Renal/urinary Flashcards
What is glomerulonephritis?
Acute and chronic
Damage inflicted by the formation of immune complexes, most commonly post streptococcal infection –> haematuria, brown urine, oedema (peri-orbital and ankles)
Why is important to check the BP when investigating haematuria?
HTN indicates kidney pathology - child needs to be admitted
What is the most common cause of haematuria in children?
UTI
What is the most common type of tumour that will cause haematuria in children?
Wilm’s tumour - should be palpable mass in the loin
Investigations for a child with haematuria?
Urine - MSU dip and culture
Bloods
- FBC, ESR, CRP, clotting screen
- plasma urea, creatinine, eGFR, U+Es, albumin, phosphate
If suggestive of renal pathology - screen for hepatitis, renal biospy, throat swab (+ ASO titre for streptococcal)
What is haemolytic uraemic syndrome (HUS)?
A triad of AKI, microangiopathic haemolytic anaemia and thrombocytopaenia
Typically affects children 3mo-3yrs after a GI infection (e.coli or shighella)
Toxins damage the renal endothelium –> intravascular thrombogenesis
No consumption of clotting factors but consumption of platelets
Symptoms and signs of HUS?
Diarrhoea and colitis from GI infection
Oliguria, pallor, jaundice, encephalopathy
Investigations of HUS?
Bloods:
- High LDH (tissue damage)
- High WCC
- Coombes -ve
- Decreased PCV (% of RBC in blood)
- Fragmented RBCs
What is nephrotic syndrome?
Oedema + hypoalbuminaemia + proteinuria
Due to increased permeability of the glomerular capillary wall –> increased loss of protein in urine
Cause = minimal change glomeurlonephritis (80%)
Presentation of nephrotic syndrome?
- peri-orbital oedema –> becomes more generalised (pitting oedema of legs/ankles and oedema of scrotum, vulva)
- Ascites and pulmonary effusion (SOB/respiratory distress)
Investigations in nephrotic syndrome?
MSU dip and culture - increased protein, may have microscopic haematuria
Bloods - FBC, U+Es, ESR
Decreased levels of albumin, increased levels of cholesterol
Renal biospy if not typical minimal change disease (85% of cases) or if haven’t responded to steroid treatment
Management of nephrotic syndrome?
2-4 weeks prednisolone and then wean down to low-dose for 4-6 weeks
If persistent recurrence treat with cyclophosphamide
Refer to specialist if symptoms do not improve with steroid treatment
Presentation of glomerulonephritis?
haematuria, oedema, HTN, oliguira +/- proteinuria
Aetiology of glomerulonephritis?
Autoimmune - SLE, IgA nephropathy, membranoproliferative
Post infection (~1-2 weeks after URTI)
Bacterial - strep, stap A, salmonella
Viral - CMV, EBV, Varicella
Fungal - aspergillus, candida
Toxins/drugs e.g. gentamicin
Symptoms/signs of glomerulonephritis?
Often asymptomatic
Nephrotic syndrome - oedema, Proteinuria, hypoalbuminaemia
Nephritic syndrome - nephrotic + haematuria
Lethargy, malaise, anorexia
Pruritis
Oliguria
Pulmonary oedema
Management of glomerulonephritis?
Infection –> penecillin 10 days
Autoimmune –> high dose oral steroids and immunosuppressants
Symptomatic - diuretics for HTN and oedema
Complications of glomerulonephritis?
AKI –> CKD
HTN and fluid overload
Infection - due to loss of immunoglobulins
Hyperlipidaemia
Hyper-coagulable state - due to loss of antithrombin II
Hyperkalemia
Acidosis
Seizures
What is hypospadias?
Urethral meatus opens proximal to it’s correct position (at top of glans) - 1 in 200 boys
Graded according to position - glns = first degree, shaft = second degree, scrotal/perineal = third degree
Results in a triad of:
ventral urethral meatus
A hooded dorsal foreskin
Chordee (ventral curvature of penile shast - most prominent on erection)
management of hypospadias?
Corrective surgery before the age of two
Aim is to fashion a normal looking penis
What is vulvovagintis?
Inflammation of the vulva most common in 3-10yr olds due to lower levels of oestrogen
Inflammation –> red, itchy, sore –> green/yellow discharge
Encourage good hygiene - not normally treated with Abx
What is the definition of nocturnal enuresis?
Involuntary passage of urine at night
Must be >5yrs
Must wet the bed >2 times a week
Absence of any abnormalities or pathology
Causes of wetting?
Waking with the urge to urinate
Detrusor control - check day time frequency
levels of ADH
Psychological - abuse/neglect, behavioural
Illness - IDDM, UTI, constipation
Functional abnormalities - detrusor overactivity, bladder neck weakness, neuropathic bladder
Investigations into bed wetting?
urine dipstick
Social Hx
+/- Ultrasound
management of nocturnal enuresis?
Address precipitating factors - stop punishments, adjust night time routine, consider abuse/bullying, stop inadvertent reinforcement (let them sleep in parents bed), refer to school nuse
Alarms - use in children where other measures don’t work - 70% dry in 2 months - 2 types matt or pad
Medication - can be first line in children >7yrs = desmopressin given at bed-time
Second line = Imipramine
What medication can be used for day-time wetting caused by detrusor overactivity?
Oxybutynin
Epidemiology and aetiology of UTIs in neonates?
M>F - usually due to a structural abnormality e.g. VUR
Risk factors for UTI?
Vesico-ureteric reflux - 1/3 have recurrence within 1 year (a cause of end-stage renal failure later in life) - mild forms usually resolve spontaneously
Incomplete voiding
Structural abnormalities - up to 50% of patients
Usual cause of UTI?
Gram -ve: E. coli (90%)
Others:
Pseudomonas - hints at structural abnormality
Proteus - hints at kidney stones
Staph saprophyticus = common in adolescent girls
Common symptoms in an infant with a UTI?
Fever - can be septic
Irritability
Lethargy
Vomiting
Common presentation for cystitis in children >3yrs?
polyuria, dysuria, (–> enuresis)
Suprapubic pain
Fever
Common presentation of pyelonephritis?
Loin pain (can radiate to back) Fever, vomiting, lethargy
Infants - Irritability, poor feeding
Investigations into UTI in children <3yrs?
Urine microscopy - look for WCC >10^5/L
Investigations into UTI for children >3 years?
Urine dip - leucocytes, nitrites, RBC, protein
When is further imaging can be done and when is required?
Ultrasound - good for structural abnormalities DMSA - scan that shows renal scarring Micturating Urethrogram (MCUG) - look for VUR
Required when child is <6months, seriously ill, atypical/recurrent infections, failure to respond to Rx in 48hrs, deranged U+E
Management for pyelonephritis?
Consider admission
Abx for 10 days e.g. co-amoxiclav
Increase fluid intake and encourage micturition
Treatment for lower UTI in children >3 years?
3 day course of trimethoprim - 4mg/kg BD
Features of atypical UTI?
Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Failure to respond to Abx within 48hrs Infection with non-E.coli organisms
