Nephrology Presentations Flashcards
Outline the pathophysiology of haematuria
Gross = blood that you can see
- 10% chance of finding cancer
Microscopic = blood that can only be seen under the microscope
- 3% chance of finding cancer
Outline the aetiology of haematuria
UTI
Pyelonephritis
Bladder/kidney stone
BPH
Prostatitis
Glomerulonephritis – IgA nephropathy
Cancer
Sickle cell anaemia
Kidney injury
Medication = anti-cancer drug cyclophosphamide, penicillin, aspirin, heparin
Strenuous exercise
What are the symptoms of haematuria?
Pink/red coloured urine
Passing clots = pain
UTI = persistent urge to urinate, pain and burning with urination, and extremely strong-smelling urine, fever
Pyelonephritis = fever, flank pain
Anaemia = pallor
How is haematuria investigated?
Urine dipstick
Urine analysis
Urine culture = suspected infection
Bloods = FBC, U+Es, coag
Imaging = CT, MRI, US
Cystoscopy
Abdo exam = assess for palpable kidneys
Genitalia exam
Kidney biopsy = in cases of: significant haematuria, abnormal renal function, recurrent persistent haematuria, serologic abnormalities, recurrent gross haematuria, FH of end-stage renal disease
How would you manage haematuria?
Asymptomatic = generally doesn’t require treatment
Abx = UTI
Medication to shrink prostate
Shock wave therapy to break up stones
Tumour/cancer = surgery
Outline HTN in children
HTN = BP above the 95th percentile for height, age, sex
Aetiology = renal parenchymal disease, renal vascular disease, aortic coarctation, endocrine causes, essential HTN, iatrogenic, renal tumours
S+S = vomiting, headache, facial palsy, HTN retinopathy, convulsions, proteinuria
Mx = weight loss, low salt, exercise, avoid smoking/alcohol, ACEi, BB, CCB, thiazide diuretic
What is Acute renal failure, how does it present and what is its DDx?
Acute decline in renal function characterized by an increase in blood urea nitrogen (BUN) and serum creatinine values, often accompanied by hyperkalaemia, metabolic acidosis, and HTN
S+S = haemorrhage, fever, rash, abdo pain, pale skin, swelling, abdo mass, oliguria (<0.5ml/kg/h)
DDx =
- prerenal (most common) = sepsis, D+V, dehydration, DI, diuretics, adrenal insufficiency, shock burns, pancreatitis
- intrinsic = haemolytic uraemic syndrome (HUS)
- postrenal = stones, posterior urethral valves
stage 1 = SCr 150-200% baseline, <0.5ml/kg/h >8h
stage 2 = SCr 200-300% baseline, <0.5ml/kg/h >16h
stage 3 = SCr >300% baseline, 0.3ml/kg/h, >24h
What is Chronic renal failure, how does it present and what is its DDx?
GFR <15ml/min per 1.73 m2
S+S = poor appetite, bone pain, vomiting, headache, stunted growth, recurrent UTI, tissue swelling, poor muscle tone, anorexia, polydipsia, HTN, normochromic normocytic anaemia
DDx =
- Prolonged obstruction
- Alport syndrome = deafness, progressive kidney damage, and eye defects.
- Nephrotic syndrome = proteinuria, low protein in the blood, high cholesterol levels, oedema
- Polycystic kidney disease = growth of numerous cysts
- Cystinosis = amino acid cystine accumulates within lysosomes in the kidney
What is glomerulonephritis, how does it present and what is its DDx?
Glomeruli become inflamed and impair the kidney’s ability to filter urine
S+S = HTN, dark brown urine, sore throat, diminished urine output, fatigue, lethargy, increased breathing effort, headache, seizures, rash, weight loss, joint pain, pale, oedema
DDx = strep, Alport syndrome, SLE, polyarteritis nodosa group, Wegener vasculitis
What are the urinary tract abnormalities, how do they present and what is its DDx?
Posterior urethral valves, hydronephrosis and hydroureters, severe vesico-ureteric reflux, duplex kidney, ureteropelvic junction obstruction, megaureter, renal agenesis, multicystic dysplastic kidney (MCDK), autosomal recessive/dominant polycystic kidney disease
S+S = recurrent UTI, anatomical abnormality, nonsyndromic
Outline the pathophysiology and aetiology of cystitis (LUTI)
Colonization with ascending spread - commonly e.coli
Hematogenous spread
Periurogenital spread
Shorter length of the female urethra allows uropathogens easier access to the bladder
What are the signs and symptoms of cystitis?
Parent report = vomiting, fever, lethargy, poor feeding, failure to thrive
Dysuria
Urinary urgency and frequency
Sensation of bladder fullness or lower abdo discomfort
Suprapubic tenderness
Flank pain and costovertebral angle tenderness (present in cystitis but suggest upper UTI)
Bloody, cloudy, offensive smelling urine
Fevers, chills, and malaise (noted in pts with cystitis, more frequently associated with upper UTI)
How is cystitis investigated?
Dipstick = leucocytes ++, protein ++, nitrites +
Infant with unexplained temp 38 = urgent urine microscopy + culture (clean catch sample) (10^5 pure growth CFU)/mm3)
USS = <6w old, sepsis, poor urine flow, abdo/bladder mass, raised serum creatinine, no response to Abx in 28h, non-E.coli MO, recurrent (2 UUTI, 1 UUTI 1 lUTI, 3 LUTI)
Dimercaptosuccinic acid (DMSA) 4-6m following acute infection = atypical, recurrent
Micturating cystourethogram (MCUG) (ONLY <6m) = atypical, recurrent
How would you manage cystitis? and how can it be prevented?
Lower uncomplicated = 3 day nitrofurantoin
Lower complicated = 5-7 day nitrofurantoin
General = paracetamol, increased fluid intake
PREVENT = hydrated, toilet more often, timed toilet sessions, empty bladder completely, double voiding, front to back wipe, avoid constipation, avoid nylon/synthetic/tight underwear, no bubble baths
Describe the pathophysiology of pyelonephritis
Bacterial invasion of the renal parenchyma
Bacteria usually reach the kidney by ascending from the lower urinary tract or the blood stream
What is the aetiology of pyelonephritis?
E.coli = 70-95%
Klebsiella spp = 1-2%
Coag-ve staphylococci = 5-10%
What are the signs and symptoms of pyelonephritis?
Fever
Nausea
Vomiting
Poor feeding
Failure to thrive
Costovertebral angle pain = may be mild, moderate, or severe; flank or costovertebral angle tenderness is most commonly unilateral over the involved kidney, although bilateral discomfort may be present
Gross haematuria
Outline how pyelonephritis should be investigated?
Dipstick = +ve leukocyte esterase, nitrites
Infant with unexplained temp 38 = urgent urine microscopy + culture (clean catch sample) (>1000 colony-forming units (CFU)/mL)
USS = if atypical, recurrent, or within 6 weeks
Dimercaptosuccinic acid (DMSA) 4-6m following acute infection = atypical, recurrent
Micturating cystourethogram (MCUG) (ONLY <6m) = atypical, recurrent
CT = identify alterations in perfusion, contrast excretion, infection, haemorrhage, masses, obstruction
MRI = detect renal infection, masses, obstruction
How should pyelonephritis be managed?
IV fluid to maintain hydration
IV Abx =
- <3m nitrofurantoin
- > 3m oral cefatexin
- > 3m IV ceftriaxone
Surgery = renal abscess, renal necrosis
Calculi-related urinary tract infection (UTI) = extracorporeal shockwave lithotripsy (ESWL)
Define nephritic syndrome
Inflam that can involve any part of the nephron or interstitium
Blood in urine (may have small amount of protein)
Injury to endothelium in capillary loops
In acute renal failure
Hypertensive = normal BP regulation by the kidney is lost
What are the common causes of nephritic syndrome?
IgA
Anti-GBM disease
Post-infectious
SLE nephritis
Henoch-Schönlein purpura nephritis
Define nephrotic syndrome
Damaged glomerulus =
- Generalised oedema
- Heavy proteinuria (>3g/24h)
- Hypoalbuminaemia (<25g/L) (usually with hypercholesterolaemia)
What are causes of nephrotic disease?
Site of injury = podocyte/subepithelial = proteinuria/haematuria
1) minimal change glomerulonephritis
2) focal segmental glomerulosclerosis (FSGS)
3) membranous glomerulonephritis
High protein loss = oedema
Give a DDx for a child presenting with oedema
Nephrotic syndrome
HF (murmur, breathlessness, cyanosis)
Allergic reaction (rash, wheezing, stridor)
Malnutrition (Kwashiorkor)
Liver failure
How should suspected nephrotic syndrome be investigated?
- urine dip
- urinary protein:creatinine ratio
- U+Es
- FBC
- serum albumin
- Hep B/C screen
- C3/4
- urine MS+C, PCR, analysis
- serum Ig electrophoresis
- lipid profile
How is nephrotic syndrome be Mx?
Oral high dose corticosteroids
Low salt diet (avoid worsening oedema)
Prophylactic Abx (leak Ig)
ACEi/ARBs = reduce proteinuria
Fluid restrict
Loop diuretic = furosemide
Daily weights
What are the possible complications of nephrotic syndrome
Fluid Mx = intravascularly depleted (shock)
Infection = (loss of Ig) capsulated bacteria, high risk peritonitis
Varicella Zoster (Chicken pox) = VZV immunoglobulin or IV acyclovir
Thrombosis
Spontaneous bacterial peritonitis
What is vesicoureteral reflux and its causes
Retrograde flow of urine from the bladder into the ureter - ureters displaced laterally and enter bladder directly rather than at an angle
- Primary = born with defect in valve
- Secondary = failure of the bladder to empty properly, either due to a blockage or failure of the bladder muscle or damage to the nerves
How does vesicoureteral reflux present?
Non-specific = failure to thrive, with or without fever; other features include vomiting, diarrhoea, anorexia, and lethargy
Older children may report voiding symptoms or abdominal pain
Pyelonephritis = abdo discomfort, fever
How should suspected vesicoureteral reflux be Ix?
Urine dip
<2y microscopy (URGENT)
Renal USS
Micturating cystourethrogram (MCUG)
Outline the Mx of vesicoureteral reflux
Prophylactic Abx - if structural abnormality
Primary = can get better or go away as a child gets older, as a child grows, the entrance of the ureter into the bladder matures and the valve works better
Secondary = surgery, Abx, intermittent urinary catheterization
What is enuresis and its causes?
Involuntary urination (night time: nocturnal enuresis, daytime: diurnal enuresis)
Most children get control of daytime urination by 2 years and night time urination by 3 – 4 years
Causes =
- lack of attention to bladder sensation - psychogenic problem
- neuropathic bladder (enlarges, fails to empty)
- detrusor instability (overactive bladder)
- bladder neck weakness
- fluid intake
- failure to wake
- psychological distress
- sec = chronic constipation, UTI, LD, CP
How should enuresis be Ix?
2 week diary of toileting, fluid intake and bedwetting episodes
Outline how enuresis should be managed?
Reassure parents of children under 5 years that it is likely to resolve without any treatment
Lifestyle changes: reduced fluid intake in the evenings, pass urine before bed and ensure easy access to a toilet, avoid fluid irritants
Encouragement, +ve reinforcement. Avoid blame or shame. Punishment should very much be avoided.
Treat any underlying causes or exacerbating factors, such as constipation
Timed urination (every 3h), alarms
Posture = legs wide apart, to relax pelvic floor, must rest legs on something
Double micturition = urinate, top for 30s, continue to urinate
Med: desmopressin, oxybutynin, imipramine
Safeguarding
What is Henoch-Schonlein purpura and its causes?
Systemic IgA vasculitis which can affect the skin, joints, bowel and kidneys
Often follow infections in the throat, tonsils or bouts of gastroenteritis
Cause = unknown
How does Henoch-Schonlein purpura present?
3-10y
Fever
Haematuria
Rash = mainly on the backs of the legs, buttocks, trunk and back
Arthralgia
Abdo pain
Proteinuria
Bilateral pedal oedema
Glomerulonephritis
How should suspected Henoch-Schonlein purpura be investigated?
Urine dip
Bloods = CRP, ESR, WBC, U+Es,
Renal USS
Kidney biopsy = immunoglobulin A(IgA) antibodies present
Skin biopsies = leucocytoclastic vasculitis
Outline the management of Henoch-Schonlein purpura
Self-resolving
Immunosuppressants may be needed to reduce inflammation
