Nephrology Flashcards
What age group + RFs (2) for HSP?
3-10yrs
Boys (2x commoner)
Winter months / preceding URTI
Describe the aetiology behind HSP
More circulating IgA → disrupts IgG synth
→ IgA + IgG react/form complexes/complement
→ deposit in affected organs
→ precipitate inflamm response with vasculitis
What are the main presenting features of HSP? (6)
Fever* Characteristic skin rash Abdo pain Arthralgia Periarticular oedema Glomerulonephritis (late sign)
Describe the characteristic skin rash seen in HSP? (3)
+ describe the abdo pain in HSP / any further complications (3)
Symmetrical
Buttocks / extensor surfaces of arms/legs/ankles (trunk spared)
Maculopapular (palpable/urticaric) + purpuric
Colicky abdo pain
Can → malaena/haematemesis (GI petechiae) / intussusception
What is the main/commonest complication of HSP?
+ some rarer complications of HSP (4)
Severe proteinuria → Nephrotic syndrome
Ileus
Orchitis
Protein losing enteropathy
CNS involvement
What are the RFs for progressive renal disease in HSP? (4)
Heavy proteinuria
Oedema
Hypertension
Deteriorating renal func
What Ix can be done in HSP? (9)
Urinalysis FBC ESR Creatinine Serum IgA / autoantibody screen Abdo USS (for obstrn) Barium enema (to confirm obstrn) Testicular USS (check for torsion) Renal biopsy (if persistent nephrotic syndrome)
What is the usual management of HSP w/wo renal involvement? (3+2)
Self-limiting (+no therapy shortens/prevents comps)
Supportive treatment: NSAIDs (joint pain - caution in renal insufficiency)
6m FU if urinalysis normal
In nephropathy: supportive steroids + longer FU (esp if persistent urinary bans as HT/renal func may deteriorate yrs later (<1% → ESRF))
Other terms for HSP (2)
Acute Nephritis
IgA vasculitis
What is the incidence of Nephrotic syndrome?
What are some poss causes (4)
16 per 100,000
Unknown but can be secondary to systemic disease
(e.g. HSP, SLE, malaria, allergens e.g. bee stings)
List some clinical features of nephrotic syndrome (5)
Heavy proteinuria Low plasma albumin Oedema (initially periorbital → scrotal/vulval, leg + ankle) Ascites SOB (pleural effusion)
List some serious complications of nephrotic syndrome at presentation/relapse (4)
Hypovolaemia
Thrombosis
Infection (ir relapse, pneumococcal + spontaneous peritonitis)
Hypercholesterolaemia
How does hypovolaemia present in nephrotic syndrome? (4)
When is urgent IV treatment indicated
Due to depleted intravascular compartment in oedema Abdo pain Feeling faint Peripheral vasocon Urinary sodium retention
Low urinary sodium / high vol packed RBCs indicates urgent IV albumin needed
Why does thrombosis occur as a complication of nephrotic syndrome? (4)
Hypercoagulable state due to: Urinary loss of antithrombin Thrombocytosis (exacerbated by steroids) Increased synth of clotting factors Increased blood viscosity (higher haematocrit)
What are the diff types of nephrotic syndrome (4)
Steroid-sensitive nephrotic syndrome (85-90%)
Steroid-resistant nephrotic syndrome:
Focal segmental GN* (familial/idio)
Membranoproliferative GN (older)
Membranous nephropathy (assoc w. HepB)
What Ix can be done for nephrotic syndrome? (12)
Urinalysis (inc. Sodium conc) Urine MC + S FBC ESR U&Es Creatinine Albumin/complement ASO titre / anti-DNAase B titre (post-strep) Throat swab Hep B/C screen Malaria screen (if foreign travel)
What are some atypical features of Nephrotic syndrome that might suggest steroid-resistant? (5)
<1yr or >10yrs Hypertensive Raised creatinine Macroscopic haematuria Failed steroid response after 4-6wks
What is the prognosis for Nephrotic syndrome (1/3rds)
1/3rd resolve
1/3rd infrequently relapse
1/3rd frequently relapse
How is oedema managed in (steroid-resistant) nephrotic syndrome? (4)
Diuretics
Salt restriction
ACEis
Poss NSAIDs (reduce proteinuria)
What age does congenital nephrotic syndrome present in?
What is the main RF?
What is the prognosis?
Presents in 1st 3m
Main RF - consanguinity
High mortality (due to hypoalbuminaemia > renal failure) + can be so bad need nephrectomy
List the possible causes of haematuria (12)
Non-glomerular: Infection (UTI - commonest, but + other symps) Tumour Trauma Stones Hypercalcuria Renal vv thrombosis Bleeding disorders Sickle cell disease
Glomerular: Acute/chronic glomerulonephritis Familial GN IgA nephropathy Thin BM disease
List the DDx/causes of acute nephritis (6)
HSP
SLE
Other vasculitis (involving kidney e.g. Wegener’s)
Post-strep
IgA nephropathy
Anti-glomerular BM disease (Goodpasture’s)
What are the clinical features of acute nephritis (5)
Reduced urine output Oedema (periorbital) Vol overload Haematuria + Proteinuria Hypertension
What population group(s) is SLE more common in?
Adolescent girls / young women
Afro-Caribbean/Asian
What are the features of Wegeners (other cause of vasculitis / nephritis) (5)
Malaise Fever Wt loss Rash Arthropathy
What biochemical markers seen in post-strep infection?
Raised ASO / anti-DNAase B titres
Reduced compliment C3 levels
(Return to normal after 3-4wks)
Why are UTIs so important in childhood? (2)
1/2 pts have structural abnormality of tract
Pyelonephritis can seriously damage a developing kidney
What is the most likely pathogenic source in UTI in neonates? + in all other age children
Neonates - likely from blood
Other ages - from bowel flora entering tract via urethra
What are the 5 commonest organisms (in order) of UTI in children (not neonates)
- E.Coli
- Klebsiella
- Proteus (more boys as in foreskin)
- Pseudomonas (indicates structural abn)
- Strep faecalis
What S&S are seen in UTIs in infants/younger children (10)
Fever*
Vomiting*
Lethargy*
Irritability*
Poor feeding
Failure to thrive
Abdo pain
Jaundice
Haematuria
Offensive urine
What are some other S&S of UTI seen in verbal aged/ potty trained children (6)
Frequency/Dysuria D+V Enuresis recurrence Loin tenderness Malaise Cloudy urine
List some diff methods of urine collection in children (4)
Clean catch
Bag urine
Urethral catheter (any org indicates infection)
Suprapubic aspiration (any org indicates infection)
What are some complications of UTI in neonates/older?
Neonates → septicaemia (may develop radically)
>6m → Febrile convulsion
What is the assumed Dx / empirical management of UTI with different dipstick results (Nitrites/Leucocyte Esterase)
N+ve + LE+ve → UTI
N+ve + LE-ve → Start Abx + await cultures
N-ve + LE+ve → start Abx only if clinical evidence + await cultures
N-ve + LE-ve → unlikely UTI
What are the NICE definition features of an atypical UTI (7)
Seriously ill Septicaemia Abdo/bladder mass Raised creatinine Failed response to suitable Abx within 48hrs Non-E.Coli organisms
What criteria of UTI episodes is considered as Recurrent UTI
1 episode acute pyelo / upper UTI
& 1+ episode cystitis/lower UTI
OR
2+ episodes acute pyelo/upper UTI
OR
3+ episodes cystitis/lower UTI
What is the general management of a first proven UTI in children?
Abx + USS of kidneys/urinary tract
What further Ix done after a normal USS post-UTI in:
<1y/o
1-3y/o
>3y/o
<1y/o → MCUG / DMSA
1-3y/o → DMSA
>3y/o → No further Ix
What is the management for Acute Pyelonephritis/Upper UTI?
Consider paediatric specialist referral
Oral Abx 7-10d (use low resistance patterns e.g. caphelosporins/co-amoxi)
IV Abx where can’t be used (cephalos) then oral 7-10d
What is the management for Cystitis/Lower UTI?
Oral Abx 3d (trimethoprim, nitrofurantoin, cephalo, amoxi)
Safetynetting (bring in if still unwell 24-48hrs later)
List some pt factors for which there is a higher incidence of vesico-ureteric reflux (RFs) (5)
White (>black) Female Red hair Febrile UTIs as infant FH
How does reflex severity vary? (3)
What other conditions is severe reflux assoc w.?
Mild - reflux during bladder emptying
Mod - reflux during bladder filling
Severe - voiding with distended ureters/ renal pelvis/ clubbed calyces
Severe assoc w. renal dysplasia, intrarenal reflux + scarring
What Ix can be done into vesicoureteric reflux (6)
Urine dipstick / MC+S → rule out UTI
U&E + Creatinine (assess renal func / antenatal hydronephrosis)
VCUG (voiding cystourethrogram - main test)
Renal/bladder USS
DMSA (occasionally)
What are some causes of VU reflux (3)
Familial
Secondary to bladder pathology
Post-UTI (temporary)
What are some symptoms of VU reflux (5)
SIM TO UTI Dysuria/frequency/urge Haematuria Fever Flank/abdo pain Difficulty voiding
List some possible features of an AKI (11)
Oliguria (<0.5ml/kg/hr) Fever Vomiting Abdo pain Oedema Periorbital swelling
Pallor Haemorrhage Bloody diarrhoea Abdo mass Rash
List some pre-renal causes of AKI (6)
Pre-renal is commonest
Hypovolaemia: Burns Sepsis Gastroenteritis Haemorrhage Nephrotic syndrome
Circulatory failure
List some renal causes of AKI (VIT G) (9)
Vascular: HUS/ Vasculitis/ Embolus/ Renal vv thrombosis
Interstitial: interstitial nephritis / pyelonephritis
Tubular: Acute Tubular Necrosis / ischaem/toxic/blockage
Glomerular: GN
List some post-renal causes of AKI (2)
Obstruction: congenital / acquired blockage
What are the general management measures in all AKIs (all causes) (2)
When is dialysis indicated? (6)
Monitor fluid balance / circulation
USS - to ID any abdo masses / obstruction
Failed conservative Tx response Hyperkal Severe hypo/hypernat Severe acidosis Pulm oedema / hypertension Multisystem failure
How is an AKI of pre-renal cause managed? (2)
Fluid replacement
Circulatory support
→ Want to avoid progression to ATN
How is an AKI of renal cause managed? (4)
What Ix is indicated if the cause is not obvious?
If circulation overload:
Fluid restriction
Diuretic
Correct Na/water balance
High cal / normal protein diet (reduce catabolism / uraemia / hyperkal)
Renal biopsy if cause not obvious (exclude rapid GN)
How is an AKI of post-renal cause managed? (4)
USS to find obstrn site
Nephrostomy/ catheterisation
Correct U&E abns
→ Then surgery
What are the GFR levels / criteria for CKD Stages 1-5
Stage 1: Normal >90 + persistent albuminuria Stage 2: 60-90 + persistent abbuminuria Stage 3: 30-60 Stage 4: 15-30 Stage 5: <15
What are the clinical features of CKD (vary with stage) (8)
Anorexia / lethargy Failure to thrive Hypertension Proteinuria Polyuria/polydipsia
Bone deformities
AKI (acute-on-chronic)
Normochromic/normocytic anaemia
Outline the management aims in CKD (6)
Allow normal growth/devel Control diet to prevent excess protein Na + Water balance needed Manage anaemia HRT (poss) Vit D analogues (poss)
What pathogens can cause HUS? (2)
Describe the pathophysiology behind HUS
E.Coli 0157 (verocytotoxin)
Shigella (uncommon)
Preceding bloody diarrhoea → org toxin enters GI mucosa → localised to renal endothelial cells
→ intravasc thrombogenesis (clot formation)
→ microangiopathic haemolytic anaemia
What are the 3 main abnormalities/features seen in typical HUS
What is the prognosis like
AKI
Thrombocytopenia
Microangiopathic haemolytic anaemia (RBC destruction due to vessel abn)
With early supportive care + dialysis → good prognosis
What are the features of atypical HUS
Whats the prognosis like
How may it be treated
No diarrhoeal prodrome
Poss familial/relapsing
Risk hypertension/ chronic renal failure
High mortality
Intracerebral involvement / atypical can be Tx with plasma exchange
Describe the pathology behind acute nephritis (GN)
+ What features seen (6)
Increased glomerular cellularity restrict glomerular blood flow → reduced filtration
Reduced urine output Volume overload + Oedema (esp periorbital) Hypertension Haematuria Proteinuria Seizures (poss)
What initial Ix done into glomerulonephritis? (8)
U&Es (asses renal func)
Creatinine (asses renal func)
FBC (infection/anaemia)
Urinalysis (infection/protein/blood)
Urine MC+S (infection)
ASO titre / anti-DNAase B
Complement levels
Serum IgA
What biochem results seen in post-strep GN?
What other Ix can be done if this cause seems unlikely / -ve results?
+ve ASO titre / anti-DNAase B
Reduced C3
Renal biopsy Renal USS (exclude other causes of HT/haematuria)
What centile is hypertension defined as in children?
What level should systolic BP be under in 1-5yrs + 6-10yrs?
HT = > 95th centile
1-5yrs → < 110
6-10yrs → <120
List some poss features of symptomatic hypertension in children (8)
Which ones are most commonly seen in infants
Vomiting Headaches Convulsions Hypertensive retinopathy Facial palsy
Proteinuria
Failure to thrive*
Cardiac failure*
List the renal causes of hypertension (4)
Renovascular (renal aa stenosis)
Renal parenchymal disease (part of CKD)
Polycystic kidneys
Renal tumour
List the cardiac causes of hypertension (1)
Coarc of Aorta
List the endocrine causes of hypertension (6)
Cushings Corticosteroid therapy Congenital adrenal hyperplasia Phaeochromocytoma (catecholamine excess) Neuroblastoma (catecholamine excess) Hyperthyroidism
List the diff types of urinary tract abnormalities seen in children (7)
Renal agenesis (bilateral) → Potter
Multicystic dysplastic kidneys (non func tissue w. cysts / poss no connection to bladder)
Autosomal rec/dom polycystic kidneys (always bilateral)
Pelvic/horseshoe kidney
Duplex system (2 ureters - obstrn/reflux)
Posterior urethral valves (obstrn/reflux)
Hydronephrosis (dilation/swelling from backup pressure)
How does renal func differ b/wn preterm + term babies
At 28/40 → GFR only 10% of term infant
At term → GFR 15-20 but increases to adult rate by 2y/o
What Ix can be done into urinary tract abnormalities? (5) + what is each one assessing
USS - anatomical (not func assessment) MCUG/VCUG - visualise bladder/urethral anatomy (detect reflux/obstrn) DMSA scan (detects functional defects) MAG3 isotope scan (dilation vs obstrn) AXR (spinal abns + poss renal stones)
What is the incidence of hypospadia in boys?
1 in 200
How does hypospadia occur?
What are the features seen (2)
Failed completion of urethral formation, proximal → distal (normally under testosterone influence)
Ventral urethral meatus on corona/shaft/perineum (normally on glans)
In severe:
Ventral curvature of penis head (due to dorsal foreskin fusion failure)
What other conditions must be excluded in severe hypospadia? (2)
Other GU bans
Intersex disorder
What is a neuropathic bladder?
What are the causes (2)
When bladder doesn’t empty properly
Neuro condition
Spina bifida
What are some features/complications of a neuropathic bladder (5)
Urinary incontinence: freq/urge/dribble/lost full sensation
UTI (from holding in)
AKI (high pressure from urine back log)
Kidney stones: pain/haematuria/fever+chills
Erectile dysfunc (later in life)
List some causes of vulvovaginitis in girls (4)
What are the features? (2)
Infection
Poor hygiene
Sexual abuse
Thread worm infestation (rare)
Vulvovaginal irritation + vaginal discharge
How can vulvovaginitis be managed?
2 conservative/ 2 medical/ 1 surgical
Conservative:
advise parents on hygiene + salt baths poss helpful
Medical:
Swabs + treat
Oestrogen creams
Surgical: EUA to exclude F.O./unusual infection (if discharge persistent/purulent)
