Paeds Written - Urology/Nephrology Flashcards
Important complications of Nephrotic syndrome
Thrombosis - loss of AT-III in urine creates hyper coagulable state
Infections - loss of immunoglobulin in urine, esp Neisseria, Haemophilus, Streptococcus
Hypercholesterolaemia - loss of albumin in urine –> reduced oncotic pressure –> drives hepatic cholesterol synthesis
Diagnostic features of Nephrotic syndrome
Proteinuria (>3.5g per 24 hours)
(Peripheral) oedema
Hypoalbuminaemia (<25g/L)
Treatment of nephrotic syndrome
High dose oral predisolone
4-6 weeks (tapered from 4 weeks)
Some will not respond (steroid resistant type)- need specialised renal biopsy + specialist care
Most common cause of nephrotic syndrome (in kids)?
Minimal change disease
Microscopy findings in minimal change disease
Light microscopy - normal
Electron microscopy - podacyte effacement (fusion)
Diagnostic features of Nephritic syndrome
Haematuria
Proteinuria
HTN
Key Ix/histology findings in Focal segmental GN
Segmental scarring
Foot process fusion
Key Ix/histology findings in Membranous GN
Widespread thickening
Granular deposits of Ig & complement
Presentation of Henoch-Schonlein purpura
Purpuric rash / petechiae
Abdo pain
Nephritic syndrome - haematuria, proteinuria, HTN
+ arthritis / joint swelling
Risk factor/ trigger for Henoch-Schonlein purpura?
Recent URTI
Presents 2-3 days later
NOTE: if longer than this, instead thing Post-infectious/Strep GN
Treatment options in Henoch-Schonlein purpura
Symptomatic
- NSAIDs for joint pain
- Oral prednisolone if scrotal involvement, severe oedema or severe abdo pain
IV corticosteroids +/- transplant if renal involvement
Key features of HUS
Anaemia (haemolytic - MAHA)
Thrombocytopenia
AKI
Trigger / cause of HUS?
Haemorrhagic E.coli O157:H7 strain
Produces shiga toxin –> bloody, infectious diarrhoea + HUS
Indications for dialysis in AKI
Refractory hyper K
Refractory fluid overload
Metabolic acidosis
Uraemic Sx - encephalopathy, nausea, pruritus, pericarditis, malaise
Pulmonary oedema (from Path notes) Dialysable drug intoxication – e.g., antifreeze, aspirin, lithium
When does Acute tubular necrosis occur in children?
Usually in context of multi organ failure in ICU OR post-cardiac surgery
Average age of day + nighttime continence?
3-4 years
Types of nocturnal enuresis
Primary = never achieved continence
- with or without daytime Sx
Secondary = achieved continence for at least 6 months prior to Sx
Treatment options for primary nocturnal enuresis WITHOUT daytime Sx
Below 5 years old - no Tx needed
Conservative measures/advice
- empty bladder regularly during day + before sleep
- Lifting + waking
Reward system
- use for behaviour e.g. using toilet
- NOT for dry nights
Enuresis alarm
- 1st line for most children
Desmopressin - ADH hormone analogue short term control needed e.g. camp, sleepover - OR failed enuresis alarm Tx - OR alarm not acceptable to family
Oxybutynin
- Anticholinergic
- not to be used in primary care
Things to exclude in child with enuresis?
Abdo exam –> constipation, UTI?
Urine dip –> UTI? DM?
Lower limb Neuro & spine exam –> NTD? (rare cause)
Spot check BP –> renal disease?
Management of secondary bedwetting?
UTI or constipation –> treat in primary care
Other –> refer as needed
- diabetes
- recurrent UTI
- psych problems
- family issues
- developmental, attention or learning difficulties
Treatment of suspected testicular torsion
Supportive: analgesia, sedation, anti-emetics
Urgent urological referral
Exploratory surgery
+/- bilateral orchiopexy
+/- orchidectomy
+/- fixation of contralateral testes - reduces risk of future torsion
Presentation of Torsion of Appendix testes (Hydatid of Morgagni)
Onset of pain over few days
+/- blue dot seen over superior pole of testes
Risk factors for testicular torsion
Undescended testes
‘Clapper bell’ testes - testes free hanging on spermatic cord
Post-pubertal (mean 16 yo)
Prehn’s sign?
Lifting testes
= MORE pain in testicular torsion
= LESS pain in epididymitis
Unilateral undescended testis - treatment?
Review at 3 months
If still undescended –> referral to urology (should be seen by 6 months)
Definitive Tx for undescended testes?
Orchidopexy
Should be completed by 12 months old
Features of ascending/upper UTI in child?
Fever >38
Loin pain, tenderness
Rigors
Abx regimen for simple UTI?
If > 3months = Oral Abx 3 days
Usually trimethoprim
Treatment of UTI in <3month old?
Immediately refer to Paeds
Upper UTI tx?
consider admission
If not admitted –> 7-10 days oral Abx
- cephalosporin or co-amoxiclav
Additional imaging requirements for child under 6 months with UTI
< 6 months simple UTI = outpatient USS within 6 weeks (+ MCUG if abnormal)
< 6 months atypical or recurrent UTI = inpatient USS + Outpatient DMSA and MCUG
Additional imaging for child with UTI (6 months - 3 years old)
Simple UTI = none
Atypical or recurrent = outpatient USS + DMSA
Dilation on USS, poor urine flow, non-E.coli, family Hx vesicoureteric reflux = outpatient USS + DMSA + MCUG
Additional imaging requirements for child >3 years with UTI
Simple = none
Atypical = inpatient USS
Recurrent = Outpatient USS + DMSA in 4-6 months
Pathophysiology of vesicoureteric reflux
Ureters displaced laterally so enter bladder at more perpendicular angle
Creates shortened intramural course for ureters + prevents vesicoureteric junction functioning adequately
Incompetence of valvular mechanism –> reflux of urine to kidneys
Grading of Vesicoureteric reflux
Grade I = reflux into ureter only, no dilatation
Grade 2 = reflux into renal pelvis on micturition, no dilatation
Grade 3 = mild-moderate dilatation of ureter, renal pelvis & calyces
Grade 4 = dilatation of renal pelvis & calyces with moderate ureteral tortuosity
Grade 5 = gross dilatation of ureter, pelvis & calyces with ureteral totuosity
Additional Imaging & purpose in Vesicoureteric reflux
Micturating/voiding cystography (MCUG) - allows grading of reflux
Dimercaptosuccinic acid (DMSA) scan - detects renal parenchymal scarring from reflux
Features of Reflux nephropathy
Chronic pyelonephritis (secondary to vesicoureteric reflux) HTN - renal scars release renin
Treatment options for vesicoureteric reflux
Monitoring/surveillance of renal growth?
Prophlactic Abx
Surgery (if severe)
What is phimosis?
Inability to retract foreskin
Causes/types of phimosis
Physiological
- by 1yo, 50% affected
- by 4yo, 10%
- by 17yo, 1%
- Can cause increased risk of infection + issues with urination & sex if persists to puberty
Pathological = Balanitis xerotica obliterans
- causes scarring of foreskin
- rare before 5yo
Treatment options for phimosis
<2yo = reassurance + review in 6 months >2yo = topical steroid cream OR circumcision (depends on severity)
Wilm’s tumour associations
Beckwith-Wiedemann syndrome
WAGR syndrome
Hemihypertrophy
Abdominal mass in child - what is the approach?
If unexplained –> Paeds review within 48 hours
Could be Wilm’s tumour
Genetics of Wilm’s tumour
1/3 of cases have WT1 gene (Chr 11) loss of function mutation
Clinical features of nephroblastoma
Aka Wilm’s tumour
Abdominal mass Painless haematuria Flank pain Anorexia Fever
