Paeds Renal + Urology Flashcards
What is a UTI
infections anywhere along urethra, bladder, ureters and kidneys pathway
What is Acute pyelonephritis
when the infection affects the tissue of the kidney
What is cystitis
inflammation of the bladder
What are symptoms of UTI in babies
Fever ** may be only sign
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
What are symptoms of UTI in older infants and children
Fever
Abdominal pain, particularly suprapubic pain
Vomiting
Dysuria (painful urination)
Urinary frequency
Incontinence
How is UTI investigated
clean catch urine sample
urine dipstix
cotton swab
urine collection pad
aspirate bladder
catheter
US
Micturating cystourethrogram
DMSA scan
What findings on urine dipstick suggest UTI
Nitrites
Leukocytes
What is a better indicator of UTI, Nitrites or
Nitrites
How is UTI managed under 3 months
All children under 3 months with a fever should start immediate IV antibiotics (e.g. ceftriaxone)
have a full septic screen, including blood cultures, bloods and lactate.
A lumbar puncture should also be considered.
How is UTI managed over 3 months
3 days Oral antibiotics can be considered if they are otherwise well.
7-10 days if unwell
Children with features of sepsis or pyelonephritis will require inpatient treatment with IV antibiotics.
What children with UTIs are followed up
All children under the age of 3 months
Children of any age who are systemically unwell
Children with recurrent UTI
what is bacteriological criterion for UTI Diagnosis
10^5 organisms/ml of single bacteria on a CCU/MSU
What are typical Abx choices for UTIs in children
Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin
what is the investigation all children under 6 months with their first UTI
abdominal ultrasound within 6 weeks, or during the illness if there are recurrent UTIs or atypical bacteria
what is the investigation for children with recurrent UTIs
abdominal ultrasound within 6 weeks
what is the investigation for children with atypical UTIs
an abdominal ultrasound during the illness
How is renal damage assessed
DMSA (Dimercaptosuccinic Acid) Scan
injecting a radioactive material (DMSA) and using a gamma camera to assess how well the material is taken up by the kidneys
what are causes of increases interstitial fluid
obstruction of Lymph drainage
obstruction of venous drainage
Lowered oncotic pressure - low albumin/protein
salt and water retention
How does DMSA scan assess damange
Where there are patches of kidney that have not taken up the material, this indicates scarring that may be the result of previous infection.
What is Vesico-ureteric reflux (VUR)
urine has a tendency to flow from the bladder back into the ureters.
associated dilatation, clubbing
What does Vesico-ureteric reflux (VUR) predisposes a patient to
developing upper urinary tract infections and subsequent renal scarring
How is Vesico-ureteric reflux (VUR) diagnosed
micturating cystourethrogram (MCUG).
How is Vesico-ureteric reflux (VUR) managed
Avoid constipation
Avoid an excessively full bladder
Prophylactic antibiotics
Surgical input from paediatric urology
What is micturating Cystourethrogram (MCUG) used to investiagte
- atypical or recurrent UTIs in children under 6 months
- family history of vesico-ureteric reflux
- dilatation of the ureter on ultrasound
- poor urinary flow
How does micturating Cystourethrogram (MCUG) work
catheterising the child, injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing into the ureters.
Children are usually given prophylactic antibiotics for 3 days around the time of the investigation.
what pyelonephritis
inflammation of the kidney resulting from bacterial infection
the inflammation affects the renal pelvis (join between kidney and ureter) and parenchyma (tissue).
What are RF for pyelonephritis
- Female sex
- Structural urological abnormalities
- Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
- Diabetes
What is the MC causative organism for pyelonephritis
Escherichia coli
What type of bacteria is E. coli
gram-negative, anaerobic, rod-shaped bacteria
Other than E. coli what are causative organisms of pyelonephritis
Klebsiella pneumoniae (gram-negative anaerobic rod)
Enterococcus
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Candida albicans (fungal)
What are the triad of pyelonephritis symptoms
similar presentation to lower urinary tract infections (i.e. dysuria, suprapubic discomfort and increased frequency)
PLUS
- Fever
- Loin or back pain (bilateral or unilateral)
- Nausea / vomiting
How is pyelonephritis investigated
Urine dipstick –> nitrities, leukocytes & blood
Midstream urine (MSU) for microscopy, culture and sensitivity
Blood tests –> WBC and CRP
how is pyelonephritis managed
1st line Abx 7-10 days
- Cefalexin
- Co-amoxiclav (if culture results are available)
- Trimethoprim (if culture results are available)
- Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
refer to hospital of sepsis suspect
What are the three tests for sepsis
Blood lactate level
Blood cultures
Urine output
What are the treatments tests for sepsis
- Oxygen to maintain oxygen saturations of 94-98% (or 88-92% in COPD)
- Empirical broad-spectrum IV antibiotics (according to local guidelines)
- IV fluids
What are two things to keep in mind in patients not responding to treatment for pyelonephritis
- Renal abscess
- Kidney stone –> obstructing the ureter, causing pyelonephritis
What can recurrent pyelonephritis lead to
scarring of the renal parenchyma, leading to chronic kidney disease (CKD).
It can progress to end-stage renal failure.
what is enuresis
involuntary urination
what is nocturnal enuresis
Bed wetting
what is diurnal enuresis
Inability to control bladder function during the day
what is average age for children to get control of daytime and nighttime urination
- daytime urination by 2 years
- nighttime urination by 3 – 4 years.
what is primary nocturnal enuresis
where the child has never managed to be consistently dry at night.
What is the most common cause of primary nocturnal enuresis
variation on normal development
What are other causes of primary nocturnal enuresis
Overactive bladder
Fluid intake
Failure to wake
Psychological distress
What are secondary causes of primary nocturnal enuresis
- chronic constipation
- urinary tract infection
- learning disability
- cerebral palsy
What is the initial step in management of primary nocturnal enuresis
establish the underlying cause.
2 week diary of toileting, fluid intake and bedwetting episodes.
What does the management of primary nocturnal enuresis involves
- Reassure parents of children under 5 years that it is likely to resolve without any treatment
- Lifestyle changes: reduced fluid intake in the evenings, pass urine before bed and ensure easy access to a toilet
- Encouragement and positive reinforcement. Avoid blame or shame.
- Treat any underlying causes or exacerbating factors, such as constipation
Enuresis alarms - Pharmacological treatment
What is Secondary nocturnal enuresis
where a child begins wetting the bed when they have previously been dry for at least 6 months
What are causes of Secondary nocturnal enuresis
Urinary tract infection ** MC
Constipation ** MC
Type 1 diabetes
New psychosocial problems (e.g. stress in family or school life)
Maltreatment
What should always be considered in cases of Secondary nocturnal enuresis
abuse and safeguarding
What is Diurnal enuresis
daytime incontinence.
MC in girls
What are two main types of Incontinence
Urge incontinence is an overactive bladder that gives little warning before emptying
Stress incontinence describes leakage of urine during physical exertion, coughing or laughing.
What are other causes of diurnal enuresis other than stress and urge incontinence
- Recurrent urinary tract infections
- Psychosocial problems
- Constipation
Name three medications for nocturnal enuresis
Desmopressin
Oxybutinin
Imipramine
What is Desmopressin
analogue of vasopressin (also known as anti-diuretic hormone).
It reduces the volume of urine produced by the kidneys. It is taken at bedtime with the intention of reducing nocturnal enuresis.
What oxybutinin
anticholinergic medication that reduces the contractility of the bladder.
It can be helpful where there is an overactive bladder causing urge incontinence.
What is Imipramine
tricyclic antidepressant.
It is not clear how it works, but it may relax the bladder and lighten sleep.
What is AKI
rapid drop in kidney function, diagnosed by measuring the serum creatinine.
Acute kidney injury is most common in acutely unwell patients (e.g., infections or following surgery).
What is criteria for diagnosing AKI
- Rise in creatinine of more than 25 micromol/L in 48 hours
- Rise in creatinine of more than 50% in 7 days
- Urine output of less than 0.5 ml/kg/hour over at least 6 hours
What are RF for predispose developing AKI
- Older age (e.g., above 65 years)
- Sepsis
- CKD
- Heart failure
- Diabetes
- Liver disease
- Cognitive impairment (leading to reduced fluid intake)
- Medications (e.g., NSAIDs, gentamicin, diuretics and ACE inhibitors)
- Radiocontrast agents (e.g., used during CT scans)
What are pre renal causes of AKI
MC - Insufficient blood supply (hypoperfusion) to kidneys
- Dehydration
- Shock (e.g., sepsis or acute blood loss)
- Heart failure
What are renal causes of AKI
intrinsic disease in the kidney
- Acute tubular necrosis
- Glomerulonephritis
- Acute interstitial nephritis
- Haemolytic uraemic syndrome
- Rhabdomyolysis
What are post renal causes of AKI
obstruction to the outflow of urine away from the kidney, causing back-pressure into the kidney and reduced kidney function
- Kidney stones
- Tumours (e.g., retroperitoneal, bladder or prostate)
- Strictures of the ureters or urethra
- Benign prostatic hyperplasia (benign enlarged prostate)
- Neurogenic bladder
what is acute tubular necrosis
refers to damage and death (necrosis) of the epithelial cells of the renal tubule
MC of AKI
What are two causes of damage to kidney cells
Ischaemia due to hypoperfusion (e.g., dehydration, shock or heart failure)
Nephrotoxins (e.g., gentamicin, radiocontrast agents or cisplatin)
What can be seen on urinalysis for acute tubular necrosis
Muddy brown casts
How long does recovery from acute tubular necrosis take
1-3 weeks
what is Acute interstitial nephritis
acute inflammation of the interstitium (the space between the tubules and vessels).
What is cause of acute interstitial nephritis
- Drugs (e.g. NSAIDs or antibiotics)
- Infections (e.g., E. coli or HIV)
- Autoimmune conditions (e.g., sarcoidosis or SLE)
What is Nephritis
inflammation within the nephrons of the kidneys
What does Nephritis cause
- Haematuria: invisible or visible amounts of blood in the urine
- Proteinuria: although less than in nephrotic syndrome
- Oliguria (significantly reduced urine output)
- Fluid retentions
