Nephrology Flashcards
What are some signs and sx of UTI in babies?
- Fever
- Lethargy
- Irritability
- Vom
- Poor feeding
- Urinary freq
What are the signs and sx of UTI in older infants and children?
Fever
Abdo pain - suprapubic
Vom
Dysuria
Urinary freq
Incontinence
How is acute pyelonephritis diagnosed?
Temp >38 degrees
Loin pain or tenderness
What are signs of UTI on dip?
Nitrites (better indicator) and leukocytes
Also need to send a MSU for MC+S
What is the management of UTI in children?
- All children <3 m w fever = IV abx and have a full septic screen (ideally before abx)
- Oral abx in children >3m if otherwise well - cefalexin, nitrofurantoin
- Sepsis or pyelonephritis = inpt IV abx
How do you ix recurrent UTIs?
<6 m = abdo US w/i 6 week of first UTI
Recurrent UTIs - abdo USS w/i 6 weeks
Atypical UTIs - abdo US
What is a DMSA scan?
Used 4-6 months after a UTI to assess for damage from recurrent or atypical UTIs
Inject DMSA and use gamma camera to assess how well material taken up by the kidneys - patches = scarring
What is vesico ureteric reflux?
Urine flows from the bladder back into the ureters = predisposition to developing UTIs and renal scarring.
How do you trest vesico ureteric reflux?
- Avoid constipation
- Avoid excessively full bladder
- Prophylactic abx
- Surgical input
What is a MCUG?
Micturating cystourethrogram - ix recurrent UTIs in children <6 months
XR w contrast
What are RF of vulvovaginitis?
Wet nappies
Chemical or soaps to clean area
Tight clothing
Poor toilet hygiene
Constipation
Threadworms
Pressure on the area
Heavily chlorinated pools
What are the CF of vulvovaginitis?
- Soreness and itching
- Erythema around the labia
- Vaginal discharge
- Dysuria
- Constipation
What is the management of vulvovaginitis?
Advice:
- Avoid washing w soap or perfumed products
- Good toilet hygiene
- Keep area dry
- Emollients
- Loos cotton clothing
- Treat constipation
What is the triad of nephrotic syndrome?
Low serum albumin <35 g/L
High urine protein content >3+ on dip
Oedema
What are the other features in nephrotic syndrome?
Frothy urine
Pallor
Derranged lipids (hypercholesterolaemia)
High BP
Hyper coag
Higher risk of infection
What are the causes of nephrotic syndrome in children?
- Minimal change disease is the most common cause in children
- Intrinsic kidney disease - focal segmental glomerulosclerosis, glomerulonephritis
- Systemic illness - Henoch schonlein purpura, diabetes, infection
What is the ix into minimal change disease?
- Renal biopsy can’t detect any changes
- Urinalysis - hyaline cysts and small proteins
How do you manage minimal change disease?
Prednisolone - most make a full recovery but can reoccur
What is the management of nephrotic syndrome?
- High dose steroids for 4 weeks and then weaned over next 8w - pred but doesn’t work for all
- Low salt diet
- Diuretics for oedema
- Albumin infusions maybe
- Abx prophylaxis
- ACEi/ARBs reduce proteinuria
- Statins if hypercholesterolaemia?
What is the alt treatment of nephrotic syndrome for steroid resistant children?
ACE inhibitors and immunosuppressants eg. cyclosporine, tacrolimus, rituximab
What are some complications of nephrotic syndrome?
- Hypovolaemia
- Thrombosis
- Infection
- Acute or chronic renal fail
- Relapse
What is HUS?
Haemolytic uraemic syndrome - thrombosis in small blood vessels. Usually triggered by shiga toxin (commonly produced by E.coli =
1. Haemolytic anaemia
2. AKI
3. Thrombocytopenia
What is the presentation of HUS?
E.coli = gastroenteritis = blood diarrhoea, HUS sx ~5 days after onset of diarrhoea:
- Reduced urine output
- Haematuria or dark brown urine
- Abdo pain
- Lethargy and irritabilty
- Confusion
- Oedema
- HTN
- Bruising
What is the management of HUS?
Medical emergency and has 10% mortality:
- Self limiting and supportive treatment mainly
- Renal dialysis may be needed
- Anti HTN if needed
- Maintain fluid balance
- May need blood transfusion
What is enuresis and what are the different types?
Enuresis - involuntary urination
Nocturnal enuresis = bed wetting -> can be primary of secondary
Diurnal enuresis = inability to control bladder func during day
When do children normally achieve bladder control?
Daytime = 2 years
Nighttime = 3-4 years
What are some causes of primary nocturnal enuresis?
- Overactive bladder
- Fluid intake prior to bedtime
- Failure to wake when need wee
- Psych distress eg. low self esteem, probs at home
- Chronic constipation, UTI, ID, cerebral palsy
What is the management of primary nocturnal enuresis?
- Toileting and fluid intake and bedwetting diary
- Reassurance if <5
- Lifestyle changes - reduce fluid at night, pass urine before bed, close to toilet
- Encouragement and positive reinforcement, no shame or punishment
- Treat underlying cause if is one
What are some secondary causes of secondary nocturnal enuresis?
Child wetting bed after prev dry for >6 m:
- UTI
- Constipation
- T1DM
- New psychosocial prob
- Maltreatment - abuse and safeguarding prob
Treat underlying cause
What are some causes of diurnal enuresis?
Daytime incontinence but dry at nice:
1. Urge incontinence - overactive bladder
2. Stress incontinence - leakage of urine
+ recurrent UTI, psych probs, constipation
What is an enuresis alarm?
Makes noise at the first sign of bed wetting - wakes child to stop them from urinating. Not v popular and need lots of dedication
What pharm treatment can be used for enuresis?
- Desmopressin - ADH, reduces vol of urine produced by kidneys
- Oxybutinin for overactive bladder
- Imipramine - tricyclic AD, not sure how works
What is nephritic syndrome?
Inflam of the kidney:
- Reduced kidney func
- Haematuria (gross or microscopic)
- Proteinuria (but less than nephrotic syndrome)
- HTN
What are the causes of nephritic syndrome in children?
- Post streptococcal glomerulonephritis
- IgA nephropathy
What are the CF of post strep glomerulonephritis?
1-3 weeks after haemolytic streptococcus infection eg. tonsillitis.
Streptococcal antigens, Ab and complement proteins cause inflam in the glomeruli = AKI.
What is the management of post strep glomerulonephritis?
- Supportive mainly, 80% pt make full recovery
- Other 20% develop CKD
- If HTN = antihypertensive meds
- If oedema = diuretics
- If AKI so bad may need temp renal replacement therapy
What are the CF of IgA nephropathy?
1-4 days post mild URTI, normally in teenagers or young adults.
IgA deposits in nephrons cause nephritis.
Renal biopsy = IgA deposits and glomerular mesangial proliferation
What is the treatment of IgA nephropathy?
- Supportive treatment of renal fail - about 15-40% pt = CKD
- ACEi/ARBs reduce proteinuria and protect renal func
- Immunosuppressants eg. steroids (helps to reduce proteinuria), cyclophosphamide
What are the differentials for nephritic syndrome?
SHARP AIM
SLE
Henoch Schonlein purpura
Goodpasture’s disease
Rapidly progressive GN
Post strep GN
Alport’s syndrome
IgA nephropathy
Membranoproliferative GN
What are the ix into nephritic syndrome?
- Urine dip = blood +/- protein
- MC+S = RBC, WBC and casts
- Biopsy = immunofluorescence = IgA deposition in IgA nephropathy
What are some differentials for haematuria?
- Nephritic syndrome - post strep GN or IgA nephropathy
- UTI
- Polycystic kidney disease
- Alport’s syndrome
- Sickle cell disease
- Hypercalciuria
- Henoch Schonlein purpura
- Wilm’s tumour
What are the ix into haematuria?
- Urine dip
- MC+S
- BP check
- Bloods - U+E, lFT, ANA and ANCA
- Throat swab
- Urine protein:creatinine ratio
- Renal tract USS and CT KUB if suspect structural cause
What are the different types of PKD?
Autosomal recessive - presents in children
Autosomal dominant - presents in adults
What are the CF of ARPKD?
- Presents in neonates, usually found on antenatal USS
- Cystic enlargement of renal collecting ducts
- Oligohydramnios (reduced urine production)
- Pulm hypoplasia - resp failure shortly after birth
- Potter syndrome
- Congenital liver fibrosis
What is Potter syndrome?
- Underdeveloped ear cartilage
- Low set ears
- Flat nasal bridge
- Abnormalities of skeleton
Due to lack of amniotic fluid
What are the consequences of ARPKD?
Liver failure due to fibrosis
Portal HTN leading to oesophageal varices
Progressive renal failure
HTN due to renal failure
Chronic lung disease
30% die in neonatal period, 30% survive to adulthood - extensive interventions to survive
What is multicystic dysplastic kidney?
Only one of the kidneys is cystic, the other is normal - this is normally enough to lead a healthy life. Cystic kidney will often atophy and disappear before the age of 5.
Can be bilat = death in infancy, normally diagnosed on antenatal USS
What are the complications of having a single kidney?
- Risk of UTIs - often prophylactic abx
- HTN
- CKD in later life
What are the CF of autosomal dominant PKD?
Renal - flank pain and haematuria in cyst rupture, flank pain and fever in cyst infection, HTN, slow progression to CKD
Extra renal - cysts elsewhere, berry aneurysms in the head circulation, valvular heart disease, diverticular disease
What is the management of ARPKD?
Fluid overload - diuretics and RRT
HTN - ACEi
UTI - Abx
CKD - Fe and EPO for anaemia, Ca supplement, phosphate etc for metabolic bone disease, GH
End stage kidney disease - transplant or dialysis
What is screening of polycystic kidney disease?
USS - don’t screen asymptomatic children at the moment
15-39 >3 renal cysts = ADPKD
Different criteria for older pt
What are the CF of Wilms tumour?
<5 presenting w mass in abdo, doesn’t cross midline, normally non tender !!!, and haematuria
- Haematuria
- Lethargy
- Fever
- HTN
- Weight loss
- Abdo distension
- Normally asymptomatic unless large tumour causes sx
What are the ix into Wilm’s tumour?
- USS
- CT chest, AP to stage
- Renal biopsy for definitive diagnosis = small round blue cells can be seen but no exclusive to nephroblastoma
What is the management of Wilm’s tumour?
- Nephrectomy - tumour and affected kidney removed
- Chemo RT adjuvant after surgery, deps on stage of disease and spread
- > 90% 5 year survival : )
What are the stages of CKD?
Stage 1. >90 ml/min
2. 60-89 ml/min
3. 30-59 ml/min
4. 15-29 ml/min
5. <15 ml/min = ESRF
What are signs and sx of CKD?
- Anaemia
- Anorexia, N+V
- Osteodystrophy = bony deformities
- Hyperkalaemia, met acidosis
- HTN
- Fluid overload
- Polydipsia and polyuria
What are the main causes of CKD in children?
- Obstructive uropathy
- Hypoplastic or dysplastic kidneys (under developed)
- Reflux nephropathy
- Focal segmental glomerulosclerosis
- AD or AR PKD
Congenital probs = <12, glomerulonephritis >12
What is the general management of CKD?
Nutrition - cal supplements, gastrotomy or NGT, restrict food w K and phosphate
Congenital structural probs - salt supplements and free access to water
Nephrotic syndrome - fluid and salt restriction to prevent fluid overload
Bicarb supplements prevent acidosis
Anaemia - EPO subcut
What is renal osteodystophy?
Phosphate retention and hypocalcaemia due to reduced activation of vit d = secondary hyperparathyroidism = osteomalacia. Is a form of metabolic bone disease.
Treat - phosphate restriction, activated vit D supplements
What are the options of RRT in CKD?
Renal replacement therapy:
- Transplantation, need to be 10kg min weight, living related donors highest success
- Immunosuppression - tacrolimus, prednisolone, mycophenolate mofetil to prevent rejection
- May need dialysis if can’t receive a transplant in time - haemodialysis, peritoneal dialysis
What are the causes of AKI in children?
Pre renal (most common in children) - hypovolaemia eg. burns, sepsis, haemorrhage, HF
Renal - HUS, vasculitis, GN, VTE, pyelonephritis
Post renal - congenital obstruction
What suggests acute on chronic renal failure?
Faltering growth, anaemia, metabolic bone disease
What are the CF of AKI in children?
Oliguria
Raised creatinine >1/5x preference reference range
What children are at risk of AKI?
- Nephro urological, cardiac, liver disease
- Malignancy or bone marrow transplant
- Dep on others for access to fluids
- Nephrotoxic meds - ACEi, ARBs, NSAIDs, tacrolimus, contrast
- Major surgery
- Septic
What are the ix in AKI?
- Bloods - FBC, U+E, cr, bone profile, albumin
- Urine dip and MC+S
- Urinary tract USS
- Can also do immunoglobulins, ANCA, CK, LDH, antiDNAase
What is the management of AKI?
Fluid balance monitoring
Remove nephrotoxic meds
Manage underlying cause
RRT if conservative management fails, hyperkalaemia, severe hyponatraemia or hypernatraemia, pulm oedema, severe met acidosis
What is posterior urethral valve?
Tissue at the proximal end of the urethra that causes obstruction, in newborn boys. Causes hydronephrosis and increases risk of UTIs.
What are the CF of post urethral valve?
- Can be asymptomatic
- Dysuria
- Chronic urinary retention
- Palpable bladder
- Recurrent UTIs
- Reduced eGFR
- Severe - oligohydramnios and bilat hydronephrosis in fetus = pulm hypoplasia
What are the ix into post urethral valve after birth?
Abdo USS = enlarged, thickened bladder and bilat hydronephrosis
MCUG = location of the tissue and reflux into bladder
Cystoscopy can be used to ablate or remove extra tissue
