Nephrology and Genito-urinary Flashcards
What are the causes of acute nephritis? (4)
- 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
Clinical features of acute nephritis?
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
Presenting features of HSP? (5)
Rash - buttocks, extensor surfaces of legs/arms, ankles
Joint pain + swelling
Abdo pain
Renal - haematuria (80%), nephotic syndrome (rare)
Often fever
What is HSP?
- 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
What % with HSP have long-term renal abnormalities?
5-10%
- All with renal involvement must be followed for 1y
Management of HSP?
- 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
Causes of acute glomerulonephritis in childhood? (5)
- Post streptococcal (most common)
- Systemic immune disease – eg SLE
- Other systemic illnesses – vasculitis, HSP
- Alport syndrome (familial nephritis)
- IgA nephropathy
Presentation of acute glomerulonephritis?
- Haematuria
- Decreased urine output
- Fatigue
- Lethargy
- Headache
Ix for acute glomerulonephritis?
- 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
What is nephrotic syndrome? (3)
Heavy proteinuria → low plasma albumin + oedema
Most common type of nephrotic syndrome in childhood?
Minimal change disease
Clinical signs of nephrotic syndrome?
- Periorbital oedema (esp on waking) → earliest sign
- Scrotal or vulval, leg + ankle oedema
- Ascites
- Breathlessness – due to pleural effusions
- Abdo distension
Management of nephrotic syndrome?
Corticosteroids - prednisolone
- Every day for 4w
- Alternate days for 4w
–> If no response - renal biopsy
Complications of nephrotic syndrome? (4)
Hypovolaemia
Thrombosis
Infection
Hypercholesterolaemia
Prognosis of steroid-sensitive nephrotic syndrome?
1/3 resolve directly
1/3 relapse infrequently
1/3 frequent relapses & steroid-dependent
What atypical features of nephrotic syndrome might prompt consideration of 2nd line treatment +/or biopsy? (5)
- <1 year old or >10 years old
- Hypertensive
- Elevated creatinine
- Macroscopic haematuria
- Failed to respond to steroids after 4-8w
Commonest organism in UTI?
E Coli
NICE definition of pyelonephritis?
Bacteriuria + fever ≥38°C
OR
Fever <38°C with loin pain/tenderness + bacteriuria
NICE definition of cystitis?
Bacteriuria but no systemic S or S
Sx of UTI in infants?
- Fever
- Vomiting
- Lethargy or irritability
- Poor feeding/failure to thrive
- Jaundice
- Septicaemia
- Offensive urine
- Febrile convulsion (>6m)
Non-specific
Sx of UTI in older children?
- 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
Features of atypical UTI? (7)
- 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
NICE definition of recurrent UTI?
- ≥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
What investigations can be done for atypical or recurrent UTIs?
- USS
- DMSA - assess renal function
- MCUG - contrast study
Treatment of acute pyelonephritis?
Treatment of cystitis?
<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
Ddx of haematuria? (2 categories)
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
Diagnostic tests for vesico-ureteric reflux (VUR)? (2)
- USS - can see hydronephrosis
- MCUG - used to see and grade reflux
Classification of causes of AKI? (3)
Pre-renal
Renal
Post-renal
Pre-renal causes of AKI? (7)
- Hypovolaemia
- Gastroenteritis
- Burns
- Sepsis
- Haemorrhage
- Nephrotic syndrome
- Circulatory failure
Renal causes of AKI? (11)
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
Post-renal causes of AKI? (2)
Obstruction
- Congenital eg posterior urethral valves
- Acquired eg blocked urinary catheter
Most common causative organism in HUS?
E Coli 0157:H7
→ Acquired through contact with farm animals or eating uncooked beef
Triad of abnormalities that occur in HUS?
- Acute renal failure
- Microangiopathic haemolytic anaemia
- Thrombocytopenia
5 stages of CKD?
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
Clinical features of CKD?
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
Causes of CKD? (5)
- Stuctural malformations = 40%
- Glomerulonephritis = 25%
- Hereditary nephropathies = 20%
- Systemic diseases = 10%
- Miscellaneous/ unknown = 5%
Normal systolic BP for
a) 1-5yo
b) 5-10yo
a) <110
b) <120
Causes of HTN in children?
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
How are most urinary tract abnormalities diagnosed?
Antenatal USS
What is a hypospadia?
Urethral opening proximal to normal position on glans in males
What is a neuropathic bladder?
Bladder does not empty properly due to neurological condition or spinal cord injury
