Paediatrics renal Flashcards
How will babies present with a UTI?
Very non specific !
- Fever
- Lethargy
- Irritability
- Vomiting
- Poor feeding
- Urinary frequency
How will a UTI present in older infants and children ?
- Fever
- Abdominal pain, particularly suprapubic pain
- Vomiting
- Dysuria
- Urinary frequency
- Incontinence
What 2 symptoms are suggestive of acute pyelonephritis ?
- Temperature greater than 38°C
- Loin pain or tenderness
How is a UTI investigated ?
- CLEAN catch urine dipstick
How are children <3mnths old with a UTI managed ?
- Immediate referral to paediatrician
- Will be treated with IV Abx (e.g. ceftriaxone)
How are children >3mnths with a UTI treated
- Oral Abx as per local guidelines
- Usually trimethoprim, nitrofuratoin, cefalexin, amoxicillin
Which children should receive an USS following a UTI and when ?
- All children <6 months with their first UTI within 6 weeks, or during the illness if there are recurrent UTIs or atypical bacteria
- Children with recurrent UTIs within 6 weeks
- Children with atypical UTIs during the illness
When should a DMSA scan be done in children with UTIs and when ?
- 4-6 mnths after illness and done to assess for damage to the kidneys following recurrent or atypical UTIs
What is a common cause of recurrent UTIs in children?
Vesico-Uteric Reflux : abnormal backflow of urine from the bladder into the ureter and kidney.
Explain the pathophysiology of VUR
- Ureters are displaced laterally, entering the bladder in a more perpendicular fashion than at an angle
How is VUR diagnosed ?
- Micturating cystourethrogram (MCUG)
Explain the 5 grades of VUR
- I : Reflux into the ureter only, no dilatation
- II : Reflux into the renal pelvis on micturition, no dilatation
- III : Mild/moderate dilatation of the ureter, renal pelvis and calyces
- IV : Dilation of the renal pelvis and calyces with moderate ureteral tortuosity
- V : Gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity
What is the classic triad of nephrotic syndrome and why does it occur ?
- Low serum albumin
- High urine protein content (>3+ protein on urine dipstick)
- Oedema
Damage to the basement membrane in the glomerulus makes it highly permeable to protein.
what 3 other features can occur in nephrotic syndrome
- Deranged lipid profile, with high levels of cholesterol, triglycerides and low density lipoproteins
- High BP
- Hyper-coagulability, with an increased tendency to form blood clots
What is the most common cause of nephrotic syndrome in children ?
- Minimal change disease
Give 5 secondary causes of nephrotic syndrome in children
- Intrinsic kidney disease : focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis
- Systemic illness : HSP, DM, infection
How does nephrotic syndrome present ?
- Ages 2-5
- Frothy urine
- Pallor
- Generalised oedema
What is seen on urinalysis in minmal change disease
- Small molecular weight proteins
- Hyaline casts
How is nephrotic syndrome managed ?
- High dose steroids (e.g. prednislone)
- Given for 4 weeks and then weaned over the next 8 weeks
Give 5 complications of nephrotic syndrome
- Hypovolaemia
- Thrombosis
- Infection.
- Acute or chronic renal failure
- Relapse
What is nephritis and give its 3 presenting features
- Inflammation within the nephrons
- Reduction in kidney function
- Haematuria
- Proteinuria (less than in nephrotic)
Give the 2 most common causes of nephritis in children
- Post-streptococcal glomerulonephritis
- IgA nephropathy
What is post-streptococcal glomerulonephritis
- Nephritis occuring 1-3 weeks after a B-haemolytic streptococcus infection (e.g. tonsilitis caused by strep pyogenes)
what are the features of post-streptococcal glomerulonephritis
- URTI 1-3 wks prior
- Haematuria
- Proteinuria causing oedema
- Bloods : raised anti-streptolysin O titre and low C3.
What causes IgA nephropathy and what tare the common features
- Deposition of IgA immune complexes in the kidney
- Young male with recurrent episodes of macroscopic haematuria
- Develops 1-2 DAYS after URTI
What is strongly associated with IgA nephropathy ?
Henoch-schonlein purpura
What does HUS lead to traid of ?
Young children with a triad of :
AKI
Thrombocytopenia
Microangiopathic haemolytic anaemia
what is HUS and why does it lead to thrombocytopenia, AKI and MAHA
- Thrombosis in small blood vessels
- Formation of clots uses up plts = thrombocytopenia
- The thrombi and damaged RBCs affects blood flow through kidney = AKI
- The blood clots obstruct the small blood vessels and destroy the RBC as they pass through = MAHA
what most commonly causes HUS
Shiga toxin-producing E.coli or shigella
How does HUS present ?
- Initial gastroenteritis (causing diarrhoea with turns bloody witin 3 days).
- 1 wk later - > features of HUS
- Fever and abdo pain
- Pallor = normocytic anaemia
- Bruising = thrombocytopenia
- Reduced urine output and haematuria
- Hypertension = renal failure
- Confusion = uraemia
what is seen on investigations in HUS ?
- FBC : anaemia, thrombocytopenia, fragmented blood film: schistocytes and helmet cells
- U&E: acute kidney injury
- Stool culture : looking for evidence of STEC infection, PCR for Shiga toxins
How is HUS managed ?
SUPPORTIVE
- Fluids
- Blood transfusion for anaemia
- Haemodialysis of severe renal failure
what can increase the risk of HUS
- Antibiotics and anti-motility medication (e.g. loperamide) used to treat gastroenteritis caused by E.coli or shigella
what kind of polycystic kidney disease presents in neonates
- Autosommal recessive polycystic kidney disease (ARPKD)
what is ARPKD a result of and when is it picked up ?
- Mutation in the polycystic kidney and hepatic disease 1 (PKHD1) gene on chromosome 6.
- This gene codes for the fibrocystin/polyductin protein complex (FPC), responsible for the creation of tubules and the maintenance of healthy epithelial tissue in the kidneys
Give the 3 main features of ARPKD
- Cystic enlargment of the renal collecting ducts
- Oligohydramnios, pulmonary hyperplasia and potter syndrome
- Congenital liver fibrosis
Explain the pathophysiology behind the features of ARPKD
- Oligohydramnios is picked up antinatally
- The lack of amniotic fluid causes Potter syndrome (dysmorphic features) and underdeveloped fetal lungs causing resp failure after birth
- Cystic kidneys take up space in the abodem and make it hard for the neonate to breathe
what is the most common childhood malignancy and when does it usually present
- Wilm’s tumour (nephroblastoma)
- <5 years
How does a Wilm’s tumour present ?
- UNEXPLAINED ENLARGED ABDO MASS (paeds review within 48hrs)
- Painless haematuria
- Flank pain
- Lethargy
- Fever
- Weight loss
How is a Wilm’s tumour managed
- Nephrectomy with adjuvant chemo or radiotherapy
Young girl
Unwell with diarrhoea for 5 days
Now lethargic and pake
Not passed urine in 14 hrs
Became unwell after earting chicken burger
Multiple petechiae on torso and limbs
Oedematous feet
Most likely underlying cause
HUS due to E.coli
- Young girl
- Recent respiratory tract infection
- Recurrent macroscopic haematuria
- Mesangial deposition of IgA immune complexes on biopsy
IgA nephropathy
Differentiating IgA nephropathy from post-streptococcal glomerulonephritis
-> IgA = short word = occurs a few days after infection = only causes haematuria
-> Post-streptococcal glomerulonephritis = long word = few weeks following febrile illness = haematuria AND proteinuria (+HTN and oliguria)
Presentation of minimal change disease
- Pure nephrotic syndrome with normotension
- Proteinuria +++++++
