Paeds renal Flashcards
How might a baby (<3 mnths) present with a UTI?
- Fever
- Lethargy
- Irritability
- Vomiting
- Poor feeding
What are the signs and symptoms of a UTI in older children (verbal and > 3 yrs)
- Frequency
- Dysuria
What is the first line examination in a UTI
-Clean catch urine dip
What is the diagnosis based on urine dip outcome
- Under 3mnths : needs MCS
- 3 mnths to 3 years : LE +ve or nitrite +ve = treat as UTI
- > 3 yrs : le +ve and nitrite +ve = UTI. If nitrite +ve but le -ve, treat as UTI and send MCS
what is the most common UTI cause in children.
- E.coli
How should all children under 3 mnths old with a fever be managed and in the case of suspected UTI ?
- Admit + IV antibiotics (cefuroxime)
When is an USS done in a child with a UTI?
- All children under 6mnths with their first UTI
- Children with recurrent UTI’s
- Children with atypical UTI’s
When is a DMSA scan done in a child with a UTI
- 4 to 6 mnths after the illness to assess for kidney scarring in recurrent or atypical UTI’s
- Patches of scarred kidney will not take up the injected material
When is a micturating cystourethrogram (MCUG) done in a child with a UTI?
- To assess for vesico-ureteric reflux when the urine has a tendency to flow from the bladder back into the ureters
- Done to assess atypical or recurrent UTI’s in children <6mnths
How is a MCUG done?
- A child is catherised and contrast is injected into the bladder.
- X-rays are then taken to determine whether the contrast refluxes into the ureters
When would a diagnosis of acute pyelonephirits be given in a child?
- Temp of greater than 38 degrees or loin pain / tenderness
Define enuresis, nocturnal enuresis and diurnal enuresis
- Enuresis : involuntary urination
- Nocturnal enuresis : bed wetting
- Diurnal enuresis : inability to control bladder functioning during the day
What is primary nocturnal enuresis
- Where a child has never managed to be consistently dry at night
- Usually caused by a variation on normal development and there will often be Fx of delayed dry nights.
- Requires reassurance
Give 4 other causes of primary nocturnal enuresis
- Overactive bladder
- Fluid intake -> fizzy drinks, juice and caffeine before bed
- Failure to wake
- Psychological distress
Give 4 secondary causes of primary nocturnal enuresis
- Chronic constipation
- UTI
- Learning disability
- Cerebral palsy
How is primary nocturnal enuresis managed ?
- Determine cause using 2 wk diary
- If <5, reassure will likely resolve
- Lifestyle changes : reduce fluids at night, pass urine before bed
- Encourage and + reinforcement
What is secondary nocturnal enuresis ?
-When a child begins wetting the bed when they have been previously dry for at least 6 mnths
Give 5 causes of secondary nocturnal enuresis
- UTI
- Constipation
- T1DM
- New psychosocial problems
- Maltreatment
Give 2 kinds of diurnal enuresis
- Urge : overactive bladder than gives little warning before emptying
- Stress : leakage of urine during physical exertion, coughing or laughing
Give 3 types of medication that can be used for nocturnal enuresis
- Desmopressin - taken at bed time to reduce the volume of urine production by the kidney
- Oxybutin - anticholinergic medication reducing contractility of the bladder in an overactive bladder causing urge incontinence
- Imipramine - tricyclic antidepressant
What is the triad of nephrotic disease ?
- Low serum albumin
- High protein on dipstick (>3)
- Oedema
Give 3 other features that occur in pts with nephrotic syndrome
- Deranged lipid profile -> high cholesterol, triglycerides and low density lipoproteins
- High BP
- Hyper-coagulability with increased tendency to form blood clots
What is nephrotic syndrome ?
-When the basement membrane in the glomerulus becomes highly permeable to protein, allowing protein to leak from the blood into the urine.
When is nephrotic syndrome most common in children and what is the most common cause
- Aged 2-5
- Minimal chnaged disease
Give 5 secondary causes of nephrotic syndrome
- Intrinsic kidney disease : focal segmental glomerulosclerosis and membranoproliferative glomerulonephritis
- Systemic illness : henoch schonlein purpura, DM, infection (HIV, hepatitis and malaria)
How will minimal change disease likely present ?
- 2 to 5 year old
- Generalised oedema : facial swelling, hands and feet
- Frothy urine
- Pallor
- Proteinuria
- Low albumin
What is seen on urinalysis in minimal change disease ?
- Small molecular weight proteins
- Hyaline casts
How is nephrotic syndrome managed ?
- Admit
- Prednislone (60mg/m2/day) for 4wks and then 40mg/m2/every other day for 28 days
- Low salt diet
- Diuretics for oedema
- Albumin infusions if severe hypoalbuminaemia
What is used to treat minimal change disease in steroid resistant children ?
- ACE inhibitors
- Immunosuppressants (cyclosporine, tacrolimus, rituximab)
Give 5 complications of minimal change disease
- Hypovolaemia : occurs as fluid leaks from the intravascular to the interstitial space causing oedema and low BP
- Thrombosis
- Infection
- Acute or chronic renal failure
- Relapse
What are the 3 characteristics of nephritis
- Haematuria
- Proteinuria : less than in nephrotic syndrome
- Reduction in kidney functione
How is UTI in >3mnths managed if very unwell
Admit + IV cefuroxime
How is a UTI managed if over 3 mnths and not very unwell
- 1st line = oral trimethoprim or nitrofurantoin
How is pyelonephritis in an >3mnth managed
- If very unwell : admit + IV cefuroxime
- No very unwell : oral cefalexin or co-amoxiclav
what is defined as recurrent UTI
- 2 upper UTI
- 1 upper UTI + 1 lower UTI
- 3 lower UTI
define atypical UTI
- Seriously ill
- Poor urine flow
- Abdo or bladder mass
- raised creatinine
- Septicaemia
- Failure to respond to tx within 48 hrs
- Infection with non e.coli
what imaging will a child under 6 mnths with a UTI need and when
- USS during acute infection if no response in 48 hrs, atypical or recurrent UTI
- USS within 6 wks of infection if they respond to abx within 48 hrs and UTI is not atypical or recurrent
- DMSA 4-6 mnths later if recurrent or atypical
- MCUG if recurrent or atypical
what abx / vaccines are given in nephrotic syndrome
- Oral penicillin V to oedematous / ascitic pts to protect against pneumococcal infection
- Pneumococcal polysaccharide vaccine
- Varicella vaccine
What is hypospadias?
- > Congenital abnormality : ventral urethral meatus, hooded prepuce and chordee (curvature) in more severe forms
- > management with surgery at 12 mnths, cicrumcision is CI
What is the common triad in HUS
- Haemolytic anaemia - normocytic anaemia
- Acute kidney injury
- Thrombocytopenia
What is the most common cause of HUS
-> Shiga toxin produced by e.coli 0157
How would HUS present ?
- Brief gastroenteritis caused by E.coli : bloody diarhoea
- Acute kidney injury : reduced urine output, haematuria
- Thrombocytopenia : brusing
- Abdo pain, lethargy and irritability, confusion, oedema, HTN
What investigations are done in HUS
- FBC : normocytic anaemia, thrombocytopenia, fragmented blood film (shistocytes and helmet cells)
- U&E : AKI
- Stool culture : PCR for shiga toxins
How would HUS present
- 18 mnth
- Recent Hx of bloody diarrhoea
- Bloods : AKI and thrombocytopenia
Give 2 conditions associated with hypospadias
- Cryptotchidism
- Inguinal hernia
Give 2 conditions associated with hypospadias
- Cryptotchidism
- Inguinal hernia
Give 3 ways VUR can present
- Antenatal period : hydronephrosis on USS
- Recurrent childhood UTI
- Reflux nephropathy -> chronic pyelonephritis secondary to VUR
What is a complication of chronic pyelonephritis caused by VUR
-Increased renin causing HTN
What are the 5 grades of VUR
- I : reflex into ureter only
- II : reflux into renal pelvis
- III : mild/moderate dilation of ureter, renal pelvis and calyces
- IV : dilation of renal pelvis, calyces with moderate ureteral tortuosity
- V : gross dilation of the ureter, pelvis, calyces with urethreal tortuosity
Focal segmental glomerulosclerosis : causes, Ix, management
- Cause of nephrotic syndrome and CKD in young adults.
- Cause : idiopathic, HIV, heroin, alport’s, sickle cell
- Ix : renal biopsy
- Manage : steroids +/- immunsuppressants
