Nephrology Flashcards
Any red coloured urine, or positive on a dipstick should be tested by microscopy. What is a positive result?
> 10 erythrocytes per field
What are the two types of Haematuria?
Glomerular
Lower UTI
How would Glomerular Haematuria present?
Brown Urine
Red deformed cells
Casts
Proteinuria
How would Haematuria due to Lower UTI present?
Red in colour
Occurring at beginning or end of stream
No Proteinuria
(Unusual in children)
Give four glomerular causes of Haematuria
Acute/Chronic Glomerulonephritis
IgA Nephropathy
Alport Syndrome
Thin Basement Membrane
Give four non glomerular causes of Haematuria
Infection
Trauma
Bleeding Disorder
Sickle Cell
Other than Urine Microscopy and Culture, what three other investigations should be done in Haematuria?
Protein and Calcium Excretion
Kidney and Urinary Tract USS
Range of bloods
What further investigations might you do for Haematuria if indicated?
Throat Swabs
Anti Streptolysin titre
Hearing Test (Alport)
Renal Biopsy
In Acute Nephritis, glomerular blood flow is restricted which reduces Urine Output and Increases Blood Pressure. Give four causes
Post Infectious (Strep)
Vasculitis (HSP, SLE, Wegener)
IgA
Good pastures
What is characteristic of Post Strep Glomerulonephritis?
Follows sore throat or skin infection
Raised ASOT and reduced C3
How does HSP present?
Characteristic skin rash on extensor surfaces
Arthralgia
Periorbital Oedema
Colicky Abdominal Pain
Usually aged 3-10 with preceding URTI
How is HSP managed?
Analgesia
If severe then steroids
What is the pathophysiology of HSP?
Raised IgA and disruption of IgG interact and deposit causing inflammation
How should Acute Nephritis be treated in Children?
Monitor fluid and electrolytes and correct where appropriate
Diuretics
What is the normal pattern of Enuresis?
Normally controlled daytime urination by 2 years old, and nighttime at 3-4 years old
What is Primary Enuresis? Give three possible causes
Never managed to be consistently dry at night
FH, Pre Bed Fluid Intake, Cerebral Palsy
How is Primary Nocturnal Enuresis managed?
Keep a two week diary
Reassure parents that if they’re less than 5 years old it’s likely to self resolve
Lifestyle changes and positive reinforcement
What is Secondary Nocturnal Enuresis? Give four causes.
Child begins wetting the bed when they’ve been previously dry for 6 months
UTI, Constipation, T1DM, New Psychosocial
What is Diurnal Enuresis? Give three examples
Person is dry at night but has episodes of incontinence throughout the day
Urge Incontinence, Constipation, UTI
One of the managements for Enuresis is Enuresis Alarms. How do these work?
Makes a noise at the first sign of bed wetting, waking the child and preventing further wetting
Needs to be used consistently for atleast 3 weeks
Describe three pharmacological managements of Enuresis and their MOA
Desmopressin - ADH Analogues taken at bed time
Oxybutinin - Anticholinergic, if underlying cause is OA bladder
Imipramine - TCA, relaxes bladder and lightens sleep
How does a UTI present in babies?
Fever Lethargy Irritability Vomiting Poor Feeds
How does a UTI present in Older Children
Fever Suprapubic Pain Vomiting Dysuria Frequency
In addition to some lower UTI symptoms, how would Pyelonephritis present?
Temp>38 degrees
Lion Pain/Tenderness
What is typically present on a dipstick of UTI? Which is a better indicator?
Nitrites
Leukocyte Esterase
Nitrites are a better indicator (treat even if leukocyte esterase not present)
How should a UTI be managed depending on age group?
<3 months - Start immediate Sepsis management (Cefotaxime + Amoxicillin +/- Gentamicin) and full septic screen
> 3 months -12 y- 3 days Oral Cefalexin if otherwise well
12-17 - 3 days Nitrofurantoin
If a child has recurrent UTIs, name three investigations you could do
USS
DMSA
Micturating Cystourethrogram
When should USS be done?
If <6m with first UTI should have scan within 6 weeks
Any child with recurrent/atypical UTIs should have USS within 6m
When should DMSA (Dimercaptosuccinic Acid Scan) be done?
Used 4-6 months after illness to assess for damage from recurrent/atypical infections
Radioactive DMSA and Gamma Camera (areas of no uptake mean scarring)
When is a Micturating Cystourethrogram used?
To diagnose Vesicoureteric Reflux which could be a cause of recurrent UTIs
How is Vesicoureteric Reflux managed?
Avoid Constipation, Excessively full bladder, Prophylactic Abx, Urological Surgery
What is a Posterior Urethral Valve?
Tissue at the proximal end of urethra causes obstruction of urine output
This creates pressure back into the bladder, causing hydronephrosis and increased UTI risk
What are the clinical features of Posterior Urethral Valve?
Mainly occurs in newborn boys
May be asymptomatic
Difficulty urinating, weak stream, chronic retention, recurrent UT
What are the clinical features of Severe Posterior Urethral Valve in Utero?
Bilateral Hydronephrosis
Oligohydramnios
Pulmonary Hypoplasia
Posterior Urethral Valves may be picked up Antenatally. How can it be investigated Post Natally?
Abdominal Ultrasound
Micturating Cystourethrogram
Cystoscopy(can also be used therapeutically to remove the tissue)
What is Nephrotic Syndrome?
Basement membrane and glomerulus become highly permeable to protein
Triad: Low Serum Albumin, High Protein Content, Oedema
May also have deranged lipid profile and hypercoaguability
Minimal Change Disease is the most common cause of Nephrotic Syndrome in children. How should it be investigated?
Urinalysis - small molecular weight proteins and hyaline casts
Renal biopsy and microscopy DOESN’T detect abnormality
Name two other causes of Nephrotic Syndrome
Secondary to Intrinsic Disease (FSGS, Membranoproliferative)
Secondary to Infection (HSP, Diabetes, Infection)
How is Neohrotic Syndrome managed?
High dose steroids for 4 weeks, then weaned over 8 weeks
Low salt diet
Diuretics for Oedema
?VTE/Abx prophylaxis
What is Steroid Dependent Nephrotic Syndrome?
Relapse as soon as weaned off steroids
What is Haemolytic Uraemic Syndrome?
Thrombosis within small vessels triggered by Shiga Toxin, commonly caused by E.Coli and Shigella
How does Haemolytic Uraemic Syndrome present?
Typically begins 5 days after Diarrhoea
Triad: Haemolytic Anaemia, AKI, Thrombocytopenia
(Reduces UO, Haematuria, Lethargy)
Haemolytic Uraemic Syndrome is a medical emergency with a 10% mortality. It’s managed supportively only, give examples.
Renal Dialysis (if required)
Antihypertensives
Maintenance of fluid balance
Blood transfusions
What is Autosomal Recessive Polycystic Kidney Disease?
Presents in neonates, and is the result of PKHD1 mutation on Chromosome 6
(As opposed to autosomal dominant condition presenting in adulthood)
How does Autosomal Recessive Polycystic Kidney Disease present?
Cystic enlargement of Kidney
Oligohydramnios and Pulmonary Hypoplasia
Liver fibrosis
How is Autosomal Recessive Polycystic Kidney Disease managed?
Requires dialysis within first few days of life
Most develop end stage renal failure before reaching adulthood
1/3 die in neonatal period
What is Multicystic Dysplastic Kidney?
One of baby’s kidneys is normal and other is normal
Usually single healthy kidney is enough to lead a normal life, and often other kidney atrophies and disappears before the age of 5
Wilms Tumour is a specific type of tumour affecting kidney in children (typically under 5y). How does it present?
Mass in abdomen
Abdominal pain
Haematuria
Weight loss
How is Wilms Tumour investigated?
US Abdomen
Biopsy for histological analysis
CT/MRI for staging
How are Wilms Tumours managed?
Nephrectomy of affected kidney
Adjuvant Chemo/radiotherapy
Early stage disease has a 90% cure
Define Hypospadias
Urethral meatus is abnormally displaced posteriorly on penis (normally close to Glans but can be anywhere along shaft)
Often has associated foreskin abnormalities and Chordee (head of penis bends down)
How is Hypospadias managed?
May not require management
Surgery between 3 and 4 months (Urethroplasty)
State three complications of Hypospadias
Bladder Spasms
Urethral Fistulae
Difficulty directing urination
A hydrocoele is a collection of fluid in tunica Vaginalis that surrounds testes. What are the two types?
Simple - common in newborns, fluid gets reabsorbed over time and hydrocoele disappears
Communicating - Processus Vaginalis is patent, hydrocoele fluctuates in size
Give three differentials for Hydrocoeles
Partially descended testes
Inguinal Hernia
Torsion
How are hydrocoeles managed?
Simple - self resolves within 2 years
Communicating - surgical ligation of processus Vaginalis
Give four features of Chronic Kidney Disease in children
Anorexia
Lethargy
Growth Failure
Bone Deformities
How are the Bone abnormalities managed in children with CKD?
Decrease dairy
Calcium Carbonate (phosphate binder)
Activated Vitamin D
(As phosphate retention leads to Hypocalcaemia, secondary hyperparathyridism and osteitis malacia)
What other medications may you consider giving in CKD?
Bicarbonate Supplements
Erythropoietin
Hormonal Abnormality correction (eg GH resistance)
What is required via microscopy to diagnose a UTI?
10^5 bacteria pure growth
0-40 white cells
How can you prevent a UTI?
Stay hydrated Use potty every 2-3 hours Double voiding Cotton Underwear Avoid Bubble Baths
