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extra 1 (e) > Renal and Urinary System > Flashcards

Renal and Urinary System Flashcards

1
Q

By what age are most children dry by night?

A

5 yrs

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2
Q

What are the two types of enuresis (involuntary urination)? More common in M or F?

A

Nocturnal - M2:1F

Diurnal (much rarer) - F>M

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3
Q

What is primary enuresis?

A

Continence never established

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4
Q

What is secondary enuresis?

A

Loss of continence after a continuous period of at least 6 months dryness (most likely to have organic cause)

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5
Q

What are some biological causes of nocturnal enuresis?

A

1) UTI = 5% secondary enuresis
2) Urinary tract abnormalities
- Low bladder capacity
- Incomplete bladder voiding
- Detrusor instability 2ndary to constipation
3) Lack of ADH during sleep
4) Genetic predisposition
- 70% have FH
5) DM

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6
Q

What are some psychosocial causes of nocturnal enuresis?

A

1) Inability to wake to full bladder sensation
2) Psychosocial trauma eg distress, bullying, abuse
3) Accidental behavioural conditioning eg child comes to parents bed when wet
4) Developmental delay

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7
Q

What is a major cause of diurnal enuresis?

A

Bacteriuria

Cycle - bacteriuria causes detrusor instability causes urge incontinence causes damp pants and perineal irritation causes bacteriuria

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8
Q

What features are important to include in an enuresis hx?

A 
Age when first dry night
Age when started wetting
Any stressors at school
Safeguarding
Does child have own room/bed
Fluid intake - fluids before bed / fizzy drinks
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9
Q

What investigations can be done for enuresis? (4)

A

1) DM testing - random and fasting blood glucose
2) Urinalysis if symptomatic
- Bacteriuria is common in diurnal enuretic girls
3) GU tract abnormality
4) Consider psychological screening

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10
Q

What is the management of enuresis?

A

Intervention not usually required until age 7

Behavioural management eg reward chart for good behaviours

Enuresis alarm

Bladder training

Avoid caffeine and fruit juice

Treat any constipation

Medication

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11
Q

What medications can be given for enuresis?

A

Desmopressin = antidiuretic can be taken as tablets, sublingual or nasal spray at bed time. Reduces UO. Avoid excessive fluid intake for 8hrs after dose

Anticholinergics = if daytime symptoms / unresponsive

Imipramine = tricyclic antidepressants if still no response (rarely used bc of side effects)

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12
Q

Why is a UTI significant in young children?

A

It may be a marker for urinary tract abnormalities =

Half of child UTI pt have renal tract abnormality

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13
Q

How common is are UTIs in children?

A

Most common bacterial infections in children <2yrs

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14
Q

How may a UTI present in neonates? What may it be associated with?

A

Atypically

May be associated with neonatal sepsis

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15
Q

What is a lower UTI?

A

UTI involving bladder and urethra

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16
Q

What is an upper UTI?

A

Involving renal pelvis and/or kidney (pyelonephritis)

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17
Q

When clinically should an upper UTI be assumed?

A

Fever of 38 or higher + bacteriuria

Fever lower than 38 but with loin pain/tenderness + bacteriuria

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18
Q

When are UTIs considered recurrent?

A

1) 2 x upper UTI
2) 3 x lower UTI
3) 1 x upper + 2 x lower UTI

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19
Q

What features make a UTI atypical?

A

1) Seriously ill / septicaemia
2) Poor urine flow
3) Presence of abdo / bladder mass
4) Lack of response within 48hrs to treatment with suitable abxs
5) Unusual causative oranges (not E coli)
6) Inc serum creatinine

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20
Q

Are UTIs more common in boys or girls?

A

More common in boys up to 6 months

More common in girls after

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21
Q

What are some risk factors for UTI?

A

1) Anything that leads to urinary stasis - renal calculi, obstructive uropathy, vesicle-ureteric reflux (VUR)
2) Poor urine flow eg phimosis (unretractable foreskin)
3) Dysfunctional elimination syndrome
4) Sexual abuse
5) Constipation
6) Spinal abnormalities

No RF in most cases

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22
Q

How may a UTI present in infants <3 months?

A

Presents differently than in older children

Fever
Vomiting
Lethargy
Irritability
\+/- poor feeding
\+/- FTT
Less commonly:
Abdo pain
Jaundice 
Haematuria
Offensive urine

More likely to develop urosepsis

Less likely to be due to E coli

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23
Q

How may a UTI present in infants and preverbal children >3 months?

A 
Fever = common
Abdo pain
Loin tenderness
Vomiting 
Poor feeding
Less commonly:
Lethargy
Irritability
Haematuria
Offensive urine
FTT
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24
Q

What is the most common presentation of a UTI in a preverbal child?

A

Fever with no apparent cause

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25
Q

How may a UTI present in a child >3yrs?

A

Urinary symptoms eg freq, dysuria, suprapubic / abdo / lumbar pain

Dysfunctional voiding

Fever, malaise, vomitn, haematuria, offensive / cloudy urine

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26
Q

Ddx for UTI (6)

A 
Vulvovaginitis
Urethritis
Irritation eg soaps
Threadworm infestation
Balanitis
Sexual abuse
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27
Q

What should be included on examination of a child with a UTI?

A

Temp

Throat and cervical LN

Abdo - constipation, tender / palpable kidney

Back - spina bifida / sacral agenesis signs

Genitalia - phimosis, labial adhesions, vulvitis or epididymo-orchitis

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28
Q

How may urine be collected in a child with a UTI?

A

Clean catch
Collection bag attached to clean genitalia
Urine collection pads (easily contaminated)

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29
Q

What may urinalysis show in a UTI?

A

Nitrites +
Leucocytes +
Haematuria +
Albumin +

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30
Q

Why are nitrites not very sensitive dipstick test in infants?

A

Not all urinary pathogens reduce nitrate to nitrite

Urine not often held in bladder long enough for conversion to occur

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31
Q

What imaging can be performed for a child with a UTI?

A

USS
Micturating cystography
DMSA scintigraphy

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32
Q

When are renal USS used?

A

Recurrent UTI

<6 months of age

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33
Q

What are USS effective and ineffective at visualising when investigating a UTI?

A

Accurately assess renal size and outline and identify most congenital abnormalities, renal calculi and hydronephrosis or hydroureter (indicating the presence of obstruction or severe reflux)

Less effective in detecting mild or moderate VUR

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34
Q

When are micturating cystography used?

A

Children <6 months of age with recurrent/atypical UTI in which dilation shown on renal USS

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35
Q

What is the gold standard investigation for VUR?

A

Micturating cystography

Only imaging technique that provides information about the urethra

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36
Q

What is a disadvantage of micturating cystography?

A

Invasive - requires catheterisation

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37
Q

What DMSA scintigraphy effective at imaging? How does it work?

A

Gold standard for renal parenchymal defects

Study renal function using a radio-pharmaceutical such as technetium

Isotope is concentrated in proximal renal tubules - its distribution correlates with functioning renal tissue

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38
Q

When are DMSA used?

A

4-6 months post infection - show scarring

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39
Q

Which children presenting with a UTI should be immediately referred to specialist care?

A

Serious illness
3 months or younger

Do not delay treatment if sample cannot be obtained and the child is at serious risk of illness

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40
Q

What factors make a UTI recurrence in a child more likely? (4)

A

1) Younger ie <6 months
2) Female
3) VUR grade 3-5 vs 1-2 or no reflux
4) Dysfunctional voiding syndrome

75% risk <1yr

Over 1yr:
40% for girls
30% boys

VUR usually resolves

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41
Q

What is the pharmacological management of a child with a UTI? Lower and upper

A

7-10 days oral antibiotics

IV if cannot tolerate or under 3 months of age but switch to oral as soon as possible

Lower UTI:
1st - trimethoprim or nitrufurantoin
2nd - cefalexin

Upper:
1st - co-amoxiiclav
2nd - cefixime

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42
Q

What is dysfunctional voiding syndrome?

A

Abnormality of emptying, due to either a small-capacity, unstable bladder or a large-capacity, poorly emptying bladder

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43
Q

What are potential complications of a UTI in children? (3)

A

1) Renal scarring - more likely in children with VUR
2) HTN - associated with renal scarring
3) Possible link with inc risk of bacteriuria, pre-eclampsia and HTN in pregnancy later in life

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44
Q

What is the diagnosis of infants or children that have:

1) Bacteriuria and a fever of 38 or more
2) Fever <38 associated with loin pain/tenderness and bacteriuria
3) Bacteriuria but no systemic symptoms or signs?

A

1) Pyelonephritis/upper UTI
2) Pyelonephritis/upper UTI
3) Cystitis/lower UTI

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45
Q

What measures can be adopted to prevent UTI?

A

Good hygiene

Encourage micturition

46
Q

What is a complication of UTI?

A

Vesicoureteric reflux (can be bilateral)

47
Q

What is primary vesicoureteric reflux?

A

Incomplete closure of the VU valve

48
Q

What is secondary vesicoureteric reflux?

A

Obstruction of the posterior urethral valve (boys)

49
Q

List some causes of haematuria (9)

A

1) UTI
2) Trauma
3) Acute glomerulonephritis
4) Stones and hypercalciuria
5) Congenital abnormalities
6) Tumour
7) Bleeding disorder
8) Exercise
9) Drugs

50
Q

What is important to include in a hx of haematuria?

A

Colour of urine
- Originating from kidney = brown / cola-coloured
- Originating from bladder / urethra = red / pink colour and may contain clots
NB not all red urine is blood eg could be from beetroots or blackberries

Urinary symptoms

Pain
- Abdo pain or renal colic suggest clot, calculus or obstructive malformation

Precipitating factor

  • Trauma
  • Preceding URTI or skin infections often precede acute glomerulonephritis
  • Intense exercise

FH
- Bleeding disorders, HTN or kidney disease

51
Q

What is important to include on examination of someone presenting with haematuria?

A

BP:
- HTN suggests renal malfunction and child should be admitted to hospital

Oedema:

  • Periorbitally and ankles
  • Can be a feature of glomerulonephritis

Renal mass:
- Palpate abdo for tenderness and renal masses

52
Q

What are the most likely diagnoses if a renal mass is found upon abdo examination of a child presenting with haematuria?

A

Hydronephrosis
Polycystic kidneys
Tumour

53
Q

What investigations are performed for haematuria?

A

1) Urinalysis
2) Urine culture
3) FBC
4) ASO titre and throat culture
5) Serum creatinine, U&Es
6) 24hr urine for creatinine, protein and calcium
7) Serum C3 level
8) ANF / autoantibodies
9) Abdo / pelvic US and intravenous pyelogram
10) Renal biopsy

54
Q

When performing urinalysis for haematuria, what may the results show?

A

Red cell casts and proteinuria = glomerular lesion

Pyuria and bacteriuria = UTI

55
Q

What the relevance of an ASO titre and throat culture when investigating haematuria?

A

Recent strep infection often precedes acute glomerulonephritis

56
Q

What the relevance of serum C3 level when investigating haematuria?

A

Low C3 is specific for certain types of glomerulonephritis

57
Q

What the relevance of ANF / autoantibodies when investigating haematuria?

A

Positive in SLE

58
Q

When is a renal biopsy required when investigating haematuria?

A

If haematuria is persistent with proteinuria, HTN or impaired renal function

59
Q

What does haematuria with dysuria, freq and urgency suggest?

A

UTI

60
Q

What does smoky, coca-cola coloured, granular and red cell casts haematuria with malaise, oliguria, HTN and oedema suggest?

A

Glomerulonephritis

61
Q

What does haematuria with renal colic suggest?

A

Renal stone

62
Q

What dues haematuria with a renal mass and abdo pain suggest?

A

Tumour

63
Q

What does haematuria with a painless renal mass suggest?

A

Congenital abnormality

64
Q

What is haemolytic uraemia syndrome (HUS)?

A

Triad of:

1) Microangiopathic haemolytic anaemia - Coombs’ test negative
2) Thrombocytopenia
3) AKI

65
Q

How common is HUS?

A

Most common cause of AKI in children

Some children may develop partial / incomplete HUS with thrombocytopenia, +/- anaemia, but serum creatinine concentrations remain normal

66
Q

What is HUS associated with?

A

90% follow infection

Infection with E coli 0157 (15% of cases will develop HUS)

Produces Shiga toxin or verotoxin

HUS can occur up to 2 weeks after infection

67
Q

What is the pathophysiology of HUS?

A

Systemic disease caused by damage arising from circulating toxin which binds to endothelial receptors, esp renal, GI and CNS

Thrombin and fibrin are deposited in the microvasculature

This occurs early in the disease, prior to development of HUS and thus abx are of no benefit

Erythrocytes are damaged as they pass through partially occluded small vessels and subsequently haemolysis occurs

Platelets are sequestered but without cascade of clotting factors (similar to in DIC)

68
Q

Other than E coli 0157, what pathogens may induce HUS?

A

Bacteria - strep pneumoniae and shigella dysenteriae type 1

Viruses - HIV and Coxsackievirus

69
Q

What can cause atypical HUS?

A

10%

Exposure to certain medications eg ciclosporin / tacrolimus

Genetic mutations in complement pathway

Systemic conditions eg lupus, cancer and pregnancy

70
Q

What is the incubation period of E coli 0157?

A

1-6 days

HUS usually arises within 14 days, even when appear to be recovering form initial illness

71
Q

List some RF for HUS (5)

A 
Rural populations
Warmer summer months
Age 6 months - 5 yrs
Altered immune response
Contact with farm animals
72
Q

When are children with E coli 0157 gastroenteritis able to go back to school?

A

After two negative stools

Post-symptomatic shedding can occur but highest transmissibility thought to occur during acute diarrhoea phase

73
Q

How may HUS present?

A

Classical = profuse diarrhoea that turns bloody 1-3 days later
- Rare for diarrhoea to be bloody from the outset

Fever (often afebrile by time reach hospital)
Abdo pain ++
Vomiting
Painful defecation

74
Q

What investigations are performed for HUS?

A

FBC and film

  • Evidence of haemolysis, anaemia and thrombocytopenia
  • Raised WCC and low platelets = early indicator
  • Features of microangiopathic haemolysis

Renal function and electrolytes
- Rise in urea and creatinine can be due to dehydration, but if associated with haemaolysis and thrombocytopenia indicates HUS

LFTs

LDH
- High is early indicator of HUS

CRP

Clotting screen

Stool culture

Urinalysis

75
Q

List some ddx for HUS (6)

A

Other causes of abdo pain and diarrhoea:
- Acute gastroenteritis, appendicitis, IBD, intussusception

DIC eg with sepsis

HELLP syndrome

Autosomal dominant form of HUS occurs with specific genes

Inherited abnormalities of complement regulation

Thrombotic thrombocytopenic purpura
- Can cause thrombotic microangiopathy

76
Q

What is HELLP syndrome?

A

Haemolysis
Elevated Liver enzymes
Low Platelet count

= complication in pregnancy usually presents in women who have pre-eclampsia or eclampsia

77
Q

What gene is affected in autosomal dominant form of HUS?

A

Abnormality of the ADAMTS13 gene which encodes vWF

Tends to present in childhood

78
Q

What is thrombotic thrombocytopenia purpura?

A

Rare form of thrombotic microangiopathy

Characterised by:

1) Microangiopathic haemolysis
2) Thrombocytopenia
3) Neurological abnormalities
4) Renal dysfunction
5) Fever

TTP = medical emergency, without treatment mortality = 90%

79
Q

What is the management of HUS?

A

Infectious diarrhoea, HUS or VTEC (verocytotoxin-producing E coli) = report to public health

Supportive treatment

New treatments include:

  • Early plasma exchange to remove mutant complement proteins
  • Specific targeted treatments eg factor H comcentrate
  • Liver or liver and kidney transplants
80
Q

What are some complications of HUS?

A

GI:

  • Intestinal strictures and perforations
  • Intussusception and rectal prolapse
  • Pancreatitis
  • Severe colitis

Neuro:

  • Altered mental state
  • CVA
  • Seizures

Renal:

  • AKI
  • CKD
  • Haematuria
  • HTN
  • Proteinuria
81
Q

What is nephrotic syndrome?

A

aka nephrosis

1) Proteinuria
2) Low albumin
3) Oedema
4) High triglycerides

82
Q

What is the pathophysiology of nephrotic syndrome?

A

Increased permeability of serum protein through damaged basement membrane in renal glomerulus

Oedema results due to hypoalbuminaemia

83
Q

What values define nephrotic syndrome?

A

Protienuria = to / more than 3.5g/day

Hypoalbuminaemia = serum albumin = to / less than <30g/L

84
Q

What is the most common cause of nephrotic syndrome in children?

A

Minimal change = 85%

Changes on renal biopsy are very mild

85
Q

How does minimal change nephrotic syndrome initially present?

A

PC usually oedema
- Most noticeable in mornings around eyelids and pitting oedema in legs

May be hx of recent viral URTI

86
Q

What is the second most common cause of nephrotic syndrome in children?

A

Focal segmental glomerulosclerosis

87
Q

Following initial presentation of oedema, what symptoms / sign follow?

A

Weight gain
Ascites
Pleural effusion

  • Due to hypoalbuminaemia
Rarely HTN
Anorexia
Abdo pain
Diarrhoea
Oliguria
88
Q

Why is there an increased risk of infections in nephrotic syndrome?

A

Leakage of immunoglobulins

89
Q

What investigations are carried out for nephrotic syndrome?

A

Urinalysis
- 3+ or 4+ protein or microscopic haematuria

Serum albumin
- Low

Serum cholesterol and triglyceride
- High

C3 levels
- High

Renal biopsy only if clinical picture does not appear typical of minimal change nephrotic syndrome or if child does not respond to treatment within a month

90
Q

What is the management of nephrotic syndrome?

A

Hospital admission

Fluid restriction
Low salt diet
Corticosteroids = prednisolone
Prophylactic penicillin until proteinuria cleared

91
Q

How long should prednisolone be continued when treating nephrotic syndrome?

A

Until remission of proteinuria (usually 2 weeks), then continued at a weaning dose over 2-3 months

Advise parents to avoid live vaccines and chickenpox during this time

92
Q

What % of children with nephrotic syndrome relapse?

A

75%

93
Q

What should be performed in children who are steroid resistant and how may they be treated?

A

Renal biopsy to confirm pathology

May need cyclophosphamide

94
Q

What is the prognosis of nephrotic syndrome?

A

Caused by minimal change = good prognosis

Other causes worse eg HSP

95
Q

What is acute glomerulonephritis?

A

Results from immunological damage to the glomerulus

Commonest form in childhood results from immune complexes following infection by nephritogenic form of streptococcus

Other forms of glomerulonephritis are rare and only considered if atypical course

96
Q

When does haematuria occur in acute glomerulonephritis?

A

1-2 weeks after throat or skin infection

97
Q

How does acute glomerulonephritis present?

A

Smokey / cola-coloured urine

Otherwise asymptomatic, can have:

  • Malaise
  • Headache
  • Vague loin discomfort
  • Oedema around eyes, necks of hands and geed

Usually mild oliguria, but can have:

  • Renal failure
  • HTN
  • Seizures
  • HF
98
Q

What may be found when investigating acute glomerulonephritis?

A

Urine microscopy shows gross haematuria with granular and red cell casts

Proteinuria

99
Q

How is acute glomerulonephritis confirmed to be post-strep form?

A

Throat swab
ASO titre
Low complement (C3) levels

100
Q

What is the management of acute glomerulonephritis?

A

No specific therapy, managed similarly acute renal failure

Monitor creatinine clearance and fluid balance

Restrict fluid intake if oliguria develops

Diuretics and hypotensive drugs if HTN

Rarely peritoneal dialysis required

Treat strep infection with penicillin but no evidence this affects course of disease

101
Q

What is the prognosis of acute glomerulonephritis?

A

Post-strep has excellent prognosis

Usually resolves in 10-14 days

Other causes have poorer prognosis

102
Q

What is hypospadias?

A

External urinary meatus is abnormally sited

Can be anywhere from ventral aspect of glans penis (most common) to penoscrotal junction or even perineum

103
Q

What is the treatment of hypospadias?

A

May be mild = needing no treatment

Severe = surgical repair (before 2 yrs)

  • Allows boys to void standing
  • Allow future sexual function
  • Psychological impacts

Parents advised not to have the child circumcised so that the foreskin tissue can be used in reconstructive surgery

104
Q

How common is hypospadias?

A

1 in 500 boys

105
Q

How common is vulvovaginitis?

A

Most common gynae problem in prepubertal girls

106
Q

List some RF for vulvovaginitis

A 
Close anatomical proximity of rectum
Lack of labial fat pads and pubic hair
Small labia minora
Thin and delicate vulvar skin
Thin, atrophic vaginal mucosa
Poor hygiene
107
Q

How may vulvovaginitis present?

A

Itching
Redness
Soreness
Green/yellow discharge

108
Q

What age is vulvovaginitis most common?

A

3-10years

109
Q

What are some causes of vulvovaginitis?

A

Infection eg candida, bv
- Prepubertal can be caused by GABS

Dermatological eg allergic dermatitis

110
Q

How is vulvovaginitis managed?

A

Lifestyle advice eg avoid irritants / tight underwear

Treat cause

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