Paediatrics: Renal + urinary Flashcards by Anish Chandrasekar

What is the difference between primary and secondary enuresis? How do the RFs vary?

Primary - delayed maturation of bladder control mechanisms (urinary continence previously never achieved)

RF: Paternal FHx, B>F

Secondary - loss of previously established bladder continence (previously achieved urinary continence for at least 6 months)

RF: Typically psychological, domestic abuse, bullying, emotional stress, UTI and other pathology

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What is the definition of enuresis

Loss of bladder control during the day or night for girls > 5yo or boys > 6yo

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Definition of nocturnal enuresis

Loss of bladder control at least twice weekly in children age > 5yo

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What are the possible mechanisms behind nocturnal enuresis

Lack of attention to bladder sensation
Physiological: detrusor muscle dysfunction, bladder neck weakness, neuropathic bladder (common in spinal bifida)
Pathological causes: UTI, ectopic ureter, constipation

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What are the features of detrusor instability

Sudden, urgent urge to void (uncontrollable), bladder contractions

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What are the features of a neuropathic bladder

Bladder enlarged (thick wall –> bladder does not empty fully)
Abnormal leg reflexes and gait
Loss of sensation to dermatomes S2-4

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What are the features of ectopic bladder

Constant dribbling
Child always damp
Girls - dry during night, wet on getting up (due to bladder pooling and change in position causes urine to release through ectopic ureter often in vagina)

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What are the possible investigations for enuresis?

Urine dip
Urine MSC
USS pevis
Cystoscopy

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What are the treatment options for enuresis under 5s?

Reasure + educate (10% of 5 year olds, 5% of 10 year oldS)

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What are the treatment options for enuresis under 7s?

Start chart for drinking and voiding - immediate, achievable, consistent, encouragement, rewards, no punishment (1st line)
Enuresis alarm

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What are the treatment options for enuresis over 7s who have already tried the star chart?

Desmopressin + fluid reduction 1 hr before bed - only for short term use like sleep overs
Imipramine (2nd line) - more SE, higher risk of OD
Oxybutynin (bladder instability)

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What is the main cause of UTIs in children

E.Coli (90%)

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What is the criteria for UTI

Clinically suggestive symptoms with significant culture of 10^5 organisms

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With which type of organisms are urinary tract stones most common

Proteus

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Which UTI organism suggests an abnormal urinary tract

Pseudomonas

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What are symptoms of a UTI in an infant

D+V, not eating, FTT, crying, irritable, fever, febrile convulsion, prolonged neonatal jaundice

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What are symptoms of a UTI in a child

Frequency, dysuria, vomiting, fever + riggers, irritable, LoA, cloudy urine, abdo/loin pain/ache, recurrence of enuresis, haematuria,

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What are the symptoms of a LUTI

^Frequency, dribbling, abdominal pain/ache (mild), enuresis

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What are the investigations for a child < 6months with an (a) typical UTI and (b) atypical/recurrent UTI after recovering from UTI

Typical - USS

atypical - USS during acute phase and 6 weeks later, DMSA, MCUG

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What are the investigations for a child between 6months and 3 years with an (a) typical UTI and (b) atypical/recurrent UTI after recovering from UTI

Typical - nothing

Atypical - USS and DMSA

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What are the investigations for a child > 6 months with an (a) typical UTI and (b) atypical/recurrent UTI after recovering from UTI

Typical - nothing

Atypical - USS (DMSA if recurrent or clinically indicated)

What features would may find on a urine dip in a UTI patient

Leukocytes (infection)
Nitrites (bacteria)
Blood

What is the Mx of a UTI in a child < 3 months

Hospitalisation
IV Abx
Care under specialist with Abx

What is the MX of a UTI in a child > 3 months with a LUTI or cystitis

PO Trimethoprime, Nitrofurantoin or cefradine (3 day)

What is the MX of a UTI in a child > 3 months with a UUTI or pyelonephritis

``` 1st line - PO cephalosporin or co-amoxiclav (7d) 2nd line (if PO not tolerated) - IV ceftriaxone or cefotaxime (2-4d) then PO ( 10d) ```

What are some self management tips you can give parents for their child to prevent UTIs

1. Encourage regular voiding and drinking 2. Cotton or nylon underwear 3. Good hygiene - wiping, washing perineum

What is the mot common structural abnormality a/w UTIs and what is the possible complications and investigations

Vesicouteric reflux (VUR) - graded 1-5 Ix - MCUG, DMSA complication - VUR + UTI --> high level of scarring --> renal failure

What are the features of an atypical UTI

1. Non E-coli organism 2. Symptoms not improving in 48hrs of Abs 3. Abdominal mass 4. Sepsis 5. ^creatinine and deranged U+Es 6. Poor urine flow 7. Seriously ill

What is the most common glomerular and non-glomerular cause of haematuria in children

``` glomerular = glomerulonephritis n-glomerular = UTI ```

What is haemolytic uraemia syndrome?

It is a syndrome of microangiopathic haemolytic anaemia, thrombocytopoenia and acute renal failure

What are the two forms of HUS? How do they differ?

Sporadic (D-HUS) - related to familial | Atypical/Epidemic (D+HUS) - related to E.Coli 0157 infection causing bloody diarrhoea

What are some of the symptoms of HUS?

Pancreas - Type 1DM, Pancreatitis | Gut - Bloody diarrhoea, rectal prolapse

What are the investigations for HUS?

Blood film: haemolysis, anaemia, thrombocytopenia | Bloods: High WCC, Low platelets

What is the management for HUS patients?

1. Hospitilisation 2. Supportive treatment - O2, Fluid balance 3. Eculizumab

What is the most common cause of AKI in children?

Haemolytic uraemia syndrome

What is nephrotic syndrome?

Damage to kidneys causing leakage of proteins into urine (proteinuria)

What is the main secondary cause of nephrotic syndrome? | Can you name two other causes?

Minimal change disease (85%) | Others include membranous glomerulonephritis, focal segment glomerulosclerosis

What are the symptoms of nephrotic syndrome?

``` 1. Classic: Facial oedema - begins periorbitally (puffy eyes) and then spreads to other areas e.g. scrotum Abdominal pain or discomfort Oliguria Frothy urine Diarrhoea Anorexia ``` 2. Late: Ascites Pleural effusion

What are the key investigations for nephrotic syndrome?

1. Urine: - Dip = +++protein - MSC - Protein:CR > 200mg/mmol - Na < 10 mmol/l (hypovolaemia) - Haematuria suggests a cause other than MCD 2. Blood: - Serum Albumin < 20g/L

What is the management ladder for nephrotic syndrome

1. Hospitalise 2. Diuretics - Furosemide or spironolactone (reduce fluid overload) 3. Limit fluid intake 4. Steroids - prednisone (95% nephrotic syndromes are steroid sensitive, induce remission) 5. Prophylactic Abx

Define glomerulonephritis. What are the two forms?

Inflammation of renal glomeruli 1. Proliferative (nephritic) - increase in number of cells --> haematuria, HTN + RBC casts 2. Non-proliferative (nephrotic) - no increase in cells --> proteinuria

What are the main causes of nephrotic and nephritic syndrome?

Nephrotic - MCD (85%), Membraneproliferative glomerulonephritis, Focal segment glomerulosclerosis Nephritic - Streptococcus

What are the symptoms of nephritic syndrome

URTI (prodrome) | Haematuria (nephritic), Proteinuria (nephrotic) HTN, oedema, oliguria

What are the symptoms of nephrotic syndrome

Proteinuria, oedema (facial and scrotal), oliguria, frothy urine, abdominal pain/discomfort, anorexia, diarrhoea

What is the investigation ladder for glomerulonephritis

1. Urine: - Dip = +++Protein +Blood + Nitrites (bacterial infection) - Microscopy - red cell casts 2. Throat swab - Strep (esp if nephritic synd) 3. USS kidney (urgent)

What is the management for Glomerulonephritis?

1. Admission - due to HTN, worsening renal function and fluid overload 2. Oliguria? start fluid management - Diuretic (furosemide), limit fluid intake 3. HTN due to overload - CCB + Tamsulosin 4. Infection? - penicilin

What are the possible complications arising from glomerulonephritis? and how are they treated?

1. Hypocalcaemia - IV Magnesium Sulphate 2. Hyperkalaemia - Calcium gluconate 3. HTN - Tamsulosin + CCB 4. Seizures - Diazepam or Lorazepam 5. Acidosis

What is hypospadias and how does it present?

A congenital disorder in boys where they fail to complete "foetal urethral tubularisation" 1. Ventral urethral meatus - external opening of urethre is incorrectly placed 2. Chordee (ventral bending penis) 3. Hooded dorsal foreskin - foreskin fails to fuse ventrally

What is the treatment for hypospadias

1.Corrective surgery within 2 years

In which demographic is nephrotic syndrome most common

Indians, Boys

At what time of year is HUS most common?

Summer and Autumn