Renal Flashcards
How may a child with a UTI present?
What is important about children with UTI’s?
Classic Sx:
- Dysuria
- Frequency (how many wet nappies?)
- Flank pain
- Recurrent UTIs
- Offensive, cloudy urine
- D&V, rigors, fever, enuresis
Infants:
- Fever
- Vomiting
- Irritability, lethargy
- Poor feeding/growth
- Jaundice
- Sepsis
- Febrile seizures
Note: up to 50% have structural abnormalities of the urinary tract e.g. VUR
What investigations would you do in a child with suspected UTI?
Ix:
- > Obs + Exam
- > *Urine dip (nitrite stick test which v specific, leucocyte esterase test which is less specific/will be +ve in children without UTI and balanitis/vulvovaginitis also)
- > Urine MC+S - Diagnose UTI (Bacteriuria)
- > Imaging only indicated unless atypical or recurrent (USS + DMSA** (only in <3yo if atypical)
- Clean catch preferably for urine collection, if not then urine collection pads, if not then catheter samples/suprapubic aspiration
- *DMSA looks at renal scarring
How may you distinguish an upper and a lower UTI clinically?
Upper/pyelonephritis:
- Bacteriruria + fever >38 degrees
- Bacteriuria + loin pain/tenderness
Lower/cystitis:
- Anything else i.e. bacteriuria/dysuria but NO systemic symptoms
How would you manage a child with a UTI: i) Neonates and children under 3m? ii) Children 3m+ ? iii) Recurrent UTI's? How may you advise avoiding UTIs?
Note: always say that antibiotic choice is guided by local guidelines/resistance patterns [below is NICE guidance]
i) Under 3m:
- Low threshold for admission + full sepsis screen
- IV ABx - Cefotaxime/Gent, and Ampicillin and then switched to oral when cultures negative/clinical improvement
- Refer to paediatric specialist
- Urgent USS should be booked for within 4-6w
ii) 3m+
- Consider admission
- IV ABx 7-10d out of:
–> Co-amoxiclav
–> Ceftriaxone
–> Cefuroxime
–> Gentamicin
- OR Oral Abx for 7-10d, or 3d if 13+
–> Cephalexin
–> Co-amoxiclav
–> Trimethoprim
–> Ciprofloxacin
for 7-10 days if stable
- If <6m when they have their first UTI then urgent USS should be booked (4-6w)
- Safety net
Recurrent UTI
- Scans: USS, MCUG (structure) and DMSA for scarring and reflux
- Refer to specialist
- Abx prophylaxis?
Medical measures to prevent UTI:
- High fluid intake to produce increased output
- Ensure complete bladder emptying
- Good perineal hygiene
- Regular voiding
- Treating/preventing constipation
- Probiotics (lactobacillus acidophilus)
When is a child normally potty trained/dry by night and day?
Potty training started around 2.5y but varies between children
- > Dry by day - by 4yo
- > Dry by day and night - by 5yo (most by 3-4y)
What is the difference between primary and secondary bedwetting?
What Ix would you do (if indicated)?
Primary:
-> Child has never been dry before
Secondary
-> Enuresis occurring after child has previously been dry for 6 months
Ix: -> Abdominal exam, rule out DDx -> Urine diary -> Urine MC+S, Dipstick Other: -> Renal USS -> MCUG
How would you manage primary enuresis (without or with daytime symptoms)?
With daytime Sx:
-> Referral to enuresis clinic, community paediatrician
Without daytime Sx:
- <5yo
= 1st line is conservative education:
–> encourage and easy access to toilet (bedside potty)
–> reduce fluids before bed, no caffeine
–> positive reward system
–> reassure parents that often resolves by 5y (as bladder capacity increases and learn to wake at the sensation of a full bladder) - if not can try other options
–> support of leaflets/site: ERIC)
- > 5yo
= 1st line is conservative + enuresis alarm (wakes child when wet)
= 2nd line is desmopressin (1st line if >7yo OR requires short-term control e.g. a trip)
= 3rd line = combination
= Referral to enuresis clinic, community paediatrician if bedwetting hasn’t responded to 2 courses of treatment
What are some causes of secondary bedwetting?
Causes include:
- UTI, recurrent UTI
- Constipation
Secondary care Mx:
- Diabetes
- Psychological problems, developmental delay/LD
- Neurological/physical problems
- Family issues
What is Wilm’s tumour? Who does it tend to affect?
AKA Nephroblastoma (undifferentiated mesodermal tumour of intermediate cell mass - primitive renal tubules and mesenchymal cells)
- > Most common intra-abdominal tumour of childhood (2nd most common cancer in children after ALL)
- > 80% are <5y, often 3yo children
- > 95% unilateral
- > 1-2% have FHx
What are some associations with Wilm’s tumour?
- Beckwith-Wiedmann syndrome (specific parts of the body overgrow, presenting at birth e..g islet cell hyperplasia)
- WAGR syndrome (Wilms, Aniridia, GU malformations, mental retardation)
- Hemihypertrophy
- 33% with a loss of function mutation on WT1 gene on X11
How may a child with Wilm’s tumour present?
Sx:
- Asymptomatic abdominal mass (painless, smooth, firm)
- Painless haematuria
- Less commonly: abode pain, anaemia due to haemorrhage into the mass, distension
- RF e.g. FHx, Congenital syndromes
How would you Ix and stage Wilm’s tumours? How would you Mx it? What is its prognosis? What should you avoid?
Ix:
- > USS
- > CT/MRI for spread
- > Avoid biopsy as may worsen condition
- > Bloods - FBC, Cr/Urea, LFTs
Staging if 1-5:
1 = limited to kidney, completely excisable
2 = not limited to kidney, completely excisable
3 = not limited to kidney, not completely excisable
4 = spread beyond abdomen, haematogenous metastasis (LN and other organs)
5 = bilateral (each tumour graded separately
Mx:
- Nephrectomy + chemotherapy (+radiotherapy before surgery if advanced disease)
- 80% cure rate
What is phimosis? Is it always physiological and why is it important?
Inability to retract foreskin
Physiological at birth:
-> By 1y, 50% have non-retractable foreskin
-> By 4y only 10% do
-> by 17y, only 1% do
If persistent to puberty, it can increase the risk of infection + cause issues with urination and intercourse
How is phimosis managed?
note: what is Balanitis Xerotica Obliterans (BXO)
Mx:
<2y = reassure and review in 6m and promote personal hygeine (clean the external surface normally, don’t need to physically/forcibly retract foreskin until separates itself)
> 2y = circumcision or topical steroid cream depending on severity
BXO = pathological phimosis where there is scarring of the foreskin (rare before 5y)
-> haematuria, painful erections, recurrent UTI, weak stream, redness, tenderness
What is Paraphimosis and how is it managed?
Paraphimosis - where the foreskin is trapped in the retracted position, proximal to the swollen glans = EMERGENCY [restricted blood to head of the penis –> turns purple]
Mx:
- Analgesia (local/nerve block) + attempt to reduce foreskin with gentle compression and saline soaked swab
- Emergency referral to urologist + surgery if required (ischaemia, necrosis, prev interventions failed)
What is hypospadias (+epispadias) and how does it present? What is the management for it?
Hypospadias = wrongly positioned meatus (ventral in hypospadias, dorsal in epispadias)
Features:
- Ventral foramen
- Hooded foreskin
- Chordee (ventral curvature)
Mx:
- No intervention required but can do surgery (after 3m) –> aim for urinating in a straight line when standing and straight erections
- HOWEVER, advise NO circumcision as the skin is required for the repair
What is balanoposthitis and how is it managed?
balanoposthitis = inflamed/purulent discharge from the foreskin
- single episodes common
- managed by warm baths, broad spectrum Abx (if recurrent, then circumcision)
What is testicular torsion and who does it tend to affect (RFs)? What is another form of torsion?
Torsion
- Urological emergency where there is twisting of the testicle on the spermatic cord (processus vaginalis) causing ischaemia of the testes
- Post-pubertal age most commonly affected i.e. 16y but ranges from 11-30y
- RF = undescended testes, ‘clapper bell’ testes (on the side)
- MUST be excluded in any boy with acute abdomen
NOTE: Torsion of the appendix testes (Hyatid of Morgani) is more common but the pain evolves over MULTIPLE days.
-> Often surgery is needed as can’t distinguish between true torsion but if a BLUE dot is seen over the superior pole of the testes then no surgery may be required/just analgesia
How would someone with TT present?
Sx:
- SUDDEN onset pain; localised to testis or in abdomen
- N+ V
- Redness
- Oedema
How would you Ix and Mx suspected TT? What is its prognosis?
Ix:
- Clinical Dx
- -> [lifting testes increases pain whereas in epididymitis it reduces pain - Prehn’s sign]
- Doppler USS (but this shouldn’t delay surgery)
Mx:
- Urgent urological/paeds surgery referral + NBM
- Exploratory surgery with bilateral orchidiopexy vs orchidectomy, and fixation of contralateral testes**
- Supportive care (analgesia/sedation/antiemetics)
note:
- If caught within <6h then >90% saved whereas if <24h then <10% saved
*Process: Raphe incision -> untort testes -> watch reperfusion in warm saline -> decide if orchidectomy needed
How can renal disease (AKI) be categorised?
AKI Stage 1:
= Increase ≥26 µmol/L serum Cr; or by 1.5-1.9x the reference sCr
= Urine output <0.5mL/kg/hr, 6-12hr
AKI Stage 2:
= Increase 2.0-2.9x the reference sCr
= UO <0.5mL/kg/hr, ≥12hr
AKI Stage 3:
= Increase ≥354 µmol/L; or by ≥3x the reference sCr
= UO <0.3mL/kg/hr, ≥24hr
or Anuric for ≥12hr
What is orthostatic proteinuria? How would you assess it?
Common transient cause of proteinuria
- measure urine PCR (protein:Cr ratio) in a series of early morning specimens
What is nephrotic syndrome? What is the most common cause of it in children?
How would a child present?
Triad of: low albumin, peripheral oedema and proteinuria
–> Most commonly = Minimal Change Disease in kids (90%; children aged 2-4y)
Sx:
- 1st sign is peri-orbital oedema (often misdiagnosed as allergy)
- 2nd is other delayed features of oedema i.e. leg swelling, features of underlying diagnosis
How would you Ix and manage suspected nephrotic syndrome?
Ix:
- Urine dip
- Urine MC+S
- Bloods - FBC, ESR/CRP, Cr, Albumin, Complement [C3,C4]
- Anti-streptolysin O or anti-DNase B titres (recent strep throat infection)
- HBV, HCV, malaria screen
- [renal biopsy but normally in kids, only if unresponsive to steroids]
Mx:
1st line:
–> Oral 60mg/m2 prednisolone for 4-6w, reducing the dose from 4w
–> Fluid restricted and low salt diet
–> If advanced, may require albumin and furosemide
2nd line:
- -> specialised renal biopsy
- -> unresponsive to steroids/atypical - CNIs and methylprednisolone
[Renal histology shows steroid sensitive nephrotic syndrome (normal on light microscopy) but electron microscopy shows fusion of podocytes (MCD)]
Complications:
- > Thrombosis (loss of AT-III in urine)
- > Infection (loss of Ig in urine)
- > Hypercholesteraemia (due to urinary albumin loss)
What are the most common causes of [acute] renal failure in children?
ARF causes:
- > HUS (low RBC, platelets and AKI) - require admission, may find schistocytes on blood film, -> Haemorrhagic E.coli O157 [shiga toxin] causes infectious diarrhoea
- > Acute tubular necrosis, usually due to organ failure in ITU/after cardiac surgery, sepsis
How would a child with ARF/CRF present? How would you specifically treat pre, intrinsic and post-renal ARF?
Sx:
- Oligouria/Anuria
- Oedema (feet, legs, abdomen, weight gain)
- Brown urine
- Fatigue, lethargy, N+V
Pre-renal failure (i.e. hypovolaemia)
- -> Urgent fluid replacement is key in these patients
- -> Adrenaline if severely hypotensive
- -> Furosemide if overloaded
Intrinsic renal failure:
- -> Monitor water and electrolyte balance
- -> High calorie, normal protein diet
- -> Furosemide if overloaded, IV fluids if pre-existing pre-renal failure
- -> Consider RRT
Post-renal failure:
- -> Refer immediately to urology if any of: pyonephrosis, obstructed solitary kidney, bilateral upper urinary tract obstruction + complications of AKI due to obstruction
- -> Assessment is needed of site of obstruction
- -> Relief can be given by nephrostomy or bladder catheterisation
- -> Furosemide if overloaded
- -> Consider RRT
How would you Ix and Mx ARF? What are 7 indications for dialysis?
Ix:
- > Urine dip for protein
- > Renal USS for obstruction identification
- AKI can show large, bright kidneys with loss of cortical and medullary differentiation
- CKD may show small kidneys
Mx: - Diuretics PRN to treat fluid overload/oedema whilst awaiting dialysis - Fluid restriction - Dialysis: Indicated when one of the following: -> Failure of conservative Tx -> Multisystem failure -> Refractory hyperkalaemia, or low/high Na -> Pul. oedema/refractory fluid overload -> Metabolic acidosis -> Uraemic sx (encephalopathy, nausea, pruritus) -> CKD stage 5 (GFR<15) 'FRUMMPE'
Good prognosis in childhood unless serious condition/masked by other things e.g. infection post cardiac surgery
What are some causes of acute glomerulonephritis?
What are some immune mediated disorders?
Many causes (see diagram by A.Ludley) but may present as nephrotic (protein losing) or nephritic (haematuria) syndrome:
- > Minimal change disease
- > IgA nephropathy (adults but includes HSP in children)
- > Vasculitis (SLE, ANCA+)
- > Goodpasture’s
- > Post-infectious (post-strep in children)
Immune-mediated:
- > Minimal change
- > Diffuse (all glomeruli)
- > Focal (some glomeruli)
- > Segmental (only parts of affected glomerulus)
What is focal segmental glomerulonephritis?
Segmental scarring and foot process fusion
- Nephrotic syndrome
- Common in older children, may be secondary to obesity or HIV
- HTN and impaired renal function is seen
- 50% respond to steroids
What is membranous nephropathy?
Widespread thickening of basement membrane of the glomeruli due to granular deposits of Ig and complement
- More common in adults
- Linked to SLE, drugs, idiopathic also
What are some signs of glomerulonephritis? {think nephrotic, nephritic syndrome signs}
Sx:
- > Nephrotic syndrome - hypoalbuminaemia, swelling/oedema, proteinuria
- > Nephritic syndrome - HTN, haematuria, proteinuria (mild-moderate)
- > Reduced urine output
- > Fluid overload
- > Hypertension and seizures
What investigations would you do in someone with suspected glomerulonephritis?
Ix:
- Urine dip
- Urine MC+S
- Bloods - FBC, ESR, Cr, Albumin, U&Es, Complement levels
- Antistreptolysin O/antiDNase B titres
- HBV, HCV, malaria screen
How would you manage glomerulonephritis?
Mx depends on type, severity and complications:
Mild
- Tx cause and supportive treatment
- May require Abx if post-streptococcal GN i.e. phenoxymethylpenicillin
Moderate:
- ACEi/ARBs
- May require Abx if post-streptococcal GN i.e. phenoxymethylpenicillin
- Furosemide
Severe:
- Corticosteroids
- Immunosuppresants e.g, Rituximab
- Prophylactic trimethoprim for early phases of Tx due to immunosuppression
Who does Henoch-Schonlein Purpura affect? What is it?
HSP = an IgA small vessel vasculitis; the most common vasculitis of childhood
- affects mainly boys aged 3-10y
- often preceded by an URTI (2-3 days before; if 1-12w before then think post-infectious glomerulonephritis)
- peaks in winter
- caused by IgA and IgG complexes depositing in the organs and activating complement
How would a child with HSP present?
Sx:
- > Purpuric rash on the extensor surfaces of legs, arms, buttocks and ankles (maculopapular, spares trunk)
- > Arthralgia and periarticular oedema: large joints with swelling of knees and ankles
- > Abdominal pain: colicky nature, haematemesis, melaena, intussusception
- > Glomerulonephritis (by 3m, most have this): microscopic/macroscopic haematuria, nephrotic syndrome is rare
What investigations would you consider for a child with suspected HSP?
Ix:
- Urine dip
- Bloods = FBC, clotting screen, U+Es, IgA* [increased IgA, normal coagulation]
- Urinalysis (RBCs, proteinuria, casts, urea, Cr, 24h protein) - to rule out meningococcal sepsis
- F/u weekly for 1m, then 2-weekly for 2m, 3m etc till 12m for BP measurements and haematuria
What is the management for HSP? What are some complications?
Mx:
> Most cases spontaneously resolve within 4w
> Symptomatic mangement i.e.:
–> Paracetamol/NSAIDs for joint pain
–> Oral prednisolone for scrotal involvement, severe oedema or severe abdominal pain
–> IV CS for those with nephrotic-range proteinuria (>3.5g) or rapidly declining renal function
–> Renal transplant may be considered if ESRD
–> F/u checks of BP and renal function
Complications:
- ARF/CRF as an adult
- Arthritis of knees
- Intussusception
- Pancreatitis
- Testicular pain (rare)
