Nephrology & GU - UTI/ Nephrotic Syndrome

Question 1

Describe HSP?

Answer 1

HSP is a characteristic

• skin rash
• arthralgia
• periarticular oedema
• abdominal pain
• glomerulonephritis

Question 2

When does HSP commonly occur?

Answer 2

twice as common in boys

between the ages of 3 and 10

Question 3

How do children with HSP present?

Answer 3

• fever
• rash (maculopapular and purpuric) is obvious and distributed over buttocks, extensor surfaces of the arms and legs
• joint pain (knees and ankles)
• colicky abdo pain
• renal involvement w? micro/macroscopic hameaturia

Question 4

What are the investigations for HSP?

Answer 4

Urinalysis 
FBC, ESR, creatinine, serum IgA, autoantibody screen 
Abdo USS (for obstruction) 
Barium enema (confirm obstruction) 
Testicular USS (check for torsion) 
Renal biopsy (if persistent nephrotic syndrome)

Question 5

How is HSP managed?

Answer 5

self limiting
supportive treatment
NSAIDS for joint pain can be used with caution
Steroids for nephropathy
Follow up for 6 months or longer if renal involvement

Question 6

What are the long term complications of HSP?

Answer 6

Nephrotic syndrome/renal disease so children with renal involvement should be followed up for at least a year
less than 1% of patients with HSP progress to end stage renal failure

Question 7

What are the triad of symptoms in nephrotic syndrome?

Answer 7

proteinuria
low plasma albumin
oedema

Question 8

What are the clinical signs of nephrotic syndrome?

Answer 8

periorbital oedema (earliest sign)
scrotal or vuval, leg or ankle oedema
ascites
breathlessness due to pleural effusions and adobe distention

Question 9

What is the most common type of nephrotic syndrome?

Answer 9

steroid sensitive nephrotic syndrome
- proteinuria resolves with corticosteroid therapy
usually precipitated by an URTI

Question 10

What are the investigations for a child presenting with nephrotic syndrome?

Answer 10

urine dipstick 
FBC, ESR, U&E’s, creatinine, albumin, complement, ASO titre/anti-DNAse B titre
throat swab
urine culture
urinary sodium concentration
hepatitis B/C screen
malaria screen if travel abroa

Question 11

What is the management for steroid sensitive nephrotic syndrome?

Answer 11

oral corticosteroids
after 4 weeks reduce the does
usually takes 1 days for urine to become free of protein

Question 12

What is the prognosis of nephrotic syndrome?

Answer 12

1/3 resolves
1/3 infrequently relapses
1/3 frequently relapses

Question 13

What are the other types of nephrotic syndrome?

Answer 13

steroid resistant nephrotic syndrome (refer to nephrologist)

congenital nephrotic syndrome (presents in first 3 weeks of life, high mortality)

Question 14

What are the atypical features of HSP which prompt consideration of second line treatment/renal biopsy?

Answer 14

<1 year and >10 years
hypertensive 
elevated creatinine 
macroscopic haematuria 
failed to respond to steroids after 4-8 weeks

Question 15

How common are UTIs?

Answer 15

3-7% of girls and 1-2% of boys will have a UTI before age of 6
~30% recur within a year
Up to 50% have a structural abnormality

Question 16

What common organism causes UTIs?

Answer 16

usually E.Coli
Proteus more common in boys
Pseudomonas may indicate UT structural abnormality

Question 17

What are the presenting features of UTIs in infants?

Answer 17

fever 
vomiting 
lethargy and irritability 
poor feeding, failure to thrive 
jaundice 
septicaemia 
offensive urine 
febrile convulsion

Question 18

What are the presenting features of a UTI in children?

Answer 18

Dysuria
frequency 
Adbo pain, 
loin tenderness 
Fever +/- rigors 
Lethargy, anorexia Vomiting, diarrhoea Haematuria 
Offensive cloudy urine
Febrile convulsion
Recurrence of enuresi

Question 19

When should you always test urine?

Answer 19

in a infant with unexplained fever >38C

Question 20

How can you collect urine from children?

Answer 20

• clean catch urine (when nappy removed)
• adhesive plastic bag after careful washing
• urethral catheter is urgent
• suprapubic aspiration under USS (rarely done)

Question 21

What are the features of an atypical UTI?

Answer 21

seriously ill
poor urine flow 
abdominal or bladder mass
raised creatinine 
septicaemia 
failure to respond to abx in 48hours 
infected with non E.coli organism

Question 22

What are the features of recurrent UTI?

Answer 22

• two or more episodes of UTI with acute polynephritis/upper UTI
• one episode of UTI with acute pyelonephritis/upper UTI plus one episode of UTI with cystitis/lower UTI
• three or more episodes of UTI with cystitis/ lower UTI

Question 23

What is vesicoureteric reflux?

Answer 23

• developmental abnormality of vesicoureteral junction

- ureters displaced laterally

Question 24

What is the difference between mild and severe vesicoureteric reflux?

Answer 24

mild = reflux into ureter only 
severe = dilation of ureter, renal pelvis and calyces -> intrarenal reflux and renal scarring

Question 25

What are the diagnostic tests for VUR?

Answer 25

Lab studies to rule out UTI
Serum creatinine and electrolytes to assess renal function
Voiding cystourethrogram is the main test, a renal bladder USS and occasionally a DMSA

Question 26

Define pyelonephritis?

Answer 26

bacterial infection of the upper urinary tract causing

inflammation of the kidney(s)

Question 27

Define cystitis?

Answer 27

inflammation of the bladder

Question 28

How is pyelonephritis treated?

Answer 28

referral to paediatrician
treat with oral abx for 7-10 days
if oral cannot be used then treat with IV such as cefotaxime or ceftriaxone then follow up with oral abx for 10 days

Question 29

What is vulvo-vaginitis?

Answer 29

common in young girls

may result from infection, poor hygiene or sexual abuse though in most cases it is not due to any of these factors

Question 30

How can vulvo-vaginitis be managed?

Answer 30

advise parents about hygiene, avoid bubble baths, use loose fitting cotton underwear
swabs should be taken to identify pathogens