Renal Flashcards
What is acute pyelonephritis
An upper tract UTI
What is acute cystitis
A lower tract UTI
What increases your risk of developing UTIs
- Urinary Tract normal in most UTIs BUT:
Vesicoureteric Reflux
Renal Abnormality
What is vesicoureteric reflux
Retrograde flow/Reflux of urine from bladder into ureter and sometimes to kidneys usually due to abnormal ureter
What are the grades of vesicoureteric reflux
Severity grade 1-5: (severity of reflux, dilation)
- Incomplete filling of upper urinary tract without dilation
- complete filling +/- dilation
- ballooned calyces
- Megaureter
- Megaureter +/- Hydronephrosis
What are some examples of renal abnormality
Malpositions e.g ectopic kidney
Duplications e.d double ureter
Megaureter + Hydronephrosis
Horseshoe Kidney
How may an infant present with a UTI
@ Often Non-specific
May present collapse with septicaemia
How may a toddler present with a UTI
@ Often Non-specific Vomiting, 'Gastroenteritis symptoms', Failure to Thrive, Colic, Fever
What specific symptoms may be seen in an Upper UTI
Fever
Systemic Illness (meningitis infancy)
Loin/Abdo Pain
Failure to thrive/Jaundice - infancy
What specific symptoms may be seen in a lower UTI
Dysuria Urinary Frequency/ Urgency Incontinence Lower Abdo pain Haematuria
What are the long term complications of recurrent UTIs
Renal Scarring
Hypertension
Renal failure
Chronic Pyelonephritis
How does renal failure occur from UTIs
Due to renal scarring secondary to UTI +/- VUR and chronic pyelonephritis
What does chronic pyelonephritis cause
Hypertension
Renal Failure
How is a UTI diagnosed
MSU sample - dipstick and MC&S
What would you likely see on a dipstick if UTI was present
Nitrates and WCC +ve
How would you get a urine sample in a child
Clean catch sample - least invasive
Catheter - invasive
Suprapubic Aspirate - invasive
When may you investigate UTIs in children further
Contraversial but investigate more intensily those under 6 mths - imaging dependent on age and type of infection
What investigations may you do to investigate UTIs further
US
DMSA scan
Micturating Cystourethrogram
What can an US detect for UTIs and why may it be used first
- Its cheap/ non invasive and effective!
- Size, location and drainage of kidney and bladder
- Scars may be visible
- Good predictor for abnormal DMSA scan
What is a DMSA scan and what’s it used for
Radionucleotide Imaging
Shows Renal scarring
What is micturating Cystourethrogram and what are its disadvantages
Its Invasive and Unpleasant
BUT best way of investigating vesicoureteric reflux
How do you manage a UTI in those under 3 months
IV amoxicillin + Gentamicin
- Increase oral fluids and give pain relief
How do you manage a UTI in those over 3 months
Trimethoprim or Nitrofurantoin
- Increase oral fluids
- give pain relief
How can you prevent recurrent UTIs
- Prophylaxis: Trimethoprim
- Screen for reflux if prophylaxis fails
- Avoid predisposing factors
What are predisposing factors for UTIs
- Constipation
- Back to front wiping
- Nylon
- Bubble Bath
- Low fluid intake
What can cause Enuresis
- Diabetes
- UTI
- GU abnormality
- Overactive Bladder
- Child Abuse
- Systemic Illness
What is secondary Enuresis
- enuresis after >6 mths dryness
- Raises concerns
- e.g Child Abuse, Systemic illness
How is eneureis managed
- Ix possible causes
- Reassurance and advice to parents
- Avoiding Caffine
- Reward Systems
What is Hypospadias
Abnormal position of external urethral meatus on ventral penis
What is Epispadias
Abnormal position of external urethral meatus on dorsal of penis
What may concern people with Hypospadias/Epispadias
How is it managed?
Cosmetic Appearance
Difficulty urinating while standing
RX: Surgical repair
What are the 2 cause of increased interstitial fluid
- Reduced Oncotic pressure due to increased loss of albumin - Nephrotic Syndrome
- Salt and Water Retention due to the kidneys impaired GFR - Nephritic Syndrome
What is AKI
Rapid increase in creatine or development of oliguria/anuria
What can cause AKI
- Cardiac Surgery
- Bone Marrow Transplant
- Toxicity/Drugs (NSAIDs, Vancomycin, Acyclovir)
- Acute Tubular Necrosis
- Sepsis
- Diarrhoea/Dehydration
- Glomerulonephritis
- Drug induced haemolysis
- Snake Biyes
- Haemolytic Uraemic Syndrome
What causes Acute Tubular Necrosis
Crush Injurys Burns Dehydration Shock Sepsis Malaria
How is AkI severity assessed
RIFLE criteria - based on changes to eGFR or urine output and outcome measures e.g end stage renal failure/loss of kidney function
What investigations may be performed in AKI
Plasma: Increased K+, Creatine and Urea, Low Ca2+, Na+ and Cl, Clotting (DIC)
MSU: Red cell casts or dipstick may be +ve for microhaematuria
US: Ureters dilated, stones
ECG
Immunology: C3, C4, ANA, ASO titre
How do you treat AKI
- Treat shock and dehydration
- Fluid balance: avoid overhydration, replace losses
- Monitor BP - and treat with diuretics
- Monitor K+ with ECG - tall tented T waves (give salbutamol or glucose with soluble insulin)
- Monitor Acidosis
- Dialysis - uncommon
What is haemolytic Uraemic Syndrome
RARE
- Haemolytic anaemia, thrombocytopenia, renal failure + endothelial damage to glomerular capillaries
- Typical HUS: Associated with Diarrhoea
What is the cause of Typical HUS
Shigella Toxin producing E.coli
How does HUS present
- Colitis
- Haemoglobinuria
- Oliguria +/- CNS signs
- Encephalopathy
- Coma
What may be found on investigations off HUS
LDH high
WCC high
Coombs -ve
PCV low
How do you treat HUS
Paediatric Nephrology for early dialysis and treatment of renal failure
What causes chronic renal failure
Congenital dysplastic kidneys Pyelonephritis Glomerulonephritis Recurrent UTIs and VUR AKI
What are complications of Chronic renal failure
Acidosis
Renal Osteodystrophy - poor mineralisation
Anaemia - low erythropoietin
How does chronic renal failure present
Weakness Tiredness Vomiting Headache restlessness twitches raised BP Anemia Failure to thrive Seizures Coma
How do you treat chronic renal failure
Haemodialysis
Kidney transplant
What are the key features of glomerulonephritis (nephritic syndrome)
Haematuria and Oliguria
+/ raised BP +/- uraemia
What are the causes of Glomerulonephritis
- Beta Haemolytic Strep via proceeding sore throat
- Henoch - Schonlein Purpura
- Others: Toxins, Heavy metals, malignancy , viruses, SLE
How does uncomplicated glomerulonephritis present
- Haematuria
- Oligouria
- BP raised
- Periorbital Oedema
- Fever
- GI disturbance
- Loin Pain
How does complicated glomerulonephritis present
- Hypertensive Encephalopathy: headache, fits, loss of vision, vomiting, coma
- Uraemia: acidosis, twitching, coma
- Cardiac: gallop rhythm, cardiac failure
What investigations should you do for glomerulonephritis
- FBC & U&Es - Urea and Creatine raised
- Compliments - C3 low and C4 normal
- ASO titre
- ANA and ANCA
- Syphillis serology, blood cultures, virolgy
- MSU: haematuria, proteinuria, & RBC casts
- Throat Swab
- Renal US and CXR for fluid overload
How do you manage Glomerulonephritis
- Treat the cause!
- HTN - Salt restriction and Diuretics
- Fluid Management to prevent overload in those with oligouria
How does poststreptococcal Glomerulonephritis present
Clinical nephritis 10 days post infection following:
- Nasopharyngeal Infection (pharyngitis)
- Skin Infection (Impetigo)
How does poststreptococcal glomerulonephritis occur
Antigen- Antibody complexes deposited in Glomerus leads to complement activation
How does poststreptococcal glomerulonephritis present
Gross haematuria and oliguria Oedema and HTN Malaise, Anorexia, Fever, Abdominal pain
How is post step glomerulonephritis diagnosed
Urinalysis: proteinuria, RBC casts +/- oliguria
Blood: raised urea, creatine, low C3
Step infection confirmed - raised ASO titre
throat swab
How do you treat post strep Glomerulonephritis
Prognosis is good!
- HTN: Monitor BP, Na+ restriction, Fluid Balance, diuretics and antihypertensives
- Restrict protein in oliguria phase
- Give penicillin
- Dialysis - uncommon
What is Henoch - Schonlein Purpura (HSP)
- Acute immune complex mediated vasculitis caused by IgA deposition in the vessels e.g kidneys - Glomerulonephritis
when do most people develop HSP
- most people have a proceeding URTI
How does HSP present
The classic Triad:
- Purpura (purple spots/nodules)
- Arthritis/ Arthalgia often knees/ ankles
- Abdo Pain
Other signs: renal involvement: haematuria/proteinuria, acute nephritis, renal impairment, HTN
What investigations may be performed in HSP
ESR raised IgA raised Proteinuria ASO titre raised U&Es BP raised
What are the complications of HSP
Massive GI bleeds
Acute Renal Failure
What is the treatment for HSP
- Usually self limiting
- Steroids can be effective e.g prednisalone
- Steroid resistant? - Immunosupression with Cyclophosphamide
How do you suppress SLE
Steroids and Cyclophosphamide
What is nephrotic syndrome
Massive increase of filtration of macromolecules across glomerulus causing massive proteinuria
What are the key features of nephrotic syndrome
Heavy Proteinuria
Hypalbuminaemia
Oedema: pitting oedema, gravitational
Hyperlipidaemia
How does steroid sensitive nephrotic syndrome present
- normal BP
- No macroscopic haematuria
- Normal renal function
- No features of nephritis
- Responds to steroids
- Histology: minimal change usually
How does steroid resistant nephrotic syndrome present
- Elevated BP
- Haematuria
- Impaired renal function
- features may suggest nephritis
- fails to respond to steroids
- histology: various underlying glomerulopathy e.g basement membrane
What type of nephrotic sndrome is most common in children
Steroid Sensitive - mainly minimal change GN
associated with allergy and IgE production
What are the symptoms of Nephrotic Syndrome
Oedema Anorexia GI disturbance Infections Irritability
What would you find on investigation of nephrotic syndrome
urinalysis: frothy, increased protein +/- casts, low sodium
Blood: low albumin, urea and creatine usually normal
Renal Biopsy: older children/ treatment failures
Wha are the complications of nephrotic syndrome
Increased infections - due to Ig loss in urine
AKI doe to hypovolaemia
How do you treat nephrotic syndrome
- Prednisolone
- If steroid toxic or relapsing - Cyclophosphamide
- Eat healthy - Na, protein and fluid moderation
- Consider diuretics if very oedematous
- Albumin Infusion in symptomatic hypovolaemia
- Consider routine vaccination for pneumococcal, Measles etc.
Key differences between nephrotic and nephritic syndrome
Nephritic
- Haematuria
- High BP
- Oliguria
- Uraemia and high creatine in blood
- Slight proteinurea
- Normal Albumin
Nephrotic
- Heavy proteinuriea
- Hypoalbuminaemia
- Oedema
- Usually normal BP
- Normal creatine and urea in blood
