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TN Pédiatrie > 14. Nephrology > Flashcards

14. Nephrology Flashcards

1
Q

Name: Common Manifestations of Renal Disease in NEONATE (3)

A
  • Flank Mass
  • Hematuria
  • Anuria/Oliguria
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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
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3
Q

Name common causes in neonates: Flank Mass (3)

A
  • Hydronephrosis
  • polycystic disease (autosomal dominant or recessive subtypes)
  • tumour
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4
Q

Name common causes in neonates: Hematuria (4)

A
  • Renal vein thrombosis
  • Asphyxia
  • Malformation
  • Trauma
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5
Q

Name common causes in neonates: Anuria/Oliguria (3)

A
  • Bilateral renal agenesis
  • obstruction
  • asphyxia
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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)
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7
Q

Name common causes in child/adolescent: Gross Hematuria (3)

A
  • Urologic disease (nephrolithiasis, trauma, etc.)
  • UTI
  • acute GN
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8
Q

Name common causes in child/adolescent: Edema (5)

A
  • Nephrotic syndrome
  • nephritis
  • acute/chronic renal failure
  • consider cardiac
  • liver disease
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9
Q

Name common causes in child/adolescent: HTN (3)

A
  • GN
  • renal failure
  • dysplasia (consider coarctation, drugs, endocrine causes)
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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)
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11
Q

Name common causes in child/adolescent: Proteinuria (3)

A
  • Orthostatic
  • nephrotic syndrome (MCD, etc.)
  • GN
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12
Q

Name common causes in child/adolescent: Oliguria (4)

A
  • Dehydration
  • ATN
  • interstitial nephritis
  • acute or chronic kidney disease (i.e. renal failure)
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13
Q

Name common causes in child/adolescent: Urgency (2)

A
  • UTI
  • vulvovaginitis
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14
Q

Name triad of: Hemolytic Uremic Syndrome (3)

A
  • non-immune microangiopathic hemolytic anemia
  • thrombocytopenia
  • acute renal injury
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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
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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
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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)
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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
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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
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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
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21
Q
A
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22
Q

Describe prognosis: Hemolytic Uremic Syndrome (2)

A
  • death in <5% of cases,
  • 5-25% long term renal damage (HTN, proteinuria, decreased renalfunction)
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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
Q

Describe epidemiology: Nephritic Syndrome (1)

A

highest incidence in children aged 5-15 yr old

26
Q

Describe etiology: Nephritic Syndrome (2)

A
  • 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
Q

Name: Major Causes of Nephritic Syndrome

A
28
Q

Describe clinical features: Nephritic Syndrome (3)

A
  • 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
Q

Describe investigation: Nephritic Syndrome (3)

A
  • 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
Q

Describe management: Nephritic Syndrome (3)

A
  • 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
Q

Describe prognosis: Nephritic Syndrome (2)

A
  • dependent on underlying etiology
  • complications include HTN, heart failure, pulmonary edema, chronic kidney injury (requiring renal transplant)
32
Q

Define: Nephrotic Syndrome (4)

A

clinical syndrome affecting the kidney, characterized by

  • significant proteinuria
  • peripheral edema
  • hypoalbuminemia
  • hyperlipidemia
33
Q

Describe epidemiology: Nephrotic Syndrome (1)

A

highest incidence in children 2-6 yr old, M>F

34
Q

Name types of Nephrotic Syndrome (3)

A
  • Primary (idopathic)
  • Secondary
  • Congenital: congenital nephropathy of the Finnish type, Denys-Drash syndrome,etc.
35
Q

Describe etiology: Nephrotic Syndrome PRIMARY (2)

A

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
Q

Describe secondary: Nephrotic Syndrome PRIMARY (6)

A

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
Q

Describe clinical features: Nephrotic Syndrome (4)

A
  • 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
Q

Describe investigation: Nephrotic Syndrome (3)

A
  • 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
Q

Describe management: Nephrotic Syndrome (7)

A
  • 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
Q

Name: Side Effects of Long-Term Steroid Use (10)

A
  • Increasedappetite
  • Weight gain
  • Dorsal hump
  • Impaired growth
  • Behavioural changes
  • Risk of infection
  • Salt and water retention
  • HTN
  • Bone demineralization
  • Skin striae
41
Q

Describe prognosis: Nephrotic Syndrome (3)

A
  • 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
Q

Define HTN (1)

A

sBP and/or dBP ≥95th percentile for sex, age, and height on ≥ 3occasions

43
Q

Define pre-HTN (2)

A
  • sBP and/or dBP ≥90th percentile but <95th percentile
  • or BP≥ 120/80 irrespective of age, gender, and height
44
Q

Fill table

A
45
Q

Describe epidemiology: Hypertension in Childhood (2)

A
  • prevalence: 3-5% for HTN, 7-10% for pre-HTN; M>F
  • increasing prevalence of pre-HTN over the last 25 +yr
46
Q

Describe etiology: Primary HTN (3)

A
  • 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
Q

Describe etiology: Secondary HTN (2)

A
  • identifiable cause of HTN (most likely etiology depends on age)
  • responsible for majority of childhood HTN
48
Q

Name: Etiology of Secondary HTN by Age Group

A
49
Q

Name risk factors primary HTN (6)

A
  • male gender
  • positive family history
  • obesity
  • obstructive sleep apnea
  • African American
  • prematurity/LBW
50
Q

Name risk factors secondary HTN (4)

A
  • history of renal disease
  • abdominal trauma
  • family history of autoimmune diseases
  • umbilical artery catheterization
51
Q

Name: Signs of Secondary HTN (6)

A
  • 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
Q

Describe clinical features: Hypertension in childhood (3)

A

often asymptomatic, but can include

  • FTT
  • fatigue
  • epistaxis
53
Q

Name: symptoms of hypertensive emergency (6)

A
  • neurologic:
    • headache
    • seizures
    • focal complaints
    • change in mental status
    • visual disturbances
  • cardiovascular:
    • symptoms of MI or heart failure (chest pain, palpitations, cough, SOB)
54
Q

Describe physical exam: Hypertension childhood (7)

A
  • measure BP with correct cuff size
  • BMI
  • full neurologic exam
  • ophthalmoscopy,
  • precordial exam
  • peripheral pulses
  • perfusion status
55
Q

Describe Investigations: Hypertension childhood (6)

A
  • 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
Q

Describe management: Hypertension childhood (5)

A
  • 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
Q

Describe prognosis: Hypertension childhood (5)

A

end-organ damage (similar to adults) including

  • LVH
  • CHF
  • cerebrovascular insults
  • renal disease
  • retinopathy

TN Pédiatrie (14 decks)

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