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Paediatrics > Renal > Flashcards

Renal Flashcards

1
Q

What is nephrotic syndrome?

A

Clinical triad of hypoalbuminemia, nephrotic range proteinuria, edema

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2
Q

What is nephrotic range proteinuria?

A

> 40mg/m2/hr OR UPCR >200mg/mmol

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3
Q

What is hypoalbuminemia?

A

<25g/L

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4
Q

What is the significance of UTI in children?

A

Renal scarring in developing kidney -> HT -> CKD

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5
Q

What are the sx of UTI?

A

Fever, malodorous urine
Infant: poor feeding, vomiting, irritability, seizure, FTT
Children: LUTS, suprapubic pain, loin pain, secondary enuresis

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6
Q

What pathogens cause UTI?

A

E coli > klebsiella > proteus

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7
Q

What are the RF of UTI?

A

VUR, constipation, indwelling catheter, intermittent catheterization

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8
Q

How to investigate UTI?

A

Urine multistix, culture & microscopy

Blood: RFT, ESR, CRP, (culture)

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9
Q

How to follow up UTI?

A

NICE guideline

Good response + first time: USG in 6w for <6m
Atypical UTI: <6m (acute USG, DMSA, MCUG), 6m-3y (acute USG, DMSA), >3y (acute USG)
Recurrent: <6m (acute USG, DMSA, MCUG), >6m (USG in 6w, DMSA)

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10
Q

How to manage UTI?

A

ABX: oral cephalosporin / augmentin x 7-14d (IV for <3m, repeated vomiting, urosepsis)
FU growth & RFT

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11
Q

How to manage recurrent UTI?

A

Surgery: circumcision, anti-reflux surgery

Long term prophylactic ABX: daily trimethoprim

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12
Q

What is VUR?

A

Incompetent ureterovesicular junction -> short intravesicular ureter -> UVJ x close during bladder contraction -> reflux to ureter -> recurrent UTI, renal scarring

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13
Q

How to manage VUR?

A

Periodic monitoring by MCUG (most resolve spontaneously)
Prophylactic ABX: grade 3
Surgery: high grade after 3yo, failed ABX

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14
Q

What are the causes of nephrotic syndrome?

A

Primary: MCD, IgA nephropathy, FSGS
Secondary: AI (SLE, HSP), inf (Hep B, APSGN)

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15
Q

What PE to perform for nephrotic syndrome?

A

Volume status (CR, BP/P, RR)
Ascites, pleural effusion
Abdominal pain
Sx of secondary causes: rash, arthritis, purpura

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16
Q

How to investigate nephrotic syndrome?

A

Urine: multistix, PCR, timed urine, specific gravity >1.035
Blood: CBC, LRFT, ESR, AI markers, serology
Renal biopsy (atypical)

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17
Q

What are the indications for renal biopsy in nephrotic syndrome?

A

Atypical case: <12m, >12y, gross hematuria, persistent HT, persistent low complement, impaired RFT unrelated to hypovolemia, Hep B/C +ve, failed steroid

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18
Q

What are and how to manage the Cx of nephrotic syndrome?

A

Hypovolemia: IV albumin then IV furosemide
Infection (loss of Ig): prophylactic ABX (penicillin V)
Thrombosis (loss of ATIII + hemoconcentration): encourage ambulation, renal USG & doppler
Hyperlipidemia

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19
Q

How to manage nephrotic syndrome?

A

Monitor I/O
Avoid bed rest, encourage ambulation
Steroid-sensitive type: PO prednisolone
Steroid-resistant: refer
Adjunctive therapy of H2RA (famotidine/ranitidine), calcium, Vit D
Significant ascites/edema: low salt diet, fluid restriction, PPX ABX, IV albumin + furosemide, paracentesis

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20
Q

What is the prognosis of nephrotic syndrome?

A

1/3 recover, 1/3 occasional relapse, 1/3 frequent relapse

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21
Q

What are the DDx of sterile pyuria?

A

Infective: partially treated bacterial UTI, UTI w/ urinary obstruction, renal TB, renal abscess, inflammation near bladder/ureter, other febrile disorders
Non-infective: stone, structural abnormality, GN, interstitial nephritis, SLE, interstitial cystitis, Kawasaki

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22
Q

What is sterile pyuria?

A

High WCC, x bacteria

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23
Q

What is enuresis?

A

Bedwetting after developmental age when bladder control should be established (>5yo)

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24
Q

What are the types of enuresis?

A

Primary: never achieved night dryness >6m
Secondary: enuresis after night dryness of >6m
Daytime VS nocturnal
Monosymptomatic: x LUTS or hx of bladder dysfunction
Non-monosymptomatic: w/ LUTS or hx of bladder dysfunction

25
Q

What are the causes of enuresis?

A

Primary: primary nocturnal enuresis, bladder dysfunction, ectopic ureter
Secondary: psychological, DM, constipation, OSA, CKD, UTI, neuropathic bladder (spinal injury e.g. trauma, neuroblastoma, spina bifida)

26
Q

What history would you take for enuresis?

A 
Voiding habit
Drinking habit
Any daytime or LUTS symptoms
A/S: movement disorder, constipation, development
FH
SH
27
Q

What PE would you perform for enuresis?

A

Abdominal mass
Bladder distention
Neuro: gait, spina bifida
Others: anal tone, growth, tonsillar hypertrophy

28
Q

How to investigate enuresis?

A

Urine: multistix, culture, specific gravity
USG kidney & bladder
Urodynamics
XR/MRI spine

29
Q

How to manage enuresis?

A

General: tx constipation, reassure, advice, motivation therapy w/ star chart
Specific: enuresis alarm, demopressin
Overactive bladder: anticholinergic (oxybutinin), beta3 agonist (mirabegron)

30
Q

What is hemolytic uremic syndrome?

A

Triad of microangiopathic hemolytic anemia, thrombocytopenia, AKI

31
Q

What are the types of hemolytic uremic syndrome?

A

Typical: E coli O157:H7, shigella -> prodromal diarrhea, better prognosis
Atypical: strep pneumoniae -> prodromal pneumonia, worse prognosis

32
Q

What are the sx of hemolytic uremic syndrome?

A

Sudden onset of oliguria, pallor, seizures

Prodromal diarrhea or pneumonia

33
Q

What PE would you perform for hemolytic uremic syndrome?

A

Pallor
Hepatosplenomegaly
AKI: edema, proteinuria, hematuria

34
Q

How to investigate hemolytic uremic syndrome?

A

Blood: CBC, PBS, LRFT, clotting, culture
CT brain
Workup for pneumonia: sputum, CXR

35
Q

How to manage hemolytic uremic syndrome?

A 
PICU
Supportive
- Blood products: packed RC, plt
- Hypovolemia: fluid resuscitation
- AKI: monitor RFT, fluid & electrolytes, RRT
- Seizure: phenytoin, diazepam
ABX for atypical: 3G cephalosporin
36
Q

What is the prognosis of hemolytic uremic syndrome?

A

95% survive acute phase, most resolve completely, 40% w/ irreversible kidney injury

37
Q

What is acute kidney injury?

A

Abrupt deterioration in kidney function, potentially reversible
High serum Cr: 26.5 micromol/L or 1.5X of baseline in 48hr
Low UO: <0.5ml/kg/hr for 6h

38
Q

What are the causes of acute kidney injury?

A

Pre-renal (MC): hypovolemia, hypotension, RAS
Renal: vascular (vasculitis, RVT, thrombotic microangiopathy e.g. HUS, ITP), glomerular (GN), tubular & interstitial (ATN, drug, inf)
Post-renal: posterior urethral valve, stone, clot

39
Q

What are the sx of acute kidney injury?

A

Edema
Low UO
Gross hematuria
HT

40
Q

What PE would you perform for acute kidney injury?

A

Dehydration
Edema & HT
Rash
Ballotable kidney

41
Q

How to investigate acute kidney injury?

A

BP/P
Urine: output, microscopy, biochemistry (Na & osmolality)
Blood: RFT (high Cr, urea, K), Ca, metabolic acidosis, CBC, C3/4, ASOT
Renal USG

42
Q

How to manage acute kidney injury?

A

Monitor: BP, fluid balance, Ca, RFT, ABG, ECG
Fluid: hypovolemic (fluid resuscitation), RF or HT (IV furosemide, low salt, fluid restriction)
Electrolyte
- Hyperkalemia: calcium gluconate (myocardium), sodium bicarbonate, glucose + insulin, IV salbutamol (ITC K shift), oral sodium polystyrene sulfonate (intestinal excretion)
- Metabolic acidosis: sodium bicarbonate
- Hyperphosphatemia: calcium carbonate, diet restriction
Nutrition (high calories)
RRT (e.g. HD, PD)

43
Q

What are the indications of RRT for acute kidney injury?

A

Refractory electrolyte disturbance, severe fluid overload, symptomatic azotemia (lethargy, neuro sx), affect nutritional support

44
Q

What is the prognosis of acute kidney injury?

A

Risk of progression to CKD -> req long term FU

45
Q

What is acute nephritis?

A

Acute onset of hematuria, proteinuria, oliguria, edema, HT

46
Q

What are the features & pathophysiology of acute nephritis?

A

Glomerular leak -> hematuria, proteinuria
Glomerular block (low GFR) -> oliguria, fluid retention
Leak + block -> anemia
Malaise, N/V, lumbar pain

47
Q

How to investigate acute nephritis?

A

BP
Blood: CBC, LRFT, CaPO4, ESR
Urine: multistix, culture, microscopy, UPCR, timed urine
Microbiology: ASOT, throat swab, HBsAg, anti-HCV
AI markers: C3/C4, anti-dsDNA, ANA
USG
Renal biopsy

48
Q

What are the indications of renal biopsy in acute nephritis?

A

Rapidly deteriorating RFT
Atypical: x post-strep infection, systemic symptoms of SLE, nephrotic range proteinuria
Delayed resolution: persistent sx, persistent low complement, persistent impaired RFT

49
Q

What is an atypical UTI?

A

Abdominal mass, septicemia, non-E Coli organism, x respond to ABX within 48 hrs, impaired RFT

50
Q

How to manage acute nephritis?

A

Monitoring: I/O, BP, RFT, proteinuria, C3/C4
Fluid: low salt, fluid restriction, anti-HT (nifedipine, furosemide)
Electrolyte: correct hyperkalemia
RRT

51
Q

What are the causes of acute nephritis?

A

Inf: APSGN (85%)
AI: IgA nephropathy

52
Q

How to diagnose APSGN?

A

Recent strep infection: pharyngitis, skin, OM (2w ago)

Lab: low C3/C4, high ASOT / anti-DNAse B titre

53
Q

How to manage APSGN?

A

x require ABX -> resolve spontaneously

54
Q

What is IgA nephropathy?

A

Synpharyngitic hematuria: occurs during/shortly after URTI

55
Q

What are the features of IgA nephropathy?

A

Wide range of presentation

  • Microscopic hematuria/proteinuria
  • Gross hematuria, AKI
  • Nephritic / nephrotic syndrome
  • Crescentic GN
56
Q

How to diagnose IgA nephropathy?

A

Renal biopsy (immunostaining of IgA immune complex)

57
Q

What is the prognosis of APSGN?

A

Good, resolve spontaneously, unlikely to recur

58
Q

What is the prognosis of IgA nephropathy

A

Stable or slow progression to CKD -> long term monitoring

Paediatrics (10 decks)

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