Paeds- Renal/ GU Flashcards
what is Henoch-Schonlein Purpura (HSP) and what does it affect?
IgA mediated, autoimmune hypersensitivity vasculitis of childhood
- skin, joints, gut, kidneys
risk factors for the development of HSP
- infections- group A strep, mycoplasma, epstein-barr
- vaccinations
- environmental- pesticides, cold exposure, insect bites
epidemiology of HSP
- 4-6 years old
- more common in males (2:1)
- winter months
- 50-90% of cases have a preceding URTI
how does HSP present clinically? (general + triad)
general:
- fever, rash, scrotal oedema, intusseception
triad:
- purpura (NON-BLANCHING)
- arthritis/ arthralgia of the knees/ ankles
- abdo pain
give 3 differential diagnosis of HSP
- intussusception
- SLE
- thrombocytopenia
how is HSP diagnosed?
- urinalysis- haematuria/ proteinuria
- raised ESR
- raised serum IgA
- FBC- raised WCC
how is HSP managed?
- usually self limiting
- NSAIDS- joint pain
- corticosteroids for arthralgia and abdo pain
what are some serious but rare complications of HSP?
massive GI bleed
ileus
haemoptysis
AKI
explain the physiology of oedema
- lymphatic drainage issues
- lowered oncotic pressure
- salt and water retention
causes of Nephrotic syndrome
minimal change disease !
- vasculidities- HSP, SLE
- infections- malaria
- allergens- bee sting
how does nephrotic syndrome present clinically?
- oedema- periobital, scortal, leg and ankle
- ascites
- breathlessness due to pleural effusions and abdo distension
give the classic triad seen in nephrotic syndrome
- heavy proteinuria
- hypoalbuminaemia
- oedema
how would you investigate a patient with nephrotic syndrome?
- urinalysis- MSU (dipstick, MC+S)
- BP
- Bloods- fbc, esr, low serum albumin !
what are the 3 types of nephrotic syndrome?
congenital
steroid sensitive nephrotic syndrome (SSNS)
steroid resistant nephrotic syndrome (SRNS)
describe the features of steroid sensitive nephrotic syndrome
- no haematuria !
- normal BP
- normal renal function
- minimal change disease on histology
how is steroid sensitive nephrotic syndrome managed?
- prednisolone
- renal biopsy
how does steroid resistant nephrotic syndrome present?
- elevated BP
- haematuria
- impaired renal function
- nephritis
- failure to respond to steroids
how is steroid resistant nephrotic syndrome managed?
- oedema- diuretic, salt restriction ace inhibitor
- NSAIDS
describe the presentation of congenital nephrotic syndrome
- first 3 months
- rare
- high mortality
- Albuminuria and hypoalbuminaemia
causes of nephritic syndrome
- post infection- group A Beta-haemolytic strep
- vasculitis- HSP and SLE
- IgA nephropathy
clinical features of acute glomerulonephritis
- haematuria
- proteinuria
- decreased urine output
how does acute glomerulonephritis present on urinalysis?
- macroscopic haematuria
- dipstick- albumin: creatinine ratio indicates proteinuria
- microscopy- RBC casts
how is acute glomerulonephritis managed?
- fluid balance- fluid moderation etc
- diuretics
- penicillin if infection
describe the presentation of post streptococcal nephritis
- follows strep sore throat/ skin infection- 7-21 days after
- diagnosis by evidence of recent strep infection- cultures etc
what is Alport syndrome?
X linked recessive disorder associated with hearing loss, ocular defects and progressive kidney disease
Almost always have haematuria
what is juvenille SLE?
chronic autoimmune disease affecting every organ of the body
has a relasping remitting pattern
what is the diagnostic criteria for juvenille SLE (SOAP BRAIN MD)
SOAP BRAIN MD
Serositis (pleuritis/pericarditis)
Oral ulcers
Arthritis
Photosensitivity
Blood (pancytopenia) Renal (proteinuria) ANA +ve (anti-nuclear antibody) Immunological Neurological (psych/seizures)
Macular rash
Discoid rash
in terms of UTI’s, what are acute pyelonephritis and acute cystitis?
acute pyelonephritis- upper tract UTI
acute cystitis- lower tract UTI
what organisms cause UTI’s?
- most common- E.coli
Klebsiella, Proteus, Pseudomonas, Streptococcus Faecalis
how does an upper tract UTI present clinically?
- fever, septicaemic illness
- general malaise, vomiting
- loin/abdo pain
- failure to thrive and jaundice
how does a lower tract UTI present clinically?
- dysuria
- urinary frequency/ urgency
- incontinence
- lower abdominal pain
- haematuria
if a patient presents with only dysuria, what is indicated in females and boys?
- vulvitis in girls
- balanitis (circumsized boys)
what is bacteriuria?
bacteria in urine contaminated by urethral flora
what are some atypical UTI features?
- poor urine flow
- abdominal flow
- seriously ill
- raised creatinine
what are the 3 (general) methods of diagnosis and investigation of a paediatric patient with a UTI?
- urine sample
- urine analysis
- imaging
describe the urinalysis done in a paeds patient with a suspected UTI
- visual inspection
- disptick- nitrates, WCC, leucoytes, e.coli, klebsiella etc
- M,C&S
what imaging is done in a patient with a suspected UTI?
- US
- micturating cystourethrogram scan (MCUG)
DMSA scan (dimercaptosuccinc acid scan)
How is a UTI managed (aged less than 3 months and over 3 months)?
<3 months- IV amoxicillin and gentamicin
> 3 months- 3 day course of trimethorpim/ nitrofurantoin/ amoxicillin
- circumcision may be required if regular UTI’s
what is vesicouteric reflux?
- developmental abnormality of the vesicoureteric junction
- ureter is displaced laterally
what is severe Vesicouteric reflux?
gross dilatation of the ureter, renal pelvis and calyces
predisposes to infrarenal reflux and scarring
what are the consequences of Vesicouteric reflux associated dilatation?
- incomplete emptying- risk of infection
- pyelonephritis
- renal damage due to increased bladder voiding pressure
- scarring of renal tissue- reflux nephropathy
When do the majority of children achieve continence?
3-4 years old
what is the difference between primary and secondary nocturnal enuresis?
primary- child never achieved continence
secondary- child has been dry for at least 6 months before
describe the aetiology of nocturnal enuresis
- genetic- lack of sphincter continence
- secondary- emotional stress
- organic causes- UTI, faecal retention (severe enough to reduce bladder volume), osmotic diuresis (diabetes, CKD), learning difficulties/ developmental delay
how is nocturnal enuresis managed?
- explain fluid intaka management etc
- star chart
- enuresis alarm- alarms when wet
- desmopressin- over 7 !
What is AKI characterised by?
rapid rise in creatine plus the development of oliguria/anuria
pre-renal causes of AKI?
- hypovolaemia- nephrotic syndrome, gastroenteritis, burns, sepsis haemorrhage
- circulatory failure
renal causes of AKI (vascular, tubular, glomerular, interstitial)
- vascular- haemolytic uraemia syndrome, vasculitis
- tubular- acute tubular necrosis, ischaemic, toxic
- glomerulonephirits
- interstitial nephritis/ pyelonephritis
post-renal causes of AKI
obstruction !
- congenital- posterior urethral valves
- acquired- blocked urinary catheter
what is acute-on-chronic renal failure?
if the child is having growth failure, anaemia and disordered mineralisation
in developed countries, what can AKI be secondary to?
- cardiac surgery
- bone marrow transplantation
- toxicity (NSAIDs, vancomycin etc)
- sepsis
in developing countries, what can AKI be secondary to?
diarrhoea, glomerulonephritis, snake bite
what blood results would be found in a patient with AKI?
RAISED- K+, creatinine, urea, phosphate
LOW- Ca2+, Na+, Cl-
what are the management options of a patient with an AKI?
- remove cause
- fluid balance monitored
what is given to a patient with AKI if:
the urine/ plasma osmolality ratio is low?
furosemide
what is given to a patient with AKI if:
BP is signifcantly raised?
nitroprusside
what is given to a patient with AKI if:
they are hyperkalaemic?
- IV calcium gluconate
- salbutamol nebuliser
what is the triad seen in haemolytic uraemia syndrome?
- acute microangipathic haemolytic anaemia
- thrombocytopenia
- renal failure
what are 95% of cases of haemolytic uraemia syndrome associated with?
diarrhoea !
how can haemolytic uraemia syndrome be aquired?
uncooked meat
contact with farm animals
(Shiga toxin)
what clinical signs are seen in a patient with haemolytic uraemia syndrome?
colitis (bloody diarrhoea)
oliguria
encephalopathy
coma
how is haemolytic uraemia syndrome treated?
early dialysis
treat renal failure
Causes of CKD in paediatric patients
- congenital dysplastic kidney
- pyelonephritis
- recurrent infection
- reflux nephropathy
- AKI
how does CKD stage 4/5 present clinically?
- anorexia, lethargy
- polydipsia
- headache and vomiting
- restlessness
- raised BP
- failure to thrive, coma, seizures and anaemia
what are the 5 essentials of managing CKD?
- diet management
- prevention of renal osteodystrophy (give calcium carbonate)
- anaemia management
- control of acidosis
- dialysis
what is hypospadias?
abnormal position of external urethral meatus on distal ventral penis
describe the aetiology of hypospadias
common- 1/200 boys
what are the 3 clinical features of hypospadias?
- ventral urethral meatus
- ventral curvature
- hooded appearance of foreskin
when is surgery appropriate in a patient with hypospadias?
- if they cannot urinate straight
- cosmetic
- performed in first 2-3 years of life
how does a horseshoe kidney present?
silent uropathy + renal infections
what is Wilm’s tumour?
Most common renal tumour in childhood that is:
95% unilaterally
presents as unilateral abdominal mass
how does a Wilm’s tumour present?
- unilateral abdo mass
- painless haematuria
- flank pain
- anorexia
- anaemia
differential diagnosis of proteinuria
- orthostatic proteinuria
- glomerular- minimal change (nephrotic syndrome), glomerulonephirits, DM
- reduced renal mass
- HTN
- PKD
differential diagnosis of haematuria
- non-glomerular- infection, trauma, stones, tumours, sickle cell
- glomerular- acute glomerulonephritis, vasculitis, IgA nephropathy, Alports, Goodpastures
