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Nephrology > nelson essential volume 2 > Flashcards

nelson essential volume 2 Flashcards

1
Q

what are the most common causes of intrinsic acute kidney injury in children?

A

tubular injury

- can have low, normal or high u/o depending on severity of the injury

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2
Q

tubular injury can occur from what mechanisms:

A
  1. acute tubular necrosis - hypoxia/ischemia
  2. infection - sepsis
  3. nephrotoxic agents - medications, contrast, myoglobin
  4. inflammation - interstitial nephritis
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3
Q

glomerular and vascular intrinsic acute kidney injury, how might they present?

A

hematuria, edema, hypertension and oliguria
glomerular injury - primary GN, vascultiis, HUS
vascular - renal vein thrombosis, arterial emboli, malignant HTN

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4
Q

How to tell pre renal from other causes of acute kidney injury?

A
  1. normal UA with high specific gravity (reflects appropriate renal retention of water when there is renal hypo perfusion) I think number is >1.03 ish (see previous flash card)
  2. urine output will be low
  3. urine Na will be 500 in child (>350 in neonate)
  4. normal renal US
    see table pg 562 baby Nelson
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5
Q

How to tell renal from pre renal when oliguria (i.e. pre renal from ATN?)

A

use the Fena and osmoses etc
in renal cause:
1. urine output can be either low, nomal or high
2. urinalysis with RBCs, WBCs, protein or casts
3. urine Na high (kidney is peeing it out) >40 in kids or >50 in neonate
4. Fena >2%
5. urine osmoles approx 300
6. renal US might show increased echogenecity, decreased corticomedullary differentiation

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6
Q

Post renal vs other causes

A

low or normal u/o, everything else variable, U/S will show hydronephrosis

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7
Q

Common lab problems in AKI

A

hyperkalemia, metabolic acidosis, hypocalcemia, hyperphosphate
anemia can be observed frequently

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8
Q

Causes of pre renal AKI

A 
dehydration
bleed
septic shock
burns
heart failure
cirrhosis
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9
Q

which has a worse prognosis, oliguric or non oliguric AKI?

A

oliguric is worse prognosis, non oliguric usually recover well

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10
Q

Indications for dialysis

A
  1. acute or chronic dialysis:
    volume overload, metabolic acidosis, eletrolyte, uremia
  2. acute: ingestions, hyperammonemia
  3. chronic: poor growth, stage 5 renal diseae
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11
Q

Common complications of chronic kidney disease

A
  1. poor growth - including delayed puberty also , resistance to growth hormone
  2. anemia - since they can’t make enough EPO as well as iron deficiency
  3. renal osteodystrophy/secondary hyperparathyroidism : because make less 1,25 OHD in the kidney , hypocalcemia and and hyper phosphate ->can lead to rickets/bone deformities if goes for a long time
  4. cardiovastular: hypertension and LVH
  5. electrolyte abnormalities: high K, low Na, metabolic acidosis
  6. impact on learning and school
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12
Q

How to treat the complications above (Pg 563 baby nelson)

A
  1. growth: increase calories, treat acidosis, treat ROD, GH **adequate nutrition very very important even if need supplements and tube feedings
  2. anemia: EPO, iron
  3. calcitriol (aka 1,25 OHD), calcium supplement, restrict phosphorus and give phosphate binders
  4. treat HTN, don’t volume overload
  5. lytes: low K diet, furosemie, sodium polystyrene, sodium supplement, give alkali (**what to do with sodium depends on the aetiology i.e. many congenital anomalies have sodium wasting, vs those with GN tend to retain salt)
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13
Q

most common cause of CKD in less than 10 year olds

A

congenital anomalies of kidney and urinary tract

in >10 year old - more likely focal segmental glomerulosclerosis and GN

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14
Q

true or false - restrict protein intake in CKD in kids?

A

not usually

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15
Q

GFR in different stages of CKD?

A 
>90 stage 1
60-90 stage 2
30-59 stage 3
15-30 stage 4
2 year old (since GFR at adult levels at this age)
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16
Q

definition of hypertension

A

BP >95th percentil for age, gender and height on at least 3 occasions
(normal is 99th

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17
Q

what is hypertensive emergency

A

severe elevation in BP with target organ damage - encephalopathy, heart failure

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18
Q

most common cause of HTN in teens? in younger kids?

A

essential in teens

more likely secondary in younger kids, with more severe elevation ->renal disease most likely

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19
Q

hypertensive and neurofibromatosis (cafe au lait) what finding to rule out

A

renal artery stenosis

see differential of HTN pg 564

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20
Q

Management of Hypertension

A
  1. lifestyle changes - asymptomatic stage 1
  2. medication - stage 2 or if stage 1 no respond
    - calcium channe blocker or ACEi most frequent 1st line, ARB, beta blocker/diuretics sometimes used
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21
Q

How to treat a hypertensive emergency?

A

hospitalize

labetalol, esmolol, nicardipine or sodium nitro

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22
Q

why is hypertension bad?

A

may increase risk of CV, CNS and renal morbidity in adults

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23
Q

true or false - most - most vesicoureteral reflex is from structural problems?

A

false - most are from congenital invompentance, minority have UV abnormalities which are structural and don’t resolve

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24
Q

true or false - VUR can be familial

A

true - 30-40% of kids with VUR can have VUR

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25
Q

associated findings with VUR?

A

renal dysplasia
duplication of the ureters (can obstruct upper collecting system)
neurogenic bladder
from increased pressure when bladder outlet is obstructed

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26
Q

when to do VCUG

A

if hydronephrosis/scaring etc on US after UTI

if two febrile UTIs

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27
Q

radionuclid cystogram - advantage and disadvantage

A

less radiation

might miss PUV in males

28
Q

renal scars?

A

DMSA scan to ID

29
Q

complications of reflux nephropathy

A

hypetension

chronic kidney disease

30
Q

What is Potter syndrome?

A

bilateral renal agensis
flat facies
clubfoot
pulmonary hypoplasia

31
Q

who is more likely to have unilateral renal agencies

A

infants of diabetic mothers and african americans

normal or minimally reduced renal function

32
Q

associated findings with unilateral renal agenesis

A 
VUR
genital tract, ear skeletal system and CV abnormalities
Turner syndrome 
Poland syndrome
VACTERL association
33
Q

true or false - renal hypoplasia/dysplasia can often progress to CKD?

A

true, because they have less nephrons, can’t fully absorb Na nd water

34
Q

true or false - bilateral multi cystic renal dysplasia is lethal

A

true, because there is minimal or no functioning renal tissue

35
Q

what should you look for in contralateral kidney of multi cystic renal dysplasia

A

VUR in contraleteral kidney - associated with multi cystic renal dysplasia
MCD often involutes on its own
rarely associated with hypertension or recurrent UTI

36
Q

Clinical manifestations of posterior urethral valves

A

most common bladder outlet obstruction males -
parents may note a poor urine stream
urethra bets dilated, might get VUR, and hypertrophied detrusor muscle
severe obstruction can lead to oligohydramnios and pulmonary hypoplasia

37
Q

What is the most common cause of ascites in the newborn period?

A

intrauterine rupture of the renal pelvis

38
Q

Polycystic kidney disease -

A

from polycystin defects
most common inherited kidney disease
1. Autosomal recessive: marked bilateral renal enlargement, hepatic fibrosis with portal HTN, bile duct ectasia/biliary dysgenesis
2. Autosomal dominant PKD: middle adulthood usually, can have hepatic cysts, cerebral aneurysms can develop

39
Q

most common abdo mass in newborn?

A

renal

most common UPJ obstruction

40
Q

differential of renal cysts

A
  1. polycystic kidneys
  2. von Hippel-Lindau
  3. Tuberous sclerosis
  4. Bardet-Biedl syndrome
41
Q

Causes of bladder stones?

A

recurrent UTI
neurogenic bladder
bladder surgery
bladder augmentation

42
Q

Causes of renal stones

A

obstructive abnormalities

Metabolic

43
Q

Causes of Urinary tract stones

A

most stones are here
symptoms when they get stuck at the ureteropelvic function or the ureterovesical junction
Metabolic causes:
1. idiopathic familial hypercalciuria, hyperoxaluria, uric acid disorders, distal RTA, cystinuria, hypercalcemic hypercalciuria, primary hyperparathyroidism

44
Q

Diagnosis of renal stones

A

US can miss UT stones, CT is good but can sometimes be obscured
urine studies for minerals/electrolytes helps figure out which type of stone it is

45
Q

Treatment of stones

A

1 .hydration - 2x maintenance rates

  1. analgesia
  2. for infection related: treat the infection, remove the stone
  3. specific treatments:
    - idiopathic familial hypercalciuria - normal calcium with low Na and low oxalate ; some need potassium citrate or thiazies, may need lithotripsy or surgery
46
Q

dysfunctional voiding what investigations to do

A

urinalysis and urine culture - to r/o occult infection, renal disease, glucose (i.e. diabetes)
daytime incontinence - should do US r/o structural problems
urodynamic- only when suspect neurogenic bladder or known neuro cause

47
Q

treatment of dysfunctional voiding

A
  1. bladder hyperactivity/sensory defects - timed voiding and anticholinergic meds; more complicated includes biofeedback, alpha blockers, intermittent catheterization
48
Q

phimosis -

A

inability to retract the prepuce
at birth - physiologic
in 90% of boys who are not circumcized, fully retractable by 3 years old
if persistent - can try a steroid cream to the foreskin
if ballooning of foreskin during voiding or phimosis beyond 10 years old and steroids don’t work, circumize

49
Q

What is paraphimosis

A

foreskin is retracted and get get it back - edna leads to pain, and it gets stuck ; lubricate and try to put back, may need emergency surgery

50
Q

1.5 year old with undescended testicle, likely to descend?

A

nope - not likely to descent after 1 year of age

other possibilities for what you think is undescended testicle is retractile testes, absent tests, ectopic tests

51
Q

cryptorchidism - what to ask in history

A

was it every in scrotum
maternal drug use - steroids
family history
true undescended testis - usually along the embryologic path of descent - with patent processes vaginalis

52
Q

what can be associated with undescended testis

A
  1. inguinal hernia
  2. risk of torsion
  3. risk of infertility
  4. increased malignancy risk (i.e. germ cell malignancy) - more if untreated or corrected during of after puberty

more likely to have cryptorchidim in newborns than older children, more in pregms, bilateral in 10% of kids

53
Q

most common cause of scrotal pain and swelling in older adolescents

A

epididymitis - diagnosis is aided by history of sex or HUTI, but should consider testicular torsion when severe pain
(meanwhile in boys <6 years, testicular torsion is the major cause of acute scrotum) - here testicle will be swollen and cremasteric reflex absent

54
Q

cryptorchidm - when should testicles descend by

A

if they haven’t descended by 4 months, it will stay undescended

55
Q

most common tumour in undescended testis in teen or adult

A

seminoma - orchiopexy reduces this risk

56
Q

when should undescended testis be treated by

A

should be treated surgically by 9-15 months of age at the latest - surgical correction at 6 months is appropriate , since spontaneous descent will not happen after 4 months of age
if the testicle stays down, start to see histological changes (atrophy/dysplasia)
early surgical correction -better chance of fertility
infrequenty - hormones (HCG) can be used to help the testicle descend

57
Q

Hydrocele

A

transillumination shows fluid
should palpate testicle - can develop with association with timor
most congenital hydroceles resolve by 12 months of age , and are non communicating, those that persist beyond 12-18 moths after communicating and should be repaired

58
Q

GN with low complement

A

post strep
lupus
membranoproliferative

59
Q

when would you repair a communicating hydrocele

A

communicating - fluid and you can push it around - most resolve by 2, so if not resolved by 2 then can do it (mainly so you can palpate the balls)
non communicating - two separate bags - if by one year they haven’t resolved

60
Q

what do you worry about with varicocele in right side or <10 year old

A

worry about renal or retroperitoneal masses

61
Q

what are exam findings in varicocele

A

bag of worms
valsalva will make it worse
usually on the left side

62
Q

false positive gross hematuria on dipstick

A
  1. beets
  2. rifampin
  3. dyes
  4. menstruating
  5. alkaline urine (urine pH .9 can give you false positive)
  6. myoglobin in urine
63
Q

false negative gross hematuria on dipstick

A
  1. formalin (used as a urine preservative)

2. increased urinary vitamin C

64
Q

most common cause of gross hematuria in children

A

UTI

65
Q

8 year old - gradual onset one ball pain with blue dot

A

appendeal tosion
resolve 7-10 days
surgery only if not resolve or not sure what is joing on

66
Q

epidydimitis organism in teen

A

epidydimitis

67
Q

in prepubescent

A

e. coli/urinary tract obstruction

Nephrology (5 decks)

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