Paediatrics - Renal/ urinary Flashcards
What is inflammation/ infection of the kidney known as?
Pyelonephritis
What is inflammation of the bladder known as?
Cystitis
What condition should all children with a fever be considered and excluded for?
UTIs
How does UTI present in babies (6)?
- Fever
- Lethargy
- Irritability
- Vomiting
- Poor feeding
- Urinary frequency
What additional symptoms of a UTI may older children have compared to babies (2)?
- Dysuria (painful urination)
- Incontinence
abdo pain (suprapubic pain) with pyelonephritis
When should pyelonephritis be suspected (2)?
- Temperature over 38
- Loin/ groin pain
How should a UTI be investigated in those under 3 months?
Send MSU for MC&S (microscopy and culture)
How should UTI be investigated in those over 3 months (2)?
- Urine dip
- Send for MC&S if necessary
What would suggest a UTI on a urine dip (2)?
- Nitrites (more specific)
- Leukocytes (more sensitive)
When should MC&S be sent in children over 3 months (4)?
- If UTI suspected from dip stick
- If high risk form complications
- If recurrent UTIs
- Upper UTI suspected
How should children under 3 months with a suspected UTI be managed (3)?
- Start IV Abx
- Urgent referral to paeds
- Septic screen
What is included in a septic screen for those under 3 months (3)?
- Blood cultures
- FBC, CRP, lactate
- Lumbar puncture considered
How should children over 3 months be treated for a UTI?
Oral Abx
How should pyelonephritis be treated in children?
(IV) Abx ceftriaxone/ co-amoxiclav
What Abx should be used for UTI in children (4)?
First line:
* Nitrofurantoin or
* Trimethoprim
Second:
* Amoxicillin
* Cefalexin/ ceftriaxone
Which antibiotic should be used for pyelonephritis in children?
Cefalexin (IV ceftriaxone if severe)
co-amoxiclav = 2nd
How should children with UTIs be managed after the initial infection?
Certain groups should be imaged with USS of urinary tract for further problems
When should children under 6 months be imaged for UTIs (2)?
- During the infection if there are recurrent UTIs or atypical bacteria
- Within 6 weeks of the UTI for all
When should children older than 6 months be imaged for UTIs (2)?
- Recurrent UTIs imaged within 6 weeks
- Atypical UTIs during the illness
What constitutes an atypical UTI (4)?
- Poor flow
- Abdo mass
- Failure to respond to typical Abx
- Non-E. coli organisms
What other scan should be used to investigate all children with recurrent/ atypical UTI (other than MCUG and USS)?
DMSA (dimercaptosuccinic acid) scan
What does a DMSA scan show?
Reveals scaring of the kidney
kidney uptakes the acid contrast thing, the areas that don’t take it up are damaged/ scarred
How soon after UTI should a DMSA scan be performed?
Within 4-6 months
What does an MCUG scan show?
The structure of the urinary tract
What other scan should children under 6 months with recurrent/ atypical UTIs be investigated with (other than USS)?
MCUG (micturating cystourethrogram)
What condition causes urine to flow back from the bladder into the ureters?
Vesico-ureteric reflux
What are some complications of vesicle-ureteric reflux (2)?
- UTIs + kidney scarring
- Hydronephrosis
How is vesico-ureteric reflux managed (3)?
- Lifestyle management (constipation, avoid excessively full bladder)
- Prophylactic Abx
- Surgery
How is vesico-ureteric reflux diagnosed?
MCUG (micturating cystourethrogram)
How are renal malformations investigated in children (5)?
- Ultrasound (pre and post natal)
- DMSA (for scarring)
- MCUG (for anatomy)
- Plasma creatinine ratio
- eGFR
What are some congenital kidney malformations (5)?
- Renal agenesis
- Renal dysplasia (cystic kidneys)
- Renal hypoplasia
- Pelvic/ horseshoe kidney
- Duplex kidney
What is renal agenesis?
The absence of the kidney (uni or bilateral)
What can cause renal dysplasia (2)?
- Multicystic dysplastic kidney
- Autosomal recessive/ dominant PKD
What is renal hypoplasia?
Kidneys are smaller than expected due to reduced number of nephrons
What is a pelvic/ horseshoe kidney?
The kidneys are fused at the lower end forming a U shape (associated with Turners)
What is a duplex kidney?
Kidney has two collecting systems and often two drain ducts (ureters)
What can a lack of amniotic fluid (oligohydramnios) in an unborn infant cause?
Potters syndrome
What is often the cause of potters syndrome/ lack of amniotic fluid?
Reduction in the production of urine from the foetus, therefore many congenital kidney malformations can cause potters syndrome
What are some features of potters syndrome (4)?
- Low set ears
- Beaked nose
- Limb deformities
- Pulmonary hypoplasia/ respiratory distress
What are some complications of kidney malformation (4)?
- UTIs
- Hypertension/ electrolyte imbalances
- CKD
- Potters syndrome
What are some urinary tract malformations (2)?
- Vesicoureteric reflux
- Obstructions
Where can an obstruction occur in the urinary tract (4)?
- Pelvic-ureteric junction (between ureter and renal pelvis)
- Vesico-ureteric junction (between ureter and bladder)
- Bladder neck
- Posterior urethra
What is a cause of vesico-ureteric junction obstruction?
Ureterocele (cystic swelling at bottom of ureter)
What may cause a bladder neck obstruction?
Neuropathic bladder (damaged nerves preventing the bladder neck from relaxing and allowing urine to drain through urethra)
Where is the posterior urethra?
Proximal urethra (closest to bladder)
What is a common obstruction at the posterior urethra?
Posterior urethral valve
What is a posterior urethral valve?
Extra tissue forms at the proximal urethra causing an obstruction to urine outflow from both kidneys
What are some complications of urinary tract malformations (2)?
- UTI
- Hydronephrosis –> dysplastic kidney –> CKD
How can urinary tract malformations present (3)?
- Difficulty urinating/ weak stream
- Recurrent UTIs
- Impaired kidney function + potters syndrome
How are urinary tract malformations investigated (3)?
- Abdo USS
- MCUG
- Cystoscopy
How is AKI diagnosed (3)?
- Rise in creatinine of 25 micromol/l within 48 hours
- Rise in creatinine of 50% in 7 days
- Urine < 0.5 ml/kg/h for 6 hours
What are the 3 categories of causes of AKI?
- Pre-renal = MC in children
- Renal
- Post-renal
What are the main causes of pre-renal AKI in children (2)?
- Hypovolaemia
- Circulatory failure
What may cause hypovolaemia in children (4)?
- Gastroenteritis
- Burns
- Sepsis
- Haemorrhage
What are some causes of renal AKI (4)?
- Micrvasulature disease e.g. HUS, HSP
- Glomerulonephritis
- Interstitial nephritis
- Acute tubular necrosis
What are some causes of post-renal AKI (4)?
- Congenital obstruction
- Blocked catheter
- Trauma
- Calculi
How is AKI managed + investigated (4)?
- Close fluid monitoring
- Urinalysis
- USS
- Dialysis
What are the signs/ symptoms of CKD in children (6)?
- Anorexia / vomiting
- Lethargy
- Polydipsia/ polyuria
- Failure to thrive/ growth failure
- Oedema
- Hypertension
What are the stages of CKD?
Same as adults stage 1-5, 5 = renal failure
What are the common causes of CKD in children (4)?
- Congenital malformations of the kidneys and urinal tract = MC
- Glomerular diseases
- Nephrotic syndrome
- Hereditary conditions e.g. PKD
What are some complications of CKD in children?
- Anaemia (low EPO)
- Rickets/ bone disease (due to low vitamin D)
- Hormonal abnormalities –> growth restriction
How is CKD managed in children (3)?
- Diet changes/ control
- Hormone replacement
- Transplant = definitive
What is the pathophysiological cause of nephrotic syndrome?
Increased permeability of the basement membrane in the glomerulus to protein
What are the 3 classical features of nephrotic syndrome?
- Hypoalbuminaemia
- Proteinuria
- Oedema
Other than the 3 classical symptoms (hypoalbuminaemia, proteinuria and oedema) what are 3 other signs/ features of nephrotic syndrome?
- Deranged lipids
- Hypertension
- Hypercoagulability
What are 3 symptoms of nephrotic syndrome in children?
- Frothy urine
- Generalised oedema
- Pallor
What is the number 1 cause of nephrotic syndrome in children?
Minimal change disease
What intrinsic kidney diseases can cause nephrotic syndrome (3)?
- Focal segmental glomerulosclerosis
- Membranoproliferative glomerulonephritis (can also be nephritic)
- Membranous nephropathy
What are some secondary causes of nephrotic syndrome in children (4)?
- Infection
- HSP/ SLE
- Drugs
- Congenital nephrotic syndrome
What age does minimal change disease most commonly occur?
2-5 year olds
How is nephrotic syndrome managed (3)?
- High dose steroids
- Low salt diet
- Diuretics
What are the two broad responses to treatment of nephrotic syndrome?
- Steroid sensitive (80%)
- Steroid resistant (20%)
How can steroid resistant nephrotic syndrome be treated (2)?
- ACE-i
- Immunosurpression e.g. cyclosporine, rituximab
What are some complications of nephrotic syndrome (5)?
- Hypovolaemia
- Thrombosis
- Infection (kidneys leak Igs)
- AKI/CKD
- Relapse
What are the two main features of nephritic syndrome?
- Haematuria
- Proteinuria (less than nephrotic syndrome however)
What are some signs/ symptoms of nephritic syndrome (3)?
- Oedema (around eyes)
- Hypertension
- Decreased urine output
What is the most common cause of nephritic syndrome in children?
Post streptococcal glomerulonephritis
Other than post streptococcal, what are some other causes of nephritic syndrome in children (4)?
- Vasculitis e.g. HSP
- IgA nephropathy
- Antiglomerular basement membrane disease (goodpastures syndrome)
- Familial nephritis
- HUS
What is the most common cause of post-streptococcal glomerulonephritis?
Strep pyogenes
How soon after infection does post strep glomerulonephritis usually occur?
1-3 weeks
What are two criteria important in the diagnosis of post-strep glomerulonephritis?
- Positive step infection (tonsillitis)
- Anti-streptolysin antibody titre
How is post strep-glomerulonephritis managed?
Supportive care - most improve on their own
How is post-strep glomerulonephritis that does not improve treated (20% of cases) (2)?
- Antihypertensives
- Diuretics
if they develop high BP and oedema
What is IgA nephropathy (Berger’s disease)?
IgA deposits in the nephrons of the kidneys cause inflammation
How is IgA nephropathy diagnosed?
Renal biopsy
What would a renal biopsy of a patient with IgA nephropathy show (2)?
- IgA deposits
- Glomerular mesangial proliferation
What age does IgA nephropathy usually present?
Late childhood/ early adulthood
What condition is closely related to IgA nephropathy?
Henoch-schonlein purpura
What is the difference between IgA nephropathy and HSP?
HSP is like a systemic IgA nephropathy with the whole body affected!!!
How is IgA nephropathy managed?
Steroids help slow the progress
How is nephritic syndrome investigated in children (4)?
- Bloods (U&Es)
- Urinalysis
- Imaging
- Renal biopsy
What is haemolytic uraemia syndrome?
Thrombosis form in small blood vessels throughout the body
What usually causes HUS?
Shiga toxin
Where does the shiga toxin come from (2)?
- E. coli (O-157)
- Shigella (bacteria)
What is the classic triad of features of HUS (3)?
- Haemolytic anaemia
- AKI
- Thrombocytopenia
During a gastroenteritis infection what drugs can increase the likelihood of developing HUS after the infection?
- Antibiotics
- Antimotilities (e.g. loperamide)
How serious is HUS?
Medical emergency
What is the mechanism by which HUS causes anaemia, AKI and thrombocytopenia?
- Thrombocytopenia = platelets used up forming clots
- AKI = thrombi affect blood flow through kidneys
- Haemolytic anaemia = thrombi cause turbulent flow and ‘churn’ up RBC damaging them leading to their destruction
What type of infection does HUS usually proceed?
Gastroenteritis
What are more specific symptoms of gastroenteritis caused by E. coli and shigella?
Bloody diarrhoea
What are the signs/ symptoms of HUS (8)?
- Fever
- Abdo pain
- Reduced urine output
- Haematuria
- Hypertension
- Bruising
- Jaundice
- Confusion
How is HUS managed (4)?
Supportive treatment:
* Haemodialysis
* Antihypertensives
* Fluids
* Blood transfusions
self limiting, 80-90% recover without complications
What is the term for involuntary urination?
Enuresis
What is daytime loss of bladder control called?
Diurnal enuresis
What is nighttime loss of bladder control called?
Nocturnal enuresis
When should children stop diurnal enuresis by?
2 years
When should children stop nocturnal enuresis by?
3-4 years
What are the 2 types of nocturnal enuresis?
- Primary
- Secondary
What is the difference between primary and secondary nocturnal enuresis?
- Primary = never grown out of it
- Secondary = started bed wetting after being dry for 6 months
What is the most common cause of primary nocturnal enuresis?
Normal variation in development
What are some other causes of primary nocturnal enuresis (other than normal variation in development) (5)?
- Failure to wake - underdeveloped bladder signals
- Bladder neck weakness
- Overactive bladder/ neuropathic bladder
- Psychological stress
- Fluid intake before bed - e.g. fizzy drinks, caffeine
What are the causes of secondary nocturnal enuresis (5)?
- Psychological stress = MC
- UTI
- Constipation
- Abuse
- Diabetes
How is enuresis investigated (4)?
- Thorough history - fluid intake, stresses, family history of bed wetting
- Urine dip
- Urine concentrating ability (diabetes insipidus)
- USS
How is enuresis managed?
- Enuresis alarm (wakes child at sign of bed wetting)
- Medications
What medications are used for enuresis (2)?
- Desmopressin
- Oxybutinin (anticholinergic) - relaxes bladder
What is phimosis?
When the foreskin cannot be pulled back/ retracted over the glans of the penis
By what age should phimosis have resolved?
10 years of age
What can cause phimosis not to resolve (4)?
- Infection/ scarring of the foreskin
- Trauma to foreskin
- Poor hygiene
- Other medical conditions e.g. diabetes
What is it known as when the urethral meatus is abnormally displaced on the ventral (underside) of the penis?
Hypospadias
What is it known as when the urethral meatus is abnormally displaced on the dorsal (top) side of the penis?
Epispadias
What is an associated condition with hypospadias where the head of the penis bends downwards?
Chordee
What age is hypospadias present from?
Congenital (from birth)
How is hypospadias managed?
Surgical correction at 3-4 months
What is inflammation of the vulva and vagina known as?
Vulvovaginitis
What age is vulvovaginitis common?
3-10 years
What is the cause of vulvovaginitis?
Bacterial spread form faeces
What are some exacerbating factors for vulvovaginitis (3)?
- Wet nappies
- Poor hygiene
- Use of soaps in the vaginal area
Why does vulvovaginitis improve after puberty?
Oestrogen helps keep the vaginal mucosa healthy and resistant to infection
What is vulvovaginitis sometimes misdiagnosed as?
- UTI
- Thrush
What age is thrush more common?
After puberty
How is vulvovaginitis managed?
Lifestyle changes, hygiene measures
