Nephrology and Urinary System Flashcards
When would a child require intervention with enuresis?
5 - 7: Non-pharmacological
7 years +: Pharmacological
What is the first line pharmacological treatment for enuresis?
Desmopressin
What is secondary enuresis?
Bed wetting a child who has previously been dry - usually due to emotional/psychological stress
Also classified as a relapse after 6 months dry
What is the most common pathological cause of enuresis in kids?
UTI
What factors would indicate an atypical urinary tract infection?
Seriously ill/septic
Poor urinary flow
Abdominal/bladder mass
Lack of response to Abx within 48hrs
How would a UTI present in neonates?
Pyrexia
Lethargy/irritability
Vomiting
Give three renal anomalies that can predispose to recurrent UTIs
Single kidney/unilateral renal agenesis
Ectopic kidney
Mutlicystic dysplastic kidneys
Autosomal dominant/recessive PKD
Give three urological anomalies that can predispose to recurrent UTIs
Ureteric obstruction Posterior urethral valves Hypospadias Phimosis/paraphimosis Vesicoureteric reflux
Which other investigations are used to determine:
(i) kidney scarring?
(ii) ureteric reflux?
i. Radioisotope scanning (DMSA)
ii. Micturating cystourethrogram (MCUG)
Which other investigations are used to determine:
(i) kidney scarring?
(ii) ureteric reflux?
i. Radioisotope scanning (DMSA)
ii. Micturating cystourethrogram (MCUG)
Give four risk factors for enuresis
Genetic Developmental delay Down's Spina bifida Cerebral palsy Caffeinated drinks Emotional stress
In a history of enuresis, why should you ask about the volume and frequency of enuresis?
Large volumes in the early hours suggests no organic cause
Variable volumes throughout the night suggests disease
When would you follow-up a child using an enuresis alarm?
After 4 weeks
When would you stop using an enuresis alarm?
After 14 consecutive dry nights
What can cause red urine?
Haematuria
Beetroot
Rifampicin
Who is nocturnal enuresis more common in?
Boys
Give three causes of nocturnal enuresis
Delayed maturation (often familial) Reduced ADH production Reduced bladder awareness Emotional stress UTI Polyuria due to diabetes or renal disease
Other than emotional stress, what else can cause secondary enuresis?
UTI
DM
Threadworm infection
Which drinks should be avoided in children with enuresis?
Caffeinated drinks
Fruit juice
What should parents not do when attempting manage nocturnal enuresis?
Lifting - this trains the child to void whilst half asleep
How and when is desmopressin given?
Nasal spray or tablets before bed
Given when(i) rapid control is needed (ii) alarms have not worked (iii) short-term control e.g. school trips
What is second line to desmopressin in the treatment of enuresis?
Oxybutinin - anticholinergic - reduces detrusor instability
Used +/- desmopressin with symptoms of bladder instability such as diurnal enuresis, urgency and frequency
Imipramine - tricyclic antidepressant
Used infrequently and only in resistant cases, it has a lot of side effects and has risk of overdose
When would you refer a child with enuresis?
Severe diurnal symptoms
Recurrent UTIa
Abnormal renal USS
Neurological signs
Comorbid conditions e.g. incontinence, DM, delay
if they have not responded to GP care after 6 months
When are children usually dry by day?
2
When are children usually dry by night?
3
How is primary enuresis defined?
Never achieved dryness in child over 5
How might a child with neurogenic bladder present?
Distended bladder
Abnormal perianal sensation
Abnormal anal tone
Abnormal leg findings e.g. weakness
What are two common causes of neurogenic bladder?
Cerebral palsy
Spina bifida
How should you advise a parent with a child with urgency incontinence?
Void frequently
Train with stream interruption exercises
What drug class is desmopressin?
Arginine vasopressin (AVP) analogue
What counselling should you give to a parent before starting their child on desmopressin?
Minimise fluid intake 1 hour before and and 8 hours after dose - can lead to fluid overload
Do not give if vomiting or diarrhoea
Horseshoe kidney is associated with which condition?
Turner’s syndrome
What is the most common cause of UTI?
E.coli
What clinical features would make you suspicious of an upper UTI?
Bacteriuria
Fever > 38
Loin pain/tenderness
What is classed as a recurrent UTI?
2 upper UTI
3 lower UTI
1 upper and 1 lower UTI
Which UTI causative organism is common in
(i) teenage girls?
(ii) children with congenital tract anomalies?
(iii) haemorrhagic cystitis?
i. Staphylococcus saphrocyticus
ii. Pseudomonas
iii. Adenovirus 11 and 12
Poor urinary stream in boys can be a sign of what?
Posterior urethral valves
How would you manage a UTI in a child under 3 months
Admit
IV Abx: broad spectrum e.g. cefotaxime, gentamicin
What drug would you give for an acute pyelonephritis?
Oral cephalosporin or co-amoxiclav, for 7 - 10 days
What is the first-line pharmacoloigcal treatment for cystitis/ lower UTI?
Trimethoprim/nitrofurantoin for 3 days
Can also give cephalosporins or amoxacillin
Orange-pink stains in the nappy are usually due to what?
Urate crystals
What does frothy urine indicate?
Presence of protein or bile
On a urine dipstick, what indicates infection?
Nitrites - urinary pathogens reduce nitrates to nitrites
Excess leucocytes indicate inflammation, and sometimes infection
When is the urine +ve for ketones?
General illness, anorexia or vomiting
Many school children who haven’t had breakfast!
What investigation(s) should you do for a child < 6 months with a typical UTI?
USS within 6 weeks
What investigation(s) should you do for a child < 6 months with an atypical/recurrent UTI?
USS
DMSA
MCUG
What investigation(s) should you do for a child aged 6 months - 3 years with a typical UTI?
None
What investigation(s) should you do for a child aged 6 months - 3 years with an atypical/recurrent UTI?
USS during acute atypical infection
USS within 6 weeks if recurrent infection
DMSA
What investigation(s) should you do for a child over 3 with a typical UTI?
None
What investigation(s) should you do for a child over 3 with an atypical/recurrent UTI?
USS during acute atypical infection
USS within 6 weeks and DMSA if recurrent infection
Give three causes of haematuria in kids
Post strep glomerulonephritis Polycystic kidneys Renal stones Renal/Wilms tumourSickle cell disease UTI HSP IgA nephropathy Alport's syndrome Thin basement membrane
What is Alport syndrome?
Autosomal dominant genetic condition characterised by kidney disease, hearing loss, and eye abnormalities
How does the inheritance pattern of PKD change between different age groups?
Autosomal recessive in kids
Autosomal dominant in adolescence/adults
When investigating haem/proteinuria, what would you changes might you see in:
(i) throat swab
(ii) serum CR complement
(iii) albumin
(iv) proteon/creatinine ratio
(v) triglycerides/cholesterol
i. Strep infection
ii. Low in some types of glomerulonephritis
iii. Low in nephrotic syndrome
iv, v. High in nephrotic syndrome
What is the commonest cause of UTI in kids?
Haemolytic uraemic syndrome
What is HUS associated with?
Thrombocytopenia
AKI
Haemolytic anaemia
How does HUS usually present?
Profuse diarrohoea that turns bloody 1 - 3 days later
Fever
Abdominal pain
Vomiting
What causes HUS?
E.coli 0157:H7
What are the risk factors for HUS?
Rural poulations Warmer summer months Young age (6 months - 5 years) Older people/those with altered immune response Farm animal contact
What changes might you see with HUS in the FBC?
Falling Hb
Fragmented RBC on blood film
Low/falling platelet count
What are early indicators of HUS onset?
Increasing urea and Cr
High LDH
What is the treatment of HUS?
Notify authorities
Fluid and electrolytes
Antihypertensives
Dialysis (if required)
Who should you notify with notifiable infectious diseases?
Public Health England
What is the criteria for diagnosis of nephrotic syndrome?
Proteinuria > 3g/day or P/Cr ratio > 300
Hypoalbuminaemia < 25
Peripheral oedema
Severe hyperlipidaemia >10
What is the commonest cause of nephrotic syndrome in children?
Minimal change glomerular disease
Who does nephrotic syndrome usually affect?
More commonly, boys under 6
What is the pattern of oedema in nephrotic syndrome?
Initially periorbital and facial
Then more generalised with pitting oedema
Give three other causes of nephrotic syndrome in children
Focal segmental glomerulosclerosis Membranous glomerular disease Membranoproliferative glomerulonephritis Infection Collagen vascular diseases e.g. SLE, RA DM Alport syndrome Pre-eclampsia Transplant rejection Malignancy
What are the other clinical features of nephrotic syndrome?
May follow viral URTI Frothy urine Ascites/pleural effusion Leuconychia Xanthelasma Infection - loss of Ig
How should nephrotic syndrome be treated?
Admit
Fluid restriction and diuretics
Low salt diet
Prednisolone, until remission of proteinuria
No live vaccines
Prophylactic penicillin , until remission of proteinuria
How does glomerulonephritis present?
Haematuria Oliguria Oedema Hypertension Variable proteinuria Most cases are post-URTI/sore throat Loin pain Malaise Headache
How does the urine appear in glomerulonephritis?
Smoky, coke-coloured
What is the treatment of glomerulonephritis?
Penicillin (if strep infection) Diuretics plus potassium Antihypertensives Lipid-lowering therapy Immunosuppression e.g. corticosteroids, cyclophosphamide, azathiprine Antithrombotics e.g. warfarin, aspirin IV Ig Dialysis
What are the complications of glomerulonephritis?
Hypertension Hyperkalaemia Acidosis Seizures Hypocalcaemia
How common is hypospadias?
1 in 500
What are some common complications that can occur with hypospadias?
Chrodee - downward curve of the penis
Cryptorchidism
Open processus vaginalis/Inguinal hernia
When should surgery for hypospadias be done?
What should you not do?
Before the age of 2
Don’t circumcise - may use
What is the most common gynaecological disorder in paediatrics?
Vulvovaginitis
What is vulvovaginits caused by?
Strep pyogenes
Staph aureus
Candida - assoc. with Abx use
How should you advise a parent to manage a child with vulvovaginitis?
Wear loose fitiing underpants made of cotton
Avoid tight fitting clothes
Avoid use of bubble baths, perfumed soaps etc
Cool compresses to releive swelling/tenderness
10 day course of amoxacillin/coamoxiclav if child not improved
