Kidney and Urinary Tract Disorders Flashcards
What are the signs and symptoms of urinary tract infections in children?
- Dysuria
- Frequency
- Flank pain
- Offensive smelling urine
- Fever / rigors
- Diarrhoea and Vomiting
- Lethargy / Irritability
- Febrile seizures
- Infants
- Fever
- Poor feeding / faltering growth
- Jaundice
- Septicaemia
- Children
- Abdominal pain / lion tenderness
- Haematuria
- Enuresis
What are the appropriate investigations for suspected urinary tract infections in children?
-
Urine dip
- Nitrite stick test – very specific
- Leucocyte esterase test
- Urine MC&S = diagnostic
- Imaging not recommended
- Unless atypical or recurrent UTIs = USS à DMSA ± MCUG
- Atypical UTI = USS ± DMSA (<3yo only)
- Recurrent UTI = USS + DMSA
- Unless atypical or recurrent UTIs = USS à DMSA ± MCUG
What is the management of urinary tract infections?
- <3m = Emergency
- Admit to hospital
- IV Abx for 5-7 days → oral prophylaxis
- Urgent USS should be booked (4-6w)
- >3m Upper UTI
- Consider hospital admission
- IV Abx for 7-10 days
- <6m old when they have 1st UTI = urgent USS should be booked (4-6w)
- >3m Lower UTI
- Oral Abx for 3 days
- Safety net parents → bring child back if they remain unwell after 48 hours (may be atypical)
- <6m old when they have 1st UTI = urgent USS should be booked (4-6w)
What is the management of recurrent UTIs in children?
- Antibiotic prophylaxis
- USS - during admission if <6m, urgent if >6m
- DMSA scan (routine)
What strategies can prevent UTIs?
- High fluid intake to produce high urine output
- Regular voiding
- Ensure complete bladder emptying
- Treatment and/or prevention of constipation
- Good perineal hygiene
- Lactobacillus acidophilus probiotic
What is Enuresis?
Bed-wetting
What is the management of primary bedwetting without daytime symptoms <5 years old?
- Reassure parents → often resolves by 5yo
- Educate
- Easy access to toilet at night
- Bladder emptying before bed
- Positive reward system
What is the management of primary bedwetting without daytime symptoms >5 years old?
- Infrequent (<2/week) → offer watch-and-see approach
- Frequent
- 1st line = enuresis alarm, positive reward system - encourage child to help change sheets
- 2nd line = desmopressin (1st line if >7yo or for short-term control (i.e. sleepovers, school trips, etc))
- 3rd line = combination
- Referral to enuresis clinic
- Community paediatrician if bedwetting not responded to 2 courses tx
What counselling should be given to parents with a child with primary bed-wetting without daytime symptoms?
- Bedwetting not the child/parent’s fault - take a neutral attitude to bedwetting so not to embarrass
- Reason is excess volume that does not wake the child to go to the toilet
- Reassure that pretty much all children become dry with time as their bladder capacity increases and they learn to wake at the sensation of a full bladder
- Child should go to the toilet regularly and before bed
- Avoid caffeine before bed
- Easy access to toilet
- Waterproof mattress or bed pads
- Lifting or waking during the night does not promote long-term dryness
- Positive reward systems - rewards for going to the toilet before bed
- Drink the recommended amount of fluid during the day
- Support groups
What is the management of primary bedwetting with daytime symptoms?
Referral to enuresis clinic and community paediatrician
What are the appropriate investigations for troubling enuresis?
- Renal USS
- Urine diary
- Dipsticks
- MCUG
- Urine MC&S
What is the management of secondary bedwetting with daytime symptoms?
- Primary care management = manage the cause
- UTI
- Constipation
- Secondary care management = manage the cause
- Diabetes
- Recurrent UTI
- Psychological problems
- Family problems
- Developmental, attention or learning difficulties
- Known or suspected physical or neurological problems
Define Secondary Bedwetting.
Enuresis that occurs after the child has previously been dry at night for 6 months.
What are the signs and symptoms of osteosarcoma?
- Occurs in end of long bones - 60-75% in the knee
- Relatively painless
- Mass/swelling that restricts movement
- Rapid metastasis to lung
What are the appropriate investigations for suspected osteosarcoma?
-
X-Ray - bone destruction and formation
- Soft tissue calcification = sunburst appearance
- Elevated periosteum = “Codman’s triangle”
- Biopsy
- CT/PET/MRI
What is the management of osteosarcoma?
- Specialised sarcoma team (London) management
-
Surgery + Chemotherapy
- Limb-sparing surgery ± amputation
- Post-treatment
- OT
- PT
- Dietician
- Orthotics/prosthetics
- Support group - Sarcoma UK
What is the difference between osteosarcoma, Ewing’s sarcoma and chondrosarcoma?
- Osteosarcoma = forms bone
- Ewing’s sarcoma = forms mesenchymal tissue (neuroectodermal)
- Chondrosarcoma = forms cartilage (occurs in those >40yo)
What is the prognosis of osteosarcoma?
60% 5-year survival
What is Nephrotic syndrome?
- Low albumin
- Peripheral oedema
- Proteinuria
What is the most common cause of nephrotic syndrome?
Minimal Change Disease - 90%
What are the signs and symptoms of nephrotic syndrome?
- 1st = Peri-orbital oedema - often misdiagnosed as allergy
- 2nd = Other delayed features of oedema + Features of underlying diagnosis
What are the types of nephrotic syndrome?
- Steroid-sensitive nephrotic syndrome - 80-95%
- Steroid-resistant nephrotic syndrome
What are the appropriate investigations for suspected nephrotic syndrome?
- Urine
- Dipstick
- MC&S
- Sodium
- Bloods
- Urea
- U&Es
- FBC
- ESR
- Creatinine
- Albumin
- Complement levels (C3, C4)
- Anti-streptolysin O or Anti-DNase B titres - recent streptococcal throat infection
- HBV, HCV, malaria screen
What is the management of nephrotic syndrome?
- 1st = Oral prednisolone for 4-6 weeks - reduced dose from 4+ weeks
- Renal histology of steroid-sensitive nephrotic syndrome = normal on light microscopy
- However, on electron microscopy, fusion of podocytes is seen (minimal change disease)
- 2nd (steroid-resistant or atypical) = specialised renal biopsy and care
What are the main complications of nephrotic syndrome?
- Risk of thrombosis → loss of AT-III in the urine = hypercoagulable state
- Risk of infection → loss of immunoglobulin in urine
- Hypercholesterolaemia → urinary albumin loss → less oncotic pressure → hepatic cholesterol synthesis
What are the causes of childhood acute glomerulonephritis?
- Minimal change disease
- Focal-segmental glomerulosclerosis
- Membranous - more common in adults
- Post-infectious (streptococcus in children)
- Vasculitis (SLE, ANCA +ve)
- IgA nephropathy (adults, but includes HSP in children)
- Mesangiocapillary glomerulonephritis
- Goodpasture’s