Nephrology/Urology Flashcards
1
Q
hypertension in children
A
- know your normal values
- newborn average systolic BP 70-75
- 1 year old average systolic BP 90
- 5 year old average systolic BP 95
- 12 year old average systolic BP 100-105
- hypertension is BP >95th percentile for age, gender & height
- Severe hypertension is >95th %-ile + 12mmHg (or 140/90)
- hypertension is more often secondary than primary (“essential”) in children
- consider renal disease, endocrine disease first
- early hypertension in children is a precursor to serious adult hypertension
2
Q
hypertension in children - differential diagnosis
A
- renal disease
- pyelonephritis
- renal parenchymal disease
- congenital anomalies
- reflux nephropathy
- acute glomerulonephritis
- Henoch-Schönlein purpura
- renal trauma
- hydronephrosis
- hemolytic-uremic syndrome
- renal stones
- nephrotic syndrome
- Wilms tumor
- hypoplastic kidney
- polycystic kidney disease
- endocrine
- hyperthyroidism
- congenital adrenal hyperplasia
- Cushing syndrome
- primary aldosteronism
- primary hyperparathyroidism
- diabetes mellitus
- hypercalcemia
- Pheochromocytoma
- Adrenogenital syndrome
- neurologic
- increased ICP
- Guillain-Barre syndrome
- pyschologic causes
- mental stress
- anxiety
- vascular causes
- renal artery abnormalities
- renal vein thrombosis
- coarctation of the aorta
- patent ductus arteriosus
- arteriovenous fistula
- drugs
- anabolic steroids
- corticosteroids, OCPs
- PCP, cocaine
- other
- pain
- collagen vascular disease
- neurofibromatosis
3
Q
evaluation of hypertension
A
- history
- CNS - headache, seizures
- hearing impairment
- CV - palpitations
- renal - edema, UTI, urine output
- medications
- neonatal history
- history of central catheter
- early CV disease
- cause
- intracranial hypertension
- Alport syndrome
- catecholamine
- nephropathy (HUS, SLE, GN, tumor, ADPKD, etc.)
- OCPs
- renal artery or aortic stenosis
- obesity, essential hypertension
- Physical
- Abdominal bruit
- Diminished leg BP/pulse in
- Café au lait spots
- Abdominal mass
- Opsoclonus myoclonus
- Tachycardia/flushing
- Striae, buffalo hump, acne
- Early puberty
- cause
- Renal vascular disease
- Coarctation of the aorta
- neurofibromatosis
- Wilm’s Tumor
- Neuroblastoma
- pheochromocytoma
- Cushing’s
- Adrenogenital syndrome
4
Q
workup of HTN in children
A
- BP measurements with appropriate cuff size on different visits
- Work UP
- Baseline etiology assessment- Urinalysis, Electrolytes, BUN, Cr, renal ultrasound
- If Clinical Suspicion- plasma metanephrines , thyroid studies, vascular imaging (renal Doppler studies)
- Target Organ- Echocardiogram
- Cardiovascular Risk Factors- Lipids, Fasting Glucose, Uric Acid
5
Q
HTN tx in children
A
- treatable causes must first be ruled out
- much more common to have a treatable cause in children than in adults
- exercise
- diet changes to address obesity and co-morbidities
- medical therapy
- diuretics
- ACE inhibitors
- β-blockers
- calcium channel blockers
- Hypertensive emergencies (encephalopathy, CHF with hypertension AND hypertensive urgency (Extreme elevations of BP without symptoms) require immediate management often require hospitalization.
- The chronicity of the process affects the rate that the BP is safely lowered.
6
Q
Hematuria
A
- red urine without urinalysis evidence of blood
- red dye, food, medication or chemical excreted in urine
- red urine with urinalysis evidence of blood but no RBC on microscopy
- free hemoglobin
- hemolysis, DIC
- free myoglobin
- crush injury, burns, myositis, asphyxia
- free hemoglobin
- red urine with urinalysis and microscopy evidence of blood but no RBC casts
- bleeding from urinary tract distal to renal tubules
- red urine with blood and casts in urine
- glomerular disease
- immunologic disease (e.g., post-streptococcal glomerulonephritis)
- inherited disease (e.g., Alport syndrome)
- vascular injury (e.g., ATN, cortical necrosis, etc.)
- glomerular disease
7
Q
A
8
Q
hematuria work-up
A
- history and physical exam
- confirm true hematuria
- if microscopic with benign H&P => recheck
- if repeatedly positive or positive H&P => workup
9
Q
hematuria ddx
A
- urinary tract infection/cystitis/urethritis
- hypercalciuria
- urolithiasis
- trauma
- post-streptococcal glomerulonephritis
- IgA nephropathy
- HSP (Henoch Schönlein purpura)
- systemic lupus erythematosus
- nephrotic syndrome (20% of cases also have hematuria)
- membranoproliferative glomerulonephritis
- Alport syndrome (sensorineural deafness, progressive renal failure)
- sickle cell trait/disease
- structural abnormality
- renal or urinary tract tumor
- benign
- benign familial hematuria
- post-exercise
10
Q
workup for hematuria
A
- Phase I
- urinalysis with microscopic examination
- CBC
- urine culture
- chem 8 (including BUN, Cr)
- 24 hour urine collection for creatinine, protein, calcium
- serum C3 level
- renal ultrasound
- phase II
- ANA titer
- throat culture for Streptococcus pyogenes
- ASO titer or DNAse B titer or streptozyme
- urine erythrocyte morphology
- coagulation studies
- sickle cell screen
- VCUG
- renal biopsy indicated for
- persistent high grade microscopic hematuria
- microscopic hematuria and
- diminished renal function
- proteinuria exceeding 150mg/24 hours
- second episode of gross hematuria
11
Q
post-streptococcal glomerulonephritis
A
- clinical presentation: NephrITIC syndrome
- 5-21 days (average 10) after streptococcal infection
- gross hematuria (65% of cases)
- edema (75% of cases)
- hypertension (headache, visual changes) – 50% of cases
- laboratory
- elevated ASO titer
- group A beta-hemolytic streptococcal infection
- decreased C3 level
- treatment
- antibiotic for Streptococcus pyogenes
- supportive care for renal function
- reduce salt intake
- treatment with diuretics
- anti-hypertensive drugs
12
Q
IgA nephropathy
A
- pathogenesis
- glomerulonephritis with IgA immunoglobulin in mesangial deposits
- absence of systemic disease
- clinical manifestations
- episode of gross hematuria 1-2 days after a viral upper respiratory infection
- may be picked up by urinalysis showing microscopic hematuria
- treatment
- usually resolves with minimal intervention in children
- some progress to have
- hypertension
- diminished renal function
- proteinuria
- 25% of adults progress to end-stage renal disease
13
Q
systemic lupus erythematosus
A
- clinical manifestations
- systemic symptoms
- malar rash
- discoid rash
- photosensitivity
- oral ulcers
- arthritis
- serositis
- renal disorder
- neurologic disorder
- hematologic disorder
- Immunologic
- positive ANA
- renal disease - variable
- spectrum from minimal renal involvement to end-stage renal
14
Q
proteinuria
A
- normal children – spot protein to creatinine ratio <0.2
- definition
- urinary protein loss of 50mg/kg per 24 hours
- may be result of normal activity
- exercise
- febrile illness
- upright posture
- Non-renal causes include
- drug and heavy metal intoxication
- processes that increase glomerular filtration
- physical damage
- abnormal hemodynamics
15
Q
nephrotic syndrome
A
- clinical diagnostic criteria
- generalized edema
- hypoproteinemia (<2.5 g/dL)
- urinary protein/creatinine ratio > 2
- hypercholesterolemia (>250 mg/dL)
- pathophysiology
- loss of basement membrane sialoproteins
- loss of normal negative charge
- allows glomerular permeability to proteins
- protein loss in urine
- hypoalbuminemia
- loss of plasma oncotic pressure – fluid shifts from vascular to interstitial compartment
- increases risk of thromboembolism
- hepatic lipoprotein synthesis stimulated by hypoproteinemia
- loss of basement membrane sialoproteins
- most often presents with sudden onset of pitting edema, weight gain or ascites
- differential diagnosis
- transient proteinuria (with fever, dehydration, etc.)
- protein to creatinine ratio reveals mild proteinuria, ratio <1
- postural (orthostatic) proteinuria
- benign condition of moderate proteinuria while upright
- rationale for 1st morning samples
- glomerular proteinuria
- associated with acute illnesses involving kidney
- minimal change disease (typical nephrotic syndrome)
- congenital nephrotic syndrome
- focal segmental glomerulosclerosis
- mesangial nephropathy
- membranous nephropathy
- transient proteinuria (with fever, dehydration, etc.)
- epidemiology
- onset < 6 years of age
- clinical findings
- edema
- periorbital swelling
- oliguria
- fluid shifts
- ascites
- pleural effusion
- scrotal/labial edema
- laboratory
- low albumin
- urinalysis (proteinuria)
- 1+ or greater proteinuria on 2 or more random specimens warrants quantitative measure or proteinuria
- first a.m. void spot protein/Cr ratio
- ratio >0.5 prompts lab and radiographic workup
- C3 level
- a low C3 level is the most sensitive & specific test to imply a presence OTHER than minimal change disease
- renal biopsy
- generally unremarkable
- foot processes of glomerular basement membrane fused
- 1+ or greater proteinuria on 2 or more random specimens warrants quantitative measure or proteinuria
- treatment
- corticosteroids
- 80% of patients respond
- low sodium diet to prevent massive fluid shifts
- if steroid not working, may try immunosuppressive agents
- renal biopsy if no response after steroids and immunosuppressive agents
- biopsy would typically precede steroids if C3 level was low (implying disease other than minimal change disease)
- corticosteroids
- complications
- infection
- peritonitis
- bacteremia/sepsis
- S. pneumoniae
- E. coli
- cellulitis
- hypercoagulability
- pleural effusion
- renal insufficiency - blood pressure instability
- infection
