PC1200: Why Hasn’t He Grown Much? Growth Failure in an 8 Year Old Boy with Urinary Incontinence

Introduction: Growth is a common concern for parents at pediatric well child visits. Specifically, short stature can be due to familial short stature and constitutional delay of growth. However, growth failure can be due to underlying chronic illness. As such, presentation should be distinguished from non-pathological causes in the primary care setting with appropriate workup and referral as needed.

Case Description: An eight-year-old boy presented with no growth for two years. He was found to be on the 3rd percentile in stature with no acute concerns. His mother reported a history of urinary incontinence, nocturnal enuresis, and occasional fecal incontinence. During his evaluation for short stature, laboratory work was significant for abnormal renal function which prompted a referral to our institution.

On presentation, there was generalized pallor but otherwise no signs of edema or weakness. Diagnostic testing was significant for a BUN of 91 mg/dL and Creatinine of 5.36 mg/dL. His WBC was 10.4 k/mm3, Hemoglobin was 8.8 g/dL, and Platelet of 220 k/mm3. His electrolytes were within normal limits with the exception of hypocalcemia (Calcium 8.0 mg/dL). PTH was elevated at 773.3 pg/mL. 25 Hydroxy Vitamin D low at 15.2 ng/mL His urinalysis showed 24 red blood cells and 840 white blood cells.

Renal ultrasound showed massive bilateral hydronephrosis and tortuous ureters with significant post-void residual. Voiding cystourethrogram (VCUG) showed severe bilateral Grade 5 vesicoureteral reflux (VUR), large tortuous dilated ureters bilaterally with normal-appearing urethra (Figure 1). A urinary catheter was placed followed by bilateral nephrostomy tubes. Given his incontinence and absence of structural obstruction of the urinary tract, an MRI of the lumbar spine was performed which demonstrated a thin intraspinal fibrolipoma suggesting a tethered cord. His abnormal electrolytes were medically managed and he did not meet the criteria for emergent renal replacement.

His clinical picture was consistent with Congenital Anomalies of the Kidney and Urinary Tract (CAKUT) secondary to vesicoureteral reflux leading to Stage 5 chronic kidney disease (CKD) with associated metabolic acidosis, anemia of CKD, and hypocalcemia with secondary hyperparathyroidism.

Discussion: The patient presented due to failure to meet growth parameters and was found to have CKD stage 5 secondary to his reflux nephropathy, resulting in the need for renal transplant. CAKUT is often detected in prenatal ultrasound depending on the etiology with hydronephrosis as the most common underlying etiology and abdominal mass in newborns. However, as demonstrated by this case it can be discovered with routine pediatric care.

Conclusion: This case highlights the importance of monitoring growth curves in children as it may lead to the discovery of underlying pathology. Prompt recognition of deviations from expected growth may lead to the early detection and treatment of chronic illness and its many sequelae.