Renal and GU Disorders Lecture Flashcards
Heme positive urine is caused by:
Hemoglobin or Myoglobin
Heme negative urine is caused by:
Drugs
Dye
Foods
What type of evaluation is needed to determine hemoglobinuria or myoglobinuria?
Microscopic evaluation
The presence of hemoglobin FREE from red blood cells
*Occurs with rapid disintegration of RBCs, exceeding the ability of blood protein to bind with hemoglobin
(ie. hemolytic anemia)
Hemoglobinuria
Caused by skeletal muscle injury
*if present, there is a fivefold increase in serum CK being increased
SEEN IN RHABDOMYOLYSIS
(can be seen after trauma or even exercise)
Myoglobinuria
Best time of day to get UA?
Early morning
(if later in day, after exercise, could have myoglobinuria)
Urine culture
Renal ultrasound
Renal panel
CBC
Must rule out sickle cell
If hematuria persists!
Isolated asymptomatic hematuria without renal abnormalities in multple family members
presence of persistent microscopic hematuria, often initially seen in childhood
*May be intermittent
*No treatment
Benign familial hematuria
MC cause:
E. Coli**
Klebsiella
Proteus
Staph
UTIs
Often peaks during toilet training
More often in uncircumcised boys
UTIs
Bacteria involvement of upper urinary tract
Presents with:
abdominal pain, flank pain, fever, lethargy, N/V, ill appearing
Pyelonephritis
Dx by:
Urinalysis
Urine culture
PE findings
Renal ultrasound may be helpful, but not necessary (enlarged kidney)
abx therapy depends on bacteria that is cultured
Pyelonephritis
DOC for pyelo (to start on, may change when culture comes back)
Nitrofurantoin
Bacteria involvement of bladder
Presents with:
Dysuria
Frequency
Urgency
Sometimes odor
Abdominal pain
Incontinence in older kids
Cystitis
How is a dx of cystitis made?
History
PE
Urinalysis
Urine culture
(do not need imaging)
Positive urine culture without symptoms
Almost exclusive to girls
Often seen with long term catheter use
Asymptomatic bacteriuria
True or false….
You should only treat a UTI if culture confirms and symptoms are present
TRUE
What population can you use sterile collection bags
Infants
If a urine collection is obtained at home, what instructions do you need to tell the parent?
Keep the sample cold until processed!!!
First UTI before age 5
Febrile UTI
Recurring UTI
Male with UTI
what must be done?
IMAGING
(voiding cystourethrogram (VCUG)= image of choice)
Image of choice for kids wth UTI problems that need imaging?
Voiding cystourethrogram (VCUG)
if a kid has an indication to get a voiding cystourethrogram (VCUG), when should you do this?
2 weeks after the UTI
(the kid should be healthy)
In addition to voiding cystourethrogram (VCUG), this type of imaging may also be helpful in determining size, shape, and renal abnormalities
Renal ultrasound
As many as 10% of routine urine dipstick screenings will be positive for protein in ages ________
8-15 years old
If proteinuria is found on dipstick with absence of other findings or concerns, repeat the dipstick on…..
2-3 other occasions (early AM)
With persisting proteinuria, what is the test of choice?
24 hour collection
If a child with a repeat normal dipstick or a normal 24 hour excretion level, is further work up required?
NO
MC cause of persisting proteinuria in kids?
Orthostatic proteinuria
In orthostatic proteinuria….
- *low levels of protein** are excreted in the ________ position
- *higher levels** of protein are excreted in the ________ position
Low protein= supine position
High protein= upright position
MC type of primary nephrotic syndrome (loss of protein)
Minimal change disease
MC primary nephrotic syndrome
Glomeruli generally normal or minimal increase in mesangial cells (support cells for glomeruli)
Excellent response to corticosteroids
Minimal change disease
Least common primary nephrotic syndrome
Increase in mesangial cells
~50% of patients respond to corticosteroid therapy
Mesangial Proliferation
Most severe form of Primary Nephrotic Syndrome
Mesangial proliferation and segmental scarring, leading to sclerosis
only ~20% of pts respond to corticosteroids
condition is progressive, leading to end stage renal failure usually
Focal segmental glomerulosclerosis
Loss of protein
Nephrotic or Nephritic?
Nephrotic
MC in males, 2:1
Generally appears between ages 2-6 (but can be seen in infancy or adulthood)
Initial episode often follows illness, infections, or allergic reaction
Primary nephrotic syndrome
Presentation typical of:
facial and lower extremity edema
*edema becomes progressive and generalized over time
can lead to pleural effusions
addominal pain, diarrhea, irritability
Primary nephrotic syndrome
3-4+ proteinuria on dipstick (persisting)
Urinary protein exceeds 150mg/24 hour
Serum creatinine is normal to minimally elevated
Primary nephrotic syndrome
In primary nephrotic syndrome and child had generalized edema (including pleural effusion, ascites, etc)
what should happen?
HOSPITALIZATION!
(diuretics should be used cautiously in children
close monitoring of volume status is a MUST)
If initial renal episode occurs between ages 1-8, it is likely to be….
Minimal change disorder
Can you start steroids in Minimal change disorder without getting a biopsy first?
YES
If initial renal episode occurs prior to age 1 or after age 8
OR
Findings of hematuria or HTN
…what should be done before giving steroids?
Renal biopsy
For primary nephrtoic syndrome…
Initial treatment of prednisone at 60 mg/day (BID or TID) for 4-6 weeks
..should see negative urine dips within ___days
10!
In primary nephrotic syndrome, if proteinuria persists beyond 8 weeks (despite steroid tx), what is the next step?
Renal biopsy
Cyclophosphamide
Cyclosporine
Tx for primary nephrotic syndrome in kids who cannot tolerate…
Steroids
Occurs secondary to other forms of glomerular disease
Must consider if the pt is GREATER THAN 8
HTN
Persisting hematuria
Renal dysfunction
Rash
Arthralgias
Secondary nephrotic syndrome
Membranous nephropathy
Membranoproliferative glomerulonephritis
Postinfectious glomerulonephritis
Henoch-Schonlein purpura nephritis
..these are examples of?
Secondary Nephrotic Syndrome
Congenital Nephrotic Syndrome develops within…
first three months of life
VERY RARE
Caused by mutation in the NPHS1 gene on chromosome 19
Congenital Nephrotic Syndrome
In utero findings of:
Significant proteinuria
Large placenta and edema
Premature birth, respiratory trouble, poorly defined cranial sutures
Congenital Nephrotic Syndrome
ACE inhibitors and unilateral nephrectomy may be helpful
Treatment of most benefit is bilateral nephrectomy, dialysis, nutritional support and ultimately kidney transplant
Congenital Nephrotic Syndrome
Characterized by interstitial inflammation with sparing of vessels and glomeruli
Tubulointerstitial Nephritis (TIN)
Caused by lymphocytic infiltration of the tubulointerstitium, tubular edema and tubular damange
traid= FEVER, RASH, ARTHRALGIA with steadily rising creatinine
Tubulointerstitial Nephritis (TIN)
Triad:
Fever
Rash (maculopapular or urticarial)
Arthralgia
N/V, fatigue, weight loss
NO hematuia and/or proteinuria
May see WBCs or casts in urine
Tubulointerstitial Nephritis (TIN)
Causes of acute:
PCN, cephalosporins, sulfa drugs, fluoroquinolones, EES
Anti-convulsants, diuretics, allopurinol, cimetidine, cyclosporine, NSAIDs
Strep infections, pyelonephritis, Hep B, EBV, HIV, adenovirus
Sarcoidosis, SLE, idiopathic
Tubulointerstitial Nephritis (TIN)
Causes of chronic:
Analgesics, cyclosporin, lithium, heavy metal exposure
Sick cell, polycystic kidney dz, Alport syndrome, SLE
Ureteropelvic junction abnormality, urinary reflux, radiation, idiopathic
Tubulointerstitial Nephritis (TIN)
A congential condition characterized by:
deafness
large thrombocytes
cataracts
*NO CURE
*Can cause chronic TIN
Alport Syndrome
MC etiology is underlying renal disease
Sxs are non specific:
Fatgue, poor growth, polyuria, polydipsia, anemia
Chronic TIN
chronic TIN is seen in ALL forms of progressive renal disease
True or False…
Chronic TIN is seen in ALL progressive renal disease
TRUE
Glomerulonephritis can occur after _________ infections
Strep
Sudden onset:
hematuria
edema
HTN
renal insufficiency
follows a strep infection (group A beta hemolytic)
Glomerulonephritis
Kidneys appear enlarged on imaging
Glomeruli are enlarged with mesangial cell proliferation
MC ages 5-12
Glomerulonephritis
MC ages are 5-12
Symptoms appear 1-2 weeks following a throat infection or skin infection
acute phase can last 6 weeks
hematuria may persist for years
Glomerulonephritis
Anti-streptolysin O titer can confirm a recent….
Throat infection
Deoxyribonuclease B anti-streptococcal can be used to confirm a recent…
skin infection
In glomerulonephritis, complete recovery occurs in most cases within….
2 months
Typically presents as isolated disease, but can be secondary to autoimmune disease, malignancy, syphilis, or Hep B infections
thickening of basement membrane without proliferative changes
*diagnosis made by biopsy
Membranous glomerulopathy
(type of glomerulonephritis)
Most pts have spontaneous recovery
Salt restriction and diuresis can be helpful
Steroids may be helpful in prolonged cases
Membranous glomerulopathy
How is diagnosis of Membranous Glomerulopathy made?
Biopsy
MC cause of acute renal failure in kids
Hemolytic-Uremic Syndrome (HUS)
MC cause of acute renal failure in kids
characterized by:
Hemolytic anemia
Uremia
Thrombocytopenia
Hemolytic-Uremic Syndrome (HUS)
Acute GI illness (E.Coli) precedes about 80% of cases
(can be associated with other bacterial infections, viral illnesses, OCPs, and cyclosporin)
Hemolytic-Uremic Syndrome (HUS)
Glomerular changes seen include thickening of capillary walls, narrowing of capillary lumens
syndrome starts due to epithelial cell injury, leading to clotting
- *anemia results** as RBCs pass thru narrowed vasculature
- *platelet drop** due to damage and possible adhesion
Hemolytic-Uremic Syndrome (HUS)
Seen usually in kids under age 4
Initial illness includes:
Fever
Abdominal pain
Bloody diarrhea
Vomiting
5-10 days later, sudden onset:
Weakness, leathargy, pallor, irritability and oliguria
Hemolytic-Uremic Syndrome (HUS)
PE may show:
Dehydration
Edema
Petechiae
Hepatosplenomegaly
Hemolytic-Uremic Syndrome (HUS)
CBC may show:
Fragmented RBC
HGB low range of 5-9
may seem helmut cells and burr cells
low platelets
Hemolytic-Uremic Syndrome (HUS)
How do you treat HUS?
Supportive! (with attention to HTN, nutrition, fluid and electrolytes)
Schistocytes/Helmet cells on blood smear
what must you think?
Hemolytic-Uremic Syndrome (HUS)
Small vessel vasculitis characterized by
purpuric rash, arthralgia, abdominal pain and glomerulonephritis
Sx occur 1-3 weeks following illness, usually URI
Henoch-Schonlein Purpura Nephritis
Do kids normally have essential HTN or HTN due to underlying dz?
usually secondary to underlying disease
Routine BP screenings should be done on all children starting at age….
3
Defined as average systolic and/or diastolic reading greater than 90th percentile for age, gender, hgt and wgt.
Pediatric HTN
High normal BP is between what percentiles?
Significant BP is greater than what percentile
Severe BP is greater than what percentile
High normal= betwene 90 and 95th percentile
Significant= over 95th percentile
Severe= over 99th percentile
Defined as retrograde flow of urine from bladder to ureter and renal pelvis
this occurs when the tunnel between the bladder mucosa and detrusor muscle is absent, causing the flap-valve to malfunction
(may resolve as child grows)
(grades I –V)
Vesicoureteral reflex
this condition causes urine to “back up”, leading to infection, inflammation and scarring
this is the leading cause of HTN in children!
Vesicoureteral reflex
What is the leading cause of HTN in children?
Vesicoureteral Reflex
Usually found during the work up of a UTI
80% are female
Typically under age 5
- *diagnosed by VCUG**
- *Catheterization is required**
Vesicoureteral Reflex
Cornerstone treatment in Vesicoureteral reflux
Antibiotic prophylaxis
DOC: Sulfamethoxazole-trimethoprim
or nitrofurantoin
Prophylaxis with: Sulfamethoxazole-trimethoprim
or nitrofurantoin
Vesicoureteral Reflex
Toilet training begins at age….
2-3
(most kids are dry thru the night by age 5)
By age _____, control of micturation is expected
5
For nocturnal eneursis. avoid pharm treatments until after age….
7 yo
Tx should just be reassurance before this
Urethral opening located on ventral surface of penis.
Due to incomplete development of the dorsal hood.
Occurs in 1 in 250 males.
Hypospadius
Treatment : circumcision should be avoided because the foreskin may be used in surgical repair.
Surgical repair is advised between 6-12 months of age.
These children should be evaluated by a pediatric urologist.
Hypospadius
Inability to retract the foreskin.
In 90% of uncircumcised males, the foreskin should be retractable by age 3.
Accumulation of epithelial debris collects under the foreskin, and hygiene is critical.
If foreskin is not retractable, application of topical steroid TID for 3 weeks may help to loosen the skin.
Circumcision is definitive treatment.
Phimosis
Occurs when foreskin is retracted beyond the glans penis, and cannot be pulled forward again.
Leads to strangulation of glans penis due to venous congestion
Lubrication may help you to push the glans penis back thru the phimotic ring and relieve the pressure, but surgical repair is often needed.
This is a medical emergency!!
Paraphimosis
