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MCQ Questions > Nephrology / Urology > Flashcards

Nephrology / Urology Flashcards

1
Q

What is the typical age of onset for post-strep glomerulonephritis?

A

5-12-years old (rare <3yo)

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2
Q

What are reasons to consider a renal biopsy in PSGN to look for an alternative diagnosis?

A
  • Presence of acute renal failure, nephrotic syndrome, absence of evidence of strep infection, normal complement levels
  • Or when hematuria + proteinuria is present and: diminished renal function and/or lo C3 level persists more than 2mo after onset
  • Alternative dx: lupus nephritis, endocarditis, membranoproliferative GN
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3
Q

What are the 4 most common causes if high grade congenital hydronephrosis?

A
  1. UPJO: Ureteropelvic junction obstruction
  2. High grade VUR: high grade vesicoureteral reflux *
  3. UVJO: ureterovesical junction obstruction *
  4. PUV: posterior urethral valves *

*dilated kidney & hyroureter -> can look identical

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4
Q

What is the most common enzyme defect in CAH?

A

21-hydroxylase (enzyme) deficiency (95% of cases)

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5
Q

What is the differential diagnosis for acute glomerulonephritis and decreased serum complement levels (C3, C50)?

A
  • Systemic diseases: Lupus nephritis, subacute endocarditis, shunt nephritis, essential mixed cryoglobulinemia, visceral abscess
  • Renal disease: acute PSGN, membranoproliferative GN Type 1
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6
Q

What is the differential diagnosis for acute glomerulonephritis and normal serum complement levels (C3, C50)?

A
  • Systemic diseases: polyarteritis nodosa, hypersensitivity vasculitis, Wegener’s granulomatous disease, HSP, Goodpasture’s
  • Renal disease: IgA nephropathy, Idiopathic rapid progressive GN (Type 1, 2, 3), post-infectious NG (non-streptococcal)
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7
Q

What is the treatment for post-strep glomerulonephritis?

A
  1. 10 day course of Penicillin (does not alter course but limits spread)
  2. Sodium restriction
  3. Diuresis with IV lasix
  4. HTN - Ca channel blockers, vasodilators, ACEi
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8
Q

What is the recommended investigations for a child with confirmed hypertension?

A
  1. Tests for underlying etiologies - renal (Cr/Urea/lytes, UA, AUS), CBC (CKD)
  2. Tests for comorbidities (fasting lipid panel, fasting glucose); sleep study & drug screen if indicated by hx
  3. Target organ damage (echo for LVH & R/O coarctation, retinal exam, albumin-Cr ratio)
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8
Q

What is the recommended investigations for a child with confirmed hypertension?

A
  1. Tests for underlying etiologies - renal (Cr/Urea/lytes, UA, AUS), CBC (CKD)
  2. Tests for comorbidities (fasting lipid panel, fasting glucose); sleep study & drug screen if indicated by hx
  3. Target organ damage (echo for LVH & R/O coarctation, retinal exam, albumin-Cr ratio)
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9
Q

What are factors that suggested a diagnosis OTHER than idiopathic MCNS in nephrotic syndrome?

A
  • Age <1y (probably congenital NS) or >10y (more likely membranous, SLE, etc.)
  • Black race (more likely SLE, FSGS)
  • FHx of kidney disease
  • Chronic disease of another organ or systemic disease
  • Sx due to intravascular volume expansion (hypertension, pulmonary edema)
  • Kidney failure
  • Active urine sediment (RBC casts)
  • Other red flags: failure to respond to 4wk steroid tx, macrohematuria, microhematuria with HTN in remission
  • Low complement levels
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10
Q

What is the treatment for typical nephrotic syndrome?

A

Steroids 2mg/kg (max 60mg) PO x6wk with a 4wk taper

NS & Fluid restriction

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11
Q

What are the complications of nephrotic syndrome?

A
  1. AKI
  2. Thromboembolic disease (e.g. DVT, PE) - due to loss of AT3, protein C/S and increased fibrinogen
  3. Infection - due to loss of IgG, e.g. spontaneous bacterial peritonitis (esp. pneumococcus)
  4. Hypercholesterolemia
  5. Side effects of steroids
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12
Q

What are the 4 most common causes of high grade congenital hydronephrosis?

A
  1. UPJO
  2. High grade VUR
  3. UVJO
  4. PUV
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13
Q

What is the most reliable imaging test to detect nephrolithiasis

A

Most reliable: CT KUB (but this is second line)

1st line: renal ultrasound (may miss small ureteric stones)

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14
Q

What are the most likely pathologies to cause AKI in children?

A
  1. Pre-renal AKI (especially due to hypovolemia)
  2. HUS (R/O early)
  3. ATN (usually post-hypotensive episode in OR, MVA)
  4. PSGN
  5. SLE PMGN
  6. HSP
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15
Q

What are the atypical features for nephrotic syndrome?

A
  1. Age < 1yo
  2. Persistent HTN (BP > 95th %)
  3. Persistently decreased renal function (eGFR < 90)
  4. Significant or gross hematuria (>50 RBCs/HPF)
  5. Steroid resistant NS
16
Q

What is the definition of steroid resistant in nephrotic syndrome? What are the different types of non minimal change NS?

A

Persistence of proteinuria after six weeks of daily prednisone therapy (urine dipstick 1+, U/A 0.3g/L+, or urine PCR 25mg/mmol+ on a 1st morning urine sample)

Focal segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), membranous nephropathy

17
Q

What is the formula for calculating free water deficit?

A

Free water deficit = total body water (TBW) x ([current plasma Na+/140] - 1)

18
Q

What are the potential complications of PSGN?

A
  • CHF due to HTN or hypervolemia
  • HTN encephalopathy → change in LOC, seizures, blurred vision, HAs
  • Nephrotic syndrome (occurs in <5% of cases)
  • Acute renal failure
  • Electrolyte imbalances (hyper-K/P, Hypo-Ca, uremia, acidosis)
19
Q

What are features that can be used to differentiate testicular torsion from torsion of the testicular appendix?

A
  • Pain → more severe (typically) + sudden onset
  • N/V → often (occasionally seen in appendix)
  • Testis position → +/- high riding, +/- transverse lie
  • Testis tenderness → throughout
  • Cremasteric → often absent
  • Blue dot → NEVER present
20
Q

What are the definitions of pre-HTN, Stage HTN?

A
  • HTN: avg sBP and/or dBP that is ≥ 95th % for age, sex & height on ≥ 3 occasions
    • Stage 1 HTN: 95-99th + 5mmHg -> if asymptomatic, non-urgent
    • Stage 2 HTN: >99th + 5 mmHg -> urgent evaluation & therapy
  • Pre-HTN: avg sBP and/or dBP that is ≥ 90th % but < 95th %
21
Q

What are the pediatric populations at greater risk of hypertension? How often should children + children with RFs be screened?

A
  • Obesity
  • Sleep disordered breathing
  • CKD
  • Prematurity
  • 3yo + RFs: every visit
  • 3yo + no RFs: every year
  • Meds to consider RF: caffeine, decongestants, NSAID, ADHD, OCP, steroids, TCA
22
Q

What is the work-up for confirmed hypertension?

A
  • Tests for underlying etiologies
    • Hx/OE - sleep, FHx, diet, habits, substances
    • RFTs, lytes, UA, urine culture
    • CBC (anemia in CKD, as indicated by history)
    • Renal US
  • Tests for comorbidity
    • Fasting lipid panel (TC, LDL, HDL, TG), fasting glucose
    • Drug screen (as indicated by history)
    • Polysomnography (OSA) (as indicated by history)
  • If obesity:
    • HbA1c, ALT/AST, fasting lipid profile
  • Target organ damage:
    • Echo (for LVH & R/O coarctation)
    • Retinal exam
    • Albumin-Cr ratio (morning)
  • Additional as indicated:
    • Ambulatory BP monitoring (white coat, when BP pattern is needed)
      • In Canada, limited availability, to be ordered by expert in HTN
    • TSH → as indicated by history
    • Plasma renin determination (low renin -> indicated mineralocorticoid related disease)
      • Indication: young children with stage 1 HTN + any child or teen with stage 2
    • Renal scan -> same indication as above
    • Plasma & urine steroid levels -> “
    • Plasma & urine catecholamines -> “
23
Q

What are risks associated with having a horseshoe kidney?

A
  • Wilms much more common
  • MCDK more likely
  • Increased risk of UPJO (urine must drain up & over the renal parenchyma, most relevant if hydronephrosis)
  • Stone disease and HN more likely
24
Q

What investigations should be sent in persistent proteinuria?

A
  • Serum renal function indices
  • Serum albumin and cholesterol
  • C3/C4 complement, ANA, ESR
  • Consider ASOT, anti-DNAase, throat culture if clinically indicated
  • HCV, HBV, HIV serology
24
Q

What investigations should be sent in persistent proteinuria?

A
  • Serum renal function indices
  • Serum albumin and cholesterol
  • C3/C4 complement, ANA, ESR
  • Consider ASOT, anti-DNAase, throat culture if clinically indicated
  • HCV, HBV, HIV serology
25
Q

What are the indications for a renal biopsy for persistent proteinuria?

A
  • Dixed, asymptomatic proteinuria, >1g/day
  • Persistent hematuria and cellular casts
  • Renal insufficiency
  • Persistently low complement levels
  • HTN
  • SLE
  • FHx of kidney disease or autoimmune disease
  • Corticosteroid-resistant nephrotic syndrome
26
Q

What are the indications for doing a VCUG?

A
  1. SFU III-IV CH
  2. 2nd febrile UTI work-up (also consider if poor growth, hypertension, atypical organism)
  3. Suspicion of PUV
27
Q

What is the management for low grade and high grade VUR?

A
  • Grade I and II VUR → observation, minimizing risk of UTI by behavioural modification (timed voiding, avoiding constipation, increased fluid intake)
    • Spontaneous resolution occur in Grade I to III VUR
  • Grade IV and V VUR → daily antibiotic prophylaxis
  • Constipation management
  • Circumcision in males can decrease risk of UTIs
  • Indications for surgical correction:
    • Persistent high-grade VUR, especially in females (concern for UTI/pyelonephritis during pregnancy)
    • Worsening renal function or new scarring
    • Recurrent UTIs/pyelonephritis
28
Q

A 18 month old M is diagnosed with his 1st febrile UTI. RBUS shows bilateral SFU II HN. A VCUG was ordered and shows bilateral grade III VUR and a normal posterior urethra.

Management, as per the CPS recommendations, is:

A) Parental counseling regarding signs of recurrence

B) Prophylactic antibiotics for 3 months

C) Referral to a Pediatric Nephrologist or Urologist

D) Repeat cystogram (VCUG or NC) in 6 months

A

Answer: A

Observation alone is recommended for VUR I-III (bilateral or unilateral) identified following a single febrile UTI

No antibiotic prophylaxis for VUR I-III, even w/ hx of febrile UTI

Referral/discussion w/ Urologist or Nephrologist for VUR IV-V or significantly abnormal RBUS findings

Repeat cystogram will not alter management if child remains UTI-free off prophylactic antibiotics

29
Q

Which children < 3yo should have their BPs checked annually + at every visit?

A
  • Neonate issues (prematurity < 32wk, SGA, VLBW, UVC, NICU)
  • CHD
  • Recurrent UTI / hematuria / proteinuria
  • Known increased BP
  • Renal or urological disease
  • FHx of congenital renal disease
  • Solid-organ transplant
  • Malignant or bone marrow transplant
  • Hx aortic arch obstruction
  • Diabetes
  • Obesity
  • Treatments known to raise BP
  • Systemic illness associated with HTN (NF1, TS, SCD)
  • Signs of increased ICP
30
Q

What is the differential diagnosis for NAGMA? (USED CRAP)

A
  • U = ureteric diversion
  • S = sigmoid fistula
  • E = excess saline (resolving DKA)
  • D = diarrea
  • C = carbonic anhydrase inhibitor
  • A = addisons
  • R = RTA
  • P = pancreatic fistula
31
Q

As per the CPS statement, what is the recommended treatment for UTIs?

A
  • Most experts recommend:
    • Oral antibiotics first for febrile UTI in non-toxic children with no known underlying abnormality
    • Limited evidence for 2-3mo old infants, so some experts recommend IV
  • Start empirical based on local susceptibility patterns
    • Most areas: Cefixime
    • In-patients: Gentamicin +/- Ampicillin
    • Other option: Ceftriaxone / Cefotaxime —> less nephrotoxic
    • Length: 7-10 days for febrile UTIs
  • Cystitis
    • Typical presentation: girls, non-febrile, post-pubertal
    • Likely 2-4 day course of oral antibiotics is likely to be sufficient
32
Q

What is the recommendation for screening AUS for renal anomalies?

A
  • Children < 2 years of age should be investigated within 2 weeks after their first febrile UTI with a renal and bladder ultrasound (RBUS) to identify significant renal abnormalities and grade IV or V VUR.
  • A voiding cystourethrogram (VCUG) is not indicated with a first febrile UTI when the RBUS is normal.
  • Febrile UTI = to confirm child had pyelonephritis or whether severe VUR or structural anomalies are present
    • Should be done when would change management
33
Q

What are signs of a complicated UTI?

A
  • When to be concerned:
    • Hemodynamically unstable patients
    • Elevated serum creatinine at any time
    • Bladder or abdominal mass
    • Poor urine flow
    • Not improving clinically after 24h of fever
    • Fever not downtrending within 48h
  • Investigation:
    • Start with renal & bladder ultrasound —> to identify obstruction or abscess
    • If complicated identified, give IV until the child is clearly improving
34
Q

What findings on a screening AUS would prompt ordering a VCUG?

A
  • Hydronephrosis, hydroureter
  • Small kidneys
  • Thick walled bladder
  • Renal parenchyma abnormal - scars, cysts
35
Q

In nephrotic syndrome, what are the definitions of: steroid responsive, steroid resistance, frequently relapsing, and steroid dependent?

A
  • Steroid responsive - responsive to prednisone within 4 weeks
  • Steroid resistance - proteinuria at 8 weeks (SK says 4wk, often with viral illness, may not develop edema)
  • Frequently relapsing - 2 relapses within 6mo of initial presentations or 4 relapses within any 1 year period
  • Steroid dependent - relapse while on alternate day steroid therapy or within 28d of stopping steroids
    • SK definition: 2 consecutive relapses durings steroid therapy OR within 2 weeks of stopping therapy, relapses on maintenance therapy
36
Q

What are the most common causes of CKD in children?

A

Renal dysplasia / Congenital structural disease

MCQ Questions (23 decks)

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