Kidney & Urinary Tract Flashcards

Question

What conditions are associated with hypospadias?

Answer 1

cryptorchidism and inguinal hernias

Answer 2

**Inflamed / purulent discharge from foreskin** (Single attacks common)

Answer 3

- Clean penis daily with lukewarm water and dry gently - Advise on sources of written information and support - Consider topical hydrocortisone - Candidal = imidazole cream - Bacterial = fluclox - If recurrent (rare) > circumcision

Answer 4

Twist of the spermatic cord resulting in testicular ischaemia and necrosis MUST be excluded in any boy with acute abdomen

Answer 5

Most common 10-30yrs (peak 13-15)

Answer 6

- Severe, sudden onset pain in testes > can be referred to lower abdomen - Nausea / vomiting **O/E** - Swollen, tender testes retracted upwards - Skin may be reddened - Cremasteric reflex lost - Elevation of testes does NOT ease pain (Prehn’s sign)

Answer 7

Doppler USS (cannot delay surgery)

Answer 8

**EMERGENCY > urgent urological referral** - Exploration surgery +/- bilateral orchiopexy +/- fixation of contralateral testes - Supportive care > analgesia, sedation, antiemetics

Answer 9

Triad of: - **Proteinuria** - **Hypoalbuminaemia** - **Oedema** - +High cholesterol and triglycerides *(protein-losing nephropathy > kidney losing protein in urine)*

Answer 10

- Minimal Change Disease (MCD) *> most common cause* - Focal segmental glomerulosclerosis (FSGS) - Membranous nephropathy (MN) Also - diabetes, lupus, amyloidosis, drugs, infections (HIV, HBV, HCV, malaria)

Answer 11

- Patient is young (2-4yrs) - Disease is mild (selective proteinuria) - Prognosis is excellent (great response to steroids) - Normal renal function / BP - Glomeruli look normal on light microscopy, but electron microscopy shows loss of foot processes

Answer 12

**Primary** = Idiopathic **Secondary** = Hodgkin's Lymphoma, infections, medications

Answer 13

> Segmental or focal scarring of glomeruli and foot process fusion - The patient is older - The disease is more severe (non-selective proteinuria) - Proteinuria, high BP, kidney failure - The prognosis is worse (poor response to steroids, 50% > CKD)

Answer 14

**Primary** = Idiopathic **Secondary** = HIV, heroin, ParvoB19

Answer 15

> Widespread thickening of membranes in the glomeruli, granular deposits of Ig and complement - Patient is older (20-60) - Non-selective proteinuria - Poor response to steroids - PLA2R antibodies - Microscopic haematuria

Answer 16

**Primary** = Idiopathic **Secondary** = Syphilis, malaria, cancer, HBV/HBC, Hodgkin's, SLE

Answer 17

- **1st = Peri-orbital oedema** (e.g. bilateral puffy eyes) - **2nd = Peripheral oedema** (leg / face / scrotum swelling, ascites, plural effusion, pulmonary oedema) - Oliguria - Lethargy - Diarrhoea / abdo pain - Poor feeding

Answer 18

**Urine:** - Dip (proteinuria, microscopic haematuria) - MC&S - PCR (high) **Bloods:** - FBC, ESR/CRP - Renal function - U&Es - LFTs (hypoalbuminaemia) - Lipid profile (hyperlipidaemia) **Renal USS:** - Check for other causes of proteinuria e.g. PKD - Mandatory to assess kidney size to ensure it is safe to proceed with renal biopsy **Renal biopsy:** - In children, almost all cases due to MCD - therefore treat empirically and only perform renal biopsy if patient is unresponsive to treatment **Also:** (to differentiate cause) - HIV, HBV, HCV, malaria screen

Answer 19

- 1st = oral prednisolone 4-6w (reduce dose from 4w) - 2nd (unresponsive / atypical) = specialised renal biopsy - Sx tx = low-sodium diet and diuretics

Answer 20

- **Thrombosis** (loss of protein = less anticoagulant proteins, also dehydration, immobility, diuretics, steroids) - **Infection** (loss of protein = weakened immune system) - Hypercholesterolaemia - High BP - AKI / CKD

Answer 21

- Oliguria or anuria - Oedema > feet, legs, abdomen - Weight gain - Discoloured urine > brown - Fatigue, lethargy - N/V

Answer 22

**Urine:** - Dip, MC&S, PCR **Bloods:** - FBC, ESR/CRP - Renal function - U&Es - LFTs - Lipid profile **Renal USS / CT:** - Identify obstruction - CKD = small kidneys - AKI = large, bright kidneys with loss of cortical medullary differentiation **Renal biopsy:** - Help diagnose underlying cause

Answer 23

1. Increase in serum creatinine of >=0.3mg/dL in 48hrs 2. Increase in serum creatinine to 1.5x the baseline within 7 days 3. Urine output <0.5mL/kg/h for >=6 hours

Answer 24

**Due to decreased blood flow into kidneys:** - Haemorrhage - Dehydration (D/V) - Severe burns - Heart failure - Low blood pressure (sepsis, anaphylaxis) - Renal vein stenosis / embolus > Should be urgently addressed with fluid replacement and circulatory support

Answer 25

*Damage to the kidney itself* - **HUS** - **Acute Tubular Necrosis** - **Glomerulonephritis** - Interstitial nephritis, vasculitis, pyelonephritis > High calorie, normal protein feed will decrease catabolism, uraemia, and hyperkalaemia

Answer 26

- Hyperkalaemia - Metabolic acidosis - Fluid overload

Answer 27

**Obstruction to outflow of urine:** - Intra-abdominal tumours - BPH - Kidney stones > Requires assessment of the site of obstruction > Relief can be achieved by nephrostomy or bladder catheterisation

Answer 28

- **Treat underlying cause** (e.g. stop nephrotic medication, treat infection) - **Supportive therapy:** Electrolyte balance, fluid balance, nutritional support, BP management - **Close monitoring**

Answer 29

- **Lifestyle changes:** Healthy diet, exercise, quit smoking - **Diuretics** PRN (i.e. to tx fluid overload or oedema whilst awaiting dialysis) - **ACEi's** to lower BP and reduce proteinuria - **Dialysis** for end-stage renal disease - **Kidney transplant**

Answer 30

- Failure of conservative mx - Multisystem failure - Refractory hyperkalaemia - Refractory fluid overload - Metabolic acidosis - Uraemic sx (encephalopathy/confusion, N/V, pruritis, malaise, pericarditis) - CKD stage 5

Answer 31

*When small vessels in kidney become damaged and inflamed* > Commonest cause of AKI in children **Presents with a triad of:** - Renal failure (AKI) - Thrombocytopaenia (small petechia) - Haemolytic anaemia (microangiopathic)

Answer 32

Most common = **E. coli** (undercooked meat, unpasteurised milk, water, veg) Also = pneumococcus, salmonella, shigella, campylobacter

Answer 33

- May be asx - Abdominal pain - Bloody diarrhoea - Decreased UO - May have superficial bleeding (petechiae, purpura) - Pallor, fatigue, weakness

Answer 34

**Bloods:** - FBC: Platelets low, RBC low, Hb low, Hct low, MCV normal - Coagulation screen: BT high, PT normal, APTT normal - Renal function: GFR low **Blood smear:** - Schistocytes **Coombs test:** - Negative **Stool culture**

Answer 35

*> Consult nephrology & haematology specialists* *>Children with typical presentation should be ADMITTED* **> > SELF-LIMITING < <** **Supportive:** - Ensure fluid / electrolyte balance - Maintain BP - treat with CCBs if elevated (ACEi's can reduce renal perfusion) **> 50% will require dialysis in the acute phase** **Avoid:** - Antibiotics - Anti-diarrhoeals - Narcotic opioids - NSAIDs - Plt transfusion (unless life-threatening bleeding) **Long-term follow-up:** - May be persistent proteinuria and development of HTN / progressive CKD

Answer 36

*Not caused by E. Coli, caused by genetic mutation* - More common in adults - NO diarrhoeal prodrome - May be familial and frequently relapses - High risk of HTN and progressive CKD with a high mortality

Answer 37

Bilateral inflammation of renal glomeruli with proliferation of cellular elements secondary to an immunological mechanism

Answer 38

- **Infections** e.g. GAS, Hep B/C, HIV - **Systemic inflammatory conditions** e.g. HUS, SLE, HSP - **Drugs** e.g. NSAIDs, heroin - **Malignancy** e.g. Hodgkin's lymphoma

Answer 39

*Based on the pattern of injury, can be:* - Diffuse (all glomeruli) - Focal (some glomeruli) - Segmental (only parts of affected glomerulus) *Causes:* - Minimal change disease (focal) - IgA nephropathy (focal or segmental) - FSGS (segmental) - Membranous nephropathy (diffuse) - Membranoproliferative glomerulonephritis (diffuse) - Rapidly progressive glomerulonephritis (diffuse)

Answer 40

- Haematuria - Hypertension - Oedema (face, ankles, ascites) - Impaired renal function > flank pain, decreased UO - Seizures

Answer 41

**Urinalysis + microscopy:** - Haematuria, proteinuria, dysmorphic RBCs, leukocytes, red cell casts **Bloods** - FBC (anaemia) - U&Es (increased urea) - Renal function (high creatinine) - LFTs (deranged, hypoalbuminaemia) - Increased ESR/CRP - VBG (metabolic acidosis) **Imaging** - Renal USS (small kidneys or normal) **Renal biopsy:** - Urgently performed if glomerulonephritis is suspected **Specific** - Increase Antistreptolysin titre (recent strep infection)

Answer 42

- **Treat underlying cause:** e.g. if infection or AI disorder - **Supportive treatment:** fluid/electrolyte balance e.g. intake of salt and water may need to be restricted - **Close monitoring** - Consider abx if infectious cause (phenoxymethylpenicllin) - Consider ACEi or ARBs (decrease proteinuria and control BP) - Consider furosemide if HTN - Consider steroids (if nephrotic syndrome)

Answer 43

IgA mediated small vessel vasculitis **RASH, ABDO PAIN, ARTHRITIS/ARTHRALGIA, GLOMERULONEPHRITIS**

Answer 44

Most common vasculitis in childhood (usually before 5yrs) Usually seen following an infection (URTI) Degree of overlap with IgA nephropathy (Berger’s disease)

Answer 45

**Purpuric rash (100%)** - Extensor surface of legs, arms, buttocks, ankles (spares trunk) - Palpable, maculopapular, urticarial **Arthralgia (60-80%)** - Periarticular oedema - Large joints - Joint pain and swelling of knees and ankles **Abdominal pain (60%)** - Colicky - Haematemesis, melena, intussusception **Glomerulonephritis (20-60% > 97% within 3m of onset)** - Microscopic or macroscopic haematuria - Nephrotic syndrome (rare)

Answer 46

**Blood Pressure:** - Normal or elevated (kidney involvement) **Urine dipstick:** - Early morning urinalysis to assess for renal involvement - RBCs, proteinuria, casts **Bloods:** - Renal function (GFR) - Serum creatinine (elevated = renal failure), - FBC, clotting screen, U&Es, ESR/CRP **Skin biopsy:** - Microscopy can be used to confirm diagnosis

Answer 47

Most cases resolve spontaneously within 4wks, so provide sx treatment **Sx management:** - Joint pain > NSAIDs - Abdo pain > paracetamol - Scrotal involvement or severe oedema or severe abdo pain > oral pred **Renal involvement:** (impaired GFR / proteinuria) - Oral > IV corticosteroids - Consider immunosuppressants - Consider ACEi or ARB - Renal transplant considered in end-stage renal disease **Lifestyle advice:** - Healthy diet, regular exercise, avoid alcohol / smoking

Answer 48

- Intussusception - Acute renal impairment - Arthritis involving ankles and knees commonly - Pancreatitis (rare)

Answer 49

Most common kidney cancer in children.

Answer 50

<5yrs (usually 3)

Answer 51

- **Beckwith-Wiedemann syndrome** (specific body parts overgrow) - **WAGR syndrome** (Wilm’s tumour, Aniridia, Genitourinary malformations, mental retardation) - **Hemihypertrophy** - 33% loss of function mutation in WT1 gene on chr11

Answer 52

**Common:** - Asx unilateral upper abdominal/flank mass - Painless haematuria **Uncommon:** - Abdominal pain - Anaemia (haemorrhage into mass) - Anorexia - HTN

Answer 53

**Avoid biopsy as may worsen condition** - **USS and/or CT/MRI** > intrinsic renal mass distorting normal structure - Bloods - FBC, renal function, LFTs, serum total protein/albumin, coagulation studies, serum Ca - Urinalysis

Answer 54

**1** = limited to kidney, completely excisable **2** = not limited to kidney, completely excisable **3** = not limited to kidney, not completely excisable **4** = spread beyond abdomen, haematogenous metastasis **5** = bilateral (each tumour graded separately)

Answer 55

1. Initial chemotherapy (vincristine, dactinomycin) followed by delayed nephrectomy 2. Tumour staged subsequently and tx planned according to surgical and pathological findings 3. Radiotherapy restricted to those with more advanced disease > 80% cure rate

Answer 56

Often metastasise early (usually to lung)

Answer 57

**Conservative management:** - IV fluids, analgesia (morphine) and anti-emetics (ondansetron) - High fluid intake is recommended in all affected children **Bacterial Infection:** - Antibiotic treatment with co-trimoxazole or nitrofurantoin, or surgical decompression **Small stones = medical expulsive therapy** - Tamsulosin OR alfuzosin OR silodosin **Larger stones / do not pass spontaneously = surgical removal** - 1st line: Extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy

Answer 58

Collection of serous fluid between the layers of the membrane (tunica vaginalis) that surround the testes or along the spermatic cord - Common in male infants and newborns and typically resolve on their own - Main symptom is a painless, swollen scrotum on 1 or both sides, which feels like a water-filled balloon

Answer 59

**< 2 years:** - Most resolve spontaneously before 2yrs so observation is appropriate provided there is no evidence of underlying pathology **2-11 years:** - Surgery **11-18 years:** *1. Idiopathic hydrocoele* - Observation is appropriate - Surgery may be considered if large or uncomfortable *2. Hydrocoele after varicocelectomy* - Observation +/- aspiration - Surgery considered in cases that don’t resolve *3. Filarial-related hydrocoele* - Surgery

Answer 60

**Symptomatic Relief:** - Bed rest - Scrotal elevation - Simple elevation - If systemically unwell with a high-grade fever, IV antibiotics and fluids are required **Eradication of Infection:** - Empirical antibiotics - Gonococcal or chlamydia – ceftriaxone + doxycycline - Enteric organisms – quinolone (e.g. ofloxacin, levofloxacin) - Mumps – supportive *Possible complications: abscess formation, infertility, chronic pain*

Answer 61

**The abnormal backflow of urine from the bladder into the ureter and kidney** - Relatively common abnormality of the urinary tract in children - Predisposes to UTI

Answer 62

- Antenatal period: hydronephrosis on USS - Recurrent childhood UTIs - Reflux nephropathy (chronic pyelonephritis secondary to VUR - renal scar may produce increased quantities of renin causing hypertension)

Answer 63

- Normally diagnosed following a micturating cystourethrogram (MCUG) - A DMSA scan may also be performed to look for renal scarring

Answer 64

- Infertility - Torsion - Testicular cancer - Psychological

Answer 65

**Unilateral undescended testis:** - Referral should be considered from around 3m, with the baby ideally seeing a urological surgeon before 6m - Orchidopexy: Surgical practices vary although the majority of procedures are performed at around 1yr **Bilateral undescended testes:** - Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation