14. Nephrology Flashcards
1
Q
Name: Common Manifestations of Renal Disease in NEONATE (3)
A
- Flank Mass
- Hematuria
- Anuria/Oliguria
2
Q
Name: Common Manifestations of Renal Disease in CHILD and ADOLESCENT (8)
A
- Cola/Red-Coloured Urine
- Gross Hematuria
- Edema
- HTN
- Polyuria
- Proteinuria
- Oliguria
- Urgency
3
Q
Name common causes in neonates: Flank Mass (3)
A
- Hydronephrosis
- polycystic disease (autosomal dominant or recessive subtypes)
- tumour
4
Q
Name common causes in neonates: Hematuria (4)
A
- Renal vein thrombosis
- Asphyxia
- Malformation
- Trauma
5
Q
Name common causes in neonates: Anuria/Oliguria (3)
A
- Bilateral renal agenesis
- obstruction
- asphyxia
6
Q
Name common causes in child/adolescent: Cola/Red-Coloured Urine (3)
A
- Acute GN (post-streptococcal, HSP, IgA nephropathy, etc.)
- hemoglobinuria (hemolysis)
- myoglobinuria (rhabdomyolysis)
7
Q
Name common causes in child/adolescent: Gross Hematuria (3)
A
- Urologic disease (nephrolithiasis, trauma, etc.)
- UTI
- acute GN
8
Q
Name common causes in child/adolescent: Edema (5)
A
- Nephrotic syndrome
- nephritis
- acute/chronic renal failure
- consider cardiac
- liver disease
9
Q
Name common causes in child/adolescent: HTN (3)
A
- GN
- renal failure
- dysplasia (consider coarctation, drugs, endocrine causes)
10
Q
Name common causes in child/adolescent: Polyuria (5)
A
- DM
- central and nephrogenic DI
- renal Fanconi’s syndrome (genetic/metabolic/acquired causes)
- hypercalcemia
- polyuric renal failure (renal dysplasia)
11
Q
Name common causes in child/adolescent: Proteinuria (3)
A
- Orthostatic
- nephrotic syndrome (MCD, etc.)
- GN
12
Q
Name common causes in child/adolescent: Oliguria (4)
A
- Dehydration
- ATN
- interstitial nephritis
- acute or chronic kidney disease (i.e. renal failure)
13
Q
Name common causes in child/adolescent: Urgency (2)
A
- UTI
- vulvovaginitis
14
Q
Name triad of: Hemolytic Uremic Syndrome (3)
A
- non-immune microangiopathic hemolytic anemia
- thrombocytopenia
- acute renal injury
15
Q
Describe epidemiology: Hemolytic Uremic Syndrome (2)
A
- annual incidence of 1-2 per 100,000 in Canada
- most common cause of acute renal failure in children
16
Q
Describe etiology: Hemolytic Uremic Syndrome (2)
A
- diarrhea positive HUS: 90% of pediatric HUS from E.coli O157:H7, shiga toxin, or verotoxin
- diarrhea negative HUS: other bacteria, viruses, drugs, familial/genetic
17
Q
Describe pathophysiology: Hemolytic Uremic Syndrome (5)
A
- toxinbinds, invades, and destroys colonic epithelial cells, causing bloody diarrhea
- toxin enters the systemic circulation, attaches to, and injures endothelial cells (especially in kidney),
- causing a release of endothelial products (e.g. von Willebrand factor, platelet aggregating factor)
- platelet/fibrin thrombi form in multiple organ systems (e.g.kidney,pancreas,brain,etc.) resulting in thrombocytopenia
- RBCs are forced through occluded vessels, resulting in fragmented RBCs (schistocytes) that are removed by the reticuloendothelial system (hemolytic anemia)
18
Q
Describe clinical features: Hemolytic Uremic Syndrome (7)
A
- initial presentation of abdominal pain and diarrhea, followed by bloody diarrhea;
- within 5-7d begins to show signs of anemia, thrombocytopenia, and renal insufficiency
- pallor
- jaundice (hemolysis)
- edema
- petechiae
- HTN
19
Q
Describe investigations: Hemolytic Uremic Syndrome (7)
A
- CBC (anemia, thrombocytopenia)
- blood smear (schistocytes)
- electrolytes
- renal function
- urinalysis (microscopic hematuria)
- stool cultures
- and verotoxin/shigella toxin assay
20
Q
Describe management: Hemolytic Uremic Syndrome (4)
A
- mainly supportive: nutrition, hydration, ventilation (if necessary), blood transfusion for symptomatic anemia
- monitor electrolytes and renal function: dialysis if electrolyte abnormality (hyperkalemia) cannot be corrected, fluid overload, or uremia
- steroids are not helpful
- antibiotics are contraindicated as death of bacteria leads to increased toxin release and worse clinical course
21
Q
A
22
Q
Describe prognosis: Hemolytic Uremic Syndrome (2)
A
- death in <5% of cases,
- 5-25% long term renal damage (HTN, proteinuria, decreased renalfunction)
23
Q
Define: Nephritic Syndrome (3)
A
- acute or chronic syndrome affecting the kidney, characterized by glomerular injury and inflammation
- defined by hematuria (>5 RBCs per high-powered microscope field), presence of dysmorphic RBCs, and RBC casts on urinalysis
- often accompanied by at least one of proteinuria (<50mg/kg/d), edema, HTN, azotemia, and oliguria
24
Q
Describe presentation: Nephritic Syndrome (6)
A
PHAROH
- Proteinuria (<50 mg/kg/d)
- Hematuria
- Azotemia
- RBC casts
- Oliguria
- HTN
25
Describe epidemiology: Nephritic Syndrome (1)
highest incidence in children aged 5-15 yr old
26
Describe etiology: Nephritic Syndrome (2)
* humoral immune response to a variety of etiologic agents → immunoglobulin deposition → complement activation, leukocyte recruitment, release of growth factors/cytokines → glomerular inflammation and injury → porous podocytes → hematuria + RBC casts ± proteinuria
* HTN secondary to fluid retention and increased renin secretion by ischemic kidneys
27
Name: Major Causes of Nephritic Syndrome
28
Describe clinical features: Nephritic Syndrome (3)
* often asymptomatic; some overlap in clinical findings for nephritic and nephrotic syndrome
* gross hematuria, mild-moderate edema, oliguria, HTN
* signs and symptoms suggestive of underlying systemic causes (e.g.fever,arthralgias,rash,dyspnea, pulmonary hemorrhage)
29
Describe investigation: Nephritic Syndrome (3)
* urine
* dipstick (hematuria, 0 to 2+ proteinuria) and microscopy (\>5 RBCs per high-powered microscope field, acanthocytes, RBC casts)
* first morning urine protein/creatinine ratio (\<200 mg/mmol)
* blood word
* CBC, electrolytes, Cr, BUN, albumin
* impaired renal function (⬆️ Cr and BUN) resulting in ⬆️ pH and electrolyte abnormalities (hyperkalemia, hyperphosphatemia, hypocalcemia)
* mild anemia on CBC (secondary to hematuria)
* hypoalbuminemia (secondary to proteinuria)
* appropriate investigations to determine etiology: C3/C4 levels, serologic testing for recent streptococcal infection (ASOT, anti-hyaluronidase, anti-streptokinase, anti-NAD, anti-DNAse B), ANA, anti-DNA antibodies, ANCA, serum IgA levels, anti-GBM antibodies
* renal biopsy should be considered only in the presence of acute renal failure, no evidence of streptococcal infection, normal C3/C4
30
Describe management: Nephritic Syndrome (3)
* treat underlying cause
* symptomatic
* renal insufficiency: supportive (dialysis if necessary), proper hydration
* HTN: salt and fluid restriction (but not at expense of renal function), ACEI or ARBs for chronic persistent HTN (not acute cases because ACEI or ARBs may decrease GFR further)
* edema: salt and fluid restriction, possibly diuretics (avoid if significant intravascular depletion)
* corticosteroids if indicated: IgA nephropathy, lupus nephritis,etc.
31
Describe prognosis: Nephritic Syndrome (2)
* dependent on underlying etiology
* complications include HTN, heart failure, pulmonary edema, chronic kidney injury (requiring renal transplant)
32
Define: Nephrotic Syndrome (4)
clinical syndrome affecting the kidney, characterized by
* significant proteinuria
* peripheral edema
* hypoalbuminemia
* hyperlipidemia
33
Describe epidemiology: Nephrotic Syndrome (1)
highest incidence in children 2-6 yr old, M\>F
34
Name types of Nephrotic Syndrome (3)
* Primary (idopathic)
* Secondary
* Congenital: congenital nephropathy of the Finnish type, Denys-Drash syndrome,etc.
35
Describe etiology: Nephrotic Syndrome PRIMARY (2)
primary (idiopathic): nephrotic syndrome in the absence of systemic disease (most common cause in pediatrics)
* glomerular inflammation ABSENT on renal biopsy: MCD (85%), focal segmental glomerular sclerosis
* glomerular inflammation PRESENT on renal biopsy: membranoproliferative GN, IgA nephropathy
36
Describe secondary: Nephrotic Syndrome PRIMARY (6)
nephrotic syndrome associated with systemic disease or due to another process causing glomerular injury (\<10% in pediatrics)
* autoimmune: SLE, DM, rheumatoid arthritis
* genetic: sickle cell disease, Alport syndrome
* infections: hepatitis B/C, post-streptococcal, infective endocarditis, HUS, HIV
* malignancies: leukemia, lymphoma
* medications: captopril, penicillamine, NSAIDs, antiepileptics
* vasculitides: HSP, granulomatosis with polyangiitis
37
Describe clinical features: Nephrotic Syndrome (4)
* non-specific symptoms such as irritability, malaise, fatigue, anorexia, or diarrhea
* edema
* often first sign; detectable when fluid retention exceeds 3-5% of body weight
* starts periorbital and often pretibial → edematous areas are white, soft, and pitting
* gravity dependent: periorbital edema ⬇️ and pretibial edema ⬆️ over the day
* anasarca may develop (i.e. marked periorbital and peripheral edema, ascites, pleural effusions, scrotal/labial edema)
* decrease in effective circulating volume (e.g. tachycardia, HTN, oliguria,etc.)
* foamy urine is a possible sign of proteinuria
38
Describe investigation: Nephrotic Syndrome (3)
* urine
* urine dipstick (3 to 4+ proteinuria, microscopic hematuria) and microscopy (oval fat bodies,hyaline casts)
* first morning urine protein/creatinine ratio (\>200 mg/mmol)
* blood work
* diagnostic: hypoalbuminemia (\<25 g/L), hyperlipidemia/hypercholesterolemia (total cholesterol \>5
mmol/L)
* secondary: electrolytes (hypocalcemia, hyperkalemia, hyponatremia), renal function (⬆️BUN and Cr), coagulation profile (⬇️PTT)
* appropriate investigations to rule out secondary causes: CBC, blood smear, C3/C4, ANA, hepatitis B/C titres, ASOT, HIV serology, etc.
* consider renal biopsy if: HTN, gross hematuria, ⬇️renal function, low serum C3/C4, no response to steroids after 4 wk of therapy, frequent relapses (\>2 in 6 mo), presentation before first yr of life (high likelihood of congenital nephrotic syndrome), presentation ≥12 yr (rule out more serious renal pathology than MCD)
39
Describe management: Nephrotic Syndrome (7)
* MCD: oral prednisone 2 mg/kg/d (or equivalent) for up to 12 wk → varicella status should be known before starting
* consider cytotoxic agents, immunomodulators, or high-dose pulse corticosteroid if steroid resistant
* symptomatic
* edema: salt and fluid restriction, possibly diuretic (avoid if significant intravascular depletion); furosemide + albumin for anasarca
* hyperlipidemia: generally resolves with remission; limit dietary fat intake; consider statin therapy if persistently nephrotic
* hypoalbuminemia: IV albumin and furosemide not routinely given; consider if refractory edema
* abnormal BP: control BP; fluid resuscitation if severe intravascular depletion; ACEI or ARBs for persistent HTN
* diet: no added salt; monitor caloric intake and supplement with Ca2+ and Vit D if on corticosteroids
* daily weights and BP to assess therapeutic progress
* secondary infections: treat with appropriate antimicrobials; antibioticprophylaxis not recommended; pneumococcal vaccine at diagnosis and varicella vaccine after remission; varicella Ig + acyclovir if exposed while on corticosteroids
* secondary hypercoagulability: mobilize, avoid hemoconcentration due to hypovolemia, prompt sepsis occur
40
Name: Side Effects of Long-Term Steroid Use (10)
* Increasedappetite
* Weight gain
* Dorsal hump
* Impaired growth
* Behavioural changes
* Risk of infection
* Salt and water retention
* HTN
* Bone demineralization
* Skin striae
41
Describe prognosis: Nephrotic Syndrome (3)
* generally good: 80% of children responsive to corticosteroids
* up to 2/3 experience relapse, often multiple times; sustained remission with normal kidney function usually by adolescence
* complications: ⬆️ risk of infections (spontaneous peritonitis, cellulitis, sepsis); hypercoagulability due to decreased intravascular volume and antithrombin III depletion (PE, renal vein thrombosis); intravascular volume depletion, leading to hypotension, shock, renal failure; side effects of drugs
42
Define HTN (1)
sBP and/or dBP ≥95th percentile for sex, age, and height on ≥ 3occasions
43
Define pre-HTN (2)
* sBP and/or dBP ≥90th percentile but \<95th percentile
* or BP≥ 120/80 irrespective of age, gender, and height
44
Fill table
45
Describe epidemiology: Hypertension in Childhood (2)
* prevalence: 3-5% for HTN, 7-10% for pre-HTN; M\>F
* increasing prevalence of pre-HTN over the last 25 +yr
46
Describe etiology: Primary HTN (3)
* diagnosis of exclusion
* most common in older children (≥10 yr), especially if positive family history, overweight, and only mild HTN
* responsible for ~90% of cases of HTN in adolescents, rarely in young children
47
Describe etiology: Secondary HTN (2)
* identifiable cause of HTN (most likely etiology depends on age)
* responsible for majority of childhood HTN
48
Name: Etiology of Secondary HTN by Age Group
49
Name risk factors primary HTN (6)
* male gender
* positive family history
* obesity
* obstructive sleep apnea
* African American
* prematurity/LBW
50
Name risk factors secondary HTN (4)
* history of renal disease
* abdominal trauma
* family history of autoimmune diseases
* umbilical artery catheterization
51
Name: Signs of Secondary HTN (6)
* Edema (renal parenchymal disease)
* Abdominal or renal bruit (RAS)
* Differential 4 limb BP/diminished femoral pulses (coarctation)
* Abdominal mass (Wilms’, neuro blastoma)
* Goitre/skin changes (hyperthyroidism)
* Ambiguous genitalia (CAH)
52
Describe clinical features: Hypertension in childhood (3)
often asymptomatic, but can include
* FTT
* fatigue
* epistaxis
53
Name: symptoms of hypertensive emergency (6)
* neurologic:
* headache
* seizures
* focal complaints
* change in mental status
* visual disturbances
* cardiovascular:
* symptoms of MI or heart failure (chest pain, palpitations, cough, SOB)
54
Describe physical exam: Hypertension childhood (7)
* measure BP with correct cuff size
* BMI
* full neurologic exam
* ophthalmoscopy,
* precordial exam
* peripheral pulses
* perfusion status
55
Describe Investigations: Hypertension childhood (6)
* laboratory
* urine dipstick for hematuria and/or proteinuria (renal disease), urine catecholamines (pheochromocytoma, neuroblastoma)
* blood work: renal function tests (electrolytes, Cr, BUN), consider renin and aldosterone levels (RAS, Conn’s syndrome, Wilms’ tumour)
* other specific hormones if indicated on history and physical
* imaging:
* Echo (coarctation, heart function)
* abdomina lU/S (RAS, abdominal mass)
* renal radionucleide imaging (renal scarring)
56
Describe management: Hypertension childhood (5)
* treat underlying cause
* non-pharmacologic: modify concurrent cardiovascular risk factors (weight reduction,exercise,salt restriction, smoking cessation)
* pharmacologic: gradual lowering of BP using thiazide diuretics; no antihypertensives havebeen formally studied in children; if hypertensive emergencies use hydralazine, labetalol, sodium nitroprusside
* management of end-organ damage (e.g.retinopathy,LVH)
* consider referral to specialist
57
Describe prognosis: Hypertension childhood (5)
end-organ damage (similar to adults) including
* LVH
* CHF
* cerebrovascular insults
* renal disease
* retinopathy
