Renal and Urology Flashcards
How does a UTI present in children?
How is it investigated?
How is it managed?
Can be very non specific, may just have a fever- always be suspicious of UTI.
Babies- poor feeding, fever, irritability, vomiting, lethargy, urinary frequency.
Infants- fever, dysuria, suprapubic tenderness, vomiting, urinary frequency, incontinence.
Suspect acute pyelonephritis if either fever>38 degrees OR loin to groin pain/tenderness.
How are UTI’s investigated in children?
How are they managed?
Investigate with urine dip- best sample is clean catch. Parents may have to have nappy off and wait for urine.
Treat for UTI if nitrites alone are positive, if nitrites and leucocytes positive (send a mid stream urine sample for MSC) or if leucocytes negative BUT clinical picture of UTI.
Management:
<3 months with temperature- admit for IV ceftriaxone and screen for sepsis- bloods, lactate, culture and LP.
If septic or pyelonephritis admit for IV Abx, otherwise give oral Abx.
Abx include; Trimethoprim, Nitrofurantoin or amoxicillin.
How are recurrent UTI’s investigated?
Need to investigate to see if any problems with the kidney or problems caused to the kidneys.
Abdominal USS-
<6 months with their first UTI- need and USS within 6wks, or during the illness if atypical.
If recurrent have within 6wks
If atypical have during the illness
DMSA Scan-
Can be used to 4-6 months after the illness to see damage caused by atypical/recurrent UTIs.
Micturating cyst urethrogram-
Useful in diagnosing vesico-ureteric reflux. Insert contrast into the bladder and observe to see if it goes up to the kidneys.
VUR- At risk of recurrent infections. Need to avoid constipation, avoid full bladder, take prophylactic Abx and need surgical input form paediatric urology.
What is vulvovaginitis?
What are the causes?
How does it present?
Inflammation and irritation of the vulva and vagina affecting girls aged 3-10yrs. Due to the thin skin which is prone to infection, this resolves after puberty.
Causes: Tight clothing trapping moisture Poor toilet hygiene Threadworms Constipation Wet nappies Chemicals and soaps used in that area
Presentation: Dysuria Itching Vaginal discharge Sore Erythema around the labia Constipation
Can be misdiagnosed as thrush and UTI.
How is vulvovaginitis managed?
Generally will self resolve
Refrain from using soaps/chemicals around the area
Wear loose fitting clothing
Reduce activities which may add pressure to the area i.e. horse riding
Better toilet hygiene
Threadworm treatment
Sudacrem/emollients to relieve the erythema
Treat constipation
What is nephrotic syndrome?
Basement membrane has an increased permeability for proteins, therefore blood protein moves into the urine.
Affecting 2-5yr olds.
Triad of: Proteinemia Hypoalbuminemia Oedema Also get hypercholesterolaemia, HTN and hyper-coagulability.
Most common cause is minimal change disease- won’t see any diagnostic features on a biopsy. Patients will just have protein in their urine and hyaline casts. Managed well on corticosteroids.
Unlikely but possible causes include FSGS or membranoproliferative GN. Also Henoch schonlein purpura, infection and diabetes.
How is nephrotic syndrome managed?
What are the complications?
Management: High dose steroids Low salt diet Diuretics for oedema If severe hypoalbuminemia- give IV Albumin Prophylactic Abx in severe cases
Steroid status:
Responding well to steroids- steroid sensitive
Not responding to steroids- steroid resistant
Difficult to wean off steroids- steroid dependant
In steroid resistant use ACEi and immunosuppressants.
Complications:
Hypovolaemia
Thrombosis- Loss of clotting proteins to kidneys, also decrease in albumin stimulates liver to make more pro-thrombotic proteins
Acute/Chronic renal failure
Infections- Loss of immunoglobulins plus use of steroids dampen immune system
Relapse
What are the two main causes of nephritis?
Nephritis- inflammation of the nephrons leading to reduction in kidney function, proteinuria (less than nephrotic) and visible/non-visible haematuria.
(1) Post-streptococcal GN-
2-3 wks post strep infection, commonly tonsillitis.
Immune complexes get stuck in the glomeruli and cause inflammation leading to AKI.
Management is supportive and should self resolve. If HTN or oedema then treat with ACEi and diuretics.
(2) IgA nephropathy (Berger’s disease)-
Deposition of IgA in nephrons cause inflammation. Biopsy will show IgA deposits and glomerular mesangial proliferation.
Manage with supportive treatment for the renal failure, along with immunosuppressants (steroids and cyclophosphamide) to slow the progression of the disease.
What is haemolytic uremic syndrome?
How does it present?
Thrombosis in small vessels around the entire body.
Caused by shiga toxin this is commonly associated with a strand of E.coli but can also come from shigella bacteria.
Post gastroenteritis
Classic triad:
Haemolytic anaemia
Thrombocytopenia
AKI
Presentation: Patient will have the bloody diarrhoea associated with this E.coli stradn. Then after 5 days: Reduced urine output Haematuria/dark brown urine Abdominal pain Oedema Confusion HTN Bruising Lethargy/irritability
How is haemolytic uremic syndrome managed?
This is a medical emergency with a mortality of 10%- management is mainly supportive and 70-80% make a full recovery.
Urgent referral to paediatric renal team for renal dialysis if required
Blood transfusion if required
Antihypertensive if required
Careful fluid balance
NB. treating gastroenteritis with Abx or anti-diarrhoeals can lead to HUS.
What is enurisis?
What is polycystic kidney disease?
What are the features?
Neonates are likely to get autosomal recessive AKD. Can detect antenatally.
Cystic kidneys
Congenital liver fibrosis
Polyhydramnios (less amniotic fluid made- due to the cystic kidney function being poor)
Polyhydramnios leads to Potter’s syndrome- low set of ears, underdeveloped ear cartilage, flat nasolabial fold.
Polyhydramnios also leads to poor lung development therefore pulmonary hypoplasia which can present as respiratory distress in the neonate.
Since cystic kidneys take up most of the abdomen space, when the baby is born its quite difficult for the baby to breathe so may require ventilatory support.
Congenital liver fibrosis means the patient will develop liver failure and portal HTN.
Chronic lung disease
Progressive renal failure which can then lead to HTN.
1/3 die in neonatal period and 1/3 survive to adulthood.
Management is required across the MDT.
What is a multi-cystic dysplastic kidney?
One kidney is covered entirely in cysts. In the case where this is bilateral this leads to death in infancy.
Usually cystic kidney will regress by age 5 yrs old.
No management required, can follow up with USS, may need prophylactic Abx as greater risk of UTI and infection with only one kidney.
What is Wilms Tumour?
How is it diagnosed?
How is it managed?
Tumour of the kidney presenting in <5yr olds. Can present with mass noticed by parents AND/OR- Haematuria Abdominal pain HTN Fever Lethargy Weight loss
Diagnose with USS. Confirm staging with MRI/CT. Definitive diagnosis with biopsy and histology.
Management:
Surgical excision + nephrectomy
+ either adjuvant chemotherapy or radiotherapy.
Prognosis is usually good when caught early and with good histology (90%), metastatic is much poorer.
What is a posterior urethral valve?
How does it present?
PUV refers to the tissue present at the proximal ureter, common in young boys.
Urine can’t drain into the bladder so get bilateral hydronephrosis.
Bladder can’t fully be emptied- risk of UTIs.
Milder cases: Asymptomatic Weak urinary stream Palpable bladder Chronic urinary retention Difficulty urinating Recurrent UTIs Renal dysfunction
Severe cases- can be picked up antenatally- bilateral hydronephrosis and oligohydramnios; where oligohydramnios can lead to pulmonary hypoplasia presenting with respiratory failure at birth.
