6n. T renal paeds Flashcards
Who needs an USS UTI?
In 6 weeks if:
- < 6 months 1st UTI
- recurrent UTIs
During illness if:
- <6 months recurrent or atypical
- atypical
What is a DMSA? when is it done?
Assesses damage to kidneys following illness
Do 4-6 months after illness
When is an MCUG performed?
If < 6 months with atypical or recurrent
If there is a family history of VUR
Management lower UTI in children
If < 3 months:
- IV cefuroxime full septic screen
If > 3 months:
- Abx for 3 days:
- Trimethoprim
- Nitrofurantoin
- Cefalexin
- Amoxicillin
safety net: bring back in 24-48 hours if still unwell
Management of upper UTI in children
If < 3 months:
- IV cefuroxime full septic screen
If > 3 months consider admission for IV cefuroxime
If not admitting use oral:
oral cefalexin or co-amoxiclav for 7-10 days
Define atypical UTI in children
- seriously unwell
- sepsis
- non-e.coli
- abdominal mass
- poor urine flow
- raised creatinine
- failure to respond to treatment within 48 hours
What is hypospadias?
urethral opening on ventral surface
a hooded prepuce
chordee (ventral curvature of the penis) in more severe forms
Management hypospadias?
Corrective surgery at 12 months
Do NOT circumsise as this tissue is needed for correction
Define acute pyleonephritis
UTI plus either of:
- temp > 38
- tenderness
Define enuresis in the context of nocturnal enuresis
Enuresis may be defined as the ‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’
Management of nocturnal enuresis
- look for underlying triggers
- advice
- star charts
- enuresis alarm (1st line)
- desmopressin (for sleepovers)
Management of undescended testes?
Unilateral:
- refer at 3 months of age
- surgery performed at ~12 months
Bilateral:
- review by senior paeds within 24 hours
Define nephrotic syndrome
Nephrotic syndrome is defined as the presence of proteinuria (>3.5 g/24 hours), hypoalbuminaemia (<30 g/L), and peripheral oedema.
What will urinalysis show minimal change disease
Urinalysis (analysis of the urine) will show small molecular weight proteins and hyaline casts.
3 year old frothy urine, generalised oedema and pallor
minimal change disease
management minimal change disease
High dose steroids (i.e. prednisolone) for 4 weeks
Low salt diet
Diuretics may be used to treat oedema
Albumin infusions may be required in severe hypoalbuminaemia
Antibiotic prophylaxis may be given in severe cases
complications minimal change disease
hypovolemia
thrombosis
infection
high lipids
high or low blood pressure
what is nephritis
Nephritis refers to inflammation within the nephrons of the kidneys. It causes:
Reduction in kidney function
Haematuria: invisible or visible amounts of blood in the urine
Proteinuria: although less than in nephrotic syndrome
nephritis developing 1-3 weeks after URTI/tonsilitis
Post-streptococcal glomerulonephritis
management of post strep glomerulonephritis
Management is supportive and around 80% of patients will make a full recovery. In some cases patients can develop a progressive worsening of their renal function. They may need treatment with antihypertensive medications and diuretics if they develop complications such as hypertension and oedema.
Pathophysiology post strep glomerulonephritis
Immune complexes made up of streptococcal antigens, antibodies and complement proteins get stuck in the glomeruli of the kidney and cause inflammation.
IgG
IgM
C3
depostion
what would bloods show strep glomerulonephritis
low C3 (as it has been deposited)
ASO titre rasied (recent strep infection)
Renal biopsy features of strep glomerulonephritis
diffuse proliferative glomerulonephritis
endothelial proliferation with neutrophils
subepithelial ‘humps’ caused by lumpy immune complex deposits
immunofluorescence: granular or ‘starry sky’ appearance
young male, recurrent episodes of macroscopic haematuria
typically associated with a very recent respiratory tract infection
IgA nephritis (bergers disease)
Management IgA nephroathy/bergers disease
isolated hematuria, no or minimal proteinuria (less than 500 to 1000 mg/day), and a normal glomerular filtration rate (GFR)
no treatment needed, other than follow-up to check renal function
persistent proteinuria (above 500 to 1000 mg/day), a normal or only slightly reduced GFR
initial treatment is with ACE inhibitors
if there is active disease (e.g. falling GFR) or failure to respond to ACE inhibitors
immunosuppression with corticosteroids
how to differentiate strep glomer from IgA neph
Age: SG young, IgA teenage
Timing of URTI: SG 1-3 weeks ago, IgA days ago
Complement levels: SG low
Proteinuria: SG has worse
Haematuria: IgA has worse
Histology IgA nephropathy
mesangial hypercellularity, positive immunofluorescence for IgA & C3
a child under the age of 5 years presenting with a mass in the abdomen
consider wilm’s
what is wilms tumour
tumour affecting the kidney in children, typically under the age of 5 years.
management of wilms tumour
Treatment involves surgical excision of the tumour along with the affected kidney (nephrectomy).
Adjuvant treatment refers to treatment that is given after the initial management with surgery. This depends on the stage of the disease, the histology and whether it has spread. The main options are:
Adjuvant chemotherapy
Adjuvant radiotherapy
invetsigations for wilms tumour: intial, staging, definitive
The initial investigation is an ultrasound of the abdomen to visualise the kidneys.
A CT or MRI scan can be used to stage the tumour.
Biopsy to identify the histology is required to make a definitive diagnosis.
Presenting feature HSP
Purpuric rash affecting the lower limbs and buttocks in children
4 classic features of HSP
Purpura (100%),
Joint pain (75%),
Abdominal pain (50%)
Renal involvement (50%)
Investigations for ?HSP
Full blood count and blood film for thrombocytopenia, sepsis and leukaemia
Renal profile for kidney involvement
Serum albumin for nephrotic syndrome
CRP for sepsis
Blood cultures for sepsis
Urine dipstick for proteinuria
Urine protein:creatinine ratio to quantify the proteinuria
Blood pressure for hypertension
Management HSP
supportive, with simple analgesia, rest and proper hydration.
monitoring:
Urine dipstick monitoring for renal involvement
Blood pressure monitoring for hypertension
Define hydrocele
collection of fluid within the tunica vaginalis that surrounds the testes
types of hydrocele
simple- fluid trapped and will be resorbed by age 2
communicating- connected via procesus vaginalis to peritoneal cavity, will fluctuate in size - needs surgical treatment
investigations hydrocele
transillumination positive
USS is diagnostic
management communicating hydrocele
surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis)
management vulvovaginitis
Avoid washing with soap and chemicals
Avoid perfumed or antiseptic products
Good toilet hygiene, wipe from front to back
Keeping the area dry
Emollients, such as sudacrem can sooth the area
Loose cotton clothing
Treating constipation and worms where applicable
Avoiding activities that exacerbate the problem
In severe cases an experienced paediatrician may recommend oestrogen cream to improve symptoms.
PResentaiton of haemolytic uraemic syndrome
E. coli 0157 causes a brief gastroenteritis, often with bloody diarrhoea. The symptoms of haemolytic uraemic syndrome typically start around 5 days after the onset of the diarrhoea.
Signs and symptoms of HUS may include:
Reduced urine output
Haematuria or dark brown urine
Abdominal pain
Lethargy and irritability
Confusion
Oedema
Hypertension
Bruising
triad of HUS
Haemolytic anaemia: anaemia caused by red blood cells being destroyed
Acute kidney injury: failure of the kidneys to excrete waste products such as urea
Thrombocytopenia: low platelet count
Management of HUS
HUS is a medical emergency and has a 10% mortality. It needs to be managed by experienced paediatricians under the guidance of a renal specialist. The condition is self limiting and supportive management is the mainstay of treatment:
Urgent referral to the paediatric renal unit for renal dialysis if required
Antihypertensives if required
Careful maintenance of fluid balance
Blood transfusions if required
70 to 80% of patients make a full recovery.
Pathophysiology HUS
Occurs when there is thrombosis within small blood vessels throughout the body.
This is usually triggered by a bacterial toxin called shiga toxin.
Most common cause HUS
e. coli 0157 –> shiga toxin
What is Alport’s syndrome
Alport’s syndrome is usually inherited in an X-linked dominant pattern*. It is due to a defect in the gene which codes for type IV collagen resulting in an abnormal glomerular-basement membrane (GBM). The disease is more severe in males with females rarely developing renal failure.
Inheritance of alport’s syndrome
X linked dominant
why may an alport’s patient’s kideny transplant fail
This may be caused by the presence of anti-GBM antibodies leading to a Goodpasture’s syndrome like picture.
What does renal biposy show Alport’s syndrome
splitting of the lamina densa of the glomerular basement membrane, resulting in a ‘basket-weave’ appearance
Define phismosis
the inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis.
Management of phismosis
Physiological phimosis -
since the foreskin becomes retractable with time these patients can be managed conservatively
topical steroids can be applied to the preputial ring may be useful (2)
Pathological phimosis -
circumcision
a short course of topical corticosteroids may be beneficial in mild scarring (2)
Reference:
Antibodies SLE
antinuclear (ANA) (this high sensitivity makes it a useful rule out test, but it has low specificity)
anti-dsDNA: highly specific (> 99%), but less sensitive (70%)
anti-Smith: highly specific (> 99%), sensitivity (30%)
also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)
Malar rash
think SLE
renal complications SLE
proteinuria
glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)
cardio complications SLE
pericarditis: the most common cardiac manifestation
myocarditis
CRP and ESR SLE
Normally in SLE, a patient’s ESR will be raised but CRP will be normal
A raised CRP in a patient with known SLE may indicate an underlying infection
specific test for SLE
Anti-dsDNA
sensitive test for SLE
ANA
first line SLE
NSAIDs
Steroids (prednisolone)
Hydroxychloroquine (first line for mild SLE)
What anaemia can you get with SLE
normocytic anaemia of chronic disease
criteria HSP
There are many different sets of criteria for diagnosing HSP, the most recent being the EULAR/PRINTO/PRES criteria from 2010. This requires the patient to have palpable purpura (not petichiae) + at least one of:
Diffuse abdominal pain
Arthritis or arthralgia
IgA deposits on histology (biopsy)
Proteinuria or haematuria
triggers HSP
upper airway infection or gastroenteritis
can ITP cause a rash
yes - petichiae
Abdominal HSP
Abdominal pain is indicative of gastrointestinal involvement. This affects around 50% of patients with HSP. In severe cases, it can lead to gastrointestinal haemorrhage, intussusception and bowel infarction.
What is prehn’s sign
Prehn’s sign is an evaluation used to determine the cause of testicular pain. It is performed by lifting the scrotum and assessing the consequent changes in pain. A positive Prehn’s sign indicates relief of pain upon elevation of the scrotum and is associated with epididymitis.
examination findings testicular torison
- loss of cremaster reflex
- negative phren’s sign
Presentation neuroblastoma
Neuroblastoma typically crosses the midline presents with symptoms of fever, fatigue, weight loss, diarrhoea and vomiting
investigation neuroblastoma tumour
raised urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels
calcification may be seen on abdominal x-ray
biopsy
what is neuroblastoma
The tumour arises from neural crest tissue of the adrenal medulla (the most common site) and sympathetic nervous system.
Management renal involvement HSP
corticosteroids
