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Renal > Pyelonephritis And congenital disease of the kidneys > Flashcards

Pyelonephritis And congenital disease of the kidneys Flashcards

1
Q

Pyelonephritis definition

A

•Cystitis - infection of the bladder
–dysuria
–frequency
–urgency
–suprapubic pain
–haematuria

•Pyelonephritis - infection of the kidney
–the above PLUS
–fever (>38ºC)
–chills/rigors
–flank pain
–costo-vertebral angle tenderness
–nausea/vomiting

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2
Q

UTI risk factors

A

•Infancy - boys and girls under 1 year
•Abnormal urinary tract - congenital or other abnormalities
•Females
–Sexual intercourse
–Pregnancy
•Bladder dysfunction/incomplete emptying
–prostate gland enlargement in men
–Constipation (‘dysfunctional elimination syndrome’)
–Neurogenic bladder
•Catheters, stones, or any ‘foreign’ body in bladder or urinary tract
•Diabetes mellitus - glycosuria promotes bacterial growth
•Renal transplant
•Immunosuppression

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3
Q

UTI in childhood

A

Female > Male

Male > female in 1st 6 months of life

50% of males <1 year

80% of female >1yr

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4
Q

Relevance of UTI in childhood

A
  1. identify structural abnormality
  • congenital renal tract abnormality in 50%
    • ves-ureteric reflux (VUR)
  1. reduce risk of further damage
  • consequences
    • renal scarring in 10-15% irreversible
    • Chronic kidney disease
      • 20% of childr and adults with ESRF have scarring
    • hypertension risk icreases with burden of scarring
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5
Q

UTI differential symptoms

A
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6
Q

Urinary tract infection diagnosis

A

Microscopy - pus cells and bacteria

Mulitstix ( Leucocyte esterase+ nitrite) -

  • useful for child >3
  • positive LE and nitrite- UTI in 90%
  • Negative for LE and nitrie - no UTI
  • NB- humans cant make nitrite bacteria convert from nitrate

Urine culture

  • In all children <3 years if clinical suspicion
    • obtain urine before starting antibiotics
    • “Clean catch”; supra pubic aspiration; catheter specimen
  • Definition
  • single organism ³ 105 CFU/ml
    • Contamination risks
  • any growth of single organism if SPA
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7
Q

UTI management in children

A

Prompt identification

  • Test urine when an infant or child presents with:
    • unexplained fever of 38°C or higher
    • or
    • symptoms and signs suggestive of UTI

Antibiotic treatment

  • –Best guess” while awaiting culture and sensitivities
  • Oral antibiotic unless
    • severely ill
    • vomiting
    • NICE: infant <3 months (in practice often < 6 months)
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8
Q

Intravenous or oral ABx treatment in children

A

Intravenous

  • 3rd generation cephalosporin
    • Cefotaxime; Ceftriaxone
  • Aminoglycoside
    • Gentamicin
    • Monitor levels and renal function

Oral

  • Trimethoprim; Cephalosporin; Co-amoxiclav; Nitrofurantoin; (Quinolone
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9
Q

Investigations and follow up of children with UTI

A

Investigations and follow up

Imaging

  • Age: < 6 months; 6 mo – 3 years; > 3 years.
  • Presentation: pyelonephritis v. cystitis
  • Infection: atypical or recurrent
  • Family history: VUR
  • Imaging abnormalities found: US; NM.

Antibiotic prophylaxis

  • Nitrofurantoin; Trimethoprim; Co-amoxiclav
  • currently if high grade reflux Abx may reduce the risk of further infection but dont alter the risk of further damage long term
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10
Q

Ultrasound use in children with UTI

A
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11
Q

MCUG imaging in children with UTI

A

Micturating cystourethrogram

-catheter into bladder and adding dye

VUR- veso-ureteric reflux

PUV= posterior uretheral valve

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12
Q

Nuclear medicine in children with UTI

A

DMSA- no differenitation between prev infection or congenital injury (scar vs dysplasia)

MAG3 - isotope study, in two ways

  1. Indirect cystogram
  • isotope go into bladder, fill up in the bladder
  • in the cooperative content patient (3-4 or >)
  • imaging taken as they pee
  • Non invasive patient
  • No urethra information
  1. diuresis renogram
  • how well it flows down
  • administer diuretic (speed up traffic flow)
  • blockage manifests quickly
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13
Q

Sign on renal ultrasoun that shows acute pyelonephritis in the acute setting

A

Echogenicity on US at lower pole

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14
Q

Imaging in UTI NICE guidelines in infants younger than 6 months

A

Depends on age

  • if responds well to treatment within 48 hours delay US
  • Ultrasound within 6 weeks
  • DMSA within 4-6 months following acute infection yes/no
  • MCUG no

It atypical UTI or reccurent UTI

  • ultrasound within 48 hours during acute infection
  • No need to repeat within 6 weeks
  • DMSA 4-6 months following acute infection
  • MCUG yes

*

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15
Q

Recommeded imaging for children aged 6 months- 3 years

A
  • If patient responds well to treatment there is no other need for US or DMSA folloing acute infecion or MCUG

Atypical

  • US during acute infection
  • Do not US within six weeks
  • DMSA 4-6 months following acute UTI
  • No MCUG*

* unless if dilation on US; poor urine flow or FH of VUR

Recurrent UTI

  • US during acute infection - NO
  • US within six weeks - yes
  • DMSA 4-6 months following acute UTI - YES
  • MCUG - yes
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16
Q

Risk factors for renal scarring

A
  • age- young
  • High grade VUR
  • Anatomical obstruction
  • Dysfunctional voiding
17
Q

Congenital abnormalities of kidney and urinary tract (CAKUT)

A
  • Vesico-ureteric reflux (VUR
  • Obstruction of urinary drainage tracts

recognize both may be associate with congenital renal dysplasia

18
Q

Antenatal renal ultrasound CAKUT alerts

A

Can be identified in antenatal u/s

  • Drainage tract: dilations
  • Renal parenchymal disease– ‘bright kidneys’
  • Oligohydramnios – lack of amniotic fluid

Confirmed post-natal

  • Ultrasound,
  • Isotope studies (DMSA static imaging or MAG-3 dynamic imaging)
  • MCUG (bladder imaging-reflux disease)
19
Q

Vesicoureteric reflux (VUR) definition and epidemiology

A

retrograde passage of urine from the bladder into the upper urinary tract

  • most common urologic finding in children
    • 1% of newborns
    • 30-40% of young children with UTI
20
Q

Presentation of VUR

A

–Antenatal hydro-uretero-nephrosis
–UTI & Pyelonephritis – VUR in 30-40%

21
Q

Gold standard to identify VUR

A

MCUG

  • dye into bladder via urethral catheter
  • taking images as fillling and emptying
  • identifying reflux
22
Q

Grading of VUR

A

UTI + VUR → 30 % have renal scarring
–Much damage due to VUR is prenatal = dysplasia

VUR grading
–‘Low grade’: I-II
–‘High grade’: III-V

VUR and spontaneous resolution
–90% of mild reflux
–30 - 40% of severe reflux

23
Q

Defining Obstruction

A
24
Q

Bladder outlet obstruction classification

A

Posterior Urethral Valve
–Commonest congenital cause in male infants

Prostatic Hypertrophy
–Commonest acquired cause in world

Functional obstruction
–Neurogenic Bladder
•Spina Bifida
•Sacral agenesis
•Spinal Dysraphism
•Transverse Myelitis
•Trauma
–Prune Belly Syndrome- megaureters, absent abdominal muscles, cryptorchidism

25
Q

Posterior urethral valve

  • Definition
  • presentation
  • mortality and risk of CRF
  • Management
A
  • Commonest cause of obstruction in male infants
  • Valve leaflets or circumferential diaphragm
  • Presentation
    • Antenatal hydronephrosis
    • Urinary tract infection
    • Poor urinary stream
    • Renal dysfunction
  • Chronic Renal Failure - 7%
  • Mortality - 7%
  • Management
    • Valve resection
    • Antibiotic prophylaxis
    • CKD care
26
Q

PUJO vs VUJO

A

Renal (12 decks)

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