Kidney and Urinary Tract Disorders Flashcards
UTI in children <3mo
ALL infants <3mo w/suspicion of UTI or if seriously ill should be referred immediately to hospital
IV co-amox 5-7d
followed by PO proph
Infants >3mo and children w/acute pyelonephritis/Upper UTI
If dip +ve for leucocyte esterases or nitrites send culture and start abx
PO trimethoprim 7d
If not IV co-amox 2-4d then stepdown
Children w/cystitis/lowerUTI
Dysuria NO systemic Sx PO trimeth/nitro for 3d Advise: seek attention if still unwell after 48hrs of abx fluids
USS DMSA MCUG
infants w/atypical or recurrent UTI should have USS DMSA within 4-6m of acute infection if: - <3y w/atypical/recurrent - >3y w/recurrent MCUG if recurrent or if abnormal USS
Medical measures to prevent UTI
Aim: ensure washout of organisms that ascending and the presence of aggressive organisms in the stool perineum and under foreskin
High fluid intake to produce high urine output
Complete bladder emptying
Good hygiene
Lactobacillus acidophilus: probiotic
FU of children w/recurrent UTI, renal scarring or reflux
Urine dipsticked with any non-specific illness incase it is UTI, MC+S Low dose abx proph. possible Circumcision in boys? anti-VUR surgery Regular BP checking Urinalysis for proteinuria (CKD)
Summary of UTI in children
<3m refer immediately to paeds
>3m w/upper UTI: consider admission otherwise PO abx 7-10d
>3m w/lower UTI PO ABx 3d
Recurrent: ?prophylaxis
Enuresis
most children dry day and night by 5 (day only by 4)
Primary bedwetting (w/o daytime Sx):
- Children <5: reassure is normal, ensure easy access to toilet at night (potty next ti bed), encourage bladder and bowel emptying before bed, consider reward sysytem
Children >5: if <2/wk then watch and see, if long term treatment required:
1st line: enuresis alarm w/reward system
2nd:desmopressin (restrict fluid 1hr before to 8hr after)
Offer desmo for short term control eg school trip
If Mx for enuresis fails
Restart previously successful in combination w/desmo and alarm
TCA and anitmuscarinics can be considered in cases
Referral for enuresis
NOT responded to 2 courses of Mx, refer to 2ndry care, specialist clinic or paediatrician
Advice on enuresis
NOT anyone’s fault
Volume exceeds capacity but doesnt wake child
Reassure almost all will become dry as bladder grows and they learn sensation
Pass regularly, esp. before bed
Caffeine drinks avoided (before bed)
Healthy diet
Easy access to toilet
waterproof mattress
Neutral attitude as not to embarrass
Older children may prefer to change it themselves
Waking in the night does NOT promote long term dryness
Positive support
support: ERIC
Primary bedwetting w/daytime Sx
Refer to secondary care/enuresis clinic
Secondary bedwetting
occurs after previously been dry for 6m
Causes that can be manged in primary care: UTI, constipation
Specialist referral:
DM, recurrent UTI, psych, family problems, developmental delay, neurological/physical problems
Summary of enuresis
Look for causes: constipation/diabetes Fluid intake, toilet behaviour reward system 1st line <7y = alarm desmopressin 1L if >7 or short term control needed
Nephrotic syndrome
PO steroids (60mg/m^2 pred) After 4wks dose reduced If no resp. after 4wks or have atypia may have more complex Dx and need biopsy NB. renal histology of steroid sens. NS is usually normal on light micros. but fusion of podocyes on EM - minimal change Dx
Cx of nephrotic syndrome
Hypovolaemia
thrombosis
infection
hypercholesterolaemiea
Henoch-Schonlein Purpura
Most will resolve 4wks
P/I for arthalgia
If scrotal involvement of severe odema or severe abdo pain give PO pred
IV corticosteroids in pts w/nephrotic range proteinuria and those w/declining renal function
Rental trx in end stage dx
FU: BP and renal function
Urinary tract calculi in children
Conservative Mx, IV fluids, consider morphine, antiemetics
Bacterial inf: co-trim/nitro
Small stones: medical expulsive Mx Tamsulosin
Larger stones: surgical (ESWL, uteroscopy)
AKI General Mx
USS may be useful to identify cause (obstruction, small kidneys in CKD, large bright kidneys w/loss of corticomedullary diff.)
Diuretics when necessary (oedema while awaiting dialysis)
Fluid restriction may behelpful
Consider renal replacement therapy if any of below not responding to Mx:
- hyperkal
- pulmonary oedema and fluid overload
- acidosis
-uraemia (pericarditis,encephalopathy)
Prognosis good unless underlying cause
Pre-renal failure
hypovolaemia
little sodium excreted
fluid replacement and circ, support
Renal failure
monitor water and electrolytes
high calorie normal protein deed decreases catabolism, uraemia, hyperkalaemia
Most common AKI in UK
- HUS, ATN (multisystem failure)
Post-renal failure
Refer imm. to urology:
pyelonephrosis
obstructed solitary kidney
bilateral upper UT obs.
Cx of UTI caused by urological obstruction
Assessment of site of obs.
Relief achieved by nephrostomy or bladder cath.
Indications for dialysis in AKI
Failure of conservative Mx Hyperkalaemia Severe hypo/hypernatraemia Pulmonary oedema or severe htn due to vol overload Severe met acidosis Multisystem failure
(J)HUS
Ix: FBC, blood smear, renal function, coagulation, LDH, haptoglobin, stool culture
Consult neph/haem
ADMIT those w/typical presentation
Management of HUS
Supportive:
monitor urine and fluid balance
avoid cardiopulomnary overload
Keep BP normal (CCBs bc ACE reduce ren. perfusion)
Avoid: Abx, antidiarr, narcotic opiods, NSAIDs
Long term FU necessary (persistent proteinuria and hypertension, and progress of CKD)
Atypical HUS: no diarrhoeal prodrome, ?familial, requent relapse (high risk CKD + HTN + mortality)
CKD Ix and aims
serum creatinine, urinalysis, renal USS
aim: prevent Sx and metabolic abnormality allow growth and development, preserve renal function
CKD diet
anorexia and vomiting common
calorie supp. or NG feed often necessary
Protein intake must be sufficient to maintain growth and normal albumin but not allowing accumulation of toxic end products of metabolism
Prevention of renal osteodystrophy
Decreased vitD activation -> PO4 retentiom and hypocal.
secondary hyperparathyroidism
osteitis fibrosa cystica + osteomal.
Phosphate restriction w/reducing milk, using CaCO3 as a PO4 binder or activated VitD supplements may help
Control of salt and water balance, and acidosis in CKD
Many will have obligatory loss of water and salt
need salt supplements and lots of water
Mx w/bicarb prevent acidosis
Anaemia in CKD
Reduced EPO prod. and circ of BM toxic metabolites causes anaemia
Respond well to sc. recombinant human EPO
Hormonal abnormalities in CKD
GH resistance a feature (high GH poor growth)
Recomb. GH effective for up to 5y of use
Many w/ stage 4/5 will have delayed puberty or subnormal pubertal growth spurt
