Nephrology/GU Flashcards
Define Nephrotic Syndrome
A glomerular disorder when the basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine.
Nephrotic syndrome proteinuria criteria
- > 200mg/mmol
Nephrotic syndrome hypoalbuminaemia criteria
- <25g/L
Nephrotic syndrome Epidemiology in the UK
- 2 per 100,000 children per year
- 6-8 times higher in UK Asian populations
- twice as common in boys
- affecting children 2 – 5 years
Ohh
Nephrotic Syndrome classic Triad
- oedema
- heavy proteinuria (>200mg/mmol)
- hypoalbuminaemia (<25g/L)
Nephrotic Syndrome Aetiology
- Minimal Change Disease (90% of the cases)
Secondary to: intrinsic kidney disease - Focal segmental glomerulosclerosis
- Membranoproliferative glomerulonephritis
Secondary to: systemic illness - Henoch schonlein purpura (HSP)
- Diabetes
- Infection, such as HIV, hepatitis and malaria
3 Highs
Nephrotic Syndrome uncommon Triad
- High Lipid profile (chol, TGL, LDL)
- HTN
- Hyper-coagulability
Nephrotic Syndrome complications
- Hypovolaemia
- Thrombosis
- Infection
- Acute or chronic renal failure
- Relapse
How do Nephrotic Syndrome lead to hypovolaemia
occurs as fluid leaks from the intravascular space into the interstitial space causing oedema and low BP
How do Nephrotic Syndrome lead to Thrombosis
can occur because proteins that normally prevent blood clotting are lost in the kidneys, and because the liver responds to the low albumin by producing pro-thrombotic proteins.
immunosuppressant
How do Nephrotic Syndrome lead to infections
occurs as the kidneys leak immunoglobulins, weakening the capacity of the immune system to respond. This is exacerbated by treatment with medications that suppress the immune system, such as steroids.
Nephrotic Syndrome Mx
- High dose steroids (i.e. prednisolone)
- Low salt diet
- Diuretics may be used to treat oedema
- Albumin infusions may be required in severe hypoalbuminaemia
- Antibiotic prophylaxis may be given in severe cases
SEs: steroids on growth
Define Wilms’ Tumour
Nephroblastoma
the most common form of renal malignancy in childhood. It usually occurs in children under 5 years
Wilms’ Tumour Sx
- Abdo pain
- Abdo distention
- HTN
RED FLAGS - unintenional WL
- Fever
- Haematuria
- Lethargy
Wilms’ Tumour clinical presentations
- Unilateral painless, NT, firm, smooth abdo mass
- ballotable and does not move with respirations
Wilms’ Tumour Risk factors
- Age <5 years
- Congenital urogenital anomalies (cryptorchidism etc.)
- L»_space; R kidney (can be bilateral)
Wilms’ Tumour Diagnostic Ix
- Abdo USS w/doppler
- CT CAP or MRI without contrast for staging
- Bloods: U&E, LFTs, FBC, Bone profile
- Bone scan (for bone met)
Wilms’ Tumour definitive Dx Ix
Bx for histology of tumour
Wilms’ Tumour Mx
- Nephrectomy followed by
1. Adjuvant chemotherapy
2. Adjuvant radiotherapy
Define Cryptorchidism
undescended testes
a congenital absence of one or both testes in the scrotum due to a failure of the testes to descend during development
Cryptorchidism Risk Factors
- FMHxof undescended testes
- Low birth weight
- Small for gestational age
- Prematurity
- Maternal smoking during pregnancy
ETA
Types of Cryptorchidism
- Ectopic testis: where the testis is found away from the normal path of decent
- True undescended testis: where testis is absent from the scrotum but lies along the line of testicular descent
- Ascending testis: where a testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum
Cryptorchidism Pathophysiology
Normally, the testis descends from the abdomen to the scrotum, pulled by the gubernaculum, within the processes vaginalis
- True undescended testis: This process is incomplete
- Ectopic testis: Tracks to an abnormal position
- Bilateral cryptorchidism:, hormonal causes such as androgen insensitivity syndrome or disorder of sex development must also be excluded
True undescended testis locations
- Abdo
- Inguinal
- Suprascrotal
Ectopic undescended testis locations
- Prepenile
- Femoral
Cryptorchidism complications
- Impaired fertility – as testis are 2-3⁰ C warmer if intra-abdominal, this can effect spermatogenesis. Although fertility in unilateral undescended testis is around 90%, this has been reported to drop to around 53% if bilateral. Risk of infertility increases with delayed correction.
-
Testicular cancer – 2-3 times more common with a history of undescended testis (2-3%), and this risk double if correction is undertaken after puberty. In addition to the managing the risk of testicular cancer, orchidopexy also allows for self-examination for testicular abnormalities by the patient when they are older.
Torsion – undescended testis are at higher risk of torsion
Cryptorchidism Mx
- Watch & wait for infant 3-6 months
- By 6 months: refer to paeds
- Surgically: Orchidopexy between 6 and 12 months of age
Define Hydrocele
a collection of fluid that builds up within the tunica vaginalis that surrounds the testes
Two types of hydrocele
- Simple Hydrocele
- Communicating Hydrocele
Define Simple Hydrocele
Simple hydroceles are common in newborn males. They occurs where fluid is trapped in the tunica vaginalis. Usually this fluid gets reabsorbed over time and the hydrocele disappears.
Define Communicating hydroceles
Communicating hydroceles occur where the tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway called the processus vaginalis. This allows fluid to travel from the peritoneal cavity into the hydrocele, allowing the hydrocele to fluctuate in size.
Hydroceles clinical findings
- soft, smooth, non-tender swelling around one of the testes
- The swelling will be in front of and below the testicle
- Transilluminate with light: pen torch flat against the skin and watch as the whole thing lights up like a bulb
Hydrocele Ix
Testicular USS
Simple hydroceles Mx
- Watch & wait: usually resolve within 2 years
- Surigically: if not resolve in 2 years
Communicating hydroceles Mx
Surgically: **laparoscopic PPV ** to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis)
Hydrocele aetiology
- Idopathic
Secondary to: - Testicular cancer
- Testicular torsion
- Epididymo-orchitis
- Trauma to testicles
Lower UTI
Cystitis
Upper UTI
pyelonephritis
Most common causative organism in children <2years
E.coli
if not E.coli = Atypical UTI
Paed UTI epidiemiology
Girls > boys
Paed UTI Risk factors
- Vesico-ureteric reflux (retrograde urine)
- Voiding dysfunction
- Caucasian
- Under 1 year
- Immunosuppression
- Girls
- Sexual activity – adolescent females
Paeds UTI
- Renal structural diseases
- Prev UTIs
Paeds UTI clinical presentations
- Fever
- Dysuria
- Increased freq.
- Haematuria
- Flank pain
Paeds referral criteria for <3months of age
- Fever
Red flag
Paeds UTI clinical presentations <3months
- Fever (Refer stat)
- Lethargy
- Vomiting
- Irritability
Paeds UTI clinical presentations >3months
- Increased Frequency
- Dysuria
- Crying whilst urinating
- Bed wetting
- Abdo pain
Paeds Atypical UTI
- UTI with non-E. coliorganisms
Paeds Atypical UTI presentations
- Failure to respond to treatment with suitable antibiotics within 48hours.
- Poor urine flow.
- Abdominal or bladder mass.
- Raised creatinine.
- Sepsis.
Unlikely Paeds UTI Sx
- Resp deficits
- Missing fever
- No dysuria
- Nappy rash
- Abnormal ear examination
Paeds UTI examinations
- Obs + vitals
- CR
- ## LNs
Acute Pylonephritis
- Fever >38 + Bacteriuria (nitrite in dipsticks)
OR - fever less than 38°C associated with loin pain/tenderness and bacteriuria.
Paeds UTI Ix
Clean catch urine
MSU
Catheter
Suprapubic aspiration (SPA)
Urinalysis: leukocyte positive and nitrite are positive
- Abx stat
- If the child 3m - 3yr, send sample for MC&S
- If over 3years and has a high or intermediate risk of serious illness, sx suggestive of uti or a history of infection, send urine sample for culture.
Urinalysis: leukocyte is negative and nitrite is positive
- > 3months start antibiotic treatment and send urine sample for culture.
If leukocyte is positive and nitrite is negative
send urine sample for microscopy and culture
Under 3m - 3 yr: start abx
Over 3 years: only start abx if good clinical evidence of infection.
If leukocyte and nitrite are negative
do not start treatment for UTI
explore other causes of illness.
Send urine mc and s if risk of serious illness or s, sx suggestive of upper UtI or recurrent UTI
Paeds upper UTI < 3months Mx
direct referral to paediatrician, full septic screen
Paeds upper UTI > 3months Mx
- consider referral to a paediatric specialist
- treat with oral antibiotics for 7-10 days
Cefalexin -
Co-amoxiclav if sensitive on culture result
Reassess if not improving/getting worse
USS
Paeds lower UTI > 3months Mx
- send urine for culture and susceptibility or dipstick
- treat with oral antibiotics for 3 days
1st line: Trimethoprim, nitrofurantion
2nd line: nitrofurantoin, amoxicillin, cefalexin
Remember anti-pyretics
Explain side effects of antibiotics : GI usually
Safety net/follow up
USS
KUB USS referral criteria
- Under 6 months
- Recurrent uti
Two or more episodes of UTI with acute upper UTI (acute pyelonephritis), or
One episode of UTI with acute upper UTI plus 1 or more episodes of UTI with lower UTI (cystitis), or
Three or more episodes of UTI with lower UTI
DMSA scan criteria
4 to 6months after the acute infectionif atypical or recurrent
KUB USS criteria for 6m to 3years
During infection if atypical
Within 6 weeks if recurrent
DMSA 4-6m post infection atypical/recurrent
MCUG not typically done
KUB USS criteria for > 3years
During infection if atypical and within 6w if recurrent
DMSA if recurrent
2ww referral criteria for Wilm’s tumour
- Abdo mass
- Haematuria (usu. microscopic)
- Organomeagly
Nephrotic Syndrome 1st clinicla presentation
Facial oedeama
Define Phimosis
Inability to retract the foreskin
Primary (physiological)
Without sign of scarring
Secondary (pathological): due to scarring from conditions
- Recurrent balanitis
- Traumatic retraction of the foreskin
- Balanitis xerotica et obliterans
Phimosis clinical presentations
- Poor stream
- Urine spraying
- Recurrent balanitis
- Ballooning of foreskin on micturition
Phimosis Mx
Non-retractile foreskin and/or ballooning during micturition in a child aged under 2 years,
- an expectant approach
- physiological phimosis which will resolve in time.
- Topical steroids can be applied to the preputial ring
Personal hygiene
Pathological phimosis:
- circumcision
- a short course of topical corticosteroids: mild scarring
Paraphimosis
Inability to pull forward a foreskin that has been retracted behind the glans penis.
Paraphimosis Mx
urological emergency
