Paediatric - Renal and urinary Flashcards
1
Q
Name an upper tract UTI and a lower tract UTI
A
Upper: Pyelonephritis / Lower: Cystitis
2
Q
Name 2 investigations for UTI in children
A
- USS renal tract
- Micturating cystourethrogram (MCUG) (prophylactic Abx / VUR?)
- DMSA scan
- Urinalysis (MSU/Clean Catch) = only if Sx of UTI (fever, vomit, lethargy, dysuria)
3
Q
3 criteria for nephrotic syndrome
A
Heavy proteinuria + Hypoalbuminaemia + Oedema
4
Q
3 criteria for Acute Glomerulonephritis
A
Haematuria + Hypertension + Oedema
5
Q
Management for Primary Nocturnal Enuresis for children under 7 years old? (+over 7 years old?)
A
- 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
- Encouragement and positive reinforcement. Avoid blame or shame. Punishment should be avoided.
- Treat any underlying causes or exacerbating factors, such as constipation
- An enuresis alarm is first-line for children under the age of 7 years
- (+ rewards system)
- Pharmacological treatment - Desmopressin
- (Over 7 years old => desmopressin may be used first-line, particularly if short-term control is needed or an enuresis alarm has been ineffective/is not acceptable to the family)
6
Q
Name some features for Urinary Tract Infection in babies?
+ older infants and children?
A
Babies:
- Fever
- Lethargy
- Irritability
- Vomiting
- Poor feeding
- Urinary frequency
Older Infants:
- Fever
- Abdominal pain, particularly suprapubic pain
- Vomiting
- Dysuria (painful urination)
- Urinary frequency
- Incontinence
7
Q
What is the ideal urine sample for UTI?
A
clean catch sample, avoiding contamination
8
Q
What 2 things might you expect on the urine dipstick of a child with a UTI?
A
- Nitrites (gram negative bacteria (such as E. coli) break down nitrates into nitrites)
- Leukocytes (inflammation)
9
Q
What should be suspected in all children with unexplained fever of 38°C or more, or loin pain/tenderness?
A
Pyelonephritis
10
Q
How might you investigate recurrent UTI’s in under 16’s?
A
- Ultrasound scan
- DMSA (Dimercaptosuccinic Acid) Scan => assesses kidney damage
- Micturating Cystourethrogram (MCUG) to assess Vesico-Ureteric Reflux (VUR) => urine may flow from the bladder back into the ureters
11
Q
Name a typical antibiotic choice for urinary tract infections in children
A
First: Cefalexin
Second: Nitrofurantoin, Co-Amoxiclav, Trimethoprim, Amoxicillin
12
Q
Name some causes of Secondary Nocturnal Enuresis
A
Urinary tract infection Constipation Type 1 diabetes New psychosocial problems (e.g. stress in family or school life) Maltreatment (abuse / safeguarding)
13
Q
Name 2 most common types of incontinence which cause diurnal enuresis
A
- Urge incontinence is an overactive bladder that gives little warning before emptying
- Stress incontinence describes leakage of urine during physical exertion, coughing or laughing.
14
Q
Name a cause of CKD
A
- Hypertension
- Diabetes mellitus.
- Glomerular disease - eg, acute glomerulonephritis.
- Acute kidney injury.
- Nephrotoxic drugs - eg, aminoglycosides, ACE inhibitors, angiotensin-II receptor antagonists, bisphosphonates, diuretics, lithium and NSAIDs.
- Conditions associated with obstructive uropathy - eg, structural renal tract disease, neurogenic bladder, benign prostatic hypertrophy, urinary diversion surgery, recurrent urinary tract calculi.
- Multisystem diseases with potential renal involvement - eg, systemic lupus erythematosus (SLE), vasculitis, myeloma.
- Family history of CKD
- Cardiovascular disease.
- Obesity with metabolic syndrome (obesity alone is not a risk factor).
- Gout.
- Solitary functioning kidney.
- Low birth weight (2.5 kg or lower).
- Incidental finding of haematuria or proteinuria.
15
Q
What is the most common cause of nephrotic syndrome in children?
(+ others)
A
Minimal change disease (2-5 yr old child)
Secondary to intrinsic kidney disease: Focal segmental glomerulosclerosis / Membranoproliferative glomerulonephritis
Secondary to an underlying systemic illness: Henoch schonlein purpura (HSP) / Diabetes / Infection
16
Q
What part of the kidney is affected in Minimal Change Disease?
A
Damage to Glomeruli
17
Q
What are some features of Minimal Change Disease?
A
- 2-5yr old child with foamy urine due to large amounts of protein leaking into your urine, called proteinuria
- Peripheral Oedema
- Weight gain due to the fluid your body is not able to get rid of
- Nephrotic Syndrome:
Oedema + Proteinuria + Hypoalbuminaemia
(Loss of protein in your blood)
(Hypercholesterolaemia)
18
Q
Management for Minimal Change Disease
A
Corticosteroids (prednisolone)
For symptoms of swelling (edema):
ACE inhibitor or ARB medicines
Diuretics (water pills)
Limit sodium (salt in your diet
19
Q
Name a cause of Congenital Nephrotic Syndrome
A
Primary CNS
- Nephrin gene mutations (NPHS1, CNF)
- Podocin gene mutations (NPHS2)
- WT1 gene mutations (Denys-Drash, isolated CNS)
- LamB2 gene mutations (Pierson syndrome)
- PLCE1 gene mutations
- LMX1B mutations (nail-patella syndrome)
- LamB3 gene mutations (Herlitz junctional epidermolysis bullosa)
- Mitochondrial myopathies
Secondary CNS
- Congenital syphilis
- Toxoplasmosis, malaria
- Cytomegalovirus, rubella, hepatitis B, HIV
- Maternal systemic lupus erythematosus
- Neonatal autoantibodies against neutral endopeptidase
- Maternal steroid–chlorpheniramine treatment
20
Q
What are the two most common causes of nephritis in children?
A
Post-streptococcal glomerulonephritis
- occurs 1 – 3 weeks after a β-haemolytic streptococcus infection, such as tonsillitis caused by Streptococcus pyogenes
- Immune complexes made up of streptococcal antigens, antibodies and complement proteins get stuck in the glomeruli of the kidney and cause inflammation
IgA nephropathy (Berger’s disease)
- Related to Henoch-Schonlein Purpura (IgA vasculitis)
- Renal biopsy shows ‘glomerular mesangial proliferation + IgA deposits’
- Fluid + electrolyte balance, immunosuppressants may be required (cyclophosphamide)
21
Q
How long after a β-haemolytic streptococcus infection (such as tonsillitis caused by Streptococcus pyogenes) might Post-streptococcal glomerulonephritis occur?
A
1-3 weeks
22
Q
IgA nephropathy is also called?
A
Berger’s disease
23
Q
What is Berger’s Disease?
A
IgA nephropathy
24
Q
Which IgA vasculitic condition is associated with Berger’s Disease?
A
Henoch-Schonlein Purpura
25
What are the 4 classic features of Alport's syndrome?
- Haematuria.
- Progressive chronic kidney disease (hereditary congenital haemorrhagic nephritis).
- Sensorineural hearing loss.
- Several ocular abnormalities.
26
Glomerulonephritis is common in what multisystem autoimmune disorder?
Systemic Lupus Erythematosus (SLE)
27
Where is the urethral meatus displaced in Hypospadias and Epispadias?
Hypospadias - Ventral side
| Epispadias - Dorsal side
28
Does Hypospadias require referral?
Hypospadias requires referral to a paediatric specialist urologist for ongoing management. It is important to warn parents not to circumcise the infant until a urologist indicates this is ok.
Mild cases may not require any treatment
Surgery is usually performed after 3 – 4 months of age
Surgery aims to correct the position of the meatus and straighten the penis
29
What is the triad of Haemolytic Uraemic Syndrome?
| Test result + Blood result + Condition
- Microangiopathic haemolytic anaemia (Coombs' test negative).
- Thrombocytopenia.
- Acute kidney injury (acute renal failure).
(The classical presenting feature is profuse diarrhoea that turns bloody 1 to 3 days later)
(Most adults infected with E.Coli remain asymptomatic)
(There is often fever, abdominal pain and vomiting)
30
What is the most common cause of acute kidney injury in children?
Haemolytic Uraemic Syndrome
31
Name a risk factor for Haemolytic Uraemic Syndrome
- Rural populations >urban populations.
- Warmer summer months (June-September).
- Young age (6 months to 5 years).
- Older people or those with altered immune response.
- Contact with farm animals.
32
Dipstick for Vulvovaginitis may lead to misdiagnosis of what condition?
urine dipstick may show leukocytes but no nitrites. This will often result in misdiagnosis as a urinary tract infection
33
Simple measures to improve symptoms of Vulvovaginitis?
- Avoid washing with soap and chemicals
- Avoid perfumed or antiseptic products
- Good toilet hygiene, wipe from front to back
- Keeping the area dry
- Emollients, such as sudacrem can sooth the area
- Loose cotton clothing
- Treating constipation and worms where applicable
- Avoiding activities that exacerbate the problem
(severe cases may be treated w oestrogen cream to improve symptoms)
34
Management of minimal change disease
corticosteroids (i.e. prednisolone) (prognosis is good and most children (2-5yrs) make a full recovery, however it may reoccur)
35
Nephrotic syndrome management
- High dose steroids (i.e. prednisolone) (given for 4 weeks and then gradually weaned over the next 8 weeks)
- Low salt diet
- Diuretics may be used to treat oedema
- Albumin infusions may be required in severe hypoalbuminaemia
- Antibiotic prophylaxis may be given in severe cases
(In steroid resistant children, ACE inhibitors and immunosuppressants such as cyclosporine, tacrolimus or rituximab may be used)
36
Haemolytic Uraemic Syndrome is caused by which toxin?
Shiga toxin produced by E.Coli + Shigella
| Symptoms typically start around 5 days after the onset of diarrhoea
37
Management of HUS?
- Urgent referral to the paediatric renal unit for renal dialysis if required
- Antihypertensives if required
- Careful maintenance of fluid balance
- Blood transfusions if required
38
Autosomal recessive polycystic kidney disease is caused by mutation of PKHD1 gene on which chromosome?
chromosome 6 (PKHD1 codes for fibrocystin/polyductin protein complex (FPC), which is responsible for the creation of tubules and the maintenance of healthy epithelial tissue in the kidneys, liver and pancreas)
39
Complications of Autosomal recessive polycystic kidney disease?
- Liver failure due to liver fibrosis
- Portal hypertension leading to oesophageal varices
- Progressive renal failure
- Hypertension due to renal failure
- Chronic lung disease
(The prognosis is poor)
40
Investigation + Management of Wilms' tumour
- Ix = USS abdomen (CT or MRI for staging) (Biopsy for staging)
- Surgical excision of the tumour with affected kidney (nephrectomy)
- Adjuvant treatment refers to treatment that is given after the initial management with surgery
○ Adjuvant chemotherapy
○ Adjuvant radiotherapy
41
```
Child <5 years presenting with a mass in the abdomen + signs of:
○ Abdominal pain
○ Haematuria
○ Lethargy
○ Fever
○ Hypertension
Weight loss
```
Wilms tumour
42
Most common complication of posterior urethral valve?
UTIs due to restriction of outflow / Severe cases in the developing fetus result in bilateral hydronephrosis and oligohydramnios (low amniotic fluid volume) leading to underdeveloped fetal lungs (pulmonary hypoplasia) with respiratory failure shortly after birth.
43
Ix + Mx of posterior urethral valve
- Abdominal USS may show enlarged, thickened bladder and bilateral hydronephrosis
- Micturating cystourethrogram (MCUG) shows the location of the extra urethral tissue and reflux of urine back into the bladder
- . Cystoscopy can be used to get a detailed view of the extra tissue + to ablate or remove the extra tissue.
44
Orchidopexy for undescended testes should be performed at what age?
between 6 and 12 months of age
45
What is the condition in which the urethral meatus is displaced on the dorsal side of the penis in males?
Epispadias
46
Where is the collection of fluid in a hydrocele?
In the tunica vaginalis that surround the testes
(In a communicating hydrocele, the tunica vaginalis is connected to the peritoneum by the processes vaginalis which allows fluctuating size of the hydrocele)
