Renal Flashcards
What are two signs that a patient may be suffering from acute pyelonephritis?
- Temperature >38C
- Loin pain or tenderness
A young brother and sister both present with dysuria alone, consider what may be the diagnoses for each?
Girl - cystitis, vulvitis
Boy - balantitis
A baby is suffering for a fever. They are vomiting not feeding well. Their skin appears slightly yellow and their urine smells funny. What may they be suffering from and name some causative organisms?
UTI:
- E.coli
- Klebsiella
- Proteus
- Pseudomonas
- Strep faecalis
A child has been diagnosed with a UTI. Compared to an infant who will present with non-specific symptoms such as a fever, what may an older child complain of in addition?
- Dysuria
- Frequency of urination
- Loin pain
What do nitrites in urine indicate?
- Nitrites: gram negative bacteria breaking down nitrates to nitrites
Considering the presence of nitrites and leukocytes in a clean catch urine sample, what may point towards a UTI?
- Nitrites and leukocytes –> Tx as UTI
- Nitrites only –> Tx as UTI
- Leukocytes only –> only Tx as UTI if clinical evidence that it’s one
What do leukocytes in urine suggest?
If significant increase then suggests infection or cause of inflammation
What is vesico-ureteric reflex (VUR)?
Tendency of urine to flow from bladder to ureters
Alongside antibiotics what investigative method should be carried out for children with a suspected UTI?
Ultrasound of the kidneys and urinary tract
What are typical antibiotics for a UTI?
Ceftriaxone, trimethoprim, cefalexin, amoxicillin
(Nitrofurantoin given in older child)
What is a patient with vesico-ureteric reflex (VUR) predisposed to?
Upper UTI and subsequent renal scarring
How is vesico-ureteric reflex diagnosed?
Micturating cystourethrogram (MCUG)
What is the management of vesico-ureteric reflex (VUR)?
Avoid constipation or excessively full bladder. Prophylactic abx.
What level of single organism is required in a clean catch urine sample for diagnosis of UTI?
> 10^5/ml single organism
What factors can predispose a child to a UTI?
Incomplete bladder emptying
Constipation
Vesicoureteric reflex
Nocturnal enuresis is more common in which sex?
Boys in a 2:1 ratio tend to grow out of it.
What are two non-organic causes of nocturnal enuresis?
- Emotional stress
- Lack of parental approval facilitating learnt nigh-time continence
What are organic causes of nocturnal enuresis?
- UTI
- Faecal retention severe enough to reduce bladder volume and cause bladder neck dysfunction
- Polyuria from osmotic diuresis
What is a medication that can be given to children suffering from nocturnal enuresis?
Desmopressin
What is desmopressin?
ADH analogue, achieving suppressant effect as opposed to a lasting one.
When a child is suffering from nocturnal enuresis, what is important to be carried out to rule out…?
Urine sample for glucose and protein to rule out infection
What is neuropathic bladder and what is it associated with in young children?
Enlarged bladder that fails to empty properly with an irregular thick wall - associated with daytime enuresis (caused by spina bifida and neuro conditions)
What are some causes of daytime enuresis?
- Lack of attention to bladder sensation
- Detrusor instability
- Bladder neck weakness
- Neuropathic bladder
- UTI, constipation
- Ectopic ureter (dribbling, child always damp)
What levels of spinal lesion should be checked to determine a possible cause of daytime enuresis?
S2, S3, S4 dermatomes
What are potential signs that a patient may have a neuropathic bladder?
Bladder found distended, abnormal perineal sensation and anal tone, abnormal leg reflexes and gait.
What management options may be used for daytime enuresis?
- Star charts, bladder training, pelvic floor exercises
- Portable alarm activated by wee
- Anticholinergic drugs e.g. oxybutynin
What may cause daytime enuresis relapse?
- Emotional upset (most common)
- UTI
- Polyuria from osmotic diuresis in diabetes mellitus or renal concentrating disease
What is the pathophysiological mechanism that causes nephrotic syndrome?
Basement membrane in the glomerulus becomes highly permeable to protein
–> proteins leak from blood into the urine
What is the classic triad of nephrotic syndrome?
- Low serum albumin
- High urine protein content (>3+ protein on urine dipstick)
- Oedema
A 4 year old presents with frothy urine, generalized oedema and pallor with breathlessness due to pleural effusion and abdominal distension. Dx?
Nephrotic syndrome
What is the commonest cause of nephrotic syndrome in children?
Minimal change disease
What is present on renal biopsy and standard microscopy for minimal change disease?
Normal
What is present on urinalysis for minimal change disease?
Small molecular weight proteins and hyaline casts
What is the management for minimal change disease?
Corticosteroids (e.g. prednisolone)
Nephrotic disease is secondary to causes that include?
Intrinsic kidney disease (focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis)
Underling systemic illness (HSP, diabetes, infection e.g. HIV, hepatitis, malaria)
What is the management medical options for nephrotic disease?
- Prednisolone (high dose steroid)
- Low salt diet
- Diuretics to treat oedema
- Prophylactic antibiotics if severe
What is the steroid course of treatment for nephrotic syndrome?
High dose for 4 weeks then wean for 8 weeks
What should be given in conjunction should patients be receiving steroid therapy for nephrotic syndrome?
Cyclosporine, tacrolimus, rituximab (ACEi and immunosuppressants)
What are potential complications of nephrotic syndrome?
- Hypovolemia
- Thrombosis
- Infection
- Acute or chronic renal failure
- Relapse
Why is hypovolemia a complication of nephrotic syndrome?
Fluid leaks from intravascular space to interstitial space causing oedema and low blood pressure
Why does nephrotic syndrome have thrombosis as a complication?
Proteins which prevent blood clotting are lost in the kidneys
Why can infection result from nephrotic syndrome?
Kidney leaks immunoglobulins weakening the capacity of the immune system to respond to infection.
This is combined with steroid which will further weaken the immune system
What is the inheritance pattern of congenital nephrotic syndrome?
Recessive inheritance - common in consanguineous families
What is the management of congenital nephrotic syndrome?
Unilateral nephrectomy followed by dialysis (if renal failure) - until old enough for renal transplantation
What is nephritis?
Inflammation within nephrons of the kidneys
What does nephritis cause (consider triad)?
- Reduced kidney function
- Haematuria (visible or invisible amounts of blood in the urine)
- Proteinuria
A patient suffered tonsillitis confirmed to be caused by streptococcus pyogenes 20 days ago. They are now suffering from haematuria and have confirmed proteinuria. What is the possible diagnosis?
Post-streptococcal glomerulonephritis
What is the pathophysiology of post-streptococcal glomerulonephritis?
Immune complexes stuck in glomeruli of kidney cause acute deterioration of renal function and therefore AKI
What are the components of the immune complex in post-streptococcal glomerulonephritis?
Streptococcal antigens
Antibodies
Complement proteins
What is the management of post-streptococcal glomerulonephritis?
Supportive - 80% recover with potential progressive deterioration of the renal function possible leading to HTN + oedema
Tx: antihypertensive meds, diuretics
IgA nephropathy (Berger’s disease) pathophysiology?
Related to HSP; IgA deposits in the nephrons of the kidney causing inflammation
What will be seen on renal biopsy in a patient with IgA nephropathy?
IgA deposits and glomerular mesangial proliferation
What is the management for IgA nephropathy?
Supportive of renal failure
Immunosuppressant medication e.g. steroids, cyclophosphamide to slow disease progression
What is Henoch-Scholein Purpura preceded by?
URTI or gastroenteritis
What is the pathophysiology of HSP?
IgA and IgG interact to produce complexes activating complement and deposited in affected organs precipitating inflammatory response to vasculitis
What is the management for HSP?
Supportive and monitor (urine dip and BP)
What are the clinical findings of HSP?
- Fever, joint pain, swelling
- Rash (symmetrical; buttocks, arms, ankles, legs)
- Periarticular oedema
- Colicky abdominal pain
- Renal involvement with haematuria and proteinuria
What can treat the abdominal pain associated with HSP?
Corticosteroids
What is the genetic inheritance pattern of Alport Syndrome?
X-linked recessive disorder
Alport syndrome is associated with?
Nerve deafness and ocular defects
Progresses to end-stage renal failure by early adult life in males
What is the management of nephritis?
- Fluid and electrolyte balance
- Diuretics
- Monitor for rapid deterioration in renal function
What is the commonest cause of AKI in children (think pre, renal, post)?
Prerenal
- Hypovolemia (gastroenteritis, burns, sepsis, haemorrhage, nephrotic syndrome)
- Circulatory failure
What is the management of pre-renal failure (to prevent what)?
Prevent acute tubular necrosis
- Treat hypovolemia with fluid replacement and circulatory support
How to treat metabolic acidosis in renal failure?
Sodium bicarbonate
What are three complications of renal failure (intrarenal) causing AKI?
- Metabolic acidosis
- Hyperphosphatemia
- Hyperkalemia
What is the treatment for hyperphosphatemia as a complication of AKI?
Calcium carbonate
Dietary restriction
What is a treatment of hyperkalemia?
CALCIUM GLUCONATE (if ECG change)
Nebulised or IV salbutamol
Glucose and insulin, dietary restriction
Dialysis
What is the classic triad of haemolytic uraemic syndrome?
- Haemolytic anaemia
- AKI
- Thrombocytopenia
What is haemolytic uraemic syndrome?
Thrombosis within the small blood vessels throughout the body
What triggers haemolytic uraemic syndrome?
Shiga toxin most commonly E.coli 0157 (shigella also)
How will a patient suffering for haemolytic uraemic syndrome tend to present?
Brief gastroenteritis with bloody diarrhoea followed by symptoms ~5 days later:
- Haematuria or dark brown urine
- Lethargy, irritability
- Confusion
- Oedema
- HTN
- Bruise
- Reduced urine output, abdominal pain
A patient has suffered acute gastroenteritis 5 days ago, they are now suffering from AKI symptoms and have been found to have haemolytic anaemia and thrombocytopenia on blood test. What is the possible diagnosis?
Haemolytic uraemic syndrome
What is the management of haemolytic uraemic syndrome?
Renal dialysis, antihypertensive, blood transfusion with careful management of fluid balance
Note: tends to be self-limiting and only support is supportive
Is chronic kidney disease common?
Rare
What is the ultimate aim of management for chronic kidney disease in children?
Prevent symptoms and metabolic abnormalities of chronic renal failure to facilitate normal growth and development whilst preserving renal function
(consider multifaceted nature)
Give examples of what may be done to support a patient in managing their chronic kidney disease?
Diet
- Supplement calories
- Sufficient protein intake
Prevent renal osteodystrophy
- Phosphate restriction
Control salt and water balance and acidosis
Anaemia - give recombinant human EPO
Hormonal abnormalities
- Recombinant human GH as often delayed puberty
Dialysis and transplantation - need to give immunosuppression with combination of pred, tacrolimus, AZA, MMF
What is hypospadias?
Urethral meatus abnormally displaced to the ventral side (towards scrotum) in lads
What is epispadias?
Meatus displace to dorsal side of penis
Chordee?
Head of penis bent down
What is the management of hypospadias in lads?
Surgery after 3-4 months of age to correct position and straighten penis
Complications of hypospadias?
- Difficulty directing urine
- Cosmetic/psychological concerns
- Sexual dysfunction
