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Paediatrics > Renal > Flashcards

Renal Flashcards

1
Q

What is oedema?

A

Increase in interstitial fluid

Swelling, pitting oedema, facial puffiness, ascites, pleural effusions, pulmonary oedema

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2
Q

What can cause oedema?

A

Lymph drainage problems (lymphoedema) - congenital/blockage
Venous drainage and pressure problems - venous obstruction (eg venous thrombosis)
Lowered oncotic pressure - low albumin/protein
Salt and water retention

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3
Q

What can cause lowered oncotic pressure?

A

Malnutrition
Decreased production - liver
Increased loss - gut/kidney (nephrotic syndrome)

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4
Q

What can cause salt and water retention?

A

Kidney impaired GFR

Heart failure

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5
Q

What is nephrotic syndrome?

A

Damaged podocytes leading to loss of protein through podocyte processes

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6
Q

What is the classic triad of symptoms in nephrotic syndrome?

A

Heavy proteinuria (frothy urine)
Hypoalbuminaemia
Oedema

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7
Q

How is protein level determined in nephrotic syndrome investigations?

A

Urine dipstick - semi-quantitative levels

First morning urine protein:creatinine

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8
Q

What levels of protein show nephrotic syndrome?

A

No definite level that is nephrotic

  • Normal < 20mg/mmol
  • > 600mg/mmol likely to produce hypoalbuminaemia but occurs at lower levels
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9
Q

What is hypoalbuminaemia?

A

Normal range 35-45g/L
Fluid retention and oedema usually with albumin < 25-30g/L but not strict cut off
Serum albumin linked to fluid retention
Other protein losses responsible for other complications eg infection, thrombosis

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10
Q

What is the oedema in nephrotic syndrome like?

A

Pitting oedema

Gravitational

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11
Q

What are the 3 types of nephrotic syndrome?

A

Congenital NS < 1 year
Steroid sensitive NS
Steroid resistant NS

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12
Q

What are the symptoms of steroid sensitive NS?

A 
Normal BP
No macroscopic haematuria
Normal renal function
No features to suggest nephritis
Respond to steroids
Minimal change on histology
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13
Q

In whom is steroid sensitive NS more common?

A

Peak age of onset 2-5
M > F
Higher incidence in those from African sub-continent

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14
Q

What causes steroid sensitive NS?

A

? Immunological aetiology

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15
Q

What is the prognosis of steroid sensitive NS?

A

Recurrent relapses in 80%
- Of these 50% have frequent relapses - problems associated with steroid usage over prolonged periods of time
5% continue into adult life
Normal renal function if steroid responsive

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16
Q

How is steroid sensitive NS treated?

A

Standard course of prednisolone for first episode - 60mg/m2 for 4 weeks, then 40mg/m2 on alternate days for 4 weeks
Other considerations - Na and water moderation, diuretics, penicillin as can get very unwell with infection, measles and varicella immunity and pneumococcal immunisation

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17
Q

What are the symptoms of steroid resistant NS?

A 
Elevated BP
Haematuria
Impaired renal function
Features may suggest nephritis
Failure to respond to steroids
Histology - various underlying glomerulopathy, basement membrane abnormalities
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18
Q

What is acute glomerulonephritis?

A

Inflammation of kidneys

Haematuria (macroscopic), proteinuria (varying degree), impaired GFR, salt and water retention

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19
Q

What does impaired GFR lead to?

A

Rising creatinine

Salt and water retention

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20
Q

What does salt and water retention lead to?

A

Hypertension

Oedema

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21
Q

What often causes acute glomerulonephritis?

A

Post-streptococcal infection
Often nasopharnygeal or skin infection
Group A beta-haemolytic strep nephritogenic strains
Antigen-antibody complexes form in glomerulus causing complement activation and glomerular injury

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22
Q

When does nephritis happen post infection?

A

Around 10 days

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23
Q

What are the signs of clinical nephritis?

A

Haematuria - swelling, decreased urine output

Oedema, hypertension, signs of CVS overload

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24
Q

How is acute glomerulonephritis managed?

A

Fluid balance - measurement of input and output, fluid moderation, diuretics, salt restriction
Correction of other imbalances - K+, acidosis
Dialysis if needed (uncommon)
Penicillin - treatment of strep infection

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25
Q

What is the prognosis of glomerulonephritis?

A

95% full recovery
Not recurrent
No long term implication of renal function if full recovery

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26
Q

What investigations should you do for acute glomerulonephritis?

A

FBC - mild, normochromic normocytic anaemia
U&Es - increased urea and creatinine, hyperkalaemia, acidosis
Immunology - raised ASOT/anti-DNAse B titre, low C3/4
Throat/other swabs
Urinalysis - haematuria (macroscopic), proteinuria, microscopy (RBC cast)

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27
Q

What are the different causes of AKI?

A

Pre-renal
Renal
Post-renal

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28
Q

What is Henoch-Schonlein purpura?

A

Clinical diagnosis based on rash - purpuric rash - red raised rash over legs and/or buttocks
Vasculitis affecting several organs

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29
Q

What organs does HSP affect?

A

Skin
Joints
Gut
Kidneys

30
Q

What are the symptoms of HSP?

A 
Rash - purpuric
Arthritis
Abdominal pain
Faecal blood
Proteinuria and haematuria
31
Q

What affect can HSP have on the kidneys?

A 
Haematuria/proteinuria
Nephrotic syndrome
Acute nephritis
Renal impairment
Hypertension
32
Q

Why does HSP caused nephritis?

A

IgA deposition

33
Q

What type of nephrotic syndrome can HSP cause?

A

Either steroid sensitive/resistant

If resistant then may need alternative immunosuppression and/or other anti-proteinuric measures

34
Q

What is the prognosis of HSP?

A

Variable

May be ESRD

35
Q

What should you do with a child who has had HSP?

A

Monitor bloods and urine after diagnosis to check for kidney problems

36
Q

What is a UTI?

A

Infection of the urinary tract with growth of bacteria within the urinary tract 10^5 organisms/ml growth on culture
2 types - acute pyelonephritis (upper), acute cystitis (lower)

37
Q

How common are UTIs in children?

A 
3-5% girls and 1-2% boys
Can cause significant acute illness
50% rate of recurrence
50% structural abnormality presenting symptom
Heavy burden on NHS and families
38
Q

What are the long term complications of UTI in children?

A

Kidney scarring
Hypertension
CKD

39
Q

What are the common symptoms and signs in infants < 3 months with UTI?

A

Fever, vomiting, lethargy, irritability
Less commonly - poor feeding, failure to thrive
Even less commonly - abdominal pain, jaundice, haematuria, offensive urine

40
Q

What are the common symptoms and signs of UTI in preverbal children > 3 months?

A

Fever
Less commonly - abdominal pain, loin tenderness, vomiting, poor feeding
Even less commonly - lethargy, irritability, haematuria, offensive urine, failure to thrive

41
Q

What are the common symptoms and signs of UTI in verbal children?

A

Frequency, dysuria
Less commonly - dysfunction voiding, changes to continence, abdominal pain, loin tenderness
Even less commonly - fever, malaise, vomiting, haematuria, offensive urine, cloudy urine

42
Q

When should you take a urine sample from a child?

A

With S&S of UTI
With unexplained fever > 38
With alternative site of infection but who remain unwell
All infants < 3 months with suspected UTI referred to paediatric specialist care and urine should be sent for M & C

43
Q

How do you collect a urine sample from a child?

A

MSU if able to urinate on command
Clean catch recommended method
Urine collection pads
Catheter sample/suprapubic aspiration - before SPA need USS guidance to demonstrate presence of urine in bladder
Don’t delay treatment to seriously ill children for urine sample
Need to specify how urine was collected

44
Q

How can you do urine analysis?

A

Visual inspection
Dipstick - nitrites, leucocyte esterase
M, C & S

45
Q

How do you interpret microscopy results?

A

Bacteruria and pyuria positive - regarded as having UTI
Bacteruria positive, pyuria negative - regarded as having UTI
Bacteruria negative and pyuria positive - antibiotic treatment only commenced if clinically UTI (could be partially treated UTI)
Bateruria and pyuria negative - UTI excluded
10^5 organisms/ml of single bacteria on clean catch/MSU OR any growth on SPA

46
Q

What is the most common type of bacteria causing UTI?

A

E coli

Proteus - more common in boys

47
Q

What bacteria may indicate structural abnormality?

A

Pseudomonas

48
Q

Which children need admission for IV antibiotics?

A

< 3 months - any child
Systemically unwell
Significant risk factors

49
Q

How do you treat an infant < 3 months that is systemically well?

A

Minimum 2-4 days IV antibiotics followed by oral for 3 days

Advice to return if no better at 24-48 hours for reassessment

50
Q

How do you treat an infant < 3 months that is systemically unwell (fever > 38 +/- loin pain/tenderness)?

A

Minimum 2-4 days IV antibiotics followed by oral 7-10 days (consider IV according to clinical judgement - use lower threshold for IV antibiotics in younger children, those with significant risk factors and severly ill)

51
Q

What constitutes an atypical UTI?

A 
Septicaemia/requires IV antibiotics
Non-E coli UTI
Poor urine flow
Abdominal mass/bladder mass
Raised creatinine
Failure to respond to treatment with suitable antibiotics within 48 hours
52
Q

What constitutes a recurrent UTI?

A

2/more UTI episodes at least one episode with systemic S&S

3/more UTI without systemic S&S

53
Q

When should you investigate further for structural abnormalities or scarring/damage to kidneys?

A

Atypical or recurrent UTI

54
Q

What is the first line investigation for a UTI?

A

USS of renal tract

  • Non-invasive
  • Observer dependent
  • Size and drainage of kidneys and bladder
  • Good for ?obstruction
55
Q

What is the second line investigation after USS for UTI and when do you do it?

A

Micturating cystourethrogram (MCUG)

  • Done if abnormalities detected on USS
  • Vesicoureteric reflux - retrograde flow of urine from bladder into ureter/pelvicalyceal system/intrarenal, severity graded on level of reflux and associated dilatation, I-V - IV and V most severe with urine backing up into kidneys, associated with UTI/renal abnormalities
  • Bladder
  • Posterior urethra
56
Q

What is the third line investigation for UTI after USS and MCUG?

A

DMSA scan - dimercaptosuccinic acid

  • Radionuclide imaging
  • Relative renal function of each kidney
  • Renal scarring and extent of scarring
57
Q

When should you give children a general paediatric follow up appointment?

A

All children < 3 months
Children of any age systemically unwell
Children with recurrent UTI
Address dysfunctional elimination syndromes and constipation
Include height, weight, BP and routine testing for proteinuria

58
Q

Name 2 possible causes of UTI

A 
E coli
Enterobacter
Klebsiella
Proteus
Pseudomonas
Enterococcus
59
Q

Name 2 antibiotics you could use to treat UTI

A

Trimethoprim
Amoxicillin
Cephalosporin
(Nitrofurantoin)

60
Q

What further investigations could you do in a child with UTI?

A

USS of urinary tract depending on age
DMSA if atypical
MCUG if atypical or doesn’t respond to treatment

61
Q

What does USS of urinary tract tell you?

A

Structural abnormalities

62
Q

What does DMSA scan tell you?

A

Function and location of kidneys

63
Q

What does MCUG tell you?

A

Shows how well bladder functions

64
Q

What factors affect your choice of investigation in UTI?

A

Age of child
- < 6 months, 6 months to 3 years, > 3 years
Recurrent/atypical infection
How well responds to treatment

65
Q

What are the causes of proteinuria in children?

A 
Non-pathological
- Transient
- Fever
- Exercise
- UTI
Orthostatic - checking at the end of the da and stood upright
Pathological
- Nephrotic syndrome
- CKD
- Glomerulonephritis
- Tubular interstitial nephritis
66
Q

What is the diagnostic criteria for nephrotic syndrome?

A

Heavy proteinuria > 3+
Urine protein/creatinine ratio > 250mg/mmol
Hypoalbuminaemia < 20g/l

67
Q

What initial investigations do you have for nephrotic syndrome?

A

BP
Urine dip - protein + blood, protein:creatinine ratio
24 hour urine collection
Urine microscopy
FBC, clotting, ESR, U&E, albumin, cholesterol, blood glucose, bone profile, chicken pox status

68
Q

What are the possible causes of nephrotic syndrome?

A

Minimal change disease > 90%
Focal segmental glomerulosclerosis
Membranous glomerular disease
Membranous nephropathy

69
Q

How would you treat nephrotic syndrome?

A 
Prednisolone 60mg/m2 for 4 weeks then wean
Maintenance pred
PPI cover
Low salt diet
Penicillin V + imms
Antihypertensives
Fluid balance
70
Q

What is the prognosis of nephrotic syndrome?

A

Most respond to steroids - 80%
50% recurrent relapse
0.5-1% mortality

Paediatrics (21 decks)

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