Nephro-urology Flashcards
Which children with a UTI should be referred urgently to a paediatrician
- <3 months
- Systemically unwell
What is the first line Abx for acute pyelonephritis/Upper UTI in children >3 months
cefalexin - remember to always get a culture
co-amoxiclav
What is the first line Abx for cystisis/lower UTI in children >3 months
trimethoprim, nitrofurantoin, amoxicillin
What are considered atypical UTI symptoms
Poor urine flow. Abdominal or bladder mass. Raised creatinine. Sepsis. Failure to respond to treatment with suitable antibiotics within 48 hours. Infection with non-E. coli organisms
Who should be referred for an US of the urinary tract (infection)
- Any child with atypical symptoms
- <6 months with recurrent UTI - During infection
- > 6 months with recurrent UTI - within 6 weeks
- Everyone <6 months that presented with first UTI that responds to Rx - Within 6 weeks
What is a dimercaptosuccinic acid scintigraphy (DMSA) scan
Scan to assess renal morphology, structure and function
Who should have a dimercaptosuccinic acid scintigraphy (DMSA) scan at 4-6 months
- Any atypical UTI <3 years old
- Any child with recurrent UTIs
Who should have an US scan during an acute UTI
- Any child with an atypical UTI
- Children <6months with recurrent UTIs
Who should have an US scan within 6 weeks of a UTI
Any child > 6 months with a recurrent UTI
Children <6 months that responds well to Rx
What is a micturating cysto-urethrogram
An X ray of the urinary tract that allows us to view the flow of urine in the tract and also how the bladder empties and fills
Who should have a micturating cysto-urethrogram
Any child <6 months with atypical or recurrent UTIs
Which children with UTI require follow up with a paediatric nephrologist
- antenatally diagnosed renal abnormality
- Hypertensive children
What is the most common bacteria causing UTI in childre
E.coli
When to suspect UTI in an infant <3 months
fever
vomiting
lethargy or irritability
poor feeding or failure to thrive.
When to suspect a UTI in an infant >3 months
fever frequency dysuria Abdominal pain loin tenderness vomiting poor feeding dysfunctional voiding changes to continence.
Who should be started on antibiotics for a UTI without a culture and microscopy
- both leukocyte esterase and nitrite are positive on dip
- leukocyte esterase is negative and nitrite is positive - send urine for sample
When should you diagnose acute pyelonephritis/upper UTI
- temp >38 + bacteriuria
- Temp <38 + loin tenderness + bacteriuria
What are the risk factors for UTI in children
- female
- <12 months
- previous UTI
- Voiding dysfunction
- Vesicoureteral reflux (VUR)
- Sexual activity
- No Hx of breastfeeding
- Immunosupression
What factors can lead to voiding dysfunction
- structural abnormalities
- neurogenic bladder
- voluntary withholding of urine (dysfunctional elimination syndrome)
- chronic constipation
- indwelling foreign bodies.
What are the possible complications of childhood UTIs
- renal scarring/damage
- hypertension
- Bacteriuria and hypertension in pregnancy; pre-eclampsia:
- Renal insufficiency and failure
What is defined as recurrent UTIs
- 2 or more episodes of upper UTI
- 1 Upper + 1 lower UTI
- 3 or more episodes lower UTI
When can you consider prophylactic Abx in children with recurrent UTIs
> 3 months with specialist input - need to rule out why and ensure it has been adequately treated
What is Henoch-Schönlein purpura (HSP)
Systemic small vessel vasculitis involving the blood vessels of the skin, GIT, kidneys and joints
What 4 areas of the body are mainly affected by Henoch-Schönlein purpura (HSP)
Skin
GIT
Kidneys
Joints
What skin symptoms can you expect with Henoch-Schönlein purpura (HSP)
- Affected in all cases
- A purple-red rash, which does not turn white when pressed.
- can turn into ulcers
- backs of the limbs, especially the legs, which can also be swollen
What digestive symptoms can you expect with Henoch-Schönlein purpura (HSP)
Tummy aches and pains which can be severe and occasionally result in blood in the stool
What joint symptoms can you expect with Henoch-Schönlein purpura (HSP)
Painful and swollen joints can occur due to inflammation, usually affecting the knees and ankles
What kidney symptoms can you expect with Henoch-Schönlein purpura (HSP)
- Protein and blood in the urine due to inflammation in the kidneys.
- Often this will resolve as the child gets better
- can be a more serious long-term problem and will need careful monitoring
Who is mostly affected by Henoch-Schönlein purpura (HSP)
Children age 3-10
Males > females
2/3 have URTI 1-3w prior
How would you describe the rash in Henoch-Schönlein purpura (HSP)
symmetrical, erythematous macular rash, especially on the back of the legs, buttocks and ulnar side of the arms.
What are the criteria for Henoch-Schönlein purpura (HSP)
Must be palpable purpura which is not thrombocytopenic/petechia plus one of:
- Diffuse abdominal pain.
- Typical histopathology
- Arthritis or arthralgia.
- Renal involvement (demonstrated by quantified proteinuria or haematuria).
What is the typical histopathaology of Henoch-Schönlein purpura (HSP)
leukocytoclastic vasculitis or proliferative glomerulonephritis with predominant IgA deposits
What are differential diagnoses of Henoch-Schönlein purpura (HSP)
- Intussusception
- Connective tissue diseases - SLE.
- Other causes of purpuric rash - eg, thrombocytopenia, meningococcal meningitis.
- IBD
What investigations should you do if suspecting Henoch-Schönlein purpura (HSP)
- Urinalysis
- FBC U&E
- ESR
- Serum IgA levels
- Autoimmune antibody screen
- ? Abdo US
What is the management of Henoch-Schönlein purpura (HSP)
- Usually self limiting
- NSAIDs (caution in renal insufficiency)
What is considered secondary bed wetting
accidents after having been dry at night without assistance for 6 months
What day time symptoms should you enquire about when taking an enuresis history
Urgency.
Frequency (more than seven times a day).
Daytime wetting.
Abdominal straining or poor urinary stream.
Pain passing urine.
Passing urine infrequently (fewer than four times a day).
Who should you consider doing a urine dip on in children with enuresis
- Bedwetting started in the past few days or weeks.
- daytime symptoms.
- signs of ill health.
- signs of UTI
- Signs of diabetes mellitus
What are the possible underlying cayuse for enuresis
- UTI
- Diabetes mellitus
- Maltreatment
- congenital malformations
- Chronic constipation
- Behavioural/emotional problems
How to explain bed wetting in children less than 5
It occurs because the volume of urine produced at night exceeds the capacity of the bladder to hold it, and the sensation of a full bladder does not wake the child.
What advise should you give regarding diet and fluid in children with enuresis
- balanced diet
- adequate fluid intake
- avoid caffeinated drinks
What advise should you give regarding toileting patterns in children with enuresis?
- encouraged to empty their bladder regularly during the day and before sleep (between 4–7 times in total).
- waterproof mattress and duvet cover
- easy access to a toilet and/or potty at night.
- If toilet trained by day for > 6 months, consider a trial of at least 2 nights in a row without nappies or pull ups
What type of positive reward symptoms can be used to help with enuresis
- avoid negative/penalties for wet nights
- Do no remove positive rewards because of set backs
- rewards for dry nights
- rewards for drinking adequate levels of water at night
what is the recommended daily intake for children aged 5-8
1000–1400 mL
what is the recommended daily intake for children aged 9-13
1200–2100 mL (girls); 1400–2300 mL (boys).
what is the recommended daily intake for children aged >13
1400–2500 mL (girls); 2100–3200 mL (boys).
In which group of people would desmospressin be an appropriate treatment for
- > 5
- in need of short term fix - sleepover/school trip
- ## enuresis alarm not desirable/appropriate
Which children with enuresis should be referred to a community paediatrician
- Failed 2 courses of treatment (desmospresson/enuresis alarm)
- Tricyclic antidepressants (such as imipramine) or antimuscarinics (such as oxybutynin) may be initiated
What is first line treatment in the management of enuresis
enuresis alarm (>7 YO) - not on NHS unfortunately
How to assess response of enuresis alarms
- check response after 4 weeks if improvement continue until 2 weeks of dry nights
- If no improvement after 4 weeks - stop
- If not dry after 3 months - consider stopping
- consider dual Rx with desmopressin
What are the aims of treatment with enuresis alarms
- Recognize the need to pass urine.
- Wake to go to the toilet or hold on.
- Learn over time to hold on or to wake spontaneously, and stop wetting the bed.
How long should a child stay on desmopression
- Check response after 4 weeks
- if response, continue for 3 months
- after 3 months, stop for 1 week to check response
How does desmopressin work?
- taken at night
- reduces amount of urine body produces mimicing the bodys own naturally occuring anti-diuretic hormone
- In most children and young people, levels of ADH rise overnight and reduce the volume of water excreted by the kidneys compared with during the daytime.
What advise should be given to parents of children on desmopressin
- reduce fluid intake 1 hour prior to taking desmopressin to sips only and for 8 hours after to reduce risk of overload and hyponatraemia
- Avoid swalloing pool water
- Avoid NSAIDs - cause water retention
- stop if vomiting and diarrhoea
