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3A > Paediatric Renal > Flashcards

Paediatric Renal Flashcards

1
Q

What is nephrotic syndrome?

A

Damage to the filtration barrier of the kidneys leading to heavy proteinuria, hypoalbuminaemia and oedema

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2
Q

What age is nephrotic syndrome most common in?

A

Ages 2-5

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3
Q

Describe the causes of nephrotic syndrome

A

Primary causes- occurs due to primary renal glomerular damage
- minimal change disease
- focal segmental glomerulosclerosis
- membranous nephropathy

Secondary causes: glomerular injury due to wider systemic injury (remember DDANI)
- Diabetes
- Drugs
- Amyloidosis
- HIV
- Henoch Schonlein purpura
- SLE

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4
Q

How can nephrotic syndrome be classified

A

Steroid sensitive or steroid resistant

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5
Q

Key features of nephrotic syndrome

A
  • proteinuria >3.5g/day
  • hypoalbuminaemia (<35g/l)
  • Oedema (peripheral or peri orbital)
  • hypercholesterolaemia
    May also have deranged liver profile, high BP and hypercoagulability
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6
Q

Why is there high cholesterol in nephrotic syndrome

A

Because the liver works in overdrive due to the low albumin

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7
Q

Why is there increased risk of infection in nephrotic syndrome?

A

Antibodies are lost through the filtration barrier

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8
Q

Presentation of nephrotic syndrome

A

Periorbital oedema
Frothy urine
Xanthelasma and xanthelomata
Fatigue
Scrotal, vulval, leg and ankle oedema
Ascites
Breathlessness
Infection- e.g peritonitis, septic arthritis

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9
Q

What might trigger nephrotic syndrome

A

A viral illlness

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10
Q

How is nephrotic syndrome diagnosed

A

Urine dipstick- heavy proteinuria
Urine protein: creatinine ratio
Plasma albumin
Gold- renal biopsy

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11
Q

Findings of renal biopsy for minimal change disease

A

Podocyte foot effacement (on electron microscopy)

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12
Q

Findings of renal biopsy for focal segmental glomerulosclerosis

A

Plaques of sclerosis (on light microscopy)

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13
Q

Treatment of nephrotic syndrome

A

High dose oral corticosteroids
If unresponsive then renal biopsy

May need additional drugs if steroid resistant:
- diuretics
- ACE inhibitors
- statins
- anticoagulants

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14
Q

Features that suggest nephrotic syndrome is steroid sensitive

A
  • age 1-10
  • no macroscopic haematuria
  • normal BP
  • normal complement levels
  • normal renal function
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15
Q

Complications of nephrotic syndrome

A

Hypovolaemia
Thrombosis
Infection

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16
Q

What is nephritic syndrome

A

An inflammatory process of the glomeruli (glomerulonephritis) leading to haematuria, variable proteinuria, renal impairment and hypertension

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17
Q

Most common causes of nephritic syndrome in children

A

Post-streptococcal glomerulonephritis and IgA nephropathy

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18
Q

Two main classifications of nephritic syndrome

A

Immune complex deposition in the glomeruli leading to an inflammatory response
Small vessel vasculitis

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19
Q

Causes of nephritic syndrome

A

Post- strep glomerulonephritis
IgA nephropathy
Systemic lupus erythematosus
Small vessel vasculitis (anti-GMB)

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20
Q

Presentation of nephritic syndrome

A

Haematuria (cola coloured urine)
Oliguria
Hypertension
Proteinuria (less than 3.5)
Oedema (peripheral or periorbital)
Shortness of breath (due to fluid overload)

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21
Q

Eplain post-streptococcal glomerulonephritis

A

Occurs 1-3 weeks after strep infection (e.g. tonsilitis with strep pyogenes)
Immune complexes to strep infection, antibodies and complement get stuck in the glomeruli and cause inflammation

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22
Q

How is pos strep glomerulonephritis confirmed

A

Evidence of a recent strep infection (either by culture or raised ASO and anti-DNAase)
Low complement levels

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23
Q

Explain rapidly progressing glomerulonephritis/ good pastures disease

A

It is a rare small vessel vasculitis where anti-GBM autoantibodies target collagen in the basement membranes leading to the deposition if IgG in the glomerular capillaries
Also targets the alveoli so may have haemoptysis

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24
Q

How does Henoch-Schonlein purpura present

A

Purpuric rash - non-blanching, usually begins on the legs and buttocks
Abdominal pain
Arthritis
Glomerulonephritis- haematuria, proteinuria, hypertension
Scrotal pain and swelling

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25
Q

What is henoch schonlein purpura

A

It is a common autoimmune vasculitis affecting children

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26
Q

Epidemiology of henoch schonlein purpura

A

Most common vasculitis in children
Peaks aged 2-10
Increased in winter (often preceded by URTI)
Increased in men

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27
Q

Diagnostic criteria for HSP

A

Clinical diagnosis based on having purpura and at least one of the following:
- abdominal pain
- arthritis
- renal involvement
- IgA deposition on renal biopsy

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28
Q

How is HSP treated

A

Mainly self-limiting
May use analgesia for abdominal and joint pain
May use steroids if severe pain

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29
Q

At what age can enuresis be diagnosed

A

In children 5 years or older

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30
Q

What is primary nocturnal enuresis

A

Bed wetting when a child has never achieved continence

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31
Q

What is secondary nocturnal enuresis

A

Loss of continence in a child who has previously been dry for at least 6 months

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32
Q

Causes of nocturnal enuresis

A

Most commonly just a variation in normal development
Others:
- overactive bladder
- fluid intake before bed
- failure to wake due to deep sleep and underdeveloped bladder signals
- psychological distress

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33
Q

Causes of secondary nocturnal enuresis

A

Constipation
UTI
Type 1 diabetes
Maltreatment

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34
Q

diagnosis of nocturnal enuresis

A

2 week diary of fluid intake, toileting and bed wetting

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35
Q

First line treatment for nocturnal enuresis (after lifestyle changes(

A

Enuresis alarm

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36
Q

First line medication for nocturnal enuresis

A

Desmopressin

37
Q

Other drug treatments for nocturnal enuresis (other than desmopressin)

A

Oxybutinin and imipramine

38
Q

What is vesiocureteric reflux

A

A developmental anomaly of the vesicoureteric junction meaning that instead of entering the bladder at an angle the ureters enter directly and have a shortened/absent intramural course

39
Q

Aetiology of vericoureteric reflux (3 causes)

A

Often familial - 30 to 50% occur in first degree relatives
Can occur with bladder pathology (neuropathic bladder, urethral obstruction)
Can occur temporarily after a UTI

40
Q

What can occur as a consequence of severe vesicoureteric reflux

A
  1. Intra-renal reflux
  2. Pyelonephtritis
  3. Renal scarring
  4. Chronic kidney disease and hypertension
41
Q

How does vesicoureteric reflux present

A

Recurrent UTIs

42
Q

When should children be investigated for vesicoureteric reflux?

A

If they have recurrent UTIs or atypical UTIs

43
Q

What are features suggesting atypical UTIs in children (6 features)

A
  • seriously ill/ septic
  • poor urine flow
  • abdominal mass or bladder mass
  • raised creatinine
  • failure to respond to suitable Abx in 48 hours
  • infection with an atypical organism (non E.coli)
44
Q

How can recurrent UTIs be classified in children (3 ways)

A

Two or more episodes of UTI with upper UTI (pyelonephritis)
One episodes or more episodes UTI with upper UTI plus one or more episodes or UTI with lower UTI (cystitis)
Three or more episodes of lower UTI

45
Q

Presentation of UTI in infants

A

Fever
Vomiting
Lethargy
Irritability
Jaundice
Poor feeding
Septicaemia
Offensive urine

46
Q

Presentation of UTI in children

A

Dysuria
Abdominal pain
Fever and shivering
Lethargy
Anorexia
Diarrhoea
Bed wetting
Darker, cloudy urine
Haematuria

47
Q

First line investigation for a UTI

A

Dipstick

48
Q

What results on a urine dipstick suggest UTI

A

Nitrites and leukocyte esterase

49
Q

Investigations for UTI in child

A

Dipstick
Urine sample- microscopy and culture
Further investigations may be done for abnormalities

50
Q

How can urine samples been collected in infants

A
  • clean catch (pot waiting when nappy is removed)
  • plastic adhesive bag applied to Perineum
  • cotton wool
  • urethral catheter
  • suprapubic aspiration (if very ill)
51
Q

Most common causes of UTIs in children

A

E. Coli
Proteus
Pseudomonas q

52
Q

Predisposing factors for UTIs in children

A

Incomplete bladder emptying- infrequent voiding, hurried micturition, obstruction due to constipation, neuropathic bladder
Vesicoureteric reflux
Poor hygiene

53
Q

Who should have an USS after a UTI (3)

A

All children under 6 months with first UTI (within 6 weeks)
Chidlren with recurrent UTIs (within 6 weeks)
Children with atypical UTIs (during the illness )

54
Q

How is vesicoureteric reflux diagnosed?

A

Micturating cystourethrogram (MCUG)
A DMSA scan may also be used to look for scarring

55
Q

Treatment of suspected UTI in child under 3 months

A

Hospital admission and IV antibiotics

56
Q

Treatment of suspected upper UTI in child >3 months

A

Start oral antibiotics (initially cefalexin or in sensitive co-amoxiclav)

57
Q

Treatment of children over 3 months with lower UTI

A

Oral antibiotics (trimethoprim or nitrofuratoin)

58
Q

When is a DMSA scan used after a UTI?

A

After the acute infection but within 4-6 months
Used for all children under 3 with atypical UTI and for those with recurrent UTI

59
Q

What does the eGFR need to be for nitrofuratoin to be used?

A

Above 45

60
Q

What is haemolytic uraemic syndrome?

A

A triad of microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury

61
Q

What is the most common cause of haemolytic uraemic syndrome

A

Gastrointestinal infection with shiga toxin secreting E.coli - mainly acquired through contact with farm animals or eating uncooked beef

62
Q

Pathophysiology of haemolytic uraemic syndrome

A

The toxin from E.coli enters the GI mucosa and localises to the endothelial cells of the kidneys where it causes intravascular thrombogenesis
This activates the clotting cascade in which platelets are consumed (thrombocytopenia).
There is damage to the RBC as they circulate through the partially occluded microcirculation leading to haemolytic anaemia

63
Q

Presentation of haemolytic uraemic syndrome

A
  • E.coli infection causing bloody diarrhoea
  • 5 days later:
  • decreased urine output (AKI)
  • haematuria
  • abdominal pain
  • lethargy
  • confusion
  • bruising
64
Q

Diagnosis of haemolytic uraemic syndrome

A
  • FBC: anaemia, thrombocytopenia
  • Blood film- shows fragmented RBC (schistocytes and helmet cells)
  • U and E shows AKI (raised creatinine)
  • Stool culture - E.coli infection, PCR for shiga toxin
  • LDH increased due to RBC destruction
65
Q

Treatment of haemolytic uraemic syndrome

A

1st line- supportive fluids (IV isotonic crystalloids)
May need:
- antihypertensives
- blood transfusions
- Haemodialysis

Plasma exchange may be used in severe cases
Eculizumab ( a monoclonal ab) may be used

66
Q

What is hypospadias

A

A congenital defect where the urethral meats is abnormally located on the penis (usually it will be on the under side of the penis rather than the tip)

67
Q

Three key features of hypospadias

A
  • ventral opening of the urethral meatus
  • ventral curvature of the penis or chordee
  • dorsal hooded foreskin
68
Q

How common is hypospadias

A

1 in 200

69
Q

How is hypospadias treated

A

May perform surgery however not mandatory

70
Q

What procedure must children with hypospadias not undergo and why?

A

Circumcision due to preservation of tissue for reconstruction

71
Q

What is phimosis

A

Tight foreskin which cannot be retracted properly from the head of the penis

72
Q

What is true phimosis

A

A scar occurs on the foreskin which prevents it from retracting

73
Q

How may phimosis present ?

A

Ballooning of the foreskin during urination
Inability to retract the foreskin
Discomfort and pain

74
Q

How is phimosis treated

A

Topical steroids for 4-6 weeks
Circumcision if not successful

75
Q

How long after URTI would post strep glomerulonephritis present?

A

7-14 days

76
Q

Which cause of nephrotic syndrome presents with podocyte foot effacement on electron microscopy

A

Minimal change disease

77
Q

How soon after URTI does IgA nephropathy present?

A

1-2 days

78
Q

Which cause of nephrotic syndrome is associated with malignancy

A

Membranous nephropathy

79
Q

Most common cause of nephrotic syndrome in those who are HIV positive

A

Focal segmental glomerulosclerosis

80
Q

What medication may be needed as prophylaxis in nephrotic syndrome

A

Low molecular weight heparin - enoxaparin

81
Q

What is present in 10% of patients with hypospadias

A

Cryptorchidism

82
Q

Most common cause of nephrotic syndrome in children

A

Minimal change disease

83
Q

What is cryptorchidism

A

Undescended testes

84
Q

What parameter should be monitored frequently in HSP

A

Blood pressure

85
Q

where should children under 3 months with a UTI be treated

A

in hospital

86
Q

what follow up test should patients with HSP have for a year

A

urine dipstick to check for remaining haematuria or proteinuria

87
Q
A
88
Q

Best method of urine collection in infant

A

Urine collection pad

3A (33 decks)

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