nephrology Flashcards
what is nephrotic syndrome
features
heavy proteinuria -> low plasma albumin and oedema
periorbital oedema (particularly on waking) which is often the earliest sign
• scrotal or vulval, leg, and ankle oedema
- ascites
- breathlessness due to pleural effusions and abdominal distension
- infection such as peritonitis, septic arthritis, or sepsis due to loss of protective immunoglobulins in the urine.
Ix performed at presentation of nephrotic syndrome
URINE TESTS
• Urine protein – on test strips (dipstick)
- protein:creatinine ration (early morning sample if possible)
BLOOD TESTS
• FBC
• Urea, electrolytes, creatinine
- Bone profile (albumin)
• Complement levels – C3, C4 LOW -> post-infectiours glomerulonephritis or SLE
• Antistreptolysin O or anti-DNAse B titres and throat swab
• Urine microscopy and culture
• Urinary sodium concentration
• Hepatitis B and hepatitis C screen
• Malaria screen if travel abroad
- chickenpox -> if on steroids, not immune we will give aciclovir
- Deranged lipid profile, with high levels of cholesterol, triglycerides and low density lipoproteins
High blood pressure
Hyper-coagulability, with an increased tendency to form blood clots
specific Ix for typical or minimal change nephrotic syndrome
Urine Tests
- urinalysis for blood and protein
- protein creatinine ratio
blood tests
- FBC
- U&Es and creatinine
- Bone profile (including albumin)
- Varicella zoster immunity status
features of a atypical presentation for nephrotic syndrome
<1 and >11 years elevated creatinine macroscopic haematuria elevated hypertension FH of nephrotic syndrome
acute Mx of nephrotic syndrome
admit to paeds - FIRST time presenting to monitor their fluid status
oral ABx - prophylaxis to oedematous pts to protect against pneumococcal infection
oral prednisolone - induce remission
complications of MCNC
peritonitis - Depressed immunity predisposes children with NS to infections
with encapsulated bacteria such as streptococcus pneumonia. Pneumococcal peritonitis
is a particularly devastating complication. Antibiotic prophylaxis and pneumococcal
vaccination are recommended.
-> phenoxymethypenicillin + macrolide if its gram -ve
Thrombosis - A hypercoagulable state due to urinary loss of antithrombin III,
thrombocytosis which may be exaggerated by steroid therapy and increased blood
viscosity from the raised haematocrit all predispose to thrombosis. Decrease the risk by
avoiding hypovolaemia, preventing sepsis and early mobilisation.
when do we start ABx
and what ABx
for UTI
nitrite +ve
Upper UTI -> 7-14 days IV for 2-4 days followed by 10 days oral
lower UTI - involve bladder only
Trimethoprim PO for 3-5 days
leukocyte esterase +ve and nitrite +ve
- Confirm with urine culture only if risk of
serious infection and/or history of previous UTI.
leukocyte esterase -ve and nitrite +ve -> confirm w urine culture
criteria for renal US
Criteria for renal ultrasound are as follows:
1. Infant <6 months old. Renal US within 6 weeks.
2. Atypical UTI as defined by: • Seriously ill. • Poor urine flow. • Abdominal/bladder mass. • Raised creatinine. • Septicaemia. • Failure to respond to antibiotics within 48 hours. • Infection with non-E. coli organism
- Recurrent UTI:
• 2 or more upper UTI.
• 1 upper and one or more lower UTIs.
• 3 or more lower UTIs.
what is glomerular haematuria
lower urinary tract haematuria
brown urine, presence of deformed RBCs
casts
accompanied bu proteinuria
LUT
red - beginning or end of stream nOT ACCOMPANIED BY PROTEINURIA
when is renal biopsy indicated
- there is significant persistent proteinuria
- there is recurrent macroscopic haematuria
- renal function is abnormal
- the complement levels are persistently abnormal.
causes of heamaturia
Nonglomerular • Infection (bacterial, viral, tuberculosis, schistosomiasis) • Trauma to genitalia, urinary tract, or kidneys • Stones • Tumours • Sickle cell disease • Bleeding disorders • Renal vein thrombosis • Hypercalciuria
Glomerular
- post infectious, streptococcal
- Vasculitis: Henoch-Schonlein purpura
SLE
Wegener’s granulomatosis
• Acute glomerulonephritis (usually with proteinuria)
• Chronic glomerulonephritis (usually with proteinuria)
• IgA nephropathy
• Familial nephritis, e.g. Alport syndrome
• Thin basement membrane disease
Ix of haematuria
- Urine microscopy (with phase contrast) and culture
- Protein and calcium excretion
- Kidney and urinary tract ultrasound
- Plasma urea, electrolytes, creatinine, calcium, phosphate, albumin
- Full blood count, platelets, coagulation screen, sickle cell screen
- ESR, complement levels, and anti-DNA antibodies
- Throat swab and antistreptolysin O/anti-DNAse B titres
- Hepatitis B and C screen
- Renal biopsy if indicated
- Test mother’s urine for blood (if Alport syndrome suspected)
- Hearing test (if Alport syndrome suspected)
Mx of bedwetting (nocturnal enureisis)
decreasing fluid inrake
toileting before bed
reward chart - should be given for agreed behaviour
NOT NORMAL IF THEY ARE ABOVE 5
< 7 yrs ENURESIS ALARM
> 7 yrs desmopressin
characteristics of glomerular haematuria
- Rusty or Coca-Cola colour
- Usually painless
- Oliguria and hypertension may be present
- Urine microscopy:
• Small and dysmorphic RBC
• Red cell casts
• Spikes/blebs on RBC
• Loss of RBC circumferential halo
characteristics of non glomerular haematuria
- Red or cranberry colour
- Usually painful, but also painless
- Urine microscopy:
• Monomorphic RBC
• No casts
• No spikes
• RBC circumferential halo present
features of a henoch schonlein purpura
purpuric rash - raised palplable over buttocks and extensor surfaces
- arthralgia
abdominal pain
HAEMATURIA/MILD PROTEINURIA
features of IgA nephropathy
macroscopic haematuria +URTI
features
- change in urine colour, haematuria, oedema and lethargy
OCCURS WITH URTI
what is post infectious glomerulonephritis
streptococcal infection elsewhere in the
body (pharyngitis, cellulitis, impetigo) up to 3-4 weeks earlier
ASOT titre and anti-DNAse B titre
Complement levels are reduced
what is nephritic syndrome
features on microscopy
glomerular inflammation - haematuria - proteinuria - decreased glomerular filtration rate with water and sodium retention results in oedema - hypertension.
Microscopy
- red cell casts
- blebs
- spikes
- loss of the circumferential halo
Sx and signs what is the diagnosis - FH of haematuria - deafness - streptococcal infection 2w before (pharyngitis/tonsillitis/impetigo/cellulitis) concurrent URTI (w haematuria) - previous gastroenteritis - palpable purpuric rash on buttocks photosensitive rash, joint pain
- FH of haematuria - Benign familial haematuria
- deafness - Alport’s syndrome
- streptococcal infection 2w before (pharyngitis/tonsillitis/impetigo/cellulitis - post-streptococcal
- concurrent URTI (w haematuria) - IgA nephropathy
- previous gastroenteritis - haemolytic uraemic syndrome
- palpable purpuric rash on buttocks - HSP
- photosensitive rash, joint pain - SLE
haematuria and abdominal pain
HSP
nephrolitiasis
UTI
CKD in children define
one of the following persisting for >3 months:
1. Structural abnormalities of the kidney seen on imaging,
2. Functional abnormalities within the kidney e.g. elevated urea or creatinine.
3. Abnormal GFR (<60ml/min/1.73m2
)
complications of CKD
BLEEDING TENDENCY - The increase in urea which accompanies CKD results in
abnormal platelet adhesion and aggregation
HYPERURICAEMIA
- decreased urinary excretion
INTELLECTUAL IMPAIRMENT - seizures severe intellectual disability to subtle
deficits resulting in poor school performance.
ANAEMIA - due to decreased erythropoietin production by the kidneys. The anaemia is
normocytic normochromic. It is associated with weakness, fatigue, increased
somnolence and decreased alertness.
ELECTROLYTE ABNORMALITIES - Metabolic acidosis with low sodium and increased potassium.
CVS disease- Due to the presence of dyslipidaemia and, hypertension.
GROWTH IMPAIRMENT - due to abnormalities in growth hormone metabolism
How to prevent a UTI
- Stay hydrated.
- Use the potty more often.
- Young children hold in their urine so as not to disturb play.
- Recommended to empty bladder every 2-3 hours.
- Time child’s potty sessions.
- Empty the bladder completely.
- Young children void just enough to relieve sensation – to go back to play.
- Encourage double voiding with each toilet visit.
- Proper wiping.
- Front to back.
- Avoid constipation.
- Clothing choices.
- Cotton underwear; avoid nylon, synthetic and tight fitting underwear.
- No bubble baths.
what is vesicoureteric reflex
urine travels backwards from the bladder
more common in females than males
a mercapto acetyl tri-glycine reflux (MAG3) test and a micturating
cysto-urethrogram (MCUG).
good fluid intake (drink enough), passing urine regularly, and avoiding constipation.
prophylatic ABx
surgery
- cystoscopy and injection of deflux
Mx of UTI
<3m refer immediately to hospital
Upper UTI >3m -> cephalosporin or co-amoxiclav should be given for 7-10 days
> 3m + lower UTI - oral ABS for 3 days per local policy
bring child back if they remain unwell after 34-48 hrs
