Key Topics in Pediatric Nephrology for INI-SS in India
The most important topics for the Indian National Internship (INI)-Student Seminar in pediatric nephrology should focus on congenital nephrotic syndrome, idiopathic nephrotic syndrome, and urinary tract infections, as these represent significant causes of morbidity and mortality in children. 1
Congenital Nephrotic Syndrome (CNS)
Comprehensive history taking should include family history of consanguinity, ethnicity, history of CNS, early infantile deaths, and prenatal findings such as increased amniotic fluid alpha-fetoprotein and fetal edema 1
First-line evaluation must include growth parameters, blood pressure, physical examination for edema, blood biochemistry (sodium, albumin, creatinine, cholesterol), thyroid function tests, and ultrasound of abdomen 1
Extended evaluation should cover dysmorphic features, neurological examination, serological testing for infections, and genetic testing 1
Management approach should be individualized based on clinical severity, with rapid referral to specialized pediatric nephrology units 1
Idiopathic Nephrotic Syndrome
Treatment algorithm for new-onset nephrotic syndrome should distinguish between children <12 years without syndromic features (treated with glucocorticoids) and those >12 years or with syndromic features (requiring biopsy and genetic testing) 1
Definitions of relapse, complete remission, partial remission, steroid-resistance, and steroid-dependence are critical for proper management 1
For steroid-resistant nephrotic syndrome, understanding the role of genetic testing is essential as mutations in podocyte-associated genes can be detected in 10-30% of cases 2
Management of frequent relapses may include calcineurin inhibitors, cyclophosphamide, levamisole, mycophenolate mofetil, or rituximab 1
Urinary Tract Infections and Vesicoureteric Reflux
Diagnostic criteria include urine culture with >10^4 colony forming units/mL when clinical suspicion is strong 3
Evaluation should include understanding when to order imaging studies like VCUG and renal functional imaging 4, 3
Management of severe renal pelvis dilatation requires immediate specialist consultation and antibiotic prophylaxis if ureteral dilation ≥7mm is present 4
Surgical intervention for high-grade vesicoureteric reflux should be considered for recurrent breakthrough febrile UTIs despite antibiotic prophylaxis 3
Fluid and Electrolyte Management
Approach to edema management should include assessment of volume status, salt restriction, and judicious use of diuretics 1
Loop diuretics should be used as first-line therapy, with twice daily dosing preferred over once daily dosing 1
Combination therapy with different classes of diuretics may be necessary for resistant edema 1
Monitoring for adverse effects of diuretics, including hypokalemia, hyponatremia, and metabolic alkalosis is essential 1
Transition from Pediatric to Adult Nephrology Care
Transition process should begin in early adolescence (12-14 years) and be individualized for each patient 1
Transfer should occur only after the adolescent/young adult has completed a transition plan and necessary patient-care information has been delivered to the adult service 1
Transition champions in both pediatric and adult units should be identified to coordinate and educate on transition issues 1
Peer support through group sessions with other young people transitioning can be valuable 1
Assessment of Kidney Function in Glomerular Disease
Understanding the appropriate use of estimated GFR formulas in children, including the Schwartz equation and Full Age Spectrum formula 1
Recognition of confounding factors in GFR estimation, such as hypoalbuminemia leading to overestimation of true GFR 1
Quantification of proteinuria is essential, with treatment goals aiming for PCR <200 mg/g or <8 mg/m²/hour in a 24-hour urine 1
Evaluation of hematuria should include assessment of erythrocyte morphology and presence of red cell casts 1