Nephrology and Genito-urinary

Question 1

What are the causes of acute nephritis? (4)

Answer 1

• Post­infectious (including streptococcus)
• Vasculitis (HSP or, rarely, SLE, Wegener granulomatosis, microscopic polyarteritis, polyarteritis nodosa)
• IgA nephropathy and mesangiocapillary
glomerulonephritis
• Anti­glomerular basement membrane disease (Goodpasture syndrome) → v rare

Question 2

Clinical features of acute nephritis?

Answer 2

Increased glomerular cellularity restricts glomerular blood flow and therefore filtration decreased
This leads to:
- Decreased urine output and vol overload
- HTN, may cause seizures
- Oedema, characteristically around eyes
- Haematuria and proteinuria

Question 3

Presenting features of HSP? (5)

Answer 3

Rash - buttocks, extensor surfaces of legs/arms, ankles
Joint pain + swelling
Abdo pain
Renal - haematuria (80%), nephotic syndrome (rare)
Often fever

Question 4

What is HSP?

Answer 4

• Cause unknown
• Pos genetic predisposition and antigen exposure increase circulating IgA levels and disrupt IgG synthesis
• IgA and IgG interact to produce complexes that activate complement and are deposited in affected organs, precipitating an inflammatory response with vasculitis

Question 5

What % with HSP have long-term renal abnormalities?

Answer 5

5-10%

- All with renal involvement must be followed for 1y

Question 6

Management of HSP?

Answer 6

• Usually self limiting
• No form of therapy has been show to appreciably shorten duration of disease or prevent complications
• NSAIDS may help joint pain but used with caution in renal insufficiency
• With nephropathy variety of drugs can be used inc steroids

Question 7

Causes of acute glomerulonephritis in childhood? (5)

Answer 7

• Post streptococcal (most common)
• Systemic immune disease – eg SLE
• Other systemic illnesses – vasculitis, HSP
• Alport syndrome (familial nephritis)
• IgA nephropathy

Question 8

Presentation of acute glomerulonephritis?

Answer 8

• Haematuria
• Decreased urine output
• Fatigue
• Lethargy
• Headache

Question 9

Ix for acute glomerulonephritis?

Answer 9

• Electrolytes and creatinine – assess renal function
• FBC – infection, anaemia
• Urinalysis – infection, protein, blood
• Urine culture – infection
• Complement levels
• ASO titre
• Anti-DNAase B
• Serum IgA measurement

Question 10

What is nephrotic syndrome? (3)

Answer 10

Heavy proteinuria → low plasma albumin + oedema

Question 11

Most common type of nephrotic syndrome in childhood?

Answer 11

Minimal change disease

Question 12

Clinical signs of nephrotic syndrome?

Answer 12

• Periorbital oedema (esp on waking) → earliest sign
• Scrotal or vulval, leg + ankle oedema
• Ascites
• Breathlessness – due to pleural effusions
• Abdo distension

Question 13

Management of nephrotic syndrome?

Answer 13

Corticosteroids - prednisolone

• Every day for 4w
• Alternate days for 4w

–> If no response - renal biopsy

Question 14

Complications of nephrotic syndrome? (4)

Answer 14

Hypovolaemia
Thrombosis
Infection
Hypercholesterolaemia

Question 15

Prognosis of steroid-sensitive nephrotic syndrome?

Answer 15

1/3 resolve directly
1/3 relapse infrequently
1/3 frequent relapses & steroid-dependent

Question 16

What atypical features of nephrotic syndrome might prompt consideration of 2nd line treatment +/or biopsy? (5)

Answer 16

• <1 year old or >10 years old
• Hypertensive
• Elevated creatinine
• Macroscopic haematuria
• Failed to respond to steroids after 4-8w

Question 17

Commonest organism in UTI?

Answer 17

E Coli

Question 18

NICE definition of pyelonephritis?

Answer 18

Bacteriuria + fever ≥38°C
OR
Fever <38°C with loin pain/tenderness + bacteriuria

Question 19

NICE definition of cystitis?

Answer 19

Bacteriuria but no systemic S or S

Question 20

Sx of UTI in infants?

Answer 20

• Fever
• Vomiting
• Lethargy or 
irritability
• Poor feeding/failure 
to thrive
• Jaundice
• Septicaemia
• Offensive urine
• Febrile convulsion (>6m)

Non-specific

Question 21

Sx of UTI in older children?

Answer 21

• Dysuria and frequency
• Abdo pain or loin tenderness
• Fever with or without rigors (exaggerated shivering)
• Lethargy and anorexia
• Vomiting, diarrhea
• Haematuria
• Offensive/cloudy urine
• Febrile convulsion
• Recurrence of enuresis

More classical sx

Question 22

Features of atypical UTI? (7)

Answer 22

• Seriously ill
• Poor urine flow
• Abdo or bladder mass
• Raised creatinine
• Septicaemia
• Failure to respond to suitable abx within 48h
• Infected with non-E.coli organisms

Question 23

NICE definition of recurrent UTI?

Answer 23

• ≥2 UTIs with acute pyelonephritis/upper UTI
  OR
• 1 episode of UTI with acute pyelonephritis/upper urinary tract infection plus ≥1 episodes of UTI with cystitis/lower urinary tract infection
  OR
• ≥3 episodes of UTI with cystitis/lower urinary tract infection

Question 24

What investigations can be done for atypical or recurrent UTIs?

Answer 24

• USS
• DMSA - assess renal function
• MCUG - contrast study

Question 25

Treatment of acute pyelonephritis? | Treatment of cystitis?

Answer 25

<3m - IV abx eg cefotaxime, switch to oral >3m - Usually oral abc e.g. co-amoxiclav - Sometimes IV cefotaxime, then oral - Total of 7-10d Cystitis - Oral abx for 3d

Question 26

Ddx of haematuria? (2 categories)

Answer 26

Non-glomerular: - Infection → MOST COMMON (seldom only sx) - Trauma to genitalia, urinary tract or kidneys - Stones - Tumours - Sickle cell disease - Bleeding disorders - Renal vein thrombosis - Hypercalciuria Glomerular: - Acute GN (usually + proteinuria) - Chronic GN (usually + proteinuria) - IgA nephropathy - Familial nephritis eg Alport syndrome - Thin basement membrane disease

Question 27

Diagnostic tests for vesico-ureteric reflux (VUR)? (2)

Answer 27

- USS - can see hydronephrosis | - MCUG - used to see and grade reflux

Question 28

Classification of causes of AKI? (3)

Answer 28

Pre-renal Renal Post-renal

Question 29

Pre-renal causes of AKI? (7)

Answer 29

- Hypovolaemia - Gastroenteritis - Burns - Sepsis - Haemorrhage - Nephrotic syndrome - Circulatory failure

Question 30

Renal causes of AKI? (11)

Answer 30

``` Vascular - HUS (most common) - Vasculitis - Embolus - Renal vein thrombosis Tubular - Acute tubular necrosis (ATN) (most common) - Ischaemic - Toxic - Obstructive Glomerular - Glomerulonephritis Interstitial - Interstitial nephritis - Pyelonephritis ```

Question 31

Post-renal causes of AKI? (2)

Answer 31

Obstruction - Congenital eg posterior urethral valves - Acquired eg blocked urinary catheter

Question 32

Most common causative organism in HUS?

Answer 32

E Coli 0157:H7 | → Acquired through contact with farm animals or eating uncooked beef

Question 33

Triad of abnormalities that occur in HUS?

Answer 33

- Acute renal failure - Microangiopathic haemolytic anaemia - Thrombocytopenia

Question 34

5 stages of CKD?

Answer 34

Stage 1: normal GFR>90 mL/min per 1.73m2 and persistent albuminuria Stage 2: GFR 60-89 mL/min per 1.73m2 and persistent albuminuria Stage 3: GFR 30-59 mL/min per 1.73m2 Stage 4: GFR 15-30 mL/min per 1.73m2 Stage 5: GFR <15 mL/min per 1.73m2 or end stage renal disease

Question 35

Clinical features of CKD?

Answer 35

Vary with stage, rarely present before GFR <1/3 normal - Anorexia or lethargy - Polydipsia and polyuria - FTT/ faltering growth - Bone deformities - HTN - Acute-on-chronic renal failure - Proteinuria - Normochromic, normocytic anaemia

Question 36

Causes of CKD? (5)

Answer 36

- Stuctural malformations = 40% - Glomerulonephritis = 25% - Hereditary nephropathies = 20% - Systemic diseases = 10% - Miscellaneous/ unknown = 5%

Question 37

Normal systolic BP for a) 1-5yo b) 5-10yo

Answer 37

a) <110 | b) <120

Question 38

Causes of HTN in children?

Answer 38

Renal - Renal parenchymal disease - Renovascular eg renal artery stenosis - Polycystic kidney disease (ARPKD + ADPKD) Coarctation of aorta Catecholamine XS - Phaeochromocytoma - Neuroblastoma Endocrine - Congenital adrenal hyperplasia - Suching syndrome or corticosteroid therapy - Hyperthyroidism Essential HTN: - Diagnosis of exclusion

Question 39

How are most urinary tract abnormalities diagnosed?

Answer 39

Antenatal USS

Question 40

What is a hypospadia?

Answer 40

Urethral opening proximal to normal position on glans in males

Question 41

What is a neuropathic bladder?

Answer 41

Bladder does not empty properly due to neurological condition or spinal cord injury