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)
What are some key differentiating features between multi cystic dysplastic kidney disease and polycystic kidney disease?
MCDK: kidney replaced by cysts - no normal tissue; can have ureteral atresia/contralateral VUR; not inherited, most common cause of abdo mass in newborn; unilateral
PCKD: AD (most common - large cysts develop over time) or AR, can be associated with syndromes like TS, von Hippel Lindau, Bardet-Biedl; bilateral; other organs affected (especially hepatobiliary)
You are referred an otherwise healthy 16 year old boy from his family doctor after proteinuria was noted on a routine urine dipstick.
- What are 2 reasons for a false positive for protein on dipstick?
- What is the most common reason for persistent proteinuria?
- What test will you perform to make this diagnosis?
- false positives:
- high urine pH (>7)
- highly concentrated urine specimen
- contamination of the urine with blood - Orthostatic Proteinuria ( 60% with persistent proteinuria)
- NOT associated with hematuria, hypertension, hypoalbuminemia, edema or renal dysfunction - First morning UA x 3
Follow child with prior urinary tract infection, 2 year free off Abx, no symptoms, no positive urine culture. Gr 1-2 reflux on last VCUG. What to do?
a) follow only
b) VCUG q2 years
c) antibiotics
a) follow only
Antibiotic prophylaxis is no longer routinely recommended after a UTI but may still be considered when a child is known to have a grade IV or V VUR, or a significant urological anomaly. NNT - 10
There are several drawbacks to performing a VCUG including expense, exposure to radiation, the risk of causing a UTI and discomfort for the child
What test do you do to confirm postural/orthostatic proteinuria?
diagnosis: obtain first morning urine sample and test for urinalysis and urine protein:cr ratio
- correct method of getting this sample: fully empty bladder before bed at night, then collect sample from first
void immediately upon getting out of bed in the morning
- obtain sample for 3 consecutive days
An African American girl presents with spots of blood on her underwear and urinary symptoms. On examination, there is a donut shaped protrusion in the introitus. What is your diagnosis?
a) sexual abuse
b) urethra prolapse
c) vulvovaginitis
d) foreign body
b) Urethral prolapse
RF: African Canadian Chronic cough Low E Connective tissue disorders Constipation Trauma
Nephrotic syndrome, has abdo pain and peritonitis. What is most likely bug?
a) strep pneumo
b) bacteroides
c) e coli
a) strep pneumo
4 year old with gross hematuria, pallor. Urine + blood and protein and WBC > 20 BP 104/65. Best way to make most likely diagnosis
- UCx
- C3
- Biopsy
C3
Did you know - PSGN often has pyuria
A child with nephrotic syndrome has recently been started on a course of oral steroids. Which of the following vaccines is contraindicated? A) Prevnar B) Hep B C) Influenza D) Varicella zoster
ANSWER: D) Varicella zoster - live attenuated vaccine is contraindicated in patients with immunocompromise including high dose steroids
A) Prevnar - inactivated bacterial
B) Hep B - Recombinant Viral
C) Influenza - nasal spray would be contraindicated (live attenuated viral vaccine), but all injected flu vaccines are inactivated or recombinant and would not be contraindicated
Teenager found to have struvite stone. What would be next investigation?
a) Urine calcium/Po4
b) Urine culture
c) 24 hour urine ca
b) Urine culture
UTI caused by urea-splitting organisms (most often proteus, klebsiella, e. Coli, pseudomonas) result in
excessive urinary alkalinization and excessive production of ammonia which can lead to precipitation of
magnesium ammonium phosphate (struvite) and calcium phosphate
Which of the following is a presentation of HUS?
Coombs + anemia
Thrombocytopenia
Myoglobinuria
Thrombocytopenia
2-day old baby with antenatal hydro, confirmed on post-natal U/S to have moderate-severe hydronephrosis. BW shows normal renal function, baby seems to be peeing well. a. consult urology prior to discharge b. DMSA c. arrange for an outpatient VCUG d. follow up in 2 months
a. consult urology prior to discharge
- advice regarding need for prophylaxis on discharge
- moderate to severe hydronephrosis does also need VCUG for further investigation (timing of VCUG - inpatient or outpatient?)
CPS Statement: Children with grade IV or V VUR or a significantly abnormal RBUS should be discussed with a paediatric urologist or nephrologist to determine whether there is an urgent need for a consult and make the best plan for further investigation and manageme
Which of the following is associated with a low C3:
a) Alport’s syndrome
b) nephrotic syndrome
c ) post-streptococcal glomerulonephritis
d) hemolytic uremic syndrome
e) Henoch-Schonlein purpura
c ) post-streptococcal glomerulonephritis (YES)
Baby with Prune Belly, was getting 90 ml/kg fluids.
Na 122, Normal K, Normal BUN/Cr. Anuric. Wt. 4 kg
What fluids, how much and how do you give glucose?
Hyponatremia:
NPO. Give IVF for insensibles and losses.
Insensibles = 400 x BSA / 24h
(BSA for infant ~0.25, to calculate BSA = sq((htxwt)/3600))
Start with D5NS, monitor bytes and glucose.
Adolescent boy with nonpainful testicular mass. What test should be done?
a) Ultrasound
b) Mumps serology
c) CT pelvis
a) Ultrasound
In adolescents, 98% of painless solid testicular masses are malignant. Should also do serum tumor markers (a-FP, b-HCG)
Child with nephrotic syndrome admitted with edema. Na=125. Best fluids:
- D5W/0.2% saline
- D5W/0.45% saline
- normal saline
- 3% saline
- nothing
- nothing (usually water + Na restrict and if need to resus albumin + diuretics)
Asymptomatic Hyponatremia Big Picture
o Hypovolemic= restore deficit w/ isotonic fluid
o Hypervolemic= water + Na restrict +/- diuretics (after albumin if low)
o Euvolemic= eliminate excess water
An 11 asymptomatic girl has hypertension 5 mmHg about the 95% for age and height. Her growth parameter is 50% for weight and height. BUN and Cr are normal. What do you do next?
a) start antihypertensives and follow up in 1 week
b) do urine collection for metanephrines
c) renal ultrasound
d) observe
d) Observe
Children with BP between the 95th and 99th percentile plus 5 mm Hg are categorized as stage 1 hypertension
- Repeat BP over 3 visits
15 yo female with 2+ protein on routine exam. What to do?
a) 24 hr urine protein
b) first morning urine analysis x 2
c) Renal function tests
b) first morning urine analysis x 2
14 year old girl with SLE. Hypertensive emergency BP 180/100.
Name 3 drugs you would use to treat her hypertension and their route of administration
IV for all:
Labetalol (a/b blocker)
Nicardipine (CCB)
Sodium nitroprusside (direct vasodilator)
± Hydralazine (vasodilator, slower to act)
-PO Nifedipine
ACE-I / ARBs are not for acute Tx
HTN Emergency: symptomatic HTN (CHF, ARF, Encephalopathy, Seizures, Retinopathy).
Reduce by 10% first hour then 15% more in next 3-12 hours (don’t get back to normal in acute phase)
A 7 year old child has an acute onset of hematuria, but is systemically well with no history of illnesses or recent
medication use. His HR is 110, RR is 24 and he is afebrile. His initial blood pressure is 140/87. What is your
medication choice for initial management of his blood pressure:
1. IV nitroprusside
2. Salt and H2O restriction
3. SL nifedipine
- SL nifedipine
hematuria and hypertension = nephritic picture
9 mo old with bronchiolitis, dehydrated was receiving IV fluid .
Now anuric euvolemic Na 120, urine specific gravity 1.020. What is going on?
What would be your next step in management.
SIADH
- Na is Low
- UOP is Normal or Low
- Urine Na is High (high specific gravity in this case)
- Fluid restriction. If unstable then give 3% Saline bolus.
5 yo male with fever and rhinorrhea presents with gross hematuria one day later. He has had a previous similar episode 3 months ago. What is the most likely diagnosis?
a) chronic glomerulonephritis
b) post-Strep GN
c) postinfectious GN
d) IgA nephropathy
e) nephrotic syndrome
d) IgA nephropathy (yes; recurrent, short latency period of 1-2 days)
post-Strep GN (no usually 7-21d latency and then last much longer)
A 12 month old has had diarrhea for 3 days and low-grade fever. One stool had scant blood. His urine output
has decreased since yesterday. On examination he is alert and interactive, has a HR of 150, BP 82/60, and skin
turgor is increased. What is the most appropriate initial management:
a. IV rehydration
b. PO rehydration
b. PO rehydration
4 year old with Proteinuria, 1+ protein in his urine on three first morning samples. He has no hypertension and no edema. What three investigations would you do?
Initial:
Serum for: Lytes, Creat, BUN, Albumin, C3/C4
- Urine Protein: Creatinine ratio - urinalysis with microscopy
Extra:
ASOT
ANA, anti-DNAse B
RVT etiology:
a) UVC
b) IDM with polycythemia and dehydration
b) IDM with polycythemia and dehydration
- sudden onset gross hematuria, unilateral/bilateral flank masses, HTN, oliguria
Antenatal U/S shows moderate hydro. U/S at 24 hrs normal. What to do next and why.
- repeat AUS after the first 3 days of life (wait for a normal neonatal fluid balance/urine output) - measuring at 24 hours is too early and can lead to false negatives
5 mo baby with UTI.
Give 2 indications for prophylaxis. Give 2 indications for referral to urology
prophylaxis:
- grade IV-V VUR
- significant urologic abnormalities
per CPS statement
referral to urology: same
15 year old with hypertensive emergency. List two medications that you can use to lower BP acutely. For each medication, list one side-effect (not including hypotension).
- hydralazine (direct vasodilator) - flushing, palpitations
- Esmolol (beta blocker) - bradycardia
- Nicardipine (CCB) - reflex tachycardia
- Sodium Nitroprusside - cyanide toxicity
- Labetalol (alpha/beta blocker) - Contraindicated in asthma
Basically all (if you need to guess): palpitations, nausea, SOB
4 yo female with persistent microhematuria on 2 urine dips. Grandfather has renal stones. What investigation would you do to prove the diagnosis (1)
renal and bladder ultrasound to rule out stones
A 10 year old boy presents to the ED post-MVC with significant fractures and a BP of 50/30. He is resuscitated,
but over the course of 48 hours in hospital his creatinine rises and he begins to have polyuria with a U/O of 5L/d.
What is the most likely cause of his condition:
a. Fat embolus
b. ATN
c. DM
b. ATN
Nonoliguria in the setting of ARF usually represent ATN.
Description of child with renal failure. What are four mechanisms for his anemia?
- decreased erythropoietin production
- iron deficiency
- Increased blood loss (frequent phlebotomy, surgery, dialysis)
- B12 deficiency
- folate deficiency
- hyperparathyroidism
- decreased RBC lifespan or destruction
- chronic inflammation (bone marrow suppression)
Management for BP in elevated range. When to recheck? What if still high?
Lifestyle: DASH diet, exercise, regular sleep
Recheck in 6 mos - do upper/lower limb BP
If still elevated at 1 year - do ABPM and workup
Kid with hypertension confirmed by ambulatory blood pressure monitoring. Has BP 121/86. What do you do?
a. start him on captopril
b. observe and repeat an ambulatory blood pressure test
c. renal ultrasound
d. 24 h urine catecholamines
c. renal ultrasound
- stage 1: BP 95-99th percentile plus 5mmHg - can evaluate prior to starting treatment
- stage 2: BP >99th percentile plus 5mmHg - prompt evaluation and pharmacologic therapy
What’s the most common cause of abdo mass in newborn?
a) hydronephrosis
b) polycystic kidneys
c) neuroblastoma
a) hydronephrosis
- hydronephrosis and multi cystic dysplastic kidneys present with abdo masses in newborns (NOT polycystic kidneys)
Teenage girl with chronic HTN, obese. What test to look for chronicity of HTN.
Echo
ECG
Urine Microalbumin
Renal Function tests
ECHO
5th Report:
Do Echo at time of starting Rx
ECG should not be done to look for LVH - not sensitive enough
Look for end organ damage:
LVH, hypertensive retinopathy, microalbuminuria, decreased GFR are all manifestations of end organ damage
What is the renal abnormality most associated with Turner’s syndrome
a) horseshoe kidney
b) vesiculo-ureteric reflux
c) cystic dysplasic kidney
d) MCKD
a) horseshoe kidney
Diabetes mellitus, microalbuminuria. Good blood sugar control. What med to start?
a) captopril
b) nifedipine
a) captopril
Renoprotective benefits with ACE inhibitors and ARBs compared with placebo have been noted in a number of trials
13 year old girl with NF1 presents to the ED with a two day history of headache, vomiting and blurry vision. She has a blood pressure of 180/100, Sats of 95% on RA, pupils are equal and reactive bilaterally. Apart from the severe headache, she is appropriate and responsive.
a. What are two medications you could use to treat her?
b. What is one complication from lowering her blood pressure too quickly?
c. What is the most likely cause of her hypertension
a) Esmolol/Labetalol, Sodium Nitroprusside, Nicardipine (IV), Hydralazine, Nifedipine (PO)
b) Decreased perfusion to brain - stroke or TIA
c) Pheochromocytoma
6 yo previously well with 10 minute GTC. Hypertensive, HR is 90. Na 115, U Na is 30.
Does not look dehydrated. What is your initial management (1). List 2 possible etiologies.
Give 3% saline (5 ml/kg - to get her to 120) bolus.
SIADH Adrenal Insufficiency Psychogenic Polydipsia Hypothyroid Water Intoxication
Recurrent hematuria in a young male with a speech delay
IgA nephropathy
Alport syndrome
PSGN
MPGN
Alport syndrome
- Hereditary nephritis
- Asymptomatic microscopic hematuria
- Single or recurrent gross hematuria 1-2d after URTI
- Proteinuria in boys
- BL SNHL
- Anterior lenticonus (pathognomonic)
Mgmt: Ace-I
An 8 year old female presents with microscopic hematuria. She has no symptoms. The most likely diagnosis is:
a. Alport’s
b. Wilms’ tumour
c. IgA nephropathy
d. Nephrocalcinosis
e. post streptococcal glomerulonephritis
?
Alports - not very common - but comes with persistent microscopic hematuria + SNHL
Wilms - no
IgA -> gross hematuria after infections
Nephrocalcinosis - well… hypercalciuria is most common cause of persistent asymptomatic hematuria in kids.
PSGN -> gross hematuria, ± nephrotic syndrome
Infantile cystinosis. What do you get?
a. cataracts
b. end stage renal failure
c. nephrocalcinosis
b. end stage renal failure
PIGN vs. IgA - which test differentiates?
a. immunoglobulins
b. C3
c. 24-hour urine collection
d. ANA
b. C3
- low in post-infectious GN, normal in IgA nephropathy
Management for BP in stage 1 range. What and When to recheck? What if still high?
Stage 1: SBP > 95%ile to +12mmHg, 130-139/80-89
+Lifestyle, Diet, Exercise and check in 1-2 weeks.
If still high in 2 weeks: Do upper/lower limb BP and weight management clinic. Check in 3 month.
If still high: ABPM, Start treatment, consider referral.
A child has bright red urine a few days after getting a URTI. What is the diagnosis?
IgA nephropathy or Alports
- if 7-8 days later : PSGN
Teenager presents with acute scrotal pain.
A) List two important features on physical exam.
B) List 4 differential diagnoses.
C) What two things would you do for management?
A) - **cremasteric reflex (absent in testicular torsion) - **abnormal lie of testis (e.g. higher than normal - seen in torsion) - swelling - discolouration B) - testicular torsion - torsion of appendix testis - epididymitis - trauma - ruptures testis, hematocele - incarcerated inguinal hernia - mumps orchitis - testicular vasulitis C) - surgery consult - ultrasound - pain medication - if suspicious of torsion can attempt manual detorsion
An 8 day old infant presents with Na 164, K 4.7. What is the most likely etiology?
a) Munchausen by proxy
b) Inadequate breastfeeding
c) CAH
d) RTA
b) Inadequate breastfeeding
CAH - hypoNa and hyperK
RTA - non-anion gap metabolic acidosis
A seven year old boy presents with bedwetting. Which of the following is more common with a diagnosis of
primary enuresis than with secondary enuresis:
a. Family history
b. Polydipsia
a. Family history
Pt with HSP. What would you do to monitor:
a. urinalysis
b. IgA
c. Stool for o/b
d. AXR
a. urinalysis
- weekly while active disease, then mostly x6 months
- also monitor BP
Description of a baby with a reducible hernia. When should he be referred to surgery for repair?
- Inguinal hernia - if <1 year refer urgently for repair in 2-3 weeks (up to 70% will incarcerate)
- if umbilical hernia: surgery is not advised unless hernia persists to 4-5 years of age, causes symptoms, becomes
strangulated or becomes progressively larger after age 1-2 years.
2 yo Kid with gastro now mod dehydration. VS normal. K+ 2.9, HCO3 12, pH 7.3. what next step?
a. ORS 300cc/h x 4 h
b. ORS 5 cc/hr x 24 h
c. IVF D5 ½ NS
d. IVF NS bolus
a. ORS 300cc/h x 4 h
CPS Oral Rehydration Therapy for Moderate dehydration:
ORS 100 mL/Kg over 4 hours
Newborn at 30 weeks how much sodium are you going to give and 2 reasons for your management?
Newborn - start with D10W for first 48h.
Newborns start of volume expanded with extra free water, kidneys unable to process exogenous sodium.
- Add in Na once physiologic diuresis started (3-5mEq/kg/day)
Baby with weak abdominal musculature. Cryptorchidism. Baby in intubated in NICU. Bilateral abdominal masses on exam. What is this associated with.
a) Bilateral wilms
b) Polycystic kidneys
c) Multicystic kidneys
d) Hydronephrosis
d) Hydronephrosis
- description of Prune Belly syndrome (aka triad or Eagle Barrett syndrome)
- urinary tract abnormalities from urethral obstruction as fetus - massive hydroureter and hydronephrosis, large bladder, patent urachus, VUR
- oligohydramnios, pulmonary hypoplasia, malrotation
5 day old infant in nursery has low urine output. Creatinine is 120. Renal ultrasound shows absent left kidney. The right kidney is at the low end of normal for size, and has consistent/uniform echodensity throughout. Which of the following is most likely?
a) Prognosis depends on liver and lung status
b) Likely will progress to end stage renal disease in childhood
c) Likely will progress to end stage renal disease in mid adulthood
d) he will have normal renal function
b) Likely will progress to end stage renal disease in childhood (Yes! Kidney should compensate so a normal or small is not normal as it should be hypertrophied. + Cr high + Kidney not uniform consistancy normally so wondering about dysplasia or hypoplasia. Without a good sole kidney can progress to RF)
- lung usually not affected because the single kidney is able to compensate
- ideally, if have unilateral renal agenesis the other kidney compensates - creatinine should be normal and the other kidney should be hypertrophied
Which is a possible etiology of neonatal hypertension:
a) autosomal recessive polycystic kidney disease
b) multicystic kidney disease
c) maternal eclampsia
d) unilateral hydronephrosis
e) peripheral pulmonic stenosis
a) autosomal recessive polycystic kidney disease
Decreased C3 is a feature of which of the following:
a. IgA nephropathy
b. HUS
c. post strep glomerulonephritis
d. nephrotic syndrome
c. post strep glomerulonephritis
- other causes of low C3: membranoproliferative GN, SLE
- kidney issues with normal C3: IgA nephropathy, idiopathic rapidly progressive GN, anti-GBM disease, HSP, Goodpasture’s, Alport, granulomatosis with polyangiitis (Wegner’s)
Best oral rehydration solution in a child with gastroenteritis and dehydration:
a) sodium 20 mmol/L, potassium 20 mmol/L, glucose 10%
b) sodium 60 mmol/L, potassium 20 mmol/L, glucose 2%
c) sodium 60 mmol/L, potassium 0 mmol/L, glucose 8%
d) ginger ale
e) apple juice
b) sodium 60 mmol/L, potassium 20 mmol/L, glucose 2%
A newborn infant has a left sided abdominal mass. A renal ultrasound demonstrates multi cystic kidney disease. Which of following would this be associated with:
a) ipsilateral hydroureter
b) posterior urethral valves
c) sensorineural hearing loss
d) cataracts
e) risk of malignancy
ANSWER: e) risk of malignancy (yes - wilms tumour arising from tissue even if cysts regress)
- hydroureter likely contralateral
- PUV not an association
- SNHL and cataracts not an association
4 year old who had dysuria and gross hematuria 4 mo ago– was give Septra for presumed UTI(urine culture not done). Since then has had repeated dysuria with hematuria (like 3-4x). Urine cultures all negative.
List TWO investigations you would do for this kid:
Urine Ca:Creatinine ratio
Renal US
Others: C3/C4 Creat, urea, lytes, albumin Urine protein:creat Renal US
Hyponatremia. Na 108. Treated with 3% NS. How to correct?
a) Na in 4-6 hours
b) 118-120 in 24 hours
c) 135-140 in 24 hours
b) 118-120 in 24 hours
Max 12 in 24 hours (0.5 per hour)
The reason that we do orchidopexy is:
a) reduce chance of testicular cancer
b) allow testicular examination
c) increase fertility potential
c) increase fertility potential and b) allow testicular examination and a) reduce chance of testicular cancer
No good consensus .
What is true of a patient with multicystic dysplastic kidney disease?
a. chance of VUR
b. likely that first degree relative will be affected
c. usually causes hematuria
d. early hypertension
ANSWER: a. chance of VUR
Increased risk of abnormalities in the contralateral kidney (21%)
b. likely that first degree relative will be affected (not usually inherited vs. PCKD is)
c. usually causes hematuria (false; AR PCKD can)
d. early hypertension (rare to have HTN; usually late)
A 3-month-old boy born at term is failing to thrive. He is otherwise asymptomatic.
Labs show Na 142, K 6.5, Cl 114, Cr 45, HCO 3 14, pH 7.24.
a) renal failure
b) renal tubular acidosis
c) hyperaldosteronism
d) cystic fibrosis
e) Fanconi syndrome
b) renal tubular acidosis
Hyperkalemic metabolic acidosis (NAGMA) - Type IV RTA
Baby with hydronephrosis, anuria. What test?
a) VCUG
b) DMSA scan
c) CT scan
a) VCUG
Rule out urethral obstruction with PUVs
Photograph of Prune Belly Syndrome. Which of the following is a consistent association:
a. Posterior urethral valves
b. Progression to renal failure
c. Sex-linked inheritance
d. Polyhydramnios
b. Progression to renal failure
Due to renal dysplasia and obstruction. Many get CKD and die in utero. 50% of those surviving infancy get CKD.
Prune Belly - lack abdo muscles, undescended testes, urinary tract abnormalities
In a newborn found to have a multicystic-dysplastic kidney, the following is likely:
a. hematuria
b. hypertension
c. ureteropelvic reflux
c. ureteropelvic reflux
A child with HSP will have:
a. increased IgA
b. decreased Hb and platelets
c. decreased immunoglobulins
a. increased IgA
- most common childhood vasculitis
- IgA deposition causing abdo pain (FOBT+, intussusception), arthritis, renal (microscopic hematuria/proteinuria)
(thought to be on same spectrum of IgA nephropathy)
A 5 day old male newborn presents to your emergency department with a 24 hour history of lethargy, poor feeding and vomiting. On bloodwork you find that his Na is 128 and his K is 6.5. The remainder of his bloodwork is unremarkable.
List 2 diagnoses on your differential
CAH
Addison’s (Adrenal Insufficiency)
10 yo with hematuria and hypertension 140/90 following URTI. You suspect post-infectious GN.
a) List one test that would help you distinguish from IgA nephropathy.
b) What do you do for the hypertension
c) List 2 indications to consult nephrology
a) C3 (will be low in PIGN)
b) Treat HTN: If symptomatic - consider Labetalol/Nitroprusside/Nicardipine.
Otherwise: salt and fluid restriction, diuresis (lasix), CCB (Nifedipine PO) ACE-I/ARB
c ) Unclear Dx (normal C3, no evidence of infection), nephrotic syndrome, renal failure, persists >2 months
Hypertension:
Normal BP
Elevated
Stage 1
Stage 2
Child <13 Normal : SBP < 90%ile Elevated: SBP 90-95 Stage 1: SBP >95%ile to 95%ile+12mmHg Stage 2: SBP >95%ile+12mmHg
Child >13 Normal: SBP <120/80 Elevated: SBP 120-129/80 Stage 1: SBP 130-139/80-89 Stage 2: SBP >140/90
Kid with diabetes insipidus.
What is result of water deprivation test.
a) increase in urine osmolality
b) increase in serum osmolality
c) decrease in urine osmolality
d) decrease in serum osmolality
b) increase in serum osmolality
Despite having no water, in DI you continue to inappropriately lose water due to inability to make ADH or inability to respond to ADH. You make lots of dilute urine.
7 year old with microscopic hematuria most likely dx?
a. IgA nephropathy
b. alports
c. idiopathic
a. IgA nephropathy
In distal Renal Tubular Acidosis what do you find?
- Glucosiuria
- Phosphaturia
- Calciuria
Distal:
Low K+
Urine pH > 5.5
Hypercalciuria
+ Nephrocalcinosis
Child had a URTI a week ago. He now presents with bloody diarrhea, abdominal pain and a petechial rash. What is his diagnosis?
HSP
3 month old boy with UTI and grade 2 VUR on Right side. Which is the most clinically relevant way to detect renal scarring. 1. IV pyelography 2. nuclear renal scan (DMSA) 3. Renal excretion scan (MAG-3 or DTPA) 4. VCUG
- nuclear renal scan (DMSA)
Which of the following is associated with a decrease in C3 and C4?
a) Alport’s
b) MPGN
c) membranous nephropathy
d) IgA nephropathy
MPGN
PSGN - low C3, low or N C4
SLE - low C3 and low C4
MPGN - low C3 and low C4
IgA nephropathy - normal C3 and C4
Table of lab values. You had to determine it was proximal RTA.
9 month old what test will confirm your diagnosis?
a. Urine Phosphate
b. Leukocyte cystine level
c. Ca:Cr ratio
b. Leukocyte cystine level
Cystinosis: Fair + Blonde French Canadians
- Accumulation of cystine kidney, liver, eye, and brain
- Severe infantile form with severe tubular dysfunction results in end stage kidney disease
- Symptoms of Fanconi syndrome – polyuria and polydipsia, growth failure, rickets
- Can also develop hypothyroidism, HSM, delayed sexual maturation
Tx: Cysteamine PO and eyedrops
A boy with family history of renal stones, presents with 24-48h right flank pain. Passed a 5 mm stone determined to be calcium oxalate.
Name 4 dietary interventions you would recommend to decrease the risk of further stones.
1) Increase daily fluid intake
2) Increase DIETARY calcium, decrease calcium supplements
3) Reduce sodium
4) Reduce dietary oxalate : spinach, beets, rhubarb
5) reduce animal protein
6) Decrease supplemental vitamin C and calcium
Midline mass and E.coli urosepsis, next diagnostic step:
a) VCUG
b) renal U/S
b) renal U/S
- renal U/S is initial screen for first febrile UTI in child less than 2
- mass suspicious for hydronephrosis
How do you differentiate Bartter from Gittelman syndrome?
Both metabolic alkalosis and hypoK, but Gittelman has hypocalciurua and low magnesium
Young girl presenting with puffy around the eyes and pale. Labs reveal albumin of 26 and normal urine protein. What further investigations would you order?
- stool alpha-1 antitrypsin
- Serum Trypsinogen
- Urine protein:creatinine ratio
- ECHO
- Stool alpha-1 antitrypsin
Elevated alpha-1-antitrypsin in stool suggests excessive GI protein losses (because it is a protein that doesn’t get broken down by digestive enzymes - a good marker for protein loss via the gut).
Trypsinogen - released by pancreas - low levels indicates pancreatic insufficiency.
Child with hematuria found during pre-camp check-up (incidental finding). What would you do next?
- Hx and PE (with BP)
Repeat UA to prove it is persistent (≥3 in 2 weeks).
If persistent : UCx, Ca:Cr ratio
- asymptomatic child with microscopic hematuria on 3 dips in a 2 week period should have: urine culture, urine ca:cr ratio +/- sickle screen. If normal, next step is urinalysis in all first degree relatives. Renal and bladder ultrasound then indicated to rule out tumour, cystic disease, hydronephrosis, urolithiasis. If normal, then check serum lytes and creatinine.
- most likely if all Ix negative is benign microscopic hematuria (often runs in families)
Periorbital swelling with no tenderness, no fever and normal blood pressure. What do you do?
a. reassure
b. check for proteinuria
c. start antibiotics
b. check for proteinuria
- edema is the most common presenting symptom in children with nephrotic syndrome
9 year old, back pain x6 months, hydronephrosis on u/s. Has a midline mass. What gives diagnosis?
a) VCUG
b) lasix scan (MAG3)
c) CT abdo
d) suprapubic tap
c) CT Abdo
a) VCUG – tells you level of obstruction but not diagnostic
b) lasix scan (MAG3) – good assessment of renal function and can characterize obstruction, not diagnostic
Given age and duration - worried about intra-abdominal tumor
For healthy children: when do we start measuring BP and how often?
Start at age 3, measure yearly
13 yr old male with BP 130/80, averaged from 3 readings at your office that visit. Height is 25% (They provided a blood pressure chart by age and height percentile). He is asymptomatic. What is your recommendation. This is 95-99% for age and height. This falls into the Stage 1 category. 1 - repeat BP check at next 3 visits 2 - send for ambulatory BP 3 - BUN/Cr, urine ACR 4 - BUN/Cr, urine ACR, ECG, lipids, u/s
1 - repeat BP check at next 3 visits
Diagnostic evaluation for confirmed HTN
- All Patients:
- Urinalysis
- Lytes, Urea, Creatinine
- Lipid profile
- Renal Ultrasound in those < 6 years or with abnormal UA or renal fcn
- Obese (BMI >95%ile), add:
- Hemoglobin A1C
- AST, ALT (screen for fatty liver)
- Fasting Lipid profile (screen for dysplidemia)
- Other Options Depending on Hx and PE:
- Fasting glucose
- TSH
- Drug Screen
- Sleep Study
- CBC (especially with growth delay or abnormal renal function)
- Echocardiogram (don’t do an ECG looking for LVH)
Description of a child with renal stones. Was a prem. Which medication was the child likely on in the
neonatal period that would contribute to this picture?
a. gentamicin
b. furosemide
c thiazide
b. furosemide - nephrocalcinosis is associated with urinary stones. The most common causes are furosemide, distal RTA, hyperparathyroidims, medullary sponge kidney, hypophosphatemic rickets, sarcoidosis, hyperoxaluria, prolonged immobilization, cushing syndrome, hyperuricosuria, renal candidiasis
An 8-year-old boy has recurrent episodes of asymptomatic gross hematuria triggered by intercurrent illnesses. Between illnesses, dipstick shows microscopic hematuria. Best test to determine etiology:
a ) immunoglobulins
b) C3 and C4 levels
c) 24-hour urine protein
d) abdominal ultrasound
e) DMSA scan
b) C3 and C4 levels
Would help distinguish IgA from PSGN. Other causes: Alports (Fhx) or Thin Basement Membrane.
Nelsons - Immunoglobulins is not helpful for distinguishing IgA nephropathy - only 15% of pediatric population have elevations.
week old with pyloric stenosis, severe metabolic alkalosis (bicarbonate 34). What to do:
- Give hydrochloric acid IV
- OR immediately
- Give large amounts of chloride IV
- Give 5mmol/kg of KCl IV bolus
- Give ascorbic acid IV
- Give large amounts of chloride IV
Pyloric stenosis = hypochloremic, hypokalemic metabolic alkalosis
Pre-op re-hydration with NS
3 wk male infant vx, lethargy, poor po intake, Na 118, K8, most important lab test a vasopressin b 17 OHP c calcium d renin
b 17 OHP
CAH
The most common cause of secondary enuresis in a 7 y/o boy is:
- DM
- Constipation
- Psychiatric problem
- UTI
- Nephrogenic DI
- Constipation
Which of the following will be found in a 6 year old with a distal RTA:
a. Glycosuria
b. Hypercalciuria
c. Metabolic alkalosis
b. Hypercalciuria
6 month M with UTI and found to have grade 2 reflux on one side. What to do?
- Prophylax with amoxil
- Prophylax with septra
- Do Urine C+S monthly
- Repeat VCUG in 6 months
- Repeat VCUG in 6 months
Probably an old question. Only VCUG if RBUS abnormal or after second febrile illness in a child <2
(CPS: no prophylaxis unless gr. 4-5 or signif uro anomaly)
Which of the following is present in tumour lysis syndrome:
a) hyperuricemia
b) hyponatremia
c) hypokalemia
d) hypophosphatemia
e) hypercalcemia
a) hyperuricemia
