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Paediatrics > Nephrology and Urogenital > Flashcards

Nephrology and Urogenital Flashcards

1
Q

Give 2 reasons why UTIs in childhood is important?`

  • 50% will have __
  • pyelonephritis may __ predisposing to__
A
  • up to 50% will have a structural abnormality of their urinary tract
  • pyelonephritis may damage the growing kidney by forming a scar, p.disposes to HT and progressive CKD of bilateral
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2
Q

UTI symptoms vary with age.
Infants: symptoms are __..what can occur rapidly
(the classical symptoms are more common with increasing age)

A
  • non-specific, +/- fever, vomiting, lethargy/irritable, poor feeding, jaundice, offensive urine, febrile seizure
  • septicaemia can occur rapidly
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3
Q

Dysuria alone is often due to cystitis or ___ in girls or ____ in uncircumcised boys. What dipstick test is positive in both these conditions?

A

-vulvitis
-balanitis
Leukocyte will be postivie

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4
Q

If both leukocyte and nitrites are present on a dipstick regard and treat as UTI, if only one is positive what should you do?

A
  • diagnosis depends on urine culture

- start Abx only if there is clinical evidence of UTI

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5
Q

Name 3 methods of urine sample collection in the young?

A
  • “clean-catch” sample into pot when nappy removed
  • adhesive plastic bag on perineum after careful washing
  • urethral catheter (if need sample urgently)
  • suprapubic aspiration (for severely ill, needing urgently)
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6
Q

What amount of CFU (colony-forming units) in a bacterial culture strongly suggest UTI

A

more than 10^5 CFU

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7
Q

What test should all infants with an unexplained fever >38degrees have done?

A

A urine sample tested

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8
Q

Name 3 common organisms causing UTIs and name one seen more commonly in boys from its presence under the prepuce.

A
  • E.coli
  • klebsiella
  • Pseudomonas
  • Strep. Faecalis
  • Proteus
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9
Q

Name some contributing factors to incomplete bladder emptying in children:

A
  • infrequent voiding –> bladder enlargement
  • vulvitis, vesicoureteric reflux (VUR)
  • incomplete micturition w residual volumes post micturition
  • obstruction by a loaded rectum
  • neuropathic bladder
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10
Q

Vesicoureteric reflux (VUR) is when the ureters are displaced ___ and enter __ into bladder (not at an __) It is __.

A
  • laterally, directly (angle)

- familial

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11
Q

What association with VUR when urine flows back from renal pelvis to CDs can lead to severe renal scarring if UTIs occur.

A

-intrarenal reflux

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12
Q

Give 3 reasons why VUR-associated ureteric dilatation is importantly bad.

A
  • if urine returns from ureters to bladder post-void, you get incomplete emptying and predisposition for infection
  • pyelonephritis may develop esp with intrarenal reflux
  • bladder voiding pressure is transmitted to the renal papillae which may contribute to renal damage if voiding pressures are high
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13
Q

VUR impacts on kidney mean infection can __ renal tissue leaving a __ of shrunken poorly functioning kidney ( __ ____). If scars are bilat and severe progressive ___ may develop. Also ~10% risk of childhood/early adult ___.

A
  • destroy
  • scar
  • (reflux nephropathy)
  • CKD
  • hypertension
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14
Q

We do not need to investigate all children w UTIs only those with atypical UTIs, name some features that come under atypical UTIs:
e.g. non-ecoli organisms..

A
  • seriously ill/septicaemia
  • poor urine flow
  • abdo/bladder mass
  • raised creatinine
  • not responding to abx in 48hrs
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15
Q

If a child with a UTI is found to be atypical and requiring investigation, what is the first line next step?

A

Ultrasound of kidneys and urinary tract

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16
Q

If urethral obstruction is identified as a probable cause for atypical UTIs in a boy with an abnormal bladder, what investigation should be carried out?
Clue: 4letters

A

MCUG: Micturating Cystourethrogram

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17
Q

What is the basis of UTI treatment in the following ages:
<3months
>3moths and children w pylonephritis
children with cystitis/lower UTI

A

<3mn: hospital for IV Abx (e.g. co-amoxiclav)
children: oral abx e.g. trimethoprim or IV abx followed by oral
lower UTI: oral abx short course

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18
Q

How can you try to prevent UTIs in children?

e.g. lactobacillus acidophilus probiotic

A
  • high fluid intake
  • regular voiding and/or double voiding
  • treat/prevent constipation as it arises
  • good perineal hygiene
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19
Q

In children with recurrent UTI/scarring/reflux what follow up should be arranged?
e.g. regular renal growth and function assessments if there are bilat defects bc of risk of CKD

A
  • dipstick urine in any non-specific illness with MC&S
  • long-term low dose abx prophylaxis
  • circumcision
  • anti-VUR surgery if scarring progresses with ongoing VUR
  • check BP annually if renal defects present
  • urinalysis to check for proteinuria as sign of CKD
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20
Q

What is a DMSA scan (it is used in the investigation of UTIs in young children <3yrs to look at the kidney’s and how they contribute to functioning;

A

Dimercaptosuccinic Acid scan

21
Q

Nephrotic Syndrome = heavy proteinuria leading to low ____ and ____.
Cause often unknown but suggest 2 systemic things it can be secondary to.

A
  • low plasma albumin, and oedema

- 2dry to: Henloch-Schonlien Purpura, SLE, infection like malaria, allergens like bee sting

22
Q

Give 3 clinical signs of nephrotic syndrome:

NB: infection e.g. peritonitis, septic arthritis or sepsis can occur, why?

A
  • periorbital oedema 1st sign (often on waking)
  • scrotal, vulval/leg/ankle oedema
  • ascites
  • SOB due to pleural effusions + abdo distension
  • infection due to loss of protective Igs in the urine
23
Q

In 90% children with nephrotic syndrome, what does is resolve with and hence won’t progress to CKD
NB: children more commonly 1-10yrs, Asian, male, often precipitated by resp tract infection
how will these children be generally?
On biopsy due to findings on EM, what is this disease called?

A

Steroid therapy (‘steroid-sensitive nephrotic syndrome)

  • associated with atopy
  • well (normal BP, normal complement level, normal renal function)
  • fusion of podocytes so called minimal change disease
24
Q

Give 3 complications of nephrotic syndrome:

clue: one issue correlates inversely with serum albumin, cause unknown, hyper______

A
  • hypovolaemia (c/o abdo pain and feel faint, give saline or albumin)
  • thrombosis due to urinary losses of antithrombin III, increased viscosity and steroid therapy
  • infection esp. capsulated bacterial e.g. pneumococcus (give flu and pneumococcal vaccine)
  • hypercholesterolaemia
25
Q

How is the oedema of steroid-resistant nephrotic syndrome managed in children ? (NB: would be referred to a paediatric nephrologist for management)

A

-manage oedema w diuretics, salt restriction and ACEi +/-NSAIDS
(also note: Genetic testing can help manage if clear cause found e.g. replace missing defect)

26
Q

Prognosis for Steroid-Sensitive Nephrotic Syndrome?
1/3
1/3
1/3

A

1/3 resolve directly
1/3 infrequent relapses
1/3 frequent relapses, steroid dependent

27
Q

Haematuria causative location?

  • brown urine with deformed red cells and casts +/- proteinuria
  • vs: more rare presentation, red blood, occurring at beginning/end of stream, no proteinuria
A
  • brown w casts suggests glomerular origin

- red is lower urinary tract haematuria

28
Q

If glomerular haematuria is suspected what extra investigations would you consider (on top of: MC&S, US, U&Es, FBC, clotting and sickle screen)

A
  • ESR, complement, anti-DNA antibodies
  • throat swab, antistreptolysin O/anti-DNAse B titres
  • Heb B and C screen
  • hearing test and test mother’s urine in Alport S. suspected
  • +/-renal biopsy
29
Q

When in haematuria presentations would a renal biopsy be indicated? Give 2

A
  • there’s significant persistent proteinuria
  • recurrent macroscopic haematuria
  • renal function is abnormal
  • complement levels are persistently abnormal
30
Q

Acute nephritis: increased glomerular cellularity restricts glomerular blood flow so GFR decreases, what features arise as a result, name 2:

A
  • decreased urine output, volume overload
  • hypertension, can -> seizures
  • oedema (starts periorbital)
  • haematuria
  • proteinuria
31
Q

Give 4 causes of acute nephritis in children:

A
  • Post infections (e.g. streptococcus)
  • Vasculitis: Henoch-Schonlein Purpura, Wegener Granulomatosis, Microscopic Polyarteritis, Polyarteritis Nodosa
  • IgA Nephropathy, mesangiocapillary glomerulonephritis
  • Anti-glomerular basement membrane disease
32
Q

How is post-streptococcal/infectinous nephritis diagnosed? (rare in developed countries, good prognosis)

A
  • evidence or recent strep infection e.g. culture, raised ASO/anti-DNAse B titres
  • low C3 levels that return to normal after few weeks
33
Q

What condition do the following features belong to?

  • skin rash on extensors, arthralgia, periarticular oedema, abdo pain, glomerulonephritis
  • 3-10yrs old, more in boys and peaks in winter months
  • precipitated by URTI often
A

Henoch-Schonlein Purpura (activated complement are deposited in organs, precipitating an inflamm response with vasculitis)

34
Q

What is the characteristic rash of Henoch-Schonlein Purpura (activated complement are deposited in organs, precipitating an inflamm response with vasculitis)

A
  • presents w fever
  • symmetrically distributed
  • over buttocks and extensor surfaces of limbs and ankles
  • trunk often spared
  • rash initially urticarial then maculopapular and purpuric
  • palpable rash, can recur over several weeks
35
Q

What disease is this describing?
“episodes of macroscopic haematuria commonly in association with URTIs”
NB: prognosis in children is better vs adults

A

IgA nephropathy

36
Q

what follow up and why is required for Henoch-Schonlein Purpura and IgA Nephropathy in children? (same follow up for both conditions)

A
  • follow for a year, check for persisting haematuria or proteinuria
  • if + may need longer term follow up
  • due to risk of HT and progressive CKD developing
37
Q

What X-linked disorder is the most common form of familial nephritis? (associated with nerve deafness and ocular defects)

A

-Alport Syndrome: progresses to end-stage CKD by early adulthood in males

38
Q

Other vasculitis that cause nephritis (Henoch-Schonlein Purpura) are: polyarterits nodosa, microscopic poluarteritis,, granulomatosis with polyangiitis…

  • what blood test is done?
  • suggest 2 rx options (may need to continue for months)
A
  • ANCA blood test +

- rx: e.g. steroids, plasma exchange, IV cyclophosphamide

39
Q

Young girls esp Asian/Black may develop what condition that has low complement C3 and C4 esp in active disease? What other blood result may be +? Give an indication for renal biopsy in these pts?

A
  • SLE
  • ds-DNA + autoantibodies
  • haematuria or proteinuria are indications for biopsy
40
Q

Generalized proximal tubular dysfunction aka Fanconi syndrome leads to urinary losses of what?
and why are these proximal tubular cells vulnerable to damage?

A

-fts: excessive urinary loss of amino acids, glucose, phosphate, bicarbonate, sodium, calcium, potassium & magnesium
–proximal tubule cells are v metabolically active
-

41
Q

In a child presenting with: polydipsia, polyuria, salt depletion, dehydration, hyperchloremic metabolic acidosis, rickets, faltering or poor growth
-what syndrome would you suspect? give 2 acquired causes of this?

A
  • Fanconi Syndrome (Generalised Proxima Tubular Dysfunction)
  • cause: heavy metals, drugs, toxins, vit D deficiency
42
Q

Fanconi syndrome (Generalised Proxima Tubular Dysfunction) can be 2ndry to inborn errors of metabolism such as? name 2+

A
  • cystinosis
  • glycogen storage disease
  • lowe syndrome
  • galactosaemia
  • fructose intolerance
  • tryosinaemia
  • Wilson’s disease
43
Q

Most common cause of AKI in children is pre-renal failure, what is the sign of this? What fraction of sodium will be excreted and why?
-Urgent fluid replacement to avoid what complication affecting tubules?

A
  • sign is hypovolaemia
  • very low Na+ excretion as body tries to retain volume
  • avoid acute tubular injury and necrosis
44
Q

How is post-renal failure managed in children after assessment of the site of obstruction?

A

relief by nephrostomy or bladder catheterisation

45
Q

Suggest 3 indications for dialysis in AKI:

A
  • failure of conservative rx measures
  • hyperK+
  • severe hypo/hyper Na+
  • pulmonary oedema or severe HT due to volume overload
  • severe metabolic acidosis
  • multisystem failure
46
Q

Haemolytic syndrome is a common cause of renal AKI in children, it is a triad of:
-AKI
-__… ___..___..
-______
typical HUS is secondary to what? caused by.. hence the prodrome is

A
  • AKI, microangiopathic haemolytic anaemia, thrombocytopaenia
  • 2ndry to GI infection w E coli 0157:H7 (or Shigella) hence prodrome of bloody diarrhoea
47
Q

Typical HUS (triad: AKI, microangiopathic haemolytic anaemia, thrombocytopaenia) is 2dry to GI infection with good prognosis, vs the more rare typical HUS which has no diarrhoea prodrome and risk of what? Mainstay of rx?

A
  • familial, frequent relapses
  • risk of HT and progressive CKD with high mortality
  • rx with plasma exchange mainly
48
Q

Undescended testes affect 5% newborns, more common in premature babies, by 3 months 99% will have descended, for undescended still,

  • how should you examine?
  • what surgery is done (about 1yr of age)? And suggest 3 reasons this is needed/favourable
A
  • examine in warm place w warm hands (retractile testes will hide otherwise) gentle pressure along line on inguinal canal
  • orchiopexy
  • cosmetic (+psychological, boy feels same as peers, if absent prosthesis can be put in when older)
  • reduced risk of torsion/trauma vs. typically groin location
  • fertility (esp. if bilateral as spermatogenesis best below body temp)
  • malignancy (in scrotum facilitates self-examination hence lumps felt earlier)

Paediatrics (12 decks)

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