calculated at 7-9 cases per 10 million children examined. With recent advances in fluroscopy, dose reduction can be easily achieved without any perceived loss of eiamge quality.


==============================================================

So the risk of doing MCU is there.. but like the doc said, MUST do means must do.. this is the only way to find out more about the severity of bb's condition for further treatment.

We did the MCU yesterday, she did not cry when the doctore inserted the catheter and fill her bladder with the dye. But she cried so hard when she was strapped down and turned about to get the right image .. anyway, the whole process takes around 30 minutes..

now, we shall wait for the report to be out in a week's time. Finger cross she will be fine or at least in a lower grade which is easier to be treated.

Duplex Kidney

From this episode, LGG & I serach quite a bit on website for information on this condition..

If a infant is diagnosed with UTI, usually they will suspect something is not right with the child's urinary tract, blockage and a condition called vesicoureteral reflux (VUR)

The test doctor usually will recommend include:
1. Ultrasound to show a picture of the kidneys & bladder

2. MCU or on web, usually they called this VCUG, which shows whether urine is backing up from your baby bladde's into her kidney. During VCUG, X-rays are taken before a catheter is inserted into the baleer through the urethra. A liquid dye is put into the bladder through the tubeand more x-ray are taken to watch the dye as the bladder fills and as your baby urinates. The porcess takes about 20 minutes <-- im not sure if this is exactly how MCU works for bb.. but should be something like this and im expecting lots of crying from her for sure.. she cried alot during the ultra sound and only kep quiet when i carry her..

aftre MCU , then only we can tell the severity of her condition and whether a surgery is needed.

Finger cross.. the waitings to the truth is very testing...