Paeds RENAL Flashcards
How does UTI present in an infant as compared to a child?
Infant: fever, vomiting, lethargy, poor feeding, jaundice, septicaemia
Children: dysuria, frequency, abdo pain, lethargy, anorexia, haematuria
How should UTI be investigated?
URINE DIP
Nitrite stick test - very specific
Leucocyte esterase - less specific than nitrites
Urine MC+S - diagnostic
Only do imaging if recurrent/ atypical UTI
What additional investigations should be performed for an atypical UTI?
USS during acute episode (as normal)
+ DMSA (4-6 months later < 3yo)
+ MCUG (if < 6m)
What is a significant level of bacterial growth from urine culture?
> 10^5
What does urine culture of proteus bacteria suggest?
Renal tract abnormalities
Recall the different UTI management for different age groups
<3m: admit, IV Abx then switch to oral prophylaxis: emergency: book urgent USS
> 3m, upper UTI: consider admission with IV Abx (7-10 days), if not, oral Abx, book USS
> 3m, lower UTI: oral Abx as local guidelines for 3 days (eg trimethoprim, nitrofurantoin)
How should recurrent UTI be managed in children?
Abx prophylaxis
USS/MCUG urgently - once initial infection has cleared
Routine DMSA scan
What do MCUG and DMSA scans look for ?
MCUG - VU reflux
DMSA - renal scarring
When should a DMSA scan be done?
4-6 months after initial atypical/recurrent/complex UTI if under the age of 3
What can cause ureteric dilation?
Vesico-ureteric reflux
Obstruction - stone, clot, tumour, papilla
Calculus
Note - infection itself DOES NOT cause dilation
By what age should children be dry by day?
4 years old
By what age should children be dry by day and night?
5 years old
What is ‘primary bedwetting’?
Bedwetting that has not previously been resolved
How should primary bedwetting be managed in children <5 years old?
Reassure parents: often resolves by 5 y/o
Educate: easy access to toilet at night, bladder emptying before bed, positive reward system
How should primary bedwetting be managed in children >5 years old?
If infrequent (<2 per week) then watch + see approach
If frequent: 1st line: enuresis alarm, pos reward system (eg encourage child to help change sheets)
2nd line: desmopressin (1st line for short-term control like sleepovers and school trips)
How should enuresis with daytime symptoms be managed?
Refer to enuresis clinic, community paediatrician
What causes of secondary bedwetting can be managed in primary care?
UTI + constipation
What causes of secondary bedwetting should be managed in secondary care?
Diabetes
Psychological
LD
Recurrent UTI
What is phimosis?
Inability to retract foreskin as it is too ‘tight’
By what age should phimosis only be present in 10% of children who were born with it?
4 years old (it is physiological at birth)
How should phimosis be managed?
If <2: reassure + review in 6 months - add personal hygiene promotion
If >2: circumcision or topical steroid creams (depending on severity)
What is the name given to pathological phimosis?
Balantis Xerotica Obliterans
What are the signs and symptoms of BXO?
Haematuria
Painful erections
Recurrent UTI
Weak stream
Swelling
What is paraphimosis?
Emergency in which foreskin becomes trapped in the retracted position proximal to swollen glans
Restriction of blood flow to head of penis: penis turns dark purple
How should paraphimosis be managed?
1st line: adequate analgesia, attempt to reduce foreskin (gently compresswith saline soaked swab)
2nd line: emergency referral to urologist
What is hypospadias?
Wrongly positioned meatus ventrally (if dorsal = epispadias)
What are the key features of hypospadias?
Ventral foramen
Hooded foreskin
Chordee (ventral curvature)
Foreskin not fused ventrally
How should hypospadias be managed?
Repair surgery after 3 month:- no management required before that
What is balanoposthitis?
Inflamed/ purulent discharge from foreskin
How common is balanoposthitis?
Single attacks are common
How should balanthoposthitis be managed?
Warm baths + Abx (broad spec)
If recurrent (rare): circumcision
What is the mean age for testicular torsion?
16 years
What is the appendixtestis?
Small remnant of Mullerian duct
How does torsion of the appendixtestis present?
Similarly to torsion but evolving over a few days
What is the one indication that surgery isn’t needed in suspected testicular torsion?
Blue dot seen over superior pole of testes (shows it is torsion of appendixtestis)
Recall the signs and symptoms of torsion?
Redness, oedema, N+V
Sudden onset pain in testis or abdomen
How can torsion and epididymitis be differentiated clinically?
Prehn’s sign: lifting tested increases pain in torsion but decreases it in epididymitis
What is the surgical management of testicular torsion?
Exploratory surgery +/- BL orchidopexy +-/ orchidectomy +/- fixation of contralateral testes
What is the key window of time in which torsion needs to be fixed?
< 6 hours
Recall the serum creatinine changes/ measurements for each stage of AKI
Stage 1: increase >26 or 1.5-1.9x reference sCr
Stage 2: 2-2.9 x reference sCr
Stage 3: >354mmol increase or >3 x the reference sCr
Recall the urinary output values for each stage of AKI
Stage 1: <0.5mL/kg/hr, 6-12 hours
Stage 2: <0.5mls/kg/hr, >12 hours
Stage 3: <0.3mL/kg/hr, >24 hours
What is the difference in clinical syndrome produced by proliferative vs non-proliferative glomerulonephritis?
Proliferative: nephritic syndrome
Non-proliferative: nephrotic syndrome
What are the 3 types of non-proliferative glomerulonephritis?
Focal segmental
Membranous glomerulonephritis
Minimal change disease
What are the 3 types of proliferative glomerulonephritis?
IgA nephropathy
Membranoproliferative glomerulonephritis
Post-infectious (post strep)
What can focal segmental glomerulonephritis be secondary to?
Obesity
HIV
What can membranous glomerulonephritis be secondary to?
SLE
Drugs
Which type of glomerulonephritis is most common in children?
Minimal change disease
Recall the triad of symptoms seen in IgA nephropathy
Petechiae
Abdo pain
Nephritic syndrome
What are the triad of symptoms in nephrotic syndrome?
Low albumin
Peripheral oedema
Proteinuria
What are the signs and symptoms of nephrotic syndrome?
1st = peri-orbital oedema (often misdiagnosed as allergy)
2nd = other features of oedema (delayed) - eg leg swelling, features of underlying dx
What % of nephrotic syndrome is steroid-sensitive?
80-95%
How quickly does steroid-sensitive nephrotic syndrome respond to treatment?
<6 weeks
How should the nephrotic syndrome be investigated?
Urine tests: dipstick, urea, U+Es, urine MC+S, urinary sodium, FBC, ESR, creatinine, albumin
Complement (C3,C4) (SLE?)
Anti-streptolysin O (recent strep throat)
HBV/HCV
If podocyte fusion is seen on microscopy, what is this indicative of?
Minimal change disease
What are the 3 main complications of nephrotic syndrome?
Risk of thrombosis
Risk of infection
Hypercholesterolaemia
How does the nephrotic syndrome cause hypercholesterolaemia?
Loss of albumin
Less oncotic pressure
Hepatic cholesterol synthesis
What are the 2 most common causes of ARF in children?
HUS + ATN
What is the triad of features that characterises the HUS?
Low RBC
Low platelets
AKI
What is the most common cause of ATN in children?
Organ failure following cardiac surgery
Recall the signs and symptoms of ARF in children
Oligo/anuria
Oedema (feet, legs, abdo, weight gain)
Brown discoularisation of urine
Fatigue, lethargy, N+V
What is the key treatent for prerenal fialure?
Fluid replacement + circulatory support
What is the key treatment for intrinsic renal failure?
High calorie, normal protein feed: to decrease catabolism, uraemia + hyperkalaemia
How should postrenal ARF be managed in children?
Assess site of obstruction: relief may be obtained by nephrostomy/ Catheter
What is the most important investigation to do in ARF children?
Renal USS
What woud be seen on USS In CKD?
Small kidneys
What would be seen on USS in AKI?
Large, bright kidneys with loss of cortical medullary differentiation
In what age group is minimal change disease most common?
2-4 years old
In what age group is focal segmental glomerulonephritis most common?
Older children
How does minimal change disease affect renal function?
Renal function will be normal
How does FSGN affect renal funcion?
Impairs renal function –> HTN
In which age group is membranous nephropathy more common?
Adults
What is another name for IgA vasculitis?
Henoch-Shonlein purpura
Which vessels does IgA vasculitis affect?
Small vessels
What is the usual cause of IgA vasculitis?
Usually preceded by an URTI by 2-3 days
What is the pathophysiolgy of IgA vasculitis?
IgA + IgG complex, deposit in organs, activating complement
Recall the signs and symptoms of IgA vasculitis?
100% = purpuric rash sparing trunk: looks a bit like HUS
60-80% = arthralgia + periarticular oedema: joint pain + swelling
60% = abdo pain: can cause intussusecption
20-60% = glomerulonephritis (within 3m of onset = 97%) with nephritic syndrome
What should be the first investigations ordered in IgA vasculitis?
FBC, clotting screen, urine dip and U+Es
Urinalysis to rule out meningococcal sepsis
How should IgA vasculitis be managed?
Most cases resolve spontaneously within 4 weeks
For joint pain: NSAIDs
If scrotal involvement/ severe oedema/ severe abdo pain: oral prednisolone
If renal involvement: IV corticosteroids
What is another name given to nephroblastoma?
Wilm’s tumour
In what age group is nephroblastoma most common?
<5 years old
Recall the common symptoms and signs of nephroblastoma
Asymptomatic abdo mass
Painless haematuria
Recall some less common signs and symptoms of nephroblastoma
Abdo pain
Anaemia (from haemorrhage into the mass)
Anorexia
HTN
When is a biopsy indicated in suspected nephroblastoma?
Never: may worsen the condition
What investigations should be done in suspected nephroblastoma?
US
SCT/MRI
How is nephroblastoma managed?
Nephrectomy + chemotherapy (+ neoadjuvant radiotherapy if advanced disease)
80% cure rate
What is the aetiology of vesicoureteric reflux?
Imcompetence of the valvular mechanism at V-U junction, allowing reflux of infected urine to the kidneys
What percentage of children presenting with a UTI will have V-U reflux?
30%
What is MCUG?
Micturating cystourethrogram
What is the management of VU reflux?
Long-term antibiotic prophylaxis
Surveillance of renal growth (as VU sometimes improves with time)
Surgery - may be needed for severe reflux
What are the complications of VU reflux?
50% of children with VU reflux will have renal scarring
Renal scarring carries a 10-20% chance of hypertension in later life
What is Henoch-Schonlein Purpura?
a.k.a IgA vasculitis
Henoch-Schonlein Purpura (HSP) is a vasculitis that most commonly occurs in children. It is the most common vasculitis of childhood.
When does HSP typically present?
Between 2-8 years old
Which vessels does HSP tend to affect?
Smaller vessels
How may HSP present?
Palpable purpura – red / purple rash, typically on the legs
GI disturbance
Arthritis
Glomerulonephritis
What systems does HSP mainly affect?
Skin - purpuric rash
GI tract - abdominal pain, pancreatitis, intussusception
Kidneys - glomerulonephritis, renal failure
Joints - bilateral swelling of large joints
What investigations would you do for HSP?
FBC - raised ESR
Clotting screen
Renal function
Urine dipstick - haem/proteinuria, RBC casts
What is the management of HSP?
Analgesia
- Regular paracetamol
- Consider NSAIDs – if not contraindicated (severe renal failure)
Steroids - mainstay of treatment but do not affect disease outcome, and do not improve renal function.
In severe renal disease, IV immunosuppressants may be considered but this is rarely needed and there is no good evidence about the benefits
What are the complications of HSP?
Arthritis
Pancreatitis
Intussusception
What is the epidemiology of HSP?
M:F ratio – up to 2 : 1
90% of cases occurs in children
50-90% of cases have a preceding URTI (studies vary)
Caucasians more likely to be affected
What are the risk factors for HSP?
Recent (often respiratory) infection – group A strep, mycoplasma, EBV
Vaccination
Drugs, allergens – including in food and to insect bites
What is the prognosis of HSP?
Often relapsing / remitting – with episodes lasting an average around 4 weeks
About 20% of cases will result in end-stage renal failure
Prognosis is worse in adults than children
