Renal Flashcards
what are 3 other jobs in the kedney besides removing wastes?
erythropoietin, or EPO, which stimulates the bone marrow to make red blood cell
renin, which regulates blood pressure
calcitriol, the active form of vitamin D, which helps maintain calcium for bones and for normal chemical balance in the body
what regulates BP?
Renin
what stimulates the bone marrow to make red blood cell
EPO
what is the active form of vitamin D, which helps maintain calcium for bones and for normal chemical balance in the body
calcitriol
problems where allow proteins and RBC to be filtered though the basement membrane into urine
problems in glomerulus
problems where allow abnormal excretion of H+ , CL- , Bicarb , Na+, K+.
Problems in tubule
What radiographic study would you use to evaluate a patient for polycystic kidney disease?
RUS - good for parenchymal disease
Your pt is a 3day old male who is brought in by his parents who state he “hasn’t been peeing much, and his belly seems to be getting larger and harder”. Good prenatal care, no complications.
The infant was a routine vaginal delivery without any complication who went home at ~36hrs feeding well without vomiting. They confirm that the infant has stooled several times. When asked, they said he didn’t pee much in the hospital but they were told that was OK, and to watch for him to start peeing more – but they don’t think he is peeing more.
Your exam is notable only for a distended abdomen with palpably enlarged bladder and right kidney. WHAT IS THIS?
posterior urethral valves
in littles HTN is a ____ problem
Renal
what are symptoms of renal disease in neonates and infants?
Abdominal or flank mass, hematuria, anuria/oliguria
Hypertension
what are symptoms of renal disease in children and adolescents?
Tea/cola/red colored urine, or hematuria Hypertension Frequency/Urgency/dysuria Polyuria, oliguria Edema proteinuria
on PE you see tachypneic / kussmal breathing …
acidosis
on PE you see tachycardia and kidney disease if
hypovolemic
on PE you see arrhythmia and kidney disease if
hyperkalemic
on PE you find on the skin…. pts towards kidney disease?
poor skin turgor, dry, edema
what genital abn will you see with kidney disease?
abnormalities, (hypospadias, cryptorchidism, ambiguous genitalia
in children abd mass that is most common is
large kidney
if you see an increased BUN
Low renal perfusion of RBF
Nitrogen also affected by protein intake, catabolism, steroids… therefore
what is BUN:cr ratio?
10:1
increased Cr =
Cr is most reliable single indicator of glomerular function
what is normal serum Cr?
Nl serum Cr < 1 in older children*
what could hematuria mean?
Glomerular – nephritis, familial, post-strep
ATN
UTI, trauma
what could proteinuria mean?
Glomerular - nephropathy
what does US show
Renal size, structure, hydronephrosis, cysts, Bladder size.
what does US w doppler show?
renal blood flow , resistance, thrombus
what does VCUG show?
VUR
voiding urethral reflux
what can CT and MRI show?
stones, parenchyma
Clinically mild or insignificant renal abnormalities
3
-Unilateral renal agenesis
IDM, VACTERL, Turner’s, + assoc with anomalies
-Horseshoe kidney
-Pelvic or ectopic kidneys
Renal parenchymal abnormalities 2
Dysgenesis – spectrum Unilateral / bilateral Polycystic kidney disease PKD Autosomal recessive Autosomal dominant
what is the most common PKD?
AD
what PKD is worse?
AR
IN childhood, may be diagnosed via palpation of abdominal mass
HTN is an early problem
Rate of progression of renal insufficiency varies
Dx by RUS
PKD
Accounts for the majority of cases of PKD
AD
PKD - Presents in infancy
AR
what PKD Associated with other cysts (ovarian - hepatic)
AD
Accounts for the majority of cases of PKD
AR
Marked bilat renal enlargement. Interstitial fibrosis and tubular atrophy. Renal Failure early childhood
ARPKD
Typically present in middle adulthood.
Assoc with other cysts : hepatic, pancreatic, ovarian and cerebral aneurysm
ADPKD
most common cause of bladder outlet obstruction in males
posterior urethral valves
Male infant with anuria or poor stream
Urgent surgical drainage necessary
posterior urethral valves
what causes hydronephrosis only?
Ureteral obstruction
Uretero-pelvic junction
what causes hydronephrosis and hydroureter?
obstruction of-vesical junction
what is Reflux of urine from bladder to ureter during bladder contraction, or back up from bladder (ie neurogenic bladder)
VUR
what are complications of VCUR?
-recurrent UTI – when we treat
-Renal damage
Hydrostatic
Infectious
-HTN, CKD
Grade of VUR that Do not typically cause renal damage
Outgrow by age 4-6 years
I-III
do we prophylax grades I-III VCUR
Nitrofurantoin (Macrobid) or
sulfamethoxazole-trimethoprim (Bactrim)
50% of UTIs recur without prophylaxis
Surveillance urine culture
what is more common in girls and may run in family?
VCUR
how do you treat grade IV VCUR?
Surgical re-implantation of ureter
what may be easily palpable on posterior urethral valves?
Kidneys and bladder
what in posterior urethral valves causes ascites?
Leakage proximal to obstruction
what is most likely cause of prune belly syndrome?
posterior urethral valves
what is cryptorchidism and absent abdominal musculature ( due to a number of urinary tract abnormalities)
prune belly syndrome
what causes non glomerular dysuria and hematuria?
cystitis or urethritis
what causes non glomerular associated with back pain and hematuria
pyelonephritis
what causes non glomerular hematuria and colicky pain?
stone
what causes non glomerular hematuria and bright red clots
bleeding d/o or trauma
what does glomerular hematuria have?
Tea colored, smoky
RBC TNTC
+/- RBC casts
Painless
what is march hematuria?
microscopic hematuria caused by running
what has Tea colored, smoky – RBCs that have been broken down
RBC TNTC – to numerous to count
+/- RBC casts
Painless
Glomerular nephritis
If proteinuria + hematuria…
probability of nephritis/nephropathy goes up
what are causes of microscopic hematuria?
March hematuria” - normal
Hypercalciuria , Stones, Sickle cell
Primary concern – glomerulonephritis*
UTI
what is the most common cause of hematuria?
UTI
what are causes of acute nephritis?
Post-infectious (PSGN)
Vasculitis (HSP)or rarely, SLE
IgA nephropathy and membranoproliferative GN
Antibody deposition and injury to glomerulus
Cancers, infections
Antiglomerular basement membrane disease (Good pasture syndrome) rare
Gross hematuria – Tea/cola/red colored.
Microscopic RBC’s too numerous to count
RBC casts (diagnostic, but not always present)
Edema, periorbital and extremities
Other symptoms non specific – fever uncommon, may have HTN. what is this?
Glomerulonephritis
if there is massive proteinuria (nephrotic syndrome) , anasarca, ascities dt injury what is it?
Glomerulonephritis
Most common form of GN in childhood
Acute post-streptococcal GN
how do you dx Acute post-streptococcal GN? hx and other associated symptoms?
History of culture + GAS , or +antistreptolysis O titer
Can have low complement (C3) levels
May develop renal failure and hypertension
Many have persistent microhematuria
how do you treat Acute post-streptococcal GN
No specific treatment. Supportive. Antibiotics if GAS still present. Treat HTN
85% of affected children recovery totally
is hematuria normal in Acute post-streptococcal GN for up to a year?
yes
what is IgA Nephropathy GN
IgA deposition – inflammation of glomeruli
how does IgA Nephropathy GN present?
Presents as asymptomatic microscopic hematuria or gross hematuria during minor acute illness
Normal complement, 50% IgA elevated, no h/o strep
who gets IgA Nephropathy GN
young adolescents and adult
if have nephrotic syndrome what do you have in urine?
protein
how do you treat IgA Nephropathy GN
steroids
most common “chronic” form of GN in children (progress 50% to renal failure over 10 years)
Membranoproliferative GN
if pt keeps coming back for GN what might they have?
Membranoproliferative GN
what is Membranoproliferative GN and presents as?
Abnormal immune response with deposition in glomerular membrane
Proteinuria, hematuria, hypocomplementemia, HTN
what is type I Membranoproliferative GN
Often responsive to steroids
what is type II Membranoproliferative GN
Rare, but Most common GN that progresses to Chronic Renal Failure (not very responsive to steroids)
how do you dx type of Membranoproliferative GN
bx
Membranoproliferative GN is caused with?
Autoimmune ( SLE, scleroderma, sjogrens)
Cancer ( leukemia, lymphoma)
Infections ( Hepatitis, endocarditis, malaria)
what is Henoch-Schönlein GN (vasculitis)
Autoimmune vasculitis following viral infections
what is common with HS purpura?
Microhematuria
how do you treat HSP?
steroids
is mild proteinuria normal?
yesVigorous exercise or febrile illness
Orthostatic
Test first morning void for protein
nephrotic syndrome is
(proteinuria and hematuria)
what is the most common primary NS
minimal change disease
Excessive proteinuria causes?
Hypoproteinemia
Edema, ascites
Hyperlipidemia
Increased infection risk
what is onset of edema in NS?
sudden
what other symptoms of NS
Anorexia, malaise, abdominal pain
HTN 25%
Diarrhea, respiratory distress from edema
Often follows flu-like illness
Presents with edema (often periorbital)
Vague malaise, oliguria, occ abdominal pain
minimal change disease (idiopathic)
what sx does minimal change disease lack that other nephrotic syndromes have?
Lack of HTN, hematuria, renal insufficiency
renal insuff is the same as….
high creatinine
how do you treat minimal change disease?
prednisone - long tapered course
what does failure to respond to steroids mean in NS
not minimal change disease
we do not use___ in minimal change syndrome?
diuretics
4 yr old patient with pallor, bloody diarrhea, abdominal pain, dark urine.
PMH unremarkable, no allergies, no meds. Child complained of belly pain after eating out with family 2 days ago. Vomited x 1and had diarrhea yesterday.Parents arent sure if it was bloody then but definitely today.
Labs: Stool culture, CBC, Electrolytes with BUN/Cr ,Serum albumin, Urinalysis
Results: Ecoli o157:H7 in stool
Hct27% ( > 40%) Platelets 70K ( > 150K)
Cr 1.8 (
Hemolytic-Uremic Syndrome
what is Hemolytic-Uremic Syndrome
Renal failure, hemolytic anemia, and thrombocytopenia
what is an important cause of acute renal failure in children?
Hemolytic-Uremic Syndrome
what does causes Hemolytic-Uremic Syndrome most commonly?
E.coli
what else can cause Hemolytic-Uremic Syndrome
Shiga toxin producing “verotoxin” which causes endothelial damage in glomeruli and interstitial vessel thrombosis.
E. coli O157:H7 most common
salm or shig less commonly
what are the age ranges for Hemolytic-Uremic Syndrome
6 mo - 4 years
Presentation:
-Abdominal pain, Vomiting and diarrhea (often bloody)
-Within a week, weakness, pallor, irritability, petechiae, oliguria
-Profound anemia, increased retic count
Platelet deposition microvascular occlusion
-HTN and seizures in some ~20%
Endothelial damage CNS
HUS
what does blood smear show for HUS?
Schistocytes, burr cells, fragmented RBC
= intravascular hemolysis
what does CBC show for HUS?
Leukocytosis common,
Platelets low
Retic count – high
what does UA show for HUS?
- hematuria, proteinuria, casts
how do you treat HUS?
Management – Primarily directed at renal failure (managing fluid and electrolytes )
No antibiotics: increases risk of HUS
No antidiarrheals: increases exposure to VT toxins
how quickly do children recover from HUS?mortality?
most commonly children recover within 2-3 weeks. 95%
50% recover normal renal function
Residual disease (ie HTN) ~ 30% , end stage renal disease ~ 15%.
Mortality associated with CNS complications 3-5%
what are prerenal cause of ARF?
Hypovolemia leads to underperfusion ATN
dehydration – most common in kids
Hemorrhage
burns
Poor cardiac output (heart failure , septic shock)
what is the most common cause of prerenal ARF
Hypovolemia leads to underperfusion ATN
what are renal causes of ARF?
Acute glomerulonephritis, vasculitis, myoglobinuria
Hemolytic-uremic syndrome
Nephrotoxic injury (medications ie gent , acyclovir)
what are post renal causes of ARF?
obstructive
marked by Sudden inability to excrete urine. Filtration and formation of urine dependent on RBF – dependent on CO and volume.
ARF
how do you treat ARF
dialysis
what are the complications of ARF?
Fluid overload
Hyperkalemia +/- hyponatremia
Metabolic acidosis
Uremia
what is the course of ARF?
Polyuria and recovery, or
Chronic Renal Failure
what are causes of CRF? under 10 and over 10
Congenital/developmental abnormalities of kidneys < 10y
Nephritis/Nephrosis (membranoproliferative GN undx) >10y
Hemolytic uremic syndrome or other causes of acute renal failure that don’t resolve
what are complications of CRF?
Hypertension
Metabolic acidosis, Growth failure, disturbances of Ca, PO4, Vit D. rickets
Anemia (normocytic, normochromic)
Later on – uremia -malaise, anorexia, nausea and CNS - coma
how do you manage CRF?
Diet and medical management
Dialysis & transplantation
renal cause of HTN?
Renal parenchymal disease
Renovascular ( ie renal artery stenosis, arterial clot)
PCKD, GN, HUS, SLE, toxins
CV causes of HTN?
coarctation of aorta
hormone cause of HTN?
Catecholamine excess
Pheochromocytoma
Endocrine
CAH, Cushings syndrome, or steroid therapy
how is essential HTN diagnosed?
diagnosis of exclusion
what is a tumor that secretes catecholamines?
pheochromocytoma
HTN +Abdominal bruit, diminished leg pulses=
CoA
HTN +Café au lait spots =
neurofibromatosis
HTN +Flank Mass =
Kidney disease
HTN +Ataxis / opsoclonus =
neurblastoma
HTN +Tachycardia with flushing and diaphoresis=
pheochromocytoma
HTN +Truncal obesity, acne, striae =
cushings
Most common secondary HTN etiology in childhood is
renal
what are renal causes of HTN
Renin-angiotensin system “failure”
Parenchymal disease or renal vascular abnormalities
how do you treat 2ndary HTN
ACE inhibitors, Ca-channel blockers
how do you treat HTN crisis?
Nifedipine, Hydralazine, nitroprusside
when does AAP recommends age to screen BP is
3
who in the neonates gets UTI?
Males > Females 3-5:1
Uncircumcised > circumcised
who in infants and children gets UTI?
boys rare after infancy 3% to 8% of girls Peak age around toilet training Uncommon after age 8, but Common again in sexually active teens
gold standard of getting urine from a lil one is?
supra pubic tap
will a UA be neg in pediatric UTI?
yes 20% of the time
what is gold standard of dx a UTI?
culture
what is the most common bug of UTI?
E.coli
what bacteria causes UTI in sexually active?
Staph saphrophyticus
how do you treat complicated UTI?
Inpatient
IV Amp and Gent
what is the presentation of complicated UTI?
High fever
Persistent vomiting
Dehydrated
any child less than 3 mo with a uti
considered complicated and should be hospitalized
how do you present with uncomplicated uti?
Nontoxic
Tolerating oral medications and fluids
how do you tx uncomplicated UTI?
Cephalosporins
Trimethoprim/Sulfa
Augmentin
7-10 days in children
who needs prophylaxis of UTI?
– recurrent UTI, high grade VUR
what do you use for prophylaxis of UTI
Bactrim and Macrobid
who should have a renal US?
All infants 2- 24 months with first UTI
what does renal US show?
Kidney size, number and position Hydronephrosis (dilation of pelvis & calyces) Hydroureter (dilation of ureter) Dysplasia Renal scarring
who should get a VCUG?
If RUS abnormal
If recurrence of febrile UTI
what does VCUG show?
Bladder anatomy
Vesicoureteral reflux (and grade of reflux)
Posterior urethral valves
who has voiding dysfxn?
Frequent in preschool age kids
what causes voiding dysfxn?
Immaturity of bladder and micturition pathways
when should child be continent?
4-5yrs
how do you work up voiding dysfxn?
UA and Ucx for UTI
how do you treat voiding dysfxn?
Behavioral modification: bed wetting alarms
Rx imipramine or DDAVP in selected kids
Inguinal hernias common
what is hypospadias?
Malposition of the urethral opening
Not assoc with urinary tract anomalies
how do you treat hypospadias?
Complex surgical repair in males
DO NOT CIRCUMCIZE
when is hypospadias repaired?
before 18 mo
what are 2 anomalies of the penis?
phimosis, paraphimosis
what is phimosis?
adherence of foreskin
Physiologic: should be retractable by adolescence
how do you treat phimosis?
, topical steroids, gentle stretching, circ
what is paraphimosis?
retractable behind glands, then stuck: causing swelling and pain
how do you treat paraphimosis?
lubricant to reduce, or emergent circumcision.
what is cryptorchidism?
: undescended teste
most of the time cryptorchidism is
unilateral in the canal
Inability to palpate testes does not =
cryptorchidism
when does spontaneous descent not occur after?
1 yrs
if they dont decend cryptorchidism has an increased risk of?
cancer and infertility
how does testicular torsion present?
Enlarged testis
Tender on palpation
Cremasteric reflex absent
The major cause of the acute scrotum in boys < 6y
testicular torsion
on testes:
Blueish hue
Transilluminates
Hydrocele
how do you dx testicular torsion?
US with doppler
the bp cuff should cover…
2/3 of the arm
what could cause renal HTN in the newborn period? 3
Congenital anomalies of kidneys or renal vasculature
Obstruction of urinary tract
Thrombosis of renal vasculature or kidneys
what can cause nephrolithiasis?
-Inborn errors of metabolism
Cystine, glycine, urates, oxlates
-Hypercalciuria (familial) , distal RTA
-Large stones in children with spina bifida with paralyzed lower limbs. (Neurogenic Bladder)
what are symptoms of nephrolithiasis? radiates?
colicky pain in flank or lower abdomen
Can radiate to the groin
Vomiting common
Younger children: mottling and fussiness.
what studies should be done for nephrolithiasis?
RUS will see stones in the kidney
CT to visualize lower tract
No contrast – will obscure view
how do you treat nephrolithiasis?
Treat primary problems
Hydration and pain control
Surgery rare – only obstruction, intractable pain, chronic infections.
what are causes of UTI?
-Dysfunctional voiding Delayed voiding Incomplete bladder emptying Spina bifida and other nerve damage -Poor hygiene – ascending infection, >85% Ecoli. (nl fecal flora) -Sexual activity -Vesicoureteral Reflux (cause vs. effect) -Neurogenic bladder -Obstruction Hydronephrosis Mass Constipation
how does a neonate present with UTI
Vomiting, fever or hypothermia, poor weight gain, strong urine odor ,
how does an infant present with UTI?
Vomiting, diarrhea, fever, poor weight gain, strong urine odor
how does a child present with UTI?
Vomiting, abdominal or flank pain, fever, frequency, urgency, dysuria, enuresis
how does an adolescent present with UTI?
Fever, abdominal or flank pain, frequency, urgency, dysuria
what is unusual in children with UTI
CVA tenderness
