Early identification of intrinsic renal disease

Intrinsic renal disease in may cause AKI in children, and early detection will aid specific management and may help reduce the risk of progression to chronic kidney disease. Look out for

• Haematuria/proteinuria: May indicate nephritic, nephrotic or haemolytic uraemic syndrome (HUS)
• Rash: Palpable purpura are present in Henoch Schonlein Purpura (HSP); all children should have a urine dip performed to look for renal involvement
• Bloody Diarrhoea: May indicate Haemolytic Uraemic Syndrome (HUS)

Haemolytic Uraemic Syndrome (HUS) is a triad of:

• microangiopathic haemolytic anaemia,
• thrombocytopaenia
• acute renal failure

It is a common cause of acute kidney injury in children and is typically infection-induced, most commonly by vero cytotoxin-producing Escherichia coli (VTEC).

Clinicians must be alert to bloody diarrhoea which may be present in up to 90% of VTEC cases. Up to 10% of cases of VTEC infection will develop Haemolytic Uraemic Syndrome (HUS)

Clinicians should have a high index of suspicion of VTEC where the patient has been in recent close contact with:

•            ruminant animals (principally cattle, goats, sheep), their faeces, and faecally contaminated environments (such as at open farm visits)
•            contact with another known or suspected case of VTEC
•            where an outbreak of VTEC infection is known, or suspected to be present locally

Public Health England guidance advises all children with bloody diarrhoea should have investigations for HUS including a full blood count and blood film. [10,11]

Henoch Schonlein Purpura (HSP) is a childhood vasculitis which is characterised by palpable purpura in the presence of at least one of the following:

• Diffuse abdominal pain
• Acute arthritis or arthralgia
• Renal involvement (haematuria and/or proteinuria)
• Biopsy showing predominant IgA deposition

Renal involvement in HSP can come weeks to months after the onset of rash, and may involve haematuria, proteinuria, nephritic or nephrotic syndrome, renal impairment or hypertension.

Children with HSP should have at a blood pressure and urine dip performed, and enquire whether follow up has been arranged.