Nephrology 2 Flashcards
Why is UTI in children important?
o up to half of patients have a structural abnormality of their urinary tract
o pyelonephritis may damage the growing kidney by forming a scar- predisposing to hypertension and to chronic renal failure if the scarring is bilateral
What are the incidences of UTI in children?
• About 3–7% of girls and 1–2% of boys have at least one symptomatic urinary tract infection (UTI) before the age of 6 years
12–30% of them have a recurrence within a year
Which organisms cause UTIs?
commonest organism is E. coli, followed by Klebsiella, Proteus & Pseudomonas and Strep. Faecalis
• Proteus infection is more commonly diagnosed in boys than in girls
Proteus infection predisposes to the formation of phosphate stones by splitting urea to ammonia and thus alkalinising the urine
• Pseudomonas infection may indicate the presence of some structural abnormality in the urinary tract affecting drainage
What are the differentials for haematuria?
UTI: bacterial, viral, schistosomiasis, TB
Glomerular: post infectious, HSP, IGA nephropathy, SLE, hereditary (aport)
Stones: hypercalciuria
Trauma
Renal tract pathology: tumour, PKD
Vascular: renal vein thrombosis
Haematological: coagulopathy, sickle cell
Drugs: cyclophosphamide
Exercise induced
How does a UTI present in an infant?
o Fever o Vomiting o Lethargy and irritability o Poor feeding/failure to thrive o Jaundice o Septicaemia o Offensive urine o Febrile convulsion (>6 months)
How does a UTI present in a child?
o Dysuria and frequency o Abdominal pain or loin tenderness o Fever with or without rigors (exaggerated shivering) o Lethargy and anorexia o Vomiting and diarrhoea o Haematuria o Offensive/cloudy urine o Febrile convulsion o Recurrence of enuresis
How can a urine sample be taken in a child with nappies?
Clean catch (recommended) Adhesive plastic bag applied to perineum after washing Urethral catheter if there is urgency/no urine has been passed Suprapubic aspiration- fine needle attached to a syringe is inserted directly into the bladder just above the symphysis pubis under ultrasound guidance, it may be used in severely ill infants
Why are urinary white cells not a reliable feature of UTI?
May lyse during storage and may be present in febrile children without a UTI and in children with balanitis or Vulvovaginitis
dipsticks can be used as a screening test
What are the criteria for diagnosis of UTI based on urine dipstick and urine culture?
Nitrite stick testing- positive, likely true UTI
Leucocyte esterase stick testing- may be present, present in balanitis and vulvovaginitis
Leucocyte esterase negative and nitrite positive- start antibiotic treatment
Leucocyte esterase positive and nitrite negative- only start antibiotics if clinical evidence of UTI
What is an atypical UTI?
o Seriously ill o Poor urine flow o Abdominal or bladder mass o Raised creatinine o Septicaemia o Failure to respond to suitable antibiotics within 48 hours o Infected with non-E.coli organisms
What is a recurrent UTI?
o Two or more episodes of UTI with acute pyelonephritis/upper urinary tract infection
o One episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episodes of UTI with cystitis/lower urinary tract infection
o Three or more episodes of UTI with cystitis/lower urinary tract infection NICE recommends guidelines for investigations for both atypical and recurrent UTIs but they are divided into the age ranges of <6 months, 6 months to 3 years and >3 years
Which investigations should be carried out in the younger age groups
o Atypical- ultrasound during acute infection, DMSA (a radionucleotide scan to assess renal function) 4-6 months following acute infection and MCUG (micturating cystourethrogram)
o Recurrent- ultrasound within 6 weeks and DMSA
o Responding to treatment- ultrasound within 6 weeks
If over 6 months, no further inv needed if responding
What is the management plan for UTIs?
Antibiotics
High fluid intake
Regular voiding, double micturition
Prevent or treat constipation
Good perineal hygiene
Consider low dose antibiotic prophylaxis if recurrent
Monitor blood pressure, renal growth and function
What is vesicoureteric reflux?
developmental anomaly of the vesicoureteric junction- the ureters are displaced laterally and enter directly into the bladder rather than at an angle, with a shortened or absent intramural course, severe cases can be associated with renal dysplasia
familial with a 30-50% chance of occurring in first degree relatives
severe VUR can be associated with intrarenal reflux and renal scarring
More common in Caucasian, red hair, females and those with febrile UTIs
Why is reflux associated with ureter dilatation important?
o Urine returning to the bladder encourages infection
o The kidneys may become infected
o Bladder voiding pressure is transmitted to the renal papillae
