A child with a urinary tract infection Flashcards
Characteristics of nephrotic syndrome
Greater than 2g/m2/hr protein in urine, Hypoproteinemia , Oedema, Hypercholesterolaemia
Clinical presentation: Pitting oedema, ascites, abdominal pain
Nephrotic syndrome triad
Oedema
Decreased Albumin
Protein
Why do you get hypercholesterolaemia in nephrotic syndrome?
Liver works overtime to produce more proteins to compensate for lost albumin
Diagnostic studies for nephrotic syndrome?
- 3+proteinuria x 3 consecutive days in first morning urine
- Urine protein:creatinine ratio >2
- Urea, electrolytes, creatinine, complements
Treatment for nephrotic syndrome?
- Steroid therapy for 12 weeks
- Steroid dependant/resistant may need additional immunosuppressive therapy.
- Cautious use of 20%albumin infusion
Complications of nephrotic syndrome
- Infections
- Spontaneous bacterial peritonitis – Strep pneumoniae, E. Coli, Klebsiella
- Hypovolaemia
- Hypercoagulable state due to loss of coagulation factors
- Hyperlipidemia
Prognosis for nephrotic syndrome
- 80% relapse
* May progress to end stage renal disease
Causes of red urine with and without blood on dipstick
- Red urine – dipstick – no blood – food, meds, free haemoglobin, myoglobin
- Red urine – dipstick – blood – RBC but no RBC casts – bleeding below renal tubules
- Red urine – dipstick – blood – RBC casts – glomerular disease
How does Glomerulonephritis present?
History: Recent streptococcal infection
Clinical features: Proteinuria, hypertension, oliguria, renal insufficiency, mild edema
Lab features: Organism culture, ASO titre, anti-DNAse B, low C3 (may return to normal in 3-4 weeks)
Complications of Glomerulonephritis
- Reduced GFR – increased sodium reabsorption – elevating plasma volume and suppressing plasma renin
- Heart failure
- Seizures
- Encephalopathy
What is Henoch-Schonlein Purpura?
- Inflammatory response with vasculitis, unclear cause
- Characteristic purpuric skin rash on extensors & buttocks, arthralgia, abdominal pain, glomerulonephritis
- 3-10years, h/o URTI
- Microscopic or macroscopic haematuria, mild proteinuria, may progress to renal failure
- Initially symptomatic treatment
- Need follow-up for atleast one year
Options for imaging of the urinary tract
- Ultrasound – anatomical assessment
- DMSA scan – functional defects e.g. scarring
- MCUG: Contrast study, Bladder & urethral anatomy e.g. VUR, Usually difficult to perform beyond 6 months
- MAG3 renogram: Dynamic study, Measures drainage, Older child
UTI – Signs & symptoms in child less than 3 months of age
fever, irritability, vomiting, faltering growth, jaundice, poor feeding
UTI – Signs & symptoms in pre verbal child
fever, lethargy, vomiting, poor feeding, abdominal pain, offensive urine
UTI - how to get clean catch urine in child
- Urine collecting pads
- Suprapubic aspirate
- Catheter
UTI Interpretation of Dipsticks - what three result combinations are definitive for UTI?
Positive leucocytes and nitrites
Positive bacteriuria without pyuria
Positive bacteriuria with pyuria
UTI Interpretation of Dipsticks - what result combination indicates a possible UTI?
Negative leucocytes with positive nitrites - possible UTI
Positive leucocytes with negative nitrites - wait for C/S
Risk factors for UTI in children
- Poor urine flow
- Family h/o vesico-ureteric reflux
- Previous confirmed UTI
- Recurrent fever of unknown origin
- Antenatal diagnosis of urogenital abnormality
- Dysfunctional voiding
- Constipation
- Spinal lesions
True or false? CRP should be used as a marker for differentiating between upper and lower UTI
FALSE
CRP should NOT be used as a marker for differentiating between upper and lower UTI
When are scans indicated in UTI in children?
If responding well to antibiotics, no imaging required at any age
Atypical UTI (Non-E.Coli):
- Less than 6 months: Urgent USS, MCUG, DMSA
- 6 months - 3 years: Urgent USS, DMSA
- Older than 3: Urgent USS
Recurrent UTI
- Less than 6 months: Urgent USS, MCUG, DMSA
- 6 months - 3 years: USS within 6 weeks, DMSA
- Older than 3 years: USS within 6 weeks, DMSA
Definition off recurrent UTI in children
2 upper UTI’s or 3 lower UTI’s or 1 upper and 1 lower
UTI imaging: What is a MCUG?
Micturating Cysto Urethro Gram (MCUG)
UTI imaging: What is a DMSA?
Di Mercapto Succinic Acid scan (DMSA) •Radionuclide study •Assesses renal morphology (scars), structure and function •Static assessment
What is Haemolytic Uraemic Syndrome?
- Microangiopathic haemolytic anaemia, thrombocytopenia & renal injury
- 6 months – 4 years
- Shiga – like toxins E.coli 0157:H7
- Pathophysiology – endothelial cell injury, microvascular thrombosis
Clinical features
•Bloody diarrhoea, lethargy, irritability, petechiae, dehydration, renal insufficiency
Lab findings
•Low platelets, blood film – schistocytes, fragmented erythrocytes, DIC, reticulocytosis, low Hb
Treatment for Haemolytic Uraemic Syndrome?
Supportive
What is Vesicoureteric reflux?
- Retrograde flow of urine
- Incompetence of ureterovesical junction
- Familial, bladder obstruction (posterior urethral valves)
Complications of Vesicoureteric reflux?
- Renal infection
- Reflux nephropathy
- Renal scarring
Treatment of Vesicoureteric reflux?
Treat the pathology (e.g. Incompetence of ureterovesical junction, bladder obstruction)
+/- prophylactic antibiotics
Congenital anomalies of urinary tract
- Renal agenesis - May be related to lung hypoplasia (Potter’s syndrome)
- Renal dysplasia
- Polycystic kidney diseases
- Posterior urethral valves (poor stream)
What is Fanconi syndrome?
- Loss of amino acids, glucose, phosphate, bicarbonate, sodium, calcium, potassium & magnesium
- Polydipsia, polyuria, salt depletion, dehydration, hyperchloraemic metabolic acidosis, poor growth
Treatment options for nocturnal enuresis
- Bladder training
- Double voiding
- Anticholinergics e.g. Oxybutynin
- Desmopressin
- Treat the pathology
