Nephrology Flashcards
MCD // Post infective GN // IgA + HSP // HUS // CKD // UTI
What are the functions of the kidney?
- Waste handling - urea/creatine
- Water handling
- Salt balance - sodium, potassium, calcium, phosphate
- Acid base control - bicarb
- Endocrine
- red cells / blood pressure / bone health
How do patients present?
Haematuria or Proteinuria
What does proteinuria signify?
Kidney damage
What is nephrotic syndrome?
- Nephrotic range of proteinuria
- Causes albumin to drop (Hypoalbuminaemia)
- Oedema
- [protein is like a magnet to water - less protein in blood, less water]
SSx of proteinuria?
- Frothy urine
- Periorbital oedema, pitting oedema legs, ascites, small pleaural effusions
How can we test for proteinuria?
- Dipstix
- >3+ is abnormal
- Protein creatinine ratio (this will confirm suspicions)
- Early morning is best
- 24hr urine collection
Minimal Change disease (MCD)
- Nephrotic syndrome
What are typical features?
- Age (2-5yrs)
- Normal blood pressure
- Resolving microscopic haematuria
- Normal renal function
MCD
What are atypical features?
When would we biopsy?
- Suggestions of autoimmune disease
- Abnormal renal function
- Steroid resistance
- Only biopsy if there is suggestion of atypical features!
Rx for MCD?
main side effect in kids
- Prednisolone 8 weeks
- Difficult behavior
Outcomes of MCD?
- •Remission
- –95% in 2-4 weeks
- •Relapse
- –80%
- •50% frequent
- –80%
- •80% long term remission
What is a steroid resistant nephrotic syndrome?
- Acquired
- Focal Segmental Glomeruloscerosis (FSGS)
- Congenital
- NPHS1 – nephrin
- NPHS 2 – podocin
What are the two different types of haematuria?
How do we test?
Microscopic and Macroscopic
Do a urine dipstix
What is persistant haematuria and proteinuria a sign of?
glomerular disease
What is nephritic syndrome?
- Clinical diagnosis
- describes glomerulonephritis
- Haem + proteinuria
- Reduced GFR
- fluid overload: raised JVP, oedema
- Hypertension
Main two causes of glomerulonephritis (nephritic)?
- Post infective GN
- IgA nephropathy
Who is affected by post infective GN and what is it caused by?
- Age of onset: 2-5
- Cause: Usually Group A Strep
- normally throat or skin
Disease progression of post infective GN?
Ix?
Self limiting
- positive ASOT
- low C3 normalises
Rx for post infective GN?
- Antibiotic – penicillin
- Support renal functions
- Overload / hypertension
- Diuretics
What is the most common nephritic syndrome? (glomerulonephritis)
IgA nephropathy
IgA nephropathy
Who gets it?
When does it present?
What is seen on urine?
- Older kids and adults
- 1-2 days after URTI
- Urine
- Recurrent macroscopic haematuria
- ± chronic microscopic haematuria
- Varying degree of proteinuria
What is the pathogenesis of IgA nephropathy?
- Increased levels of circulating Gd-IgA1
- Production of anti-IgA1 antibodies
- Immune complexes form in circulation
- Immune complexes form in situ
- Immune complexes in the mesangium cause local immune activation & injury
Ix for IgA nephropathy?
- Clinical picture
- Negative autoimmune workup
- Normal compliment
- Confirmation Biopsy
Rx for IgA?
Mild: ACEi
Severe: Immunosuppresion
What is HSP?
Basically it is the same disease of IgA nephropathy except it is effecting the vessels (vasculitis).
aka Henoch Schonlein Pupura
How can we identify HSP?
- Mandatory palpable purpura
- Plus one of 4
- Abdo pain, renal involvement, Arthritis, biopsy
What are prodromal features of HSP?
- 1-3 days post trigger
- Viral URTI in 70%
- Streptococcus, drugs
Rx for HSP?
- Immmunosuppresion
- Trial in moderate to severe renal disease
- Long term
- Hypertension and proteinuria screening
What is AKI?
- Serum creatinine: > 1.5x age specific reference creatinine (or previous baseline if known)
- Urine output<0.5 ml/kg for > 8hours
- AKI 1: Measured creatinine >1.5-2x reference creatinine/ULRI
- AKI 2: Measured creatinine 2-3x reference creatinine/ULRI
- AKI 3: Serum creatinine >3x reference creatinine/ULRI
How do we prevent AKI?
3 Ms
-
Monitor
- Urine Output, PEWs, BP, weight
-
Maintain
- good hydration
-
Minimise
- drugs
Intrinsic causes of AKI?
- Glomerular problem: HUS
- Tubular injury
- Interstitial nephritis
What is HUS?
Haemolytic-Uraemic Syndrome
- Occurs post diarrhoea
- Entero-Haemorrhagic E.coli (EHEC)
Bloody diarrhoea is a medical emergency in children
Rx?
- Assess for HUS risk (15% will develop)
Triad of features of HUS:
- Microangiopathic haemolytic anaemia
- Thrombocytopenia
- Acute renal failure / AKI
Rx for HUS?
- IV normal saline and fluid
What are main causes of CKD?
- Congenital Anomalies of the Kidney and Urinary Tract (CAKUT): reflux nephropathy, dysplasia
What factors can increase progression in CKD?
- Hypertension
- Proteinuria
CKD
How do we assess BP in kiddo?
Doppler – gold standard for under age 5years
at what eGFR does CKD become symptomatic?
- <60
UTI
How does it present in neonates, pre-verbal kids and verbal kids?
- Neonates: vomiting, lethargy, fever, irratability
- Pre-verbal: Abdo pain, lethary, irratability
- Verbal: Abdo pain, frequency and dysuria
UTI
How do we urgently obtain a urine sample from a kid?
- Catheter samples or suprapubic aspiration (USS)
UTI
How do we make a diagnosis?
-
Dipstix
- Leucocyte esterase activity, nitrites
- unreliable < 2 yrs of age
-
Microscopy
- Pyuria >10 WBC per cubic mm
- Bacturia
-
Culture > 105 Colony forming units
- E.coli
Complications of UTI?
Scarring
UTI
Rx?
- Oral – From 3 months of age - Trimethorim, Co-amoxiclav, cephalosporin
- IV - 3rd generation Cephalosporin or Co-amoxiclav, IV Aminoglycosides effective (good renal excretion)
- Prophylaxis – abnormal urinary tract / VUR grade 3 and above
What imaging can we use for kidneys?
- ultrasound for structure
- DMSA (isotope) for scarring
- MAG3 scan for dynamic
