Nephro and Urology - 2019 Updated! Flashcards
Child with nephrotic syndrome treated with steroids, weaned off 3 months ago and was clinically well. Now
presents with albumin 10, ascites, 3+ protein in urine. Name three specific therapies
mgmt of relapsed nephrotic syndrome:
- repeat course of prednisone
- acute mgmt: Na restriction (<1500mg daily), diuresis (furosemide - loop diuretic), fluid restriction if hyponatremia
- low fat diet if dyslipidemia
Testicular torsion
a) Blue discoloration of the scrotum is pathognomonic
b) Absence of cremasteric reflex is common
c) 36 hrs to treat before losing testis
b) Absence of cremasteric reflex is common
* a) Blue discoloration of the scrotum is pathognomonic (blue dot in keeping with torsion of appendix testis)
6 hours to treat
Painful scrotum, scrotal wall erythema
In boys with normal cremasteric reflex, testicular torsion is unlikely. Absence of a cremasteric reflex is nondiagnostic
All of the following about Alport’s are true except:
- Girls have worse prognosis
- Bad prognosis is with gross hematuria in childhood
- Progressive sensorineural hearing loss in childhood
- 15% have end stage renal disease before age 15
- 2-3% of all end stage renal disease is due to Alport’s
- Girls have worse prognosis
- Alport = hereditary nephritis
- all have micro hematuria, may have gross hematuria, may have proteinuria
- progressive bilateral SNHL
- poor prognosis: gross hematuria in childhood, nephrotic syndrome, prominent GBM thickening, male
- mgmt: ACEi slows rate of progression
Most common cause hypertension in adolescents:
a) primary (essential) hypertension
b) renal artery stenosis
c) congenital renal disease
d) coarctation of the aorta
e) pheochromocytoma
a) primary (essential) hypertension
Risk factors for HTN
Obesity
HTN
Prematurity
Kidney disease
8 month old baby with gastroenteritis.
Na 160, Cl elevated, Bicarb 14, HR 220, BP 60/30.
1) What is your initial management
2) Once stable what is your ongoing fluid management (eg - type, duration).
1) IVF resuscitation with 20 ml/kg bolus NS until stable (up to 60 ml/kg).
2) Repeat Lytes.
- Calculate Total Body Water (weight x 0.6) - Calculate Free Water Deficit (TBW x (Current Na - Desired Na)/Desired Na) - Calculate Insensibles (400 ml x BSA) Where BSA = sq(Htxwt/3600)
Replace the FW Deficit/24h + Insensibles + Losses
Start with D51/2NS, check bytes q4h. If too fast or cerebral edema give back Na+ with 3%
Newborn with increased creatinine, palpable mass in midline. How do you confirm the diagnosis?
a. VCUG
b. Abdo Ultrasound
c. CT abdo
b. Abdo Ultrasound - concern is about an obstructive renal lesion
- 2/3 of abdominal masses in neonates are renal in origin
- boys with PUV have walnut size mass above pubic symphysis
A newborn infant has Cr of 83. Which of these statements is true?
a) this value reflects the mothers creatinine.
b) this is a normal value for a newborn infant.
a) this value reflects the mothers creatinine.
When should secondary nephrotic syndrome be suspected and how do you investigate?
- gross hematuria, HTN, renal insufficiency, age <1 or >12
- C3 (normal in MCD, low in other causes), ANA, dsDNA, Hep B, Hep C, HIV; kidney biopsy in kids over 12
An 8 year old boy presents with hematuria and hypertension. His ASOT is positive. List one test that you
could do that would support your diagnosis of post-infectious glomerulonephritis.
- complement C3 level (reduced in >90% of cases of post strep GN in the acute phase, returns to normal within
6-8 weeks post infection) - PSGN occurs following staph, strep, gram negative bacterial infections, flu, parvo
6-year-old girl with incidental finding of a 2 cm renal cyst. Appropriate management:
a) observe and repeat US
b) CT abdomen
c) ultrasound liver
d) urology consult
e) full nephrologic workup
a) observe and repeat US
Re: liver U/S - hepatbiliary issues more related to AR PCKD
- simple cysts with normal renal function only need observation
- complex cysts may have risk of cancer - need more ix
Child with back pain. Ultrasound shows left hydronephrosis. Test to give Dx?
A. Mag-3-Scan 99mTc-DTPA for function
b. Urine culture
A. Mag-3-Scan 99mTc-DTPA for function (renal scintigraphy assesses renal anatomy and function) -
nuclear medicine test that provides images of the kidneys to help determine their level of functioning and if there
are any obstructions. They can be very important in the diagnosis of hydronephrosis and UPJ obstructions (which present with abdo/flank or back pain).
8 yo female with incidental pick up of microscopic hematuria on urinalysis. No protein. Micro shows rbc’s of 8-10 per hpf. Diagnosis?
- Alports Syndrome
- IgA nephropathy
- Nephrolithiasis
- post strep GN
- Nephrolithiasis - not totally true but HYPERCALCIURIA would be a better option.
If they give a +ve FHx then pick Alports. Females with X-lined AS may only get microscopic hematuria.
IgA doesn’t totally fit. Classic would be episodes of gross hematuria 1-2 days after URTI. They get + protein.
– Thin basement membrane would be a good option
5 year old with asthma. Treated with ventolin overnight and Q 30 this morning. Aminophyline added this morning
to help improve oxygenation. Child complaining of nausea and weakness. You should check:
A) serum sodium
B) serum glucose
C) serum potassium
D) serum magnesium
C) serum potassium
The following are shared by cystinosis and renal tubular acidosis EXCEPT:
a) hypokalemia
b) nephrolithiasis
c) concentrating defect
d) aminoaciduria
e) hyperchloremic metabolic acidosis
d) aminoaciduria Features of cystinosis: - Fanconi syndrome - french Cdn, fair complexion and blonde hair - healthy at birth - develop FTT, polyuria, polydipsia, dehydration - photophobia by 3-6 years - nephrocalcinosis
4 yo female with persistent microhematuria on 2 urine dips. Grandfather has renal stones. What investigation would you do to prove the diagnosis (1)
Urine calcium : creatinine ratio
Hypercalciuria can cause persistent hematuria
6 yr old previously well with 10 minute generalized tonic clonic seizure. Hypertensive , HR 90, Na 115 , Urine
Na 30 . Euvolemic on exam. What is your initial management? List 2 possible etiologies.
- 3% NS 5ml/kg IV push
- euvolemic hyponatremia:
- SIADH, glucocorticoid deficiency (adrenal insufficiency), hypothyroid, water intoxication
Toddler with gastroenteritis and moderate dehydration. What management is most appropriate:
a) give IV fluids now
b) give IV fluids if vomiting
c) give oral solution containing 20-65 mmol of Na
d) stop breastfeeding and give electrolyte solution
e) hold re-feeding for 72 hours
c) give oral solution containing 20-65 mmol of Na (AAP says 45-50 Na for mild-moderate dehydration; WHO says 75; European says 60)
· Contraindications: protracted vomiting despite small frequent feeds, severe dehydration, paralytic ileus,
monosaccharide malabsorption
8 year old child is embarrassed by nocturnal enuresis. What percent persists to adulthood? 3 treatments?
- 20% of children over age 5 have nocturnal enuresis; resolves spontaneously in 15% of children every year
thereafter; <1% of adults continue to have nocturnal enuresis
- 20% of children over age 5 have nocturnal enuresis; resolves spontaneously in 15% of children every year
- reassurance
- limit fluid intake to 60mls after 6pm
- no caffeine after 4pm
- motivational therapy (star chart)
- bedwetting alarm
- pharmacologic (second line in specific situations only) -DDAVP
most common cause of hypertension in a neonate?
- Coarctation
- renovascular
- Renovascular
Secondary to umbilical artery catheterization and RA thrombosis.
4 yr girl with post void enuresis. What is most likely diagnosis?
Vaginal voiding - fused labia (incontinence occurs after voiding when girl stands up - run-off from behind labia)
Post strep GN. What two lab tests that would confirm your dx of PSGN.
- complement C3 (expect to be low)
- ASOT for proof of recent strep infection
What are some reasons to measure BP earlier than 3 years
Prematurity, SGA, NICU, Umbilical line CHD Recurrent UTI CKD Urologic malformations Systemic illnesses a/w HTN (NF, TS, SCD)
Pt had GAS 2 weeks ago. Now presents with hemoglobin 70, Platelets of 30 and rising Cr and BUN. What is the
diagnosis?
a) HUS
b) HSP
a) HUS
- HSP should not have anemia or TCP
- patients with familial HUS can be triggered by preceding illness
HUS: triad of anemia, thrombocytopenia and renal insufficiency. Most commonly caused by E coli. Case reports of atypical HUS caused by group A beta hemolytic streptococcus
Teenaged boy is in competitive atheletics. Comes to you for a routine physical. Found to have proteinuria 1+ to 2+. Physical exam including vitals and blood pressure are normal.
What is the most likely cause of his proteinuria (1)? What investigation do you order (1)?
- Orthostatic proteinuria
2. Repeat UA x3 on first morning void.
10 year old girl presents with dark urine for 1 day. No fever, dysuria, or abdominal pain. On exam non-toxic, normal vital signs except for hypertension, clinically mildly edematous. Urine dip shows large blood and protein. Bloodwork shows low C3.
What is the most likely diagnosis?
1. Post-strep glomerulonephritis
2. Membranoproliferative glomerulonephritis
3. Lupus
4. IgA nephropathy
- Post-strep glomerulonephritis
MPGN - lowC3/C4
SLE - Low C3/C4
9 mo old boy with undescended testes.
a) refer to urology
b) hcg trial
c) follow up
a) refer to urology
Canadian Urology Association recommends referral by 6 months, to allow for orchidopexy between 6 and 18 months, to preserve fertility.
Which of the following has the lowest relapse rate when used for primary enuresis in a 7 year old boy?
a) Imipramine
b) DDAVP
c) alarm system
d) nighttime fluid restriction
c) alarm system
What is most common kidney stone in pediatrics?
a) Ca oxylate
c) Struvate
d) Cystine
e) Uric acid
a) Ca oxylate - (many causes - hypercalciuria, increased Ca absorption from gut, renal leak (decreased tubular
reabsorption of calcium), primary hyperparathyroidism, iatrogenic, loop diuretics, ketogenic diet, corticosteroids,
exogenous adrenocorticotropic hormone, theophylline, distal RTA type I (calcium phosphate stones),
hypocitraturia (citrate inhibits calcium crystallization), high vitamin D, immobilization, sarcoid, cushing disease,
heterozygous cystinuria, hyperoxaluria)
c) Struvate - (magnesium ammonium phosphate - secondary to UTI, foreign body, urinary stasis)
d) Cystine - secondary to cystinuria
e) Uric acid - hyperuricosuria, Lesch-Nyhan syndrome, myeloproliferative disorders, post-chemo, IBD
You are assessing a 3 week old infant. The weight is 4 kg, the birth weight was 3.6 kg, the blood pressure is 90/55. The mother states that the infant is feeding well. The labs show: Na 142 K 3.6 Cl 113 Cr normal pH 7.25, urine pH 5.0 What is the most likely etiology a. Hyperaldosteronism b. RTA, proximal c. CF d. Psychosocial failure to thrive
b. RTA, proximal
RTA: normal AG metabolic acidosis (less HCO3 reabsorbed - proximal, or less H+ out - distal)
- type 1: distal - HCO3 <15, urine pH >5.5, hyperCauria
- type 2: proximal - HCO3 >15, urine pH <5.5
- type 4: hypoaldosteronism - high K, low Na
*acidic pH means distal tubule is working fine - so not type 1 or 4
A child has progressive periorbital and peripheral edema, abd pain and distention for 1 week. She is now febrile
with a temperature of 39.2 degrees. Blood pressure is within normal limits and her abdomen is diffusely tender. On U/A there is no blood but there is 4+ protein. What is the most likely diagnosis:
1. Post-strep GN
2. Nephritic syndrome with peritonitis
3. HUS
4. Appendicitis
- Nephritic syndrome with peritonitis
?nephrotic syndrome more likely - maybe typo?
Most common renal stone in children
a) oxalate
b) struvite
c) pyruvate
d) calcium
d) calcium
90% have Ca++ as major constituent (60% Ca Oxalate)
You are seeing an otherwise healthy 4 month old boy for a routine visit in your office. On examination you note
that he has an undescended testis on the right side
a. At what age is referral to a Pediatric General Surgeon appropriate in the case of an undescended testis?
b. Name 2 complications that can occur if an undescended testis is not repaired.
a. most descend in first 3 months; if not down by 4 months then unlikely to come down so refer
* note testes descend at 7-8 months gestation so normal for prems to be undescended
b. decreased fertility
- poor testicular growth
- malignancy (more difficult to screen)
- torsion
A 14 year old boy has hypertension. He is at the 99th percentile for height and weight.
What are the THREE investigations you need to do to assess for effects of his hypertension, and what would you be testing for?
If this boy wants to play hockey, what finding from an investigation would prevent him from doing so?
1) Echo - to look for long standing HTN causing dilated or thickened LV
Urinalysis, PCR, creat - to look for renal injury
Ophthalmology - to look for retinal changes
2) LVH on ECHO - limit until BP has normalized
2 day old infant presents with fever of 39.5 ax. He is breast-fed and his weight has fallen from 3.8 to 3.5 kg.
He is lethargic but rouses during the examination. His fontanelle is normal. Na 150, K 7.3, Cl 110, BUN 8,
Cr 110, uncong bili 190, normal CBC. What is the likely diagnosis?
a ) hypernatremic dehydration due to decreased fluid intake
b) hypertonic breast milk
c) diabetes insipidus
d) sepsis
e) meningitis
Hypernatremic + Hyperkalemia + Jaundice.
a ) hypernatremic dehydration due to decreased fluid intake
9 mo old male with inguinal hernia. What to do?
Refer to surgery
Follow up at 12 mo
Refer to surgery
- Inguinal hernias do not resolve spontaneously
- Risk of incarceration is highest in infancy, therefore infants with inguinal hernias should have repair within 2-3 weeks. Over 1 year old, less urgency required
Teen girl with a history of strange staring episodes. Has been drinking excessively and up to void through the night. Sodium is 118, potassium 3.4, chloride 84, BUN 4.5 and serum osmolarity 242 with a urine sodium <20 and urine osmolarity <80.
What is the diagnosis?
- SIADH
- psychogenic polydipsia
- psychogenic polydipsia
Normal serum osmol 275-295
Normal urine osmol 300-900
SIADH - too much ADH (vasopressin). More aquaporins in collecting duct. Absorb more water (low serum osmol) and excrete concentrated pee (high urine osmol)
Psycho Polydipsia - low serum osmol from drinking ++ water. Kidney works to excrete Dilute urine (low osmol urine)
Infant post cardiac surgery with poor urine output. BUN 25, Cr 177, urine (low Na, concentrated)
a. ATN
b. prerenal failure
c. anaesthetic injury to kidney
d. obstructive uropathy
e. renal vein thrombosis
b. prerenal failure (likely related to CO; low urine Na means body trying to keep in Na due to perceived low intravascular volume)
- Patients whose urine shows an elevated specific gravity (>1.020), elevated urine osmolality (UOsm > 500 mOsm/kg), low urine sodium (UNa < 20 mEq/L), and fractional excretion of sodium (FENa) <1% (<2.5% in neonates) most likely have prerenal ARF.
Child with vomiting and diarrhea who was fed a home concoction of enteral feed. Now is lethargic and seizing.
Na 115, creatinine elevated. Ur Na 12, Bicarb 18, glucose 3.5. Which is the best next step:
1. Administer 3% NaCl at a rate to increase Na by 2mEq/L/hr.
2. Give Lasix to increase urine output
3. Give bicarb
4. Give bolus of D5W0.45 20cc/kg
- Administer 3% NaCl at a rate to increase Na by 2mEq/L/hr.
Do not go faster than 12mEq/L/24hrs
A 6-year-old child has hypertension and persistent hypokalemia. Most likely diagnosis:
a) hyperaldosteronism
b) Bartter syndrome
c) Addison’s disease
d) renal vein thrombosis
e) aortic coarctation
a) hyperaldosteronism
Addison’s disease (primary adrenal insufficiency- not enough steroid hormones -> abdo pain, FTT,
darkening of skin, adrenal crisis= low BP, LOC, high K and low Na)
Barter - Hypokalemic metabolic acidosis
Renal Vein thrombosis and Aortic Coarct don’t explain the hypokalemia
8 month old baby with gastroentereitis. Na 160, Cl elevated, bicarb 14, HR 220, BP 60/30. What is your
initial management. Once stable what is your ongoing fluid management?
- Bolus 20ml/kg 0.9% normal saline by IV over 20 minutes and repeat as necessary until BP and HR normalize
- Recheck Lytes. Calculate Free Water Deficit + Insensibles + ongoing losses (vomiting and diarrhea)
- use D5/0.45%NS to start and monitor Na q4h
- do not lower Na by more than 0.5mEq/h (10-12mEq/24h)
FWD: TBW x (currentNa-targetNa/targetNa) / 24-48h
where TBW = 0.6mlxkg
Insens = 400 x BSA/24h
where BSA = sq((htxwt/3600)) or estimate 0.25 baby, 0.5 toddler, 1 kid
–> easier real life option and depending on how much space on exam: D545 +20KCl at 1.25-1.5x maintenance
Management for BP in stage 2 range.
Do upper/lower limb, consider referral, consider starting tx
- Should start with ACE-I, ARB, LA-Ca++ Blocker, or Thiazide Diuretic
- don’t give ACEi/ARB if risk of pregnancy
- ACEi/ARBs good if have DM or CKD
10 mo irritable. Acute onset of red scrotal swelling. Parents had noted on + off swelling in the past few days.
Today irritable, VSS mild tachycardia. On exam Rt red swollen and transilluminates well. What is the diagnosis?
b. Epididimytis
c. Testicular torsion
d. Acute hydrocele
e. Incarcerated hernia
e. Incarcerated hernia
15 yo post trauma observed for 24 hr and d/c home. Presents a day later with orange urine and oliguria and high Cr, no improvement with fluids
a) rhabdomyolysis
b) Renal vein Thrombosis
c) Pre renal failure
a) rhabdomyolysis
breakdown of damaged skeletal muscle, causing the release of myoglobin into the bloodstream, and urine (myoglobinuria)
myalgias, weakness, and elevated serum muscle enzymes (CK)
Child with testicular pain and blue dot sign what to do next. It has been more than 4 hours.
a. Call surgery
b. Reassurance
c. Scrotal support and NSAID
d. Testicular US with Doppler
c. Scrotal support and NSAID
Description of testicular torsion. How can this diagnosis be confirmed?
a) testicular ultrasound
b) nuclear scan
a) testicular ultrasound
Which of the following usually accompanies hypernatremic dehydration?
a. hypercalcemia, hypoglycemia
b. hypocalcemia, hyperglycemia
c. hypercalcemia, hyperglycemia
d. hypocalcemia, hypoglycemia
b. hypocalcemia, hyperglycemia
- there is a Na-Ca exchanger - so if Na is high to pull water in, Ca is by definition lost
Rash, Abdominal pain, diarrhea post URTI - what is diagnosis and most important complication to follow long term.
HSP
Risk of nephritic/nephrotic syndrome and progression to renal failure.
Serial BP and urinalysis:
- weekly x 1 month, then
- q2weeks x 2 months
- qmonthly x 3 mos
(95% who will have renal involvement will present in first 6 months)
A several day old baby presents E.coli sepsis. He has had decreased urine output since birth. His creatinine is elevated. On examination, he has a midline mass in his abdomen. What is the test that will give the diagnosis?
a) Renal ultrasound
b) VCUG
c) bHCG
d) Urine VMA, HVA
b) VCUG
A child is brought to the emergency department after an MVA. There has been a period with prolonged hypotension/hypovolemia. His urine output is now 0.3 ml/kg/hr. His mother states that he was evaluated for hematuria and proteinuria 1 year ago and was told that the child may have renal disease. What is the best way to detect parenchymal kidney disease:
a. Increased tubular reabsorption of urea
b. Decreased urinary creatinine
c. Urinary sodium <10 mmol/L
d. Fractional excretion of Na <3%
e. IVP
d. Fractional excretion of Na
(would be more correct if they said FENA >2%)
<3% - FeNA is best way to differentiate prerenal AKI from ATN. You would want to make sure patient euvolemic first to see if that improves status.
Then FeNa >2% suggests tubular damage because kidney is not able to conserve sodium.
14 mos male, FTT, vx, met acidosis, pH 7.31, bicarb 14, K 3.5, Na140, Cl 118, urine pH 6.3 a distal RTA b Bartters c organic acidopaty d nutrit. deprivation
a distal RTA
metabolic acidosis with normal K and alkalotic urine= poor H into urine= distal issue= type 1
- Bartters - alkalosis
What anomaly is most likely to be found when there is a single umbilical artery:
d. Renal anomaly
e. No anomaly
f. Cardiac anomaly
e. No anomaly
Premature - IUGR
A 17 year old boy presents to the ED 48 hours after being in an MVC with oliguria and orange coloured urine.
There was a prolonged extrication from the car. Despite adequate hydration in hospital his creatinine rises from 57 to 177. What is the next step in your management:
a. Epinephrine perfusion
b. Norepinephrine perfusion
c. Mannitol perfusion
c. Mannitol perfusion (theoretical benefit; pull fluid into vasculature and improve urinary flow
+++ IVF
± Bicarbonate if rising CK
± Mannitol
What are some lab features that differentiate renal from prerenal causes of AKI?
● Intrinsic AKI: specific gravity < 1.010, urine osmolality low (<350 mOsm/kg), high urine Na (>40), fractional
excretion > 2% (> 10% in neonates)= likely intrinsic
● Pre-renal AKI: elevated specific gravity (> 1.0200), elevated urine osmolality (> 500), low urine Na (< 20),
fractional excretion < 1% (< 2.5 for neonates)
6mm pelicalviceal dilatation noted on antenatal and postnatal u/s. What should be done next?
a) start prophylactic antibiotics
b) VCUG
c) DMSA
d) repeat U/S in 2 months
d) repeat U/S in 2 months
16 year old girl comes to your office. Her BMI is 27 and she has stage 1 hypertension. No protein present on urinalysis. What is the next step in managing her high blood pressure?
1) Beta blocker
2) Calcium channel blocker
3) Lifestyle
4) ACEi
3 ) Lifestyle
Kid with blue testes and gradual pain over days. Tender superior pole of teste.
a) ultrasound with Doppler
b) reassure
b) reassure
- > NSAIDs + scrotal support
Assuming by blue - they mean blue dot and torsion of appendix testis / epididymis
Do US if Dx not clear
Na 136, Cl 120, K 4, HCO3 14
What is the anion gap?
List 2 causes of NAGMA.
List 2 causes of WAGMA
AG = Na - Cl - HCO3 = 2
NAGMA = HARDUPS Hyperchloremia / HyperPTH ***Addisons ***RTA ***Diarrhea / Drugs Uteroenteric fistula Pancreatic Fistula
WAGMA = MUDPILES Methanol Uremia ***DKA Paraldehyde Iron / ***IEM ***Lactic Acidosis Ethanol Salicylates/ASA
Newborn with 6 mm pelvicaliectasis documented on antenatal U/S. What to do?
- Prophylax with antibiotics
- U/S prior to discharge
- U/S in 3 weeks
- VCUG
- U/S prior to discharge
What are the diagnostic findings for minimal change nephrotic syndrome (most common type)?
- periorbital edema progressing to generalized
- urine protein:cr ratio >2
- lytes, BUN, Cr usually normal
- hypoalbuminemia
- high cholesterol and triglycerides
6 yo female with prior history of recurrent UTI, 2 of them afebrile, known bilateral reflux. Last VCUG shows
ongoing low grade reflux. She has been off antibiotics and infection free for 2 years. What to do next?
a) Restart antibiotics
b ) Observe only
c) VCUG every 2 years
b ) Observe only
CPS:
For older children with no fever and presumed cystitis: 2 to 4 day course of oral abx is adequate; do NOT need prophylactic antibiotics for gr I - III VUR
Child presents with failure to thrive, polydipsia, polyuria, and hypokalemic metabolic alkalosis.
a) hyperaldosteronism
b) Bartter syndrome
c) cystinosis
d) renal tubular acidosis
e) congenital adrenal hyperplasia
ANSWER: b) Bartter syndrome
- hypoK, metabolic alkalosis, hypercalciuria, salt wasting
- dysmorphic: triangle face, protruding ears, large eyes, droopy mouth
Bartter -like being on lassie all the time.
a) hyperaldosteronism (K low but not polyuria/dipsia)
c) cystinosis (polyuria/dipsia, low K BUT non AG metabolic acidosis)
e) congenital adrenal hyperplasia ( not enough aldosterone = high K+, low Na)
