Renal Flashcards
Urinary Tract Infection
Common infection which is important to investigate properly in children due to potential for structural abnormalities in the urinary tract and scarring of the kidneys if pyelonephritis develops which can lead to renal failure.
Common organisms that cause UTI
: E coli, Klebsiella, Proteus, Pseudomonas
Symptoms of UTI in infants
Fever, vomiting, lethargy, poor feeding, jaundice, septicaemia, smelly urine and febrile convulsions
Symptoms of UTI in Older Children
Dysuria, abdominal pain, fever, lethargy, vomiting/diarrhoea, haematuria, smelly/cloudy urine
Ix for UTI
A clean catch urine sample needs to be collected for dipstick which often can be very difficult for children. - In the older child, a midstream urine sample can be used and cultured. - Ultrasound of urinary tract and kidneys
Management of UTI
Antibiotics - IV for all those <3 months e.g Cefotaxime
Atypical UTI Symptoms/Signs
- Seriously ill/Septicaemia - Poor urine flow - Abdominal mas - Raised creatinine - Failure to respond to Abx within 48 hours - Infection with non E coli organism
What happens to people presenting with Atypical UTIs?
All those with an atypical UTI should undergo ultrasound to look for abnormalities with potential DMSA and MCUG scans to look for scarring and vesicoureteric reflux.
UTI Prevention
- High fluid intake to produce a high urine output - Regular voiding - Ensuring complete bladder emptying - Prevention/Treatment of constipation - Prophylactic Abx can be considered
What is pediatric pyelonephritis?
Pediatric pyelonephritis is an infection of the kidneys in children, typically resulting from bacteria ascending from the bladder to the kidneys, leading to inflammation and potential kidney damage.
Which bacterium is most commonly responsible for pediatric pyelonephritis?
A) Klebsiella species
B) Escherichia coli
C) Pseudomonas aeruginosa
D) Enterococcus species
B) Escherichia coli
List common risk factors for developing pyelonephritis in children.
Bladder dysfunction
Bladder obstruction
Neurogenic bladder
Vesicoureteral reflux (VUR)
Use of urinary catheters
True or False: Fever and flank pain are specific indicators of pyelonephritis in children.
False. While fever and flank pain are common in pyelonephritis, they are neither sensitive nor specific indicators.
In infants, the most common presenting findings in pyelonephritis are _______ and _______.
Fever and irritability
Which imaging modality is considered the most reliable for diagnosing acute pyelonephritis in children?
A) Ultrasound
B) CT Scan
C) DMSA Scan
D) MRI
C) DMSA Scan
What laboratory findings are commonly associated with pediatric pyelonephritis?
Elevated peripheral white blood cell counts
Elevated nonspecific markers of inflammation
Which of the following is an appropriate oral antibiotic for treating acute pyelonephritis in children?
A) Amoxicillin/clavulanate
B) Ciprofloxacin
C) Doxycycline
D) Azithromycin
A) Amoxicillin/clavulanate
True or False: A 5-day course of antibiotics is sufficient for treating acute pyelonephritis in children.
False. A 10-day treatment regimen is recommended for children with suspected pyelonephritis.
Name potential complications of untreated pyelonephritis in children.
Kidney scarring
High blood pressure
Reduced kidney function
Sepsis
Meningitis (in infants)
Prompt medical care for children with a UTI and _______ is critical to prevent possible permanent kidney damage.
Fever.
True or False: Acute pyelonephritis is a rare bacterial illness during childhood.
False. Acute pyelonephritis is one of the most serious bacterial illnesses during childhood.
Which of the following ultrasound findings may indicate pyelonephritis?
A) Kidney enlargement
B) Loss of corticomedullary differentiation
C) Abscess formation
D) All of the above
D) All of the above
Define pyelonephritis.
Pyelonephritis is inflammation of the kidney, typically due to a bacterial infection, leading to symptoms such as fever, flank tenderness, and urinary abnormalities.
What are the long-term management strategies for children with recurrent pyelonephritis?
Investigate for underlying anatomical abnormalities
Consider long-term preventive antibiotic treatment
Monitor kidney function regularly
Nocturnal Enuresis
Known as ‘bed wetting’, this is a common problems of middle childhood
Causes of Nocturnal Enuresis
There is a genetically determined delay in acquiring sphincter competence and emotional stress can cause secondary enuresis however underlying disorders should always be considered: 1. UTI 2. Faecal retention which is severe enough to reduce bladder volume and cause bladder dysfunction 3. Polyuria from osmotic diuresis
Management of Nocturnal Enuresis
Explanation to the child and the parent that this is common and beyond conscious control - Star charts - Enuresis Alarm -Desmopressin
What is the function of an enuresis alarm ?
sounds when it becomes wet to awaken the child
Desmopressin function
used to provide short term relief from bedwetting
Acute Kidney Injury (AKI)
Acute renal failure with oliguria (<0.5ml/kg/hour) is usually present
Prerenal causes of AKI
Hypovolaemia caused by infections such as gastroenteritis, burns, sepsis, haemorrhage and nephrotic syndrome
Renal causes of AKI
HUS, vasculitis, renal vein thrombosis, acute tubular necrosis, glomerulonephritis, pyelonephritis
Post Renal causes of AKI
obstructions such as posterior urethral valves, blocker catheters
Management of AKI
- Regular monitoring of circulation and fluid balance 2. Ultrasound scan to identify any obstruction of the urinary tract 3. Treatment depending upon the cause e.g. fluid replacement, assessment of the site of obstruction, renal biopsy 4. Dialysis in severe cases
What is the most common cause of AKI in children?
Pre renal causes
Chronic Renal Failure
eGFR < 15ml/min
Causes of Chronic Renal Failure
- Structural malformations - Glomerulonephritis - Hereditary nephropathies - Systemic diseases
Symptoms of Chronic Renal Failure
- Symptoms generally do not develop until renal function falls to less than ⅓ of normal and is often picked up on antenatal ultrasound - Anorexia and lethargy - Polydipsia and polyuria - Faltering growth
- HTN
- Acute-on-chronic renal failure precipitated by infection/dehydration
- Incidental finding of proteinuria
Managment of Chronic Renal Failure
- Sufficient feeding with good protein intake to maintain growth -> this can supplemented with NG/gastrostomy feeding if necessary - Phosphate restriction and activated vit D to prevent renal osteodystrophy - Bicarbonate supplements to prevent acidosis - EPO to prevent anaemia - Growth hormone - Dialysis and transplantation if necessary
Nephrotic Syndrome
When the basement membrane in the glomerulus becomes highly permeable to protein resulting in protein leaking into the urine
Nephrotic Syndrome - 3 key features
Proteinuria, Hypoalbuminaemia, Oedema
Nephrotic Syndrome - Proteinuria values
Proteinuria with 3+/4+ on urine dipstick or a urine protein:creatinine ratio of >200mmg/mol
Nephrotic Syndrome - Hypoalbuminaemia value
Hypoalbuminaemia <25g/l
Primary causes of Nephrotic Syndrome
Primary is generally an idiopathic cause (80-90%)
Most common cause of Nephrotic Syndrome in children
Minimal change disease
Secondary causes of Nephrotic Syndrome
systemic diseases such as HSP, SLE
Other causes of Nephrotic Syndrome
●drugs: NSAIDs, rifampicin ●Hodgkin’s lymphoma, thymoma ●infectious mononucleosis
Symptoms of Nephrotic Syndrome
Periorbital oedema, often on awakening - Scrotal, vulval, leg and ankle oedema -Ascites
- SOB due to presence of pleural effusions and abdominal distension
Ix for Nephrotic Syndrome
Urine dipstick - Urine protein:creatinine ratio - Urine microscopy - Urine cultures - Bloods - FBC, U+E, albumin, bone profile
Definitive dx for Nephrotic Syndrome
Renal biopsy (avoided in children)
Medical Management of Nephrotic Syndrome
- Corticosteroid therapy: - Prednisolone 60 mg/m2 /day in a single morning dose (maximum 80mg/day) for 28 days. - Then reduce dosage to 40mg/m2 /alternate day (maximum 50mg/alternate day) given once daily, for 28 days and then stop without tapering. 2. Diuretics may be needed to control oedema whilst the steroids are taking effect: furosemide 1-2mg/kg/day 3. Diet with reduced salty food diet 4. Pneumococcal immunisations - 23 valent pneumococcal polysaccharide vaccine
Complications of Nephrotic Syndrome
-Risk of relapses -Hypovolaemia -Thrombosis -Infection -Renal failure
Relapses of Nephrotic Syndrome
Most children will have remissions and relapses however the relapses will generally become less frequent and may stop once they are in teenage years.
What is Steroid-Resistant Nephrotic Syndrome
this is a potential complication of nephrotic syndrome and requires specialist paediatric nephrologist involvement.
Steroid-Resistant Nephrotic Syndrome is common in ___
Asian boys
What can Steroid-Resistant Nephrotic Syndrome cause
It can lead to hypovolaemia, thrombosis, infection and hypercholesterolaemia - It may resolve or can cause relapses and can progress to renal failure
Tx for Steroid-Resistant Nephrotic Syndrome
Some patients may respond to cyclophosphamide, tacrolimus or rituximab
Causes of Steroid-Resistant Nephrotic Syndrome
focal segmental glomerulosclerosis (most common) and membranous nephropathy.
Nephritic Syndrome
Inflammation within the nephrons on the kidneys
3 Key features of Nephritic Syndrome
Reduction in kidney function - Haematuria - Proteinuria
Causes of Nephritic Syndrome
Post Strep Glomerulonephritis, IgA nephropathy
What is Post Strep Glomerulonephritis ?
Occurs 1-3 weeks after a B-haemolytic streptococcus infection such as tonsillitis Immune complexes made up of streptococcal antigens, antibodies and
complement proteins get lodged in the glomeruli and cause inflammation and
AKI
What is IgA Nephropathy?
This condition is related to HSP which is an IgA vasculitis - IgA deposits in the nephrons of the kidneys causing inflammation
Ix for Nephritic Syndrome
- Urine microscopy - Protein and calcium excretion - Kidney and urinary tract ultrasound - Bloods including FBC, U+E, creatinine
Management for Nephritic Syndrome
- Supportive therapy of the renal failure - Diuretics and antihypertensive medications can be used for complications like HTN and oedema - Immunosuppressant medications such as steroids
Hypospadias
A condition affecting males where the urethral meatus (opening of the urethra) is abnormally displaced to the underside of the penis towards the scrotum. Hypospadias is a congenital condition where the urethral opening (meatus) is located on the underside of the penis instead of at the tip.
When is Hypospadias diagnosed?
It is a congenital condition which affects babies from birth and is usually diagnosed on NIPE exam
Managment of Hypospadias
Management is surgery which is usually performed after 3-4 months of age and aims to correct the position of the meatus and straighten the penis.
True or False: Hypospadias affects approximately 1 in 150 male infants.
t
Which of the following is a type of hypospadias?
A) Anterior (distal) hypospadias
B) Middle hypospadias
C) Posterior (proximal) hypospadias
D) All of the above
D) All of the above
Explanation: Hypospadias is classified based on the location of the urethral opening:
Anterior (distal) hypospadias: Opening near the tip of the penis.
Middle hypospadias: Opening located midway up the penis.
Posterior (proximal) hypospadias: Opening near the scrotum or perineum
What are common symptoms of hypospadias?
Abnormal location of the urethral opening
Downward urinary spray
Downward curve of the penis (chordee)
Hooded appearance of the penis
How is hypospadias typically diagnosed?
A) Physical examination
B) Blood tests
C) Imaging studies
D) Genetic testing
A) Physical examination
Explanation: Hypospadias is usually diagnosed at birth through a physical examination.
Which of the following is a common treatment for hypospadias?
A) Observation
B) Surgical correction
C) Both A and B
D) None of the above
B) Surgical correction
Explanation: Surgical repair is often performed between 6 to 24 months of age to correct the urethral opening and any associated abnormalities.
True or False: Most children with hypospadias have normal urinary and sexual function after surgical correction.
True. With appropriate surgical intervention, most children achieve normal urinary and sexual function.
What are potential complications of untreated hypospadias?
Urinary tract infections
Fertility issues
Psychological impact due to appearance
There is no known way to prevent hypospadias, as it is a congenital condition.
t
After surgical correction of hypospadias, how often should follow-up evaluations occur?
A) Annually
B) Every 6 months
C) As recommended by the healthcare provider
D) No follow-up needed
C) As recommended by the healthcare provider
Explanation: Follow-up care is individualized based on the surgical outcome and the child’s development.
What is pediatric phimosis?
Pediatric phimosis is a condition where the foreskin of the penis cannot be retracted over the glans (head) of the penis.
Which of the following is a type of phimosis?
A) Physiologic phimosis
B) Pathologic phimosis
C) Both A and B
D) None of the above
C) Both A and B Explanation: Phimosis is categorized into two types:
Physiologic phimosis: A normal condition in infants and young children where the foreskin is non-retractable due to natural adhesions.
PMC
Pathologic phimosis: Occurs when the foreskin becomes non-retractable due to scarring, infection, or other pathological causes.
True or False: Phimosis is uncommon in newborn boys.
False. Phimosis is a normal occurrence in newborn boys.
What are common symptoms of phimosis in children?
Difficulty retracting the foreskin
Pain during urination
Ballooning of the foreskin during urination
How is phimosis typically diagnosed?
A) Blood tests
B) Physical examination
C) Ultrasound
D) MRI
B) Physical examination
Explanation: A careful physical examination by a healthcare provider is usually sufficient to diagnose phimosis.
Which of the following is a recommended treatment for pathologic phimosis?
A) Topical steroid creams
B) Oral antibiotics
C) Observation
D) None of the above
A) Topical steroid creams
Explanation: Topical steroid creams can be effective in treating phimosis and should be considered before surgical options.
Which surgical procedure involves making a limited dorsal slit with transverse closure to treat phimosis?
A) Circumcision
B) Preputioplasty
C) Dorsal slit
D) Ventral slit
B) Preputioplasty
Explanation: Preputioplasty is a surgical procedure that involves making a limited dorsal slit with transverse closure to widen a narrow non-retractile foreskin.
What are potential complications of untreated phimosis?
Recurrent infections
Urinary retention
Paraphimosis
Scarring
To prevent phimosis, it is important to avoid _______ the foreskin in infants and young children.
forcibly retracting
True or False: Most cases of physiologic phimosis resolve without intervention by age 3.
True. Physiologic phimosis often resolves naturally as the child grow
What are pediatric renal malformations?
Pediatric renal malformations are congenital anomalies of the kidney and urinary tract (CAKUT) that result from disruptions in normal kidney and urinary tract development during fetal life.
Which of the following is a type of pediatric renal malformation?
A) Horseshoe kidney
B) Polycystic kidney disease
C) Renal agenesis
D) All of the above
D) All of the above
Explanation: Common congenital kidney anomalies include:
Horseshoe kidney: A condition where the kidneys are fused together.
Polycystic kidney disease: A condition where one or both kidneys are filled with cysts.
Renal agenesis: A condition where a baby is born with one or no kidneys.
True or False: Renal malformations are the most common cause of chronic kidney disease in children.
True. Congenital malformations of the kidney and urinary tract are the most common cause of chronic kidney disease in children.
What are common symptoms of pediatric renal malformations?
Frequent urinary tract infections (UTIs)
Persistent fatigue
Loss of appetite
Nausea and vomiting
Stunted growth
Edema/swelling of the belly, hands, feet, or face
Unexplained fever
How are pediatric renal malformations typically diagnosed?
A) Blood tests
B) Physical examination
C) Ultrasound
D) MRI
C) Ultrasound
Explanation: Congenital malformations of the kidney and urinary tract can usually be diagnosed by ultrasound during pregnancy.
Which of the following is a recommended treatment for pediatric renal malformations?
A) Observation
B) Surgical correction
C) Both A and B
D) None of the above
C) Both A and B
Explanation: Treatment depends on the specific malformation and its severity. Options may include observation, surgical correction, or other interventions as needed.
What are potential complications of pediatric renal malformations?
Chronic kidney disease
Hypertension
Recurrent urinary tract infections
Renal failure
True or False: The prognosis for children with renal malformations depends on the type and severity of the malformation.
True. The prognosis varies based on the specific malformation and its impact on kidney function.
Vesicoureteric reflux
Vesicoureteric reflux: Developmental abnormality where the ureters are displaced and enter directly into the bladder rather than at an angle causing reflux of urine into the renal pelvis and can cause scarring with UTI
What is pediatric vesicoureteral reflux (VUR)?
VUR is a condition where urine in the bladder flows backward into the ureters and kidneys, increasing the risk of urinary tract infections (UTIs) and potential kidney damage.
True or False: Vesicoureteral reflux is uncommon in infants and children.
False. VUR affects approximately 1-3% of all infants and children.
What are common symptoms of VUR in children?
Recurrent urinary tract infections (UTIs)
Fever
Painful urination
Abdominal or back pain
Incontinence
Which diagnostic test is commonly used to confirm VUR?
A) Abdominal ultrasound
B) Voiding cystourethrogram (VCUG)
C) Blood tests
D) MRI
B) Voiding cystourethrogram (VCUG)
Explanation: VCUG is the gold standard for diagnosing VUR, as it allows visualization of urine flow and reflux during bladder filling and voiding
How is the severity of VUR classified?
A) Grade I to V
B) Stage 1 to 5
C) Mild to severe
D) None of the above
A) Grade I to V
Explanation: VUR is graded from I to V, with Grade I being the mildest (reflux into the non-dilated ureter) and Grade V being the most severe (gross dilatation of the ureter, pelvis, and calyces; ureteral tortuosity; loss of papillary impressions).
Which of the following is a common treatment for VUR?
A) Prophylactic antibiotics
B) Surgical correction
C) Both A and B
D) None of the above
C) Both A and B
Explanation: Treatment may include prophylactic antibiotics to prevent UTIs and, in some cases, surgical correction to reimplant the ureter and prevent reflux.
True or False: Most cases of VUR resolve spontaneously.
True. Approximately 85% of Grade I and II VUR cases resolve spontaneously
What are potential complications of untreated VUR?
Recurrent UTIs
Kidney scarring
Hypertension
Renal failure
To prevent UTIs in children with VUR, it is important to maintain proper _______ hygiene.
perineal
How often should children with VUR be monitored?
A) Annually
B) Every 6 months
C) Every 3 months
D) As recommended by a healthcare provider
D) As recommended by a healthcare provider
Explanation: Follow-up care depends on the severity of VUR and the child’s response to treatment. Regular monitoring is essential to assess kidney function and detect any complications.
Haemolytic Uraemic Syndrome 3 Key features
A triad of acute renal failure (AKI), microangiopathic anaemia and thrombocytopenia.
Causes of Haemolytic Uraemic Syndrome
Usually occurs secondary to GI infection, contact with farm animals or eating uncooked beef. (E.coli, Shigella,)
Pathophysiology of Haemolytic Uraemic Syndrome
Toxin enters the GI mucosa and localises to the endothelial cells in the kidney causing activation of the clotting cascade and consumption of platelets. - Anaemia is caused by damage to RBC as they circulate
Symptoms of Haemolytic Uraemic Syndrome
- Reduced urine output - Haematuria - Abdominal pain - Lethargy and irritability - Confusion - Oedema - HTN
Managment of Haemolytic Uraemic Syndrome
- Early supportive therapy including dialysis usually gives a good prognosis - Anti hypertensives if needed - Careful maintenance of fluid balance - Blood transfusions if needed
