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Child Health > Nephrology > Flashcards

Nephrology Flashcards

1
Q

What age group + RFs (2) for HSP?

A

3-10yrs
Boys (2x commoner)
Winter months / preceding URTI

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2
Q

Describe the aetiology behind HSP

A

More circulating IgA → disrupts IgG synth
→ IgA + IgG react/form complexes/complement
→ deposit in affected organs
→ precipitate inflamm response with vasculitis

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3
Q

What are the main presenting features of HSP? (6)

A 
Fever*
Characteristic skin rash
Abdo pain
Arthralgia
Periarticular oedema
Glomerulonephritis (late sign)
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4
Q

Describe the characteristic skin rash seen in HSP? (3)

+ describe the abdo pain in HSP / any further complications (3)

A

Symmetrical
Buttocks / extensor surfaces of arms/legs/ankles (trunk spared)
Maculopapular (palpable/urticaric) + purpuric

Colicky abdo pain
Can → malaena/haematemesis (GI petechiae) / intussusception

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5
Q

What is the main/commonest complication of HSP?

+ some rarer complications of HSP (4)

A

Severe proteinuria → Nephrotic syndrome

Ileus
Orchitis
Protein losing enteropathy
CNS involvement

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6
Q

What are the RFs for progressive renal disease in HSP? (4)

A

Heavy proteinuria
Oedema
Hypertension
Deteriorating renal func

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7
Q

What Ix can be done in HSP? (9)

A 
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)
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8
Q

What is the usual management of HSP w/wo renal involvement? (3+2)

A

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))

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9
Q

Other terms for HSP (2)

A

Acute Nephritis

IgA vasculitis

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10
Q

What is the incidence of Nephrotic syndrome?

What are some poss causes (4)

A

16 per 100,000
Unknown but can be secondary to systemic disease
(e.g. HSP, SLE, malaria, allergens e.g. bee stings)

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11
Q

List some clinical features of nephrotic syndrome (5)

A 
Heavy proteinuria
Low plasma albumin
Oedema (initially periorbital → scrotal/vulval, leg + ankle)
Ascites
SOB (pleural effusion)
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12
Q

List some serious complications of nephrotic syndrome at presentation/relapse (4)

A

Hypovolaemia
Thrombosis
Infection (ir relapse, pneumococcal + spontaneous peritonitis)
Hypercholesterolaemia

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13
Q

How does hypovolaemia present in nephrotic syndrome? (4)

When is urgent IV treatment indicated

A 
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

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14
Q

Why does thrombosis occur as a complication of nephrotic syndrome? (4)

A 
Hypercoagulable state due to:
Urinary loss of antithrombin
Thrombocytosis (exacerbated by steroids)
Increased synth of clotting factors
Increased blood viscosity (higher haematocrit)
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15
Q

What are the diff types of nephrotic syndrome (4)

A

Steroid-sensitive nephrotic syndrome (85-90%)

Steroid-resistant nephrotic syndrome:
Focal segmental GN* (familial/idio)
Membranoproliferative GN (older)
Membranous nephropathy (assoc w. HepB)

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16
Q

What Ix can be done for nephrotic syndrome? (12)

A 
Urinalysis (inc. Sodium conc)
Urine MC + S
FBC
ESR
U&amp;Es
Creatinine
Albumin/complement
ASO titre / anti-DNAase B titre (post-strep)
Throat swab
Hep B/C screen
Malaria screen (if foreign travel)
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17
Q

What are some atypical features of Nephrotic syndrome that might suggest steroid-resistant? (5)

A 
<1yr or >10yrs
Hypertensive
Raised creatinine
Macroscopic haematuria
Failed steroid response after 4-6wks
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18
Q

What is the prognosis for Nephrotic syndrome (1/3rds)

A

1/3rd resolve
1/3rd infrequently relapse
1/3rd frequently relapse

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19
Q

How is oedema managed in (steroid-resistant) nephrotic syndrome? (4)

A

Diuretics
Salt restriction
ACEis
Poss NSAIDs (reduce proteinuria)

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20
Q

What age does congenital nephrotic syndrome present in?
What is the main RF?
What is the prognosis?

A

Presents in 1st 3m
Main RF - consanguinity
High mortality (due to hypoalbuminaemia > renal failure) + can be so bad need nephrectomy

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21
Q

List the possible causes of haematuria (12)

A 
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
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22
Q

List the DDx/causes of acute nephritis (6)

A

HSP
SLE
Other vasculitis (involving kidney e.g. Wegener’s)
Post-strep
IgA nephropathy
Anti-glomerular BM disease (Goodpasture’s)

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23
Q

What are the clinical features of acute nephritis (5)

A 
Reduced urine output
Oedema (periorbital)
Vol overload
Haematuria + Proteinuria
Hypertension
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24
Q

What population group(s) is SLE more common in?

A

Adolescent girls / young women

Afro-Caribbean/Asian

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25
Q

What are the features of Wegeners (other cause of vasculitis / nephritis) (5)

A 
Malaise
Fever
Wt loss
Rash
Arthropathy
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26
Q

What biochemical markers seen in post-strep infection?

A

Raised ASO / anti-DNAase B titres
Reduced compliment C3 levels
(Return to normal after 3-4wks)

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27
Q

Why are UTIs so important in childhood? (2)

A

1/2 pts have structural abnormality of tract

Pyelonephritis can seriously damage a developing kidney

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28
Q

What is the most likely pathogenic source in UTI in neonates? + in all other age children

A

Neonates - likely from blood

Other ages - from bowel flora entering tract via urethra

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29
Q

What are the 5 commonest organisms (in order) of UTI in children (not neonates)

A
  1. E.Coli
  2. Klebsiella
  3. Proteus (more boys as in foreskin)
  4. Pseudomonas (indicates structural abn)
  5. Strep faecalis
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30
Q

What S&S are seen in UTIs in infants/younger children (10)

A

Fever*
Vomiting*
Lethargy*
Irritability*

Poor feeding
Failure to thrive

Abdo pain
Jaundice
Haematuria
Offensive urine

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31
Q

What are some other S&S of UTI seen in verbal aged/ potty trained children (6)

A 
Frequency/Dysuria
D+V
Enuresis recurrence
Loin tenderness
Malaise
Cloudy urine
32
Q

List some diff methods of urine collection in children (4)

A

Clean catch
Bag urine
Urethral catheter (any org indicates infection)
Suprapubic aspiration (any org indicates infection)

33
Q

What are some complications of UTI in neonates/older?

A

Neonates → septicaemia (may develop radically)

>6m → Febrile convulsion

34
Q

What is the assumed Dx / empirical management of UTI with different dipstick results (Nitrites/Leucocyte Esterase)

A

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

35
Q

What are the NICE definition features of an atypical UTI (7)

A 
Seriously ill
Septicaemia
Abdo/bladder mass
Raised creatinine
Failed response to suitable Abx within 48hrs
Non-E.Coli organisms
36
Q

What criteria of UTI episodes is considered as Recurrent UTI

A

1 episode acute pyelo / upper UTI
& 1+ episode cystitis/lower UTI

OR

2+ episodes acute pyelo/upper UTI

OR

3+ episodes cystitis/lower UTI

37
Q

What is the general management of a first proven UTI in children?

A

Abx + USS of kidneys/urinary tract

38
Q

What further Ix done after a normal USS post-UTI in:
<1y/o
1-3y/o
>3y/o

A

<1y/o → MCUG / DMSA
1-3y/o → DMSA
>3y/o → No further Ix

39
Q

What is the management for Acute Pyelonephritis/Upper UTI?

A

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

40
Q

What is the management for Cystitis/Lower UTI?

A

Oral Abx 3d (trimethoprim, nitrofurantoin, cephalo, amoxi)

Safetynetting (bring in if still unwell 24-48hrs later)

41
Q

List some pt factors for which there is a higher incidence of vesico-ureteric reflux (RFs) (5)

A 
White (>black)
Female
Red hair
Febrile UTIs as infant
FH
42
Q

How does reflex severity vary? (3)

What other conditions is severe reflux assoc w.?

A

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

43
Q

What Ix can be done into vesicoureteric reflux (6)

A

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)

44
Q

What are some causes of VU reflux (3)

A

Familial
Secondary to bladder pathology
Post-UTI (temporary)

45
Q

What are some symptoms of VU reflux (5)

A 
SIM TO UTI
Dysuria/frequency/urge
Haematuria
Fever
Flank/abdo pain
Difficulty voiding
46
Q

List some possible features of an AKI (11)

A 
Oliguria (<0.5ml/kg/hr)
Fever
Vomiting 
Abdo pain
Oedema
Periorbital swelling
Pallor
Haemorrhage
Bloody diarrhoea
Abdo mass
Rash
47
Q

List some pre-renal causes of AKI (6)

A

Pre-renal is commonest

Hypovolaemia:
Burns
Sepsis
Gastroenteritis
Haemorrhage
Nephrotic syndrome

Circulatory failure

48
Q

List some renal causes of AKI (VIT G) (9)

A

Vascular: HUS/ Vasculitis/ Embolus/ Renal vv thrombosis
Interstitial: interstitial nephritis / pyelonephritis
Tubular: Acute Tubular Necrosis / ischaem/toxic/blockage
Glomerular: GN

49
Q

List some post-renal causes of AKI (2)

A

Obstruction: congenital / acquired blockage

50
Q

What are the general management measures in all AKIs (all causes) (2)

When is dialysis indicated? (6)

A

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
51
Q

How is an AKI of pre-renal cause managed? (2)

A

Fluid replacement
Circulatory support
→ Want to avoid progression to ATN

52
Q

How is an AKI of renal cause managed? (4)

What Ix is indicated if the cause is not obvious?

A

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)

53
Q

How is an AKI of post-renal cause managed? (4)

A

USS to find obstrn site
Nephrostomy/ catheterisation
Correct U&E abns
→ Then surgery

54
Q

What are the GFR levels / criteria for CKD Stages 1-5

A 
Stage 1: Normal >90 + persistent albuminuria
Stage 2: 60-90 + persistent abbuminuria
Stage 3: 30-60
Stage 4: 15-30
Stage 5: <15
55
Q

What are the clinical features of CKD (vary with stage) (8)

A 
Anorexia / lethargy
Failure to thrive
Hypertension
Proteinuria
Polyuria/polydipsia

Bone deformities
AKI (acute-on-chronic)
Normochromic/normocytic anaemia

56
Q

Outline the management aims in CKD (6)

A 
Allow normal growth/devel 
Control diet to prevent excess protein
Na + Water balance needed
Manage anaemia
HRT (poss)
Vit D analogues (poss)
57
Q

What pathogens can cause HUS? (2)

Describe the pathophysiology behind HUS

A

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

58
Q

What are the 3 main abnormalities/features seen in typical HUS
What is the prognosis like

A

AKI
Thrombocytopenia
Microangiopathic haemolytic anaemia (RBC destruction due to vessel abn)

With early supportive care + dialysis → good prognosis

59
Q

What are the features of atypical HUS
Whats the prognosis like
How may it be treated

A

No diarrhoeal prodrome
Poss familial/relapsing
Risk hypertension/ chronic renal failure
High mortality

Intracerebral involvement / atypical can be Tx with plasma exchange

60
Q

Describe the pathology behind acute nephritis (GN)

+ What features seen (6)

A

Increased glomerular cellularity restrict glomerular blood flow → reduced filtration

Reduced urine output
Volume overload + Oedema (esp periorbital)
Hypertension 
Haematuria
Proteinuria
Seizures (poss)
61
Q

What initial Ix done into glomerulonephritis? (8)

A

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

62
Q

What biochem results seen in post-strep GN?

What other Ix can be done if this cause seems unlikely / -ve results?

A

+ve ASO titre / anti-DNAase B
Reduced C3

Renal biopsy
Renal USS (exclude other causes of HT/haematuria)
63
Q

What centile is hypertension defined as in children?

What level should systolic BP be under in 1-5yrs + 6-10yrs?

A

HT = > 95th centile
1-5yrs → < 110
6-10yrs → <120

64
Q

List some poss features of symptomatic hypertension in children (8)
Which ones are most commonly seen in infants

A 
Vomiting
Headaches
Convulsions
Hypertensive retinopathy
Facial palsy

Proteinuria
Failure to thrive*
Cardiac failure*

65
Q

List the renal causes of hypertension (4)

A

Renovascular (renal aa stenosis)
Renal parenchymal disease (part of CKD)
Polycystic kidneys
Renal tumour

66
Q

List the cardiac causes of hypertension (1)

A

Coarc of Aorta

67
Q

List the endocrine causes of hypertension (6)

A 
Cushings
Corticosteroid therapy
Congenital adrenal hyperplasia
Phaeochromocytoma (catecholamine excess)
Neuroblastoma (catecholamine excess)
Hyperthyroidism
68
Q

List the diff types of urinary tract abnormalities seen in children (7)

A

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)

69
Q

How does renal func differ b/wn preterm + term babies

A

At 28/40 → GFR only 10% of term infant

At term → GFR 15-20 but increases to adult rate by 2y/o

70
Q

What Ix can be done into urinary tract abnormalities? (5) + what is each one assessing

A 
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)
71
Q

What is the incidence of hypospadia in boys?

A

1 in 200

72
Q

How does hypospadia occur?

What are the features seen (2)

A

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)

73
Q

What other conditions must be excluded in severe hypospadia? (2)

A

Other GU bans

Intersex disorder

74
Q

What is a neuropathic bladder?

What are the causes (2)

A

When bladder doesn’t empty properly

Neuro condition
Spina bifida

75
Q

What are some features/complications of a neuropathic bladder (5)

A

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)

76
Q

List some causes of vulvovaginitis in girls (4)

What are the features? (2)

A

Infection
Poor hygiene
Sexual abuse
Thread worm infestation (rare)

Vulvovaginal irritation + vaginal discharge

77
Q

How can vulvovaginitis be managed?

2 conservative/ 2 medical/ 1 surgical

A

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)

Child Health (14 decks)

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