Nephrology Flashcards

Question

What is daytime enuresis and its causes?

Answer 1

Lack of bladder control in the day in a child (3-5 years) old enough to be continent Can also occur in the night Lack of attention to bladder sensation - development or psychogenic problem - too busy to respond to sensation of full bladder Detrusor instability - sudden urgent urge to void Bladder neck weakness Neuropathic bladder - bladder is enlarged, fails to empty properly UTI, in absence of other symptoms Constipation Ectopic ureter causes constant dribbling, child always damp

Answer 2

Examination may show neuropathic bladder e.g. distended, abnormal perineal sensation, abnormal leg reflexes Sensory loss in S2, 3, 4 Girls dry at night but wet on getting up - ectopic ureter opening into vagina Urine sample - MC&S USS, urodynamic studies

Answer 3

If neurological cause excluded; star charts, bladder training, pelvic floor exercises Alarm bad to alert when lack of attention to sensation Treatment of constipation Anticholinergic drugs e.g. oxybutynin to damp down contractions

Answer 4

Loss of previously achieved continence Emotion upset UTI Polyuria from osmotic diuresis in diabetes mellitus or renal concentrating disorder e.g. sickle cell or chronic renal failure

Answer 5

Test urine sample - infection, glycosuria, proteinuria Assessment of urinary concentrating ability - early morning sample USS of renal tract

Answer 6

Orthostatic proteinuria - when child is active and upright during the day Glomerular abnormalities e.g. minimal change, abnormal glomerular basement membrane Increased glomerular filtration pressure Reduced renal mass HTN Tubular proteinuria

Answer 7

``` Urine protein - test strips, dipstick FBC, ESR Urea, electrolytes, creatinine and albumin Complement levels - c3, c4 Antistreptolysin O, anti-DNAse Urine microscopy and culture Urinary sodium conc Hep B and C, malaria ```

Answer 8

The proteinuria resolves with corticosteroid therapy Do not progress to renal failure ``` Age between 1-10 No macroscopic haematuria Normal blood pressure Normal complement levels Normal renal function ```

Answer 9

Referral to paediatric nephrologist Management of oedema with diuretic therapy, salt restriction, ACE inhibitors Sometimes NSAIDs to reduce proteinuria

Answer 10

Hypovolaemia - complains of abdominal pain and feels faint, peripheral vasoconstriction and urinary sodium retention. Thrombosis due to urinary losses of antithrombin Can be exacerbated by steroid therapy Infection - children in relapse at risk of infection with capsulated bacteria esp. pneumococcus Spontaneous peritonitis may occur Vaccinations needed Chickenpox and shingles treated with aciclovir Hypercholesterolaemia

Answer 11

Non glomerular - Infection (bacteria, viral, TB, schistosomiasis) Trauma to genitalia, urinary tract or kidneys Stones, tumours, sickle cell Bleeding disorders Renal vein thrombosis Hypercalciuria Glomerular - Acute glomerulonephritis, with proteinuria Chronic glomerulonephritis with proteinuria IgA nephropathy Familial nephritis e.g. Alport Thin basement membrane disease

Answer 12

Urinary tract infection

Answer 13

Significant persistent proteinuria Recurrent macroscopic haematuria Renal function abnormal Complement levels persistently abnormal

Answer 14

Urine microscopy with phase contrast, culture Protein and calcium excretion Kidney and USS urinary tract Plasma urea, electrolytes, creatinine, calcium, phosphate, albumin FBC, platelets, clotting, sickle cell ``` If indicative of glomerular haematuria: ESR, complement, anti-DNA Throat swab Hep B and C Renal biopsy if indicated Test mother's urine for blood if alport syndrome suspected, and test hearing ```

Answer 15

Post infections, including streptococcus Vasculitis - Henoch-Schonlein purpura or rarely SLE, Wegener's IgA nephropathy Anti glomerular basement membrane disease - Goodpasture's

Answer 16

Brown urine, the presence of deformed red cells and casts, and proteinuria

Answer 17

Usually follows strep throat or skin infection Evidence of recent strep infection Low complement C3 returns to normal after 3-4 weeks Hx of e.g. tonsillitis, positive throat swab, anti-streptolysin antibody titres Management is supportive, may need antihypertensives and diuretics if e.g. hypertension and oedema

Answer 18

Characteristic skin rash - buttocks, extensor surfaces of arms and legs, ankles Joint pain and swelling Abdominal pain - haematemesis and malaena, intussusception Renal - microscopic/macroscopic haematuria, nephrotic syndrome, glomerulonephritis

Answer 19

Inflammation within the nephrons of the kidney Reduction in kidney function Haematuria - visible, invisible Proteinuria Most common Post-strep IgA - Berger's disease

Answer 20

Henoch-Schonlein purpura - IgA vasculitis IgA nephropathy is Berger's IgA deposits and glomerular mesangial proliferation Management is supportive treatment and immunosuppressant medications

Answer 21

``` Renal Parenchymal disease Renal artery stenosis PCKD Renal tumours ``` Coarctation of the aorta Catecholamine excess e.g. phaeochromocytoma Endocrine Congenital adrenal hyperplasia Cushing's, hypothyroid Essential HTN Diagnosis of exclusion

Answer 22

``` Vomiting Headaches Facial palsy Hypertensive retinopathy Convulsions Proteinuria Failure to thrive and cardiac failure most common in infants ```

Answer 23

``` Unilateral Multicystic kidney Compensatory hypertrophy Obstructed hydronephrosis Renal tumour - Wilm's ``` Bilateral Polycystic kidneys Tuberous sclerosis Renal vein thrombosis

Answer 24

Uncommon Predisposing factors e.g. UTI, structural abnormalities, metabolic abnormalities Commonest are phosphate stones associated with infection Calcium in idiopathic hypercalciuria

Answer 25

Generalised proximal tubular dysfunction Vulnerable to cellular damage Due to accumulation of cystine, fructose intolerance, Wilson's, heavy metals, drugs, toxins, Vit D deficient Leads to excessive urinary loss of amino acids, glucose, phosphate, bicarbonate, sodium, potassium, calcium urate.

Answer 26

``` polydipsia, polyuria salt deposition, dehydration hypercholraemic met acidosis rickets failure to thrive ```

Answer 27

<0.5ml/kg per hour

Answer 28

Sudden potentially reversible reduction in renal function Prerenal Hypovolaemia - gastroenteritis, burns, sepsis, nephrotic syndrome Circulatory failure Renal Vascular - haemolytic uraemic syndrome, vasculitis, embolus Tubular - acute tubular necrosis, ischaemia, obstruction Glomerular - glomerulonephritis Interstitial - interstitial nephritis, pyelonephritis Postrenal Obstruction - congenital e.g. posterior urethral valves, acquired e.g. blocked catheter

Answer 29

Correct hypovolaemia Fractional excretion of sodium will be low as body tries to retain fluid Correct with fluids

Answer 30

If circulatory overload, restrict fluid intake and challenge with diuretic Renal biopsy to identify any glomerulonephritis as may need immediate treatment with immunosuppression.

Answer 31

Assessment of site of obstruction | Relief by nephrostomy or bladder catheterisation

Answer 32

``` Failure of conservative management Hyperkalaemia Severe hypo or hypernatraemia Pulmonary oedema or HTN Severe acidosis Multisystem failure ```

Answer 33

Sodium bicarbonate

Answer 34

Calcium carbonate | Dietary restriction

Answer 35

``` Calcium gluconate if ECG changes Salbutamol nebulised or iV Calcium exchange resin Glucose and insulin Dietary restriction Dialysis ```

Answer 36

Acute renal failure Haemolytic anaemia Thrombocytopenia - low platelet count There is thrombosis within small vessels throughout the body ``` Also reduced urine output Haematuria, dark brown urine Abdominal pain Lethargy and irritability Confusion Oedema HTN Bruising ```

Answer 37

Bacterial toxin shiga toxin Most commonly e coli 0157 Antibiotics and anti-motility medications e.g. loperamide to treat gastroenteritis caused by these pathogens increases the risk Toxin enters gastrointestinal mucosa, localises to endothelial cells of kidney causing intravascular coagulation Normal clotting cascade, platelets consumed, RBCs damaged - so haemolytic anaemia

Answer 38

Medical emergency Self limiting and supportive management Urgent referral for dialysis if needed Antihypertensives, fluid, blood transfusions if required

Answer 39

GFR < 15ml/min/1.73m | Congenital and familial causes most common in childhood

Answer 40

Anorexia, lethargy Polydipsia, polyuria Failure to thrive Bony deformities from renal osteodystrophy Hypertension Acute on chronic renal failure - precipitated by infection or dehydration Incidental finding of proteinuria Unexplained normochromic normocytic anaemia

Answer 41

Diet - improve nutrition because anorexia and vomiting are common Protein intake sufficient for normal growth Prevention of ricks Phosphate retention and hypocalcaemia due to decreased activation of Vit D leads to secondary hyperparathyroidism, so reduce phosphate intake, calcium carbonate as phosphate binder, and activated Vit D supplements Control of salt and water balance and acidosis Treatment with bicarbonate Recombinant human erythropoietin as there is reduced production, and metabolites that are toxic to bone marrow Recombinant growth hormone to improve growth due to many hormonal abnormalities Dialysis, renal replacement therapy in end stages Minimum weight of 10kg to avoid renal vein thrombosis Ideally child transplanted before dialysis required, immunosuppression with prednisolone, tacrolimus, azathioprine.

Answer 42

``` look for possible underlying causes/triggers (e.g. Constipation, diabetes mellitus, UTI if recent onset) advise on fluid intake, diet and toileting behaviour reward systems (e.g. Star charts). NICE recommend these 'should be given for agreed behaviour rather than dry nights' e.g. Using the toilet to pass urine before sleep ``` NICE advises: 'Consider whether an alarm or drug treatment is appropriate, depending on the age, maturity and abilities of the child or young person, the frequency of bedwetting and the motivation and needs of the family'. Generally: an enuresis alarm is first-line for children under the age of 7 years desmopressin may be used first-line for children over the age 7 years, particularly if short-term control is needed or an enuresis alarm has been ineffective/is not acceptable to the family

Answer 43

Nephroblastoma One of most common childhood malignancies Abdominal mass most common presenting feature Painless haematuria Flank pain Anorexia, fever Unilateral Mets found commonly in lung in 20% patients Management - nephrectomy, chemo, radiotherapy Good prognosis

Answer 44

There is tissue at proximal end of urethra - closest to bladder Causes obstruction of urine output Creates back pressure into bladders, ureters and up to kidneys causing hydronephrosis

Answer 45

``` Difficulty urinating Weak urinary stream Chronic urinary retention Palpable bladder Recurrent urinary tract infections Impaired kidney function ``` Severe causes can cause obstruction to outflow in developing fetus - bilateral hydronephrosis and oligohydramnios Can lead to underdeveloped lungs, resp failure

Answer 46

Severe cases picked up on scans Abdominal ultrasound - enlarged thickened bladder, bilateral hydronephrosis Micturating cystourethrogram - location of extra urethral tissue and reflux of urine into bladder Cystoscopy to ablate or remove tissue if possible

Answer 47

Mild cases observed Temporary urinary catheter whilst awaiting definitive Ablation, removal of extra urethral tissue during cystoscopy

Answer 48

Autosomal recessive | Autosomal dominant presents in later life

Answer 49

``` Cystic enlargement of renal collecting ducts Oligohydramnios Pulmonary hypoplasia Potter syndrome Congenital liver fibrosis ```

Answer 50

Oligohydramnios Polycystic kidneys on scans Lack of amniotic fluid leads to Potter syndrome and underdeveloped lungs

Answer 51

``` Liver failure due to fibrosis Portal hypertension - oesophageal varices Progressive renal failure Hypertension due to renal failure Chronic lung disease ``` 1/3 survive to adulthood Dialysis