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3A Paediatrics > Renal > Flashcards

Renal Flashcards

1
Q

What is oedema

A

Defined as an increase in interstitial fluid

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2
Q

In a clinical setting what causes oedema?

A

“swelling”, pitting oedema, facial puffiness, ascites, pleural effusions, pulmonary oedema

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3
Q

What are some causes of increased interstitial fluid

A
  • Obstruction of lymphatic drainage
  • Obstruction of venous drainage
  • Lowered oncotic pressure
  • Salt and water retention
    Venous obstruction (venous thrombosis)
    Lymphoedema - congenital or blockage
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4
Q

What causes of lowered oncotic pressure and what does it cause?

A

Low albumin/ protein
Malnutrition
Decreased production:
Liver
Increased loss:
Gut
Kidney- nephrotic syndrome

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5
Q

What causes increased Salt and Water retention

A

Kidney – impaired GFR

Heart failure

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6
Q

3 year old boy referred by GP with a 3 days history facial swelling, abdominal swelling. Treated for allergy. Passing foaming urine. Well in himself. Recent cold 10 days ago. No PMHx. No FHx.

Useful findings
Differential diagnosis
Initial investigation
Initial management

A
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7
Q

3 Key features of Nephrotic syndrome

A

Heavy proteinuria
Hypoalbunaemia
Oedema

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8
Q

What do we have in nephrotic syndrome

A

Podocytes

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9
Q

What does quantitative heavy proteinuria look like?

A

First morning urine protein:creatinine

Normal < 20 mg/mmol
No definite level that is nephrotic

BUT > 600 mg/mmol likely to produce hypoalbuminaemia BUT occurs at lower levels

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10
Q

Semin- quantitative proteinuria

A

Negative 0 mg/dL
trace 15-30
1+ 30-100
2+ 100-300
3+ 300-1000
4+ >1000

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11
Q

Hypalbuminaemia features

A

Normal range ~ 35 – 45 g/l
Fluid retention & oedema usually with albumin < 25 – 30 g/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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12
Q

What are the 3 types of nephrotic syndrome?

A

Congenital NS (<1 year)
Steroid sensitive NS
Steroid resistant NS

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13
Q

Features of steroid sensitive NS

A

Normal BP
No macroscopic haematuria
Normal renal function
No features to suggest nephritis
Respond to steroids
Histology – “minimal change” usually

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14
Q

Features of steroid resistant NS

A

Elevated BP
Haematuria
May be impaired renal function
Features may suggest nephritis
Failure to respond to steroids
Histology – various, underlying glomerulopathy, basement membrane abnormality

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15
Q

S + S of Steroid sensitive NS

A

Peak age of onset 2 – 5 yrs
M > F
Higher incidence in those from Asian sub-continent
? Immunological aetiology
Recurrent relapses
~ 5% continue into adult life
Normal renal function if steroid responsive

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16
Q

Treatment for SSNS

A

Standard course of prednisolone for first episode:
60mg/m2 for 4 weeks
40mg/m2 on alternate days for 4 weeks

Other considerations:
Na & water moderation
Diuretics
Pen V
Measles & varicella immunity & pneumococcal immunisation

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17
Q

Features of acute glomerulonephritis

A

Haematuria – often macroscopic
Proteinuria – varying degree

Impaired GFR – rising creatinine, variable degree

Salt and water retention – hypertension, oedema

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18
Q

Features of acute post-streptococcal glomerulonephritis

A

Nasopharyngeal or skin infection
Gp A β haemolytic streptococcus, “nephritogenic” strains

Antigen-antibody complexes in glomerulus, complement activation

Clinical nephritis 10 days post infection
Haematuria, swelling, decreased urine output

Oedema, hypertension, signs of cardiovascular overload

19
Q

3 types of AKI

A

Pre- renal

Renal

Post renal

20
Q

IN RAAS Aldosterone is released by angiotensin II which also causes increased BP - what does this cause

A

Salt and Water retention

21
Q

Management of acute post-streptococcal glomerulonephritis

A

Fluid balance – measurement of input/output, fluid moderation, diuretics, salt restriction
Correction of other imbalances – potassium, acidosis
Dialysis - if needed (uncommon)
Penicillin - treatment of streptococcal infection

22
Q

Prognosis of Acute post-streptococcal glomerulonephritis

A

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

23
Q

Investigations for Acute post-streptococcal glomerulonephritis

A

FBC – mild normochromic, normocytic anaemia

U&Es – increased urea and creatinine, (hyperkalaemia, acidosis)
Immunology – raised ASOT/antiDNAse B titre, low C3, C4
Throat /other swabs
Urinalysis

Haematuria – usually macroscopic

Proteinuria – dipstick, protein:creatinine

Microscopy – RBC cast

24
Q

What is Henoch-Scholein Purpura (HSP)

A

Vasculitis
Affects
Skin
Joints
Gut
Kidneys

25
Q

Features of HSP nephritis

A

IgA deposition

Variable renal presentation:
haematuria/proteinuria
nephrotic syndrome
acute nephritis
renal impairment
hypertension
If nephrotic are steroid resistant, may need alternative immunosuppression and/or other anti-proteinuric measures
Variable prognosis, may be ESRD

26
Q

What is the definition of a UTI?

A

Growth of bacteria within the urinary tract - (105 organisms/ml grown on culture of appropriate sample)
Acute pyelonephritis ie upper tract UTI
Acute cystitis ie lower tract UTI

27
Q

Why are finding UTIs in children important

A

3-5% of girls & 1-2% of boys
Can cause significant acute illness
50% rate of reoccurrence
50% have structural abnormality – presenting symptom
Long term complication : kidney scarring – hypertension – CKD
Heavy burden on the NHS and families

28
Q

When should we suspect UTI in infants younger than 3 months?

A

Fever
Vomiting
Lethargy
Irritability
Poor feeding
Failure to thrive
Abdominal pain
Jaundice
Haematuria
Offensive urine

29
Q

When should we suspect UTI in preverbal children older than 3 months?

A

Fever
Abdominal pain
Loin tenderness
Vomiting
Poor feeding
Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive

30
Q

When should you suspect UTI in verbal children over 3 months?

A

Frequency
Dysuria
Dysfunctional voiding
Changes to continence
Abdominal pain
Loin tenderness
Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine

31
Q

When do we need a urine sample?

A

with symptoms and signs of UTI (from table above)
with unexplained fever of 38°C or higher
with an alternative site of infection but who remain unwell
All infants younger than 3 months with suspected UTI should be referred to paediatric specialist care and a urine should be sent for urgent microscopy and culture

32
Q

How do we collect a urine sample?

A

MSU
clean catch - recommended method
urine collection pads
catheter samples or suprapubic aspiration (SPA)
Before SPA is attempted, ultrasound guidance should be used to demonstrate the presence of urine in the bladder.
Do not delay treatment in seriously ill infants

33
Q

How should we analyse urine?

A

Visual inspection
Dipstick
Nitrites
Leucocyte esterase
M,C & S

34
Q

Microscopy results

A

Bacteria Pos Pyuria Pos: UTI
Bacteria Neg Pyuria Pos: Antibiotic treatment should only be started if clinically UTI (Could be partially treated UTI
Bacteria Pos Pyuria Neg: UTI
Bac neg Pyuria neg: No UTI

35
Q

How do we interpret results for a UTI?

A

105 organisms/ml of single bacteria on a CCU/MSU is the bacteriological criterion for UTI Diagnosis
Any growth on a SPA is considered significant
E. coli – most common bacteria
Proteus – more common in boys
Pseudomonas – may indicate structural abnormality

36
Q

When do children need admission?

A

< 3months
Systemically unwell
Significant risk factors

37
Q

How do we treat Infants younger than 3 months with a UTI

A

Minimum 2-4 Days IV antibiotics followed by oral

38
Q

How do we treat Systemically wellChildren with no systemic features and absence of significant fever

A

Treat with 3 days oral antibiotics. Advised to return if no better at 24-48hrs for reassessment

39
Q

How do we treat Systemically Unwell
(Fever > 38 +/- loin pain / tenderness

A

Treat with 7-10 days oral antibiotics (Consider IV antibiotics according to clinical judgement. Use lower threshold for IV antibiotics in younger children, those with significant risk factors and severely ill.)

40
Q

What are the features of 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 48hrs

41
Q

What are the features of recurrent UTI

A

Two or more UTI episodes at least one episode with systemic symptoms or signs
Three or more UTI’s without systemic symptoms/ signs

42
Q

Investigation of UTI

A

ULTRASOUND RENAL TRACT
- Non – invasive
- Observer dependent
- Size and drainage of kidneys & bladder
- Good for ? obstruction

Micturating cystourethrogram
- Vesicoureteric reflux
- Bladder
- Posterior urethra

DMSA scan
Radionuclide imaging
Dimercaptosuccinic acid (DMSA) scan
Relative renal function
Renal “scarring

43
Q

What is the Vesicoureteric reflux

A

Retrograde flow of urine from bladder into ureter/ pelvicalyceal system/intrarenal
Severity graded on level of reflux and associated dilatation, clubbing
Associated with UTI, renal abnormality

44
Q
A

3A Paediatrics (19 decks)

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