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Y4 paeds > Nephrology > Flashcards

Nephrology Flashcards

1
Q

What is enuresis?

A

involuntary bed wetting after the age of 7- most children toilet trained by age 5

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2
Q

Give 5 possible causes of enuresis

A
  • small bladder
  • nerves slow to mature so cannot recognise full bladder
  • low ADH
  • UTI
  • sleep anoea
  • diabetes
  • chronic constipation
  • structural problems in the urinary tract or nervous system
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3
Q

How should enuresis be managed?

A
  • avoid caffeine and limit fluid intake at night
  • treat cause if any identified (constipation/ sleep apnoea)
  • moisture alarms: go off when moisture detected- effective but take 16 weeks
  • desmopressin (synthetic ADH)- only if over 5 yrs
  • oxybutynin (anticholinergic)- reduced contractions and increases bladder capacity
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4
Q

What is henoch- schonlein purpura?

A
  • AKA IgA vasculitis

- causes small blood vessels in skin, joints, intestines and kidneys to become inflamed and bleed

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5
Q

What may cause/ trigger henoch schonlein purpura

A
  • cause is autoimmune

- triggers inc URTI, chickenpox, strep throat, measles, hepatitis, meds, food, insect bites, exposure to cold

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6
Q

How does HSP present// what body systems are affected?

A
  • skin: palpable red- purple non blanching purpuric rash on buttocks, legs and feet
  • joints: arthritis, pain and swelling around knees and ankles- can preceed rash
  • GI: acute, diffuse, colicky belly pain, nausea, vomiting, bloody stools
  • Kidney: protein or blood in urine, red cell clasts, IgA deposition on biopsy
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7
Q

Give risk factors for HSP

A
  • age 2-6
  • M>F
  • white or asian
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8
Q

how is HSP diagnosed

A

Purpura or petichae with lower limb predominance + 1 of:

  • diffuse abdo pain at onset
  • biopsy showing IgA deposits
  • arthritis or arthralgia of acute onset
  • proteinuria/ haematuria
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9
Q

Give 2 complications of HSP

A
  • permanent kidney damage- may require dialysis or transplant
  • bowel obstruction from intussusception
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10
Q

How is HSP managed?

A
  • rest, plenty of fluids and pain releif if mild as self resolving
  • prednisolone if significant GI involvement or complications (decreases duration of abdo and joint pain but not complications)
  • IVIg and plasmapheresis if severe
  • DMARDs inc aza if chronic renal disease
  • surgery if complications develop
  • monitor BP and urinalysis for 6 months after diagnosis if nephritic
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11
Q

What is the most common cause of nephrotic syndrome in paediatrics

A

minimal change disease (steroid responsive)
other steroid responsive= SLE, HSP, post strep
Steroid resistant: congenital, FSGS, Menangiocapillary glomerular nephritis, membranous nephropathy

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12
Q

Describe the clinical features of nephrotic syndrome

A
  • odema (typically facial/ periorbital and in morning)
  • scrotal/ vaginal/ leg/ ankle odema
  • ascites
  • breathlessness from pleural effusion + abdo distension
  • infections (sepsis, peritonitis, septic arthritis) due to immunoglobulin loss in urine
  • proteinuria
  • hypoalbuminaemia
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13
Q

How is nephrotic syndrome managed?

A
  • high dose steroids- need admission and monitoring for at least 24 hrs as intravascularly deplete- dont give diuretics
  • some may need low dose maintenance therapy or immunomodulatory drugs (ciclosporin, rituximab, mycophenolate) if steroid resistant, dependant or relapsing
  • low salt diet, fluid restriction
  • prophylactic abx as at high risk of infections as leak immunoglobulins
  • 30% FSGS, 100% congenital (unilateral nephrectomy initially to control hypoalbuminuria), mesangiocapillary glomerular nephritis may need renal transplant
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14
Q

What may cause acute glomerular nephritis in a child? (4)

A
  • post strep/ any inf
  • vasculitis (HSP, SLE, wengers)
  • IgA nephropathy
  • mesangiocapillary glomerularnephritis
  • anti GBM (rare)
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15
Q

describe the clinical features of acute glomerular nephritis

A
  • haematuria + oliguria
  • HTN
  • sometimes odema, fever, loin pain, GI disturbance
  • complicated: hypertensive encephalopathy, uraemia, arrhythmias
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16
Q

How does post streptococcal glomerularnephritis present?

A
  • 7-21 days after strep infection

- with gross haematuria, odema, HTN, anorexia, fever and abdo pain

17
Q

How is post streptococcal glomerular nephritis managed?

A
  • restrict protein, sodium
  • give diuretics, anti hypertensives
  • penicillin orally for 10 days
  • nitroprusside if hypertensive encephalopathy
  • odema resolves in 5-10 days but HTN and proteinuria can last weeks
18
Q

Other than acute glomerularnephritis, what can haematuria in children? (3)

A
  • UTI
  • wilms tumour
  • calculi
  • polycystic kidney disease
  • sickle cell disease
  • surgery/ trauma
  • IgA nephropathy
  • thin basement membrane disease
  • alports/ famillairl nephritis
19
Q

How may a UTI present in a child that is preverbal

A
  • vomiting
  • fever
  • lethargy
  • poor feeding
  • failure to thrive
  • irritability
  • offensive smelling urine
  • haematuria
20
Q

What are the indications for a USS in a child with UTIs?

A
  • UTI age < 6 months (get one within 6 weeks)
  • Atypical UTI: seriously ill, failure to respond to abx within 48hrs, septicaemia, infection with non e. coli organism, raised creatinine, abdominal or bladder mass
  • Recurrent UTI: >2 episodes of severe/ acute pyleonephritis/ upper UTI, 1 episode upper and one episode lower UTI, >3 episodes lower UTI
21
Q

How are lower UTIs managed?

A
  • trimethoprim for 3 days (if low risk of resistance (4mg/kg/ 12hrs)
  • or nitrofurantoin if eGFR >45ml/min for 3 days
22
Q

How are upper UTIs managed?

A
  • cefalexin for 10 days
  • or co amox for 10 days is culture susceptible
  • if IV needed: cefuroxime, ceftriaxone, gentamicin
23
Q

How are UTIs managed if <3 months old?

A
  • IV amoxicillin + gent or IV cephalosporin

- USS, MCUG

24
Q

What advice can be given to help prevent UTIs

A
  • encourage high fluid intake
  • treat constipation
  • encourage full voiding
  • avoid nylon underwear
  • clean perineum front to back
25
Q

What investigations should be done to confirm UTI?

A
  • urine dip: nitrites, leukocyte esterase, blood, (leukocytes and protein may be present from fever of any cause) can be used from >3yrs. LE and nitritis +ve= treat as UTI, one +ve= MCS to confirm, neither -ve= UTI unprobable
  • urine collection: microscopy and culture (>10x5 colony forming units/ ml of same organism) OR WCC>40 if age <3yrs or inconclusive dipstik
26
Q

What is vesicoureteric reflux and what causes it?

A
  • abnormal flow or urine from bladder back up ureters
  • primary: born with defect in valve which normally prevents urine from flowing backward from bladder into ureters- as child grows ureters lengthen and valve function tends to improve
  • secondary vesicoureteric reflux: urinary tract malfunction often due to abnormally high pressure in bladder from blockage or nerve damage
27
Q

How should suspected vesicoureteric reflux be investigated?

A
  • urinalysis
  • kidney and bladder US
  • voiding cystourethrogram (VCUG)
  • consider DSMA for renal scarring
28
Q

How is vesicoureteric reflux graded?

A
  • on extent of urine back up and dilation of ureter/ pelvis/ calyces
  • 1= urine backs up to ureter only
  • 5= severe hydronephrosis and twisting of ureter
29
Q

Describe the clinical features of vesicoureteric reflux?

A
  • strong persistent urge to urinate
  • burning sensation when urinating
  • passing frequent but small amounts of urine
  • frequent/ severe UTIs
  • flank or abdo pain
  • hesitancy
  • hydronephrosis
  • enuresis, constipation, renal scarring, HTN, kidney failure and proteinuria if untreated
30
Q

How is vesicoureteric reflux managed?

A
  • manage UTIs promptly
  • prophylactic abx
  • monitor kidney function, height, weight, BP, proteinuria
  • many dont need sugrical correction- unless severe, specific cause eg posterior urethral valves or renal parenchymal damage
31
Q

how should nephrotic syndrome be investigated?

A
  • bloods: fbc,u&e, complement, esr, crp, albumin
  • urine: mcs, pcr, dip, sodium
  • throat swab and anti streptolysin O titres
  • hep b and c
  • autoantibodies
  • biopsy if atypical (steroid resistant, age <1 or >12, haematuria, high BP, abnormal complement levels, abnormal renal function)
32
Q

When should DMSA and MCUG scans be done?

A 
MCUG= whenever abnormal USS, severe or recurrent UTIs if <6 months 
DMSA= 6 months after acute infection(also need to give prophylactic abx 3 days before) and when recurrent UTIs OR severe or atypical and age <5
ATYPICAL= septic, non ecoli, febrile 48 hrs after appropriate treatment, high creatinine, abdo mass or poor urine flow
RECURRENT= two or more UTIs w/ systemic illness// upper UTIs or 3 or more without
33
Q

How can dipstik results be interpreted? When can they be used to diagnose UTI and you dont need MC&S?

A

Can be used age >3. If <3yrs, need MCS

  1. Nitrite and LE +ve= UTI, treat,
  2. Nitrite -ve, LE +ve= possibly UTI, clinical judgement/ MCS
  3. Nitritie +ve, LE -ve= probably UTI, treat/ MCS
  4. both -ve= not UTI,
34
Q

When should urine be sent for M,C and S? (6 indications)

A 
- Systemically unwell child
or
- age <3 
or
- single +ve result for nitrites or leukocyte esterase 
or
- Recurrent UTIs
or
- No response to tx in 24-48hrs
or 
-clinical symptoms and dipstik dont correllate

Y4 paeds (14 decks)

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