CLMD - Renal Topics in Pediatrics Flashcards
Definition of normal BP for children aged 1-13 years old (in terms of percentile)
Normal BP: < 90th percentile
Trained healthcare professionals in the office setting should make a dx of HTN if a child or adolescent has auscultatory confirmed BP readings >95th percentile at ____ different visits
3
What clinical intervention is indicated for children with elevated BP regardless of its severity whether it was initial or subsequent measurement?
Lifestyle counseling (weight and nutrition)
When should a pediatric HTN pt be referred for emergency care?
If pt is symptomatic or BP is >30 mm Hg above the 95th percentile
T/F: primary HTN is the predominant cause of HTN in US children
True
The severity of BP elevation is similar between primary and secondary, however, diastolic HTN is predictive of ____ cause
Secondary
[systolic HTN is predictive of primary HTN]
What are some secondary causes for pediatric HTN?
Renal parenchymal disease or renal structural abnormalities
Renovascular disease
Aortic coarctation (occurs with various syndromes including neurofibromatosis, williams, alagille, takayasu arteritis, etc.)
Various drugs (decongestants, caffiene, NSAIDs, stimulants, contraception, steroids, TCAs, cocaine)
What is the difference between white-coat HTN and masked HTN?
What is the recommendation in either case?
White-coat HTN: pt with BP levels >95th percentile in clinic, but normotensive outside clinical setting
Masked HTN: pt with BP levels >95th percentile outside the clinic, but normotensive in clinical setting
Ambulatory blood pressure monitoring (ABPM) helpful in either case
Describe Karotkoff sounds used in BP measurement
1st sound: Systolic BP 2nd sound 3rd sound 4th sound: becomes muffled 5th sound: silence, pressure drops below diastolic BP
[in some kids, 4th sound never goes away, so muffled sound is used as DBP]
In older, school age children, prevalence of primary HTN has increased hand-in-hand with the ____ epidemic
Obesity
______ is the most prominent evidence of target-organ damage in children and adolescents with HTN, and establishes the chronicity of their high blood pressure
Left Ventricular Hypertrophy (LVH) — so get an echocardiogram to determine their chronicity
A blood pressure cuff that is too small causes an artificially ____ BP
High
[a blood pressure cuff that is too large causes an artificially low BP]
Clinical definition of hematuria
Presence of 5+ RBCs per hpf in 3 consecutive fresh, centrifuged specimens obtained over the span of a few weeks
Can be gross or microscopic
A positive urine dipstick for hematuria may occur with no RBCs presence, thus what is an important test you must always order with your UA?
Microscopy
What are some things that cause discoloration of urine that may mislead you to think hematuria?
Drugs: rifampin, nitrofurantoin, pyridium, sulfa drugs
Foods: beets, rhubarb, fruit juice
Dehydration in newborns — uric acid crystals in urine of newborn cause brick red color in diaper
Bilirubin
When are UAs done as part of normal pediatric check ups?
Often done at 5 y/o checkup
Often done as part of pre-participation physical
What urinary findings regarding RBC casts, morphology, proteinuria, clots, and color likely suggest a glomerular source for hematuria?
RBC casts may be present, RBCs are dysmorphic, proteinuria may be present, no clots, color may be red or brown
[if the cause is extra-glomerular, RBC casts will be absent, RBCs appear uniform, no proteinuria, clots may be present, color may be red]
Hematuria is not as ominous as hematuria and ____ together
Proteinuria
Signs and symptoms of post infectious acute glomerulonephritis
Recent strep throat followed by:
Gross hematuria with glomerular involvement
HTN
Swelling/edema
Elevated ASO titer
Low serum complement C3
What type of renal involvement should be associated with lupus? What is the most common type?
Glomerulonephritis
Most common is mesangial proliferative lupus nephritis
Signs and symptoms of HSP
Gross hematuria Abdominal pain May have bloody stools Purpura present over buttocks, lower legs, elbows Hives Emesis and nausea Diarrhea
The development of ____ along with hematuria in HSP patients is prognostically indicative of potential long term renal damage
Proteinuria
Patients with asymptomatic, isolated hematuria rarely have significant renal disease. 25% of pts will no long demonstrate hematuria if followed for 5 years. Ask FH questions to r/o Benign Familial Hematuria (thin basement membrane disease); these pts should be regularly monitored for ____ and _____
Proteinuria; HTN
What electrolyte abnormality causes asymptomatic microscopic hematuria?
Hypercalcuria
[urine Ca-to-creatinine ratio of more than 0.2 — indicative of excess Ca excretion]
Host factors that influence predisposition to UTI in children
Age (boys < 1 yr, girls < 4 yrs)
Lack of circumcision
Female
Race/ethnicity: caucasian 2-4x higher risk than AA
Genetic predisposition
Urinary obstruction
Bladder and bowel dysfunction
Causes of urinary obstruction in kids
Anatomic:
Posterior urethral valves (boys only)
Ureteropelvic junction obstruction
Cysts or ureteroceles
Neurologic:
Myelomeningocele with neurogenic bladder
Functional:
Bladder or bowel dysfunction
How is urine specimen obtained in children when UTI is suspected?
When are bag samples ok to be used?
If child can void on command, a clean-catch urine may be obtained
Otherwise utilize catheterization or suprapubic aspiration
Bag samples are only helpful if negative, they are NOT appropriate for culture
Criteria for dx of UTI
If by clean catch — presence of both pyuria and 50,000+ colonies/mL of single organism
If by catheter — pyuria and colony count of 50,000 CPM or 10,000-50,000 CPM confirmed by repeat
If by suprapubic aspiration — pyuria and ANY growth on culture
What result on UA indicates presence of WBCs? Certain types of bacteria?
Leukocyte esterase indicates WBCs
Nitrites indicate certain types of bacteria (including E.coli—most common)
If you are going to treat empirically for UTI, what should you choose?
If not acutely ill and tolerating PO, use oral abx: cephalosporin (cefixime or cefdinir), fluoroquinolones can be used
If acutely ill or not tolerating PO, IV abx: 3rd gen cephalosporin (ceftriaxone) — add ampicillin if enterococcus suspected
If afebrile, tx for 3-10 days; if febrile, tx for 10-14 days
When do you image a child’s urinary tract?
In boys with first UTI, common practice is to do renal and bladder US AND VCUG
In girls with first UTI, both VCUG and US are ONLY done if there are symptoms of chronic renal disease, high fever, pathogen other than E.coli, poor growth and HTN, or urologic anomaly suspected
After the second UTI in children, a VCUG is often done looking for evidence of ______ ______ which can be graded 1-5. This condition is notorious for causing renal ______
Vesicoureteral reflux; scarring
[VUR that is graded anywhere from 3-5 requires urologic consult and probably surgery]
What is renal scarring? What are long term complications?
Loss of renal parenchyma between calyces and renal capsule
Long term complications can be HTN, decreased renal function, proteinuria, endstage renal disease
When does the child’s primary care provider refer to a specialist?
In cases of dilating VUR (III-V)
If obstructive uropathy is present
When renal abnormalities are identified
When kidney function is impaired
If a pt is hypertensive
If bowel and bladder dysfunction is refractory to primary care measures
