Paediatrics - Renal and Urology Flashcards
How do UTIs present in children
Presentaiton of pyelonephritis?
Common organisms?
Ix?
Rx? - neonates vs older children?
Fever may be the only symptom of a urinary tract infection, especially in young children. Always consider (and exclude) a urinary tract infection in a child with a temperature, unless there is a clear alternative source of infection.
Babies might also present with other non-specific symptoms:
- vomitting, irritability, poor feeding and urinary frequency
older children are more specific
- abdominal pain, particularly supraprubic
- vomiting
- dysuria
- freqeuncy/incontinence
The diagnosis of acute pyelonephritis is made if either there is:
A temperature greater than 38°C
Loin pain or tenderness
Pyelonephritis can lead to scarring in the tissue and consequently a reduction in kidney function.
Common infection which is important to investigate properly in children due to potential for structural abnormalities in the urinary tract and scarring of the kidneys if pyelonephritis develops which can lead to renal failure.
Common organisms: E coli, Klebsiella, Enterococcus, Proteus, Pseudomonas, KEEPP
Ix:
- Urine dipstick from a clean catch sample (no nappy and hold a urine pot) - nitrites or leukocytes
- MSU for culture and sensitivity testing
Management:
- all children under 3 months with a fever should immediately start IV antibiotics (ceftriaxone) and hav a full septic screen, conisder lumbur punture
- Children over 3 months - Typical antibiotic choices in urinary tract infections in children are:
Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin
Lecture:
- lower - 3 days oral Abx
- Upper (Pyelonephritis) - 10/7 IV antibiotics.
Definition of recurrent UTI and atypical UTI?
Children with recurrent Urinary tract investigations require what investigations?** 3 scans, what are they each for**
Management of Vesico-ureteric reflux
Recurrent UTI:
- 2 x pylenephritis
- 3 x lower UTI
Atypical - Not Ecoli
Ultrasound Scans:
- recurrent UTIs - within 6 weeks
- Atypical UTI during infection
- Babies under 6 months, including first UTI
Basically everyone gets an US if recrurrent or under 3 months
DMSA (Dimercaptosuccinic Acid) Scan
DMSA scans should be used 4 – 6 months after the illness to assess for damage from recurrent or atypical UTIs. This involves injecting a radioactive material into the bloodstream (DMSA) and using a gamma camera to assess how well the material is taken up by the kidneys. Where there are patches of kidney that have not taken up the material, this indicates scarring that may be the result of previous infection.
Micturating cystourethrogram (MCUG):
- used to diagnose Vesico-ureteric reflux (backflow of urine back into the ureters - predisposes to Upper UTIs)
- Micturating cystourethrogram (MCUG) should be used to investigate atypical or recurrent UTIs in children under 6 months. It is also used where there is a family history of vesico-ureteric reflux, dilatation of the ureter on ultrasound or poor urinary flow. A MCUG is used to diagnose VUR.
- It involves catheterising the child, injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing into the ureters
Indications - Abdo US and DMSA - recurrent or atypical UTIs. MCUG - same but in infants under 6 months
Management of vesico-ureteric reflux depends on the severity:
Avoid constipation
Avoid an excessively full bladder
Prophylactic antibiotics
Surgical input from paediatric urology
What is Enuresis?
Primary Causes of nocturnal enuresis?
Management of primary?
Secondary causes of nocturnal enuresis?
Causes of diurnal enuresis?
3 specialist medications?
The term enuresis is used to describe involuntary urination. Bed wetting is called nocturnal enuresis. Inability to control bladder function during the day is called diurnal enuresis. Most children get control of daytime urination by 2 years and nighttime urination by 3 – 4 years.
Primary nocturnal enuresis is where the child has never managed to be consistently dry at night (like how primary amennorrhea is never having menarche). It can be normal before 5 years, particularly when there is a family history of delayed dry nights.
Other causes:
- overactive bladder
- fluid intake
- failure to wake - deep dleep
- psychological distress
- chronic contipation, learning disability
A 2 week diary of toiletting, fluid intake and bedwetting can help establis a cause
Management:
- reassurance - likely to resolve without management before the age of 5
- lifestyle factors - reduce fluid intale in the evenings
- encouragement and avoiding blame or shame
Secondary nocturnal enuresis is where a child begins wetting the bed when they have previously been dry for at least 6 months. This is more indicative of an underlying illness than primary enuresis.
Causes of secondary nocturnal enuresis include:
Urinary tract infection
Constipation
Type 1 diabetes
New psychosocial problems (e.g. stress in family or school life)
Maltreatment
Diurnal Enuresis
Diurnal enuresis is daytime incontinence. This occurs when the person has become dry at night but still has episodes of urinary incontinence during the day. This occurs more frequently in girls. Incontinence comes in two main types:
Urge incontinence is an overactive bladder that gives little warning before emptying
Stress incontinence describes leakage of urine during physical exertion, coughing or laughing.
Other causes of diurnal enuresis include
Recurrent urinary tract infections
Psychosocial problems
Constipation
Pharmacological Treatment
Medication for nocturnal enuresis is usually initiated by a specialist.
Desmopressin is an analogue of vasopressin (also known as anti-diuretic hormone). It reduces the volume of urine produced by the kidneys. It is taken at bedtime with the intention of reducing nocturnal enuresis.
Oxybutinin is an anticholinergic - overactive bladder causing urge incontinence.
Imipramine is a tricyclic antidepressant. It is not clear how it works, but it may relax the bladder and lighten sleep.
What causes the nephrotic syndrome?
Classical triad of nephrotic syndrome?
Sx?
Cause?
Ix? what does it show?
Rx?
Nephrotic syndrome occurs when the basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine. It is most common between the ages of 2 and 5 years. It presents with frothy urine, generalised oedema and pallor.
Nephrotic syndrome features a classic triad of:
Low serum albumin
High urine protein content (>3+ protein on urine dipstick)
Oedema
Also presents with deranged lipids, hypercoagulability and high blood pressure
Clinical Presentation
- Periorbital oedema, often on awakening
- Scrotal, vulval, leg and ankle oedema
- Ascites
- SOB due to presence of pleural effusions and abdominal distension
Causes:
- 90% are minimal change disease - a primary cause
- Secondary to intrinsic kidney disease (focal segegmental glomerulosclerosis or membranoproliferative glomerulonephritis) or systemic illness HSP, diabetes, SLE, diabetes
LECTURE - Initial investigations:
- urine Albumin:Creatinine ratio and blood albumine
Ix in minimal change:
- renal biospy and microscopy unlikely to detect minimal change disease
- Urinalysis will show small molecular weight proteins and hyalin casts
Rx in minimal change:
- predinisalone (high dose for 4 weeks)- good prognosis. In steroid reistant disease - ACE inhibitors with immunisupressants.
- low salt diet
- diuretics may be used for oedma
- albumin infusions in severe cases
- Oral Pen V should be started until peripheral oedema resolves - they tested this: Infection can occour because the kidneys leak immunglobulins, exercerbated by immunosupressive treatments…
What is nephritis/nephritic syndrome?
3 features?
the two most common causes in children?
Management of each?
Ix?
Inflammation within the nephrons of the kidneys. It causes:
- Reduced kidney function
- Haematuria - miscroscopic or macroscopic
- proteinurea - less than in nephrotic syndrome
The two most common causes of nephritis in children are post-streptococcal glomerulonephritis and IgA nephropathy (Berger’s disease).
Post-streptococcal glomerulonephritis:
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. This inflammation leads to an acute deterioration in renal function, causing an acute kidney injury.
Ix - throat swab, or anti-streptoclysin antibodies titres in blood test
Urinalysis - for Albumin:Creatine ratio and microscopy (RBC casts)
Mx - Supportive (dont need steroids!!), 80% make a full reocvery some have declining kidney function. May require antihypertensive medication if hypetertension and duiretics for oedema.
IgA nephropathy:
- Berger’s disease, related to henoch-schonlein purpura, an IgA vasculitis. IgA deposits in the nephrons leading to inflammation (nephritis).
- presents with non-blanching rash starting ont he lower limb, without systemic illness, followed by joint and abdominal pain
- Ix: needs a renal biopsy!
- Renal biopsy shows IgA depositve and glomerula mesangial proliferation
- presents in adolescnets
- Supportive treatment for the AKI and immunosupressant medications (steroids and cycophosphamide) to slow disease progression.
What is Hypospadias?
Hypospadias is a condition affecting males, where the urethral meatus (the opening of the urethra) is abnormally displaced to the ventral side (underside) of the penis, towards the scrotum. This might be further towards the bottom of the glans (in 90% of cases), halfway down the shaft or even at the base of the shaft. Epispadias is where the meatus is displaced to the dorsal side (top side) of the penis. Usually, the foreskin is abnormally formed to match the position of the meatus. There can also be an associated condition called chordee, where the head of the penis bends downwards.
Hypospadias is a congenital condition affecting babies from birth and is usually diagnosed on the examination of the newborn.
Management:
- delay any circumcirsion!
- 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
Complications:
- difficulty directing urination
- cosmetic and psychological concenrs
- sexual dysfuntion
How does AKI present
oligouria with urine output of less than 0.5 ml/kg/hour over at least 6 hours - THE MAIN ONE TO LEARN
50% rise in creatinine in one week
25 micromol/L rise in creatinine in 48 hours
Management is dependant on the cause:
- IV fluid replacement if hypovolemic,
- treatment of renal disease in intrarenal causes, and qithdrawal of nephrotoxic medications (DAMN)
- relieve the obstruction in post-renal
- dialysis in severe cases
What is Haemolytic ureamic syndrome?
triad of features?
Cause?
Management.
Haemolytic uraemic syndrome (HUS) involves thrombosis in small blood vessels throughout the body, usually triggered by Shiga toxins from either E. coli O157 (VTEC) or Shigella.
HUS leads to the classic triad of:
Microangiopathic haemolytic anaemia - tiny blood clots cause red blood cells to rupture as the pass through them
Acute kidney injury - thrombi and damaged red cells affect blood flow through the kidneys
Thrombocytopenia (low platelets) - due to the formation of clots
It most often affects children following an episode of gastroenteritis. Antibiotics and anti-motility medication (e.g., loperamide) used to treat gastroenteritis caused by E. coli O157 or Shigella increase the risk of HUS.
Presentation:
Diarrhoea which turns bloody followed by HUS sx:
- fever
- abdominal pain
- lethargy
- pallor
- oligourea
- jaundice
- brising
- hypertension
- confusion
Ix - stool culture
HUS is a medical emergency and requires hospital admission and supportive management with treatment of:
Hypovolaemia (e.g., IV fluids)
Hypertension
Severe anaemia (e.g., blood transfusions)
Severe renal failure (e.g., haemodialysis)
It is self-limiting, and most patients fully recover with good supportive care.
In about 5% of boys the testes have not made it out of the abdomen by birth. At this point they are called undescended testes. This can also be referred to as cryptorchidism. They might be palpable in the inguinal canal (in the inguinal region), which is not technically classed as undescended testes, although they have not fully descended at that point.
What is the management for undecended testes?
Watching and waiting is appropriate in newborns. In most cases the testes will descend in the first 3 – 6 months. If they have not descended by 6 months they should be seen by a paediatric urologist. Orchidopexy (surgical correction of undescended testes) should be carried out between 6 and 12 months of age.
Undescended testes in older children or after puberty hold a higher risk of testicular torsion, infertility and testicular cancer.
Retractile testicles are considered a normal varient which normally resolves with puberty. If the testicle fully retracts or fails to decent then surgical correction with an orchidopexy is required.
