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Paeds > Renal & Urinary Tract Disorders > Flashcards

Renal & Urinary Tract Disorders Flashcards

1
Q

Most common cause of nephrotic syndrome in children

A

Minimal change disease

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2
Q

Nephrotic syndrome triad

A

Low serum albumin
High urine protein content(>3+ proteinon urine dipstick = frothy urine)
Oedema (especially peri-orbitally or of testes)

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3
Q

How does proteinuria present as?

A

frothy urine

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4
Q

Where does oedema present in minimal change disease?

A

especially peri-orbitally or of testes

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5
Q

Features of minimal change disease

A

Nephrotic syndrome triad:
Low serum albumin
High urine protein content(>3+ proteinon urine dipstick = frothy urine)
Oedema (especially peri-orbitally or of testes)

Other features:
Deranged lipid profile – due to increased hepatic activity trying to replace albumin
Hypercoagulability – antithrombin 3 is one of the proteins lost

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6
Q

What causes hypercoagulable state in minimal change disease?

A

Antithrombin III

NOTE: Antithrombin III inactivates F9,10,11. If antithrombin III lost –> no inactivation of factors so hypercoagulable.

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7
Q

What medication potentiates antithrombin III?

A

Heparin potentiates antithrombin III to inactivate F9,10,11

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8
Q

Diagnostic investigation for nephrotic syndrome

A

kidney biopsy allows us to differentiate between the different causes of nephrotic syndrome

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9
Q

1st line investigation for nephrotic syndrome

A

Urine dipstick –> check for proteinuria

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10
Q

Investigative findings on kidney biopsy in minimal change disease

A

Light microscopy – no signs
Electron microscopy – loss of foot processes on podocytes
Immunofluorescence – no immune deposits

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11
Q

Management of minimal change disease

A

High dose steroidsare given for 4 weeks and then gradually weaned over the next 8 weeks:
Diuretics may be used to treat oedema
Albumin infusions may be required in severe hypoalbuminaemia

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12
Q

What is henoch schonelin purpura?

A

IgA vasculitis is an AI disease involving IgA immune complexes.

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13
Q

When does henoch schonlein purpura occur?

A

occurs after a viral or bacterial upper respiratory tract infection, especially streptococcal infections.

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14
Q

Presentation of henoch schonlein purpura

A

Purpuric rash – from buttocks downwards stereotypically
Arthralgia (70%) – knees and ankles commonly
Abdominal pain (50%) – N+V, can cause bowel haemorrhage/infarction
Kidney sx (40%) – haematuria, proteinuria

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15
Q

How does rash in henoch schonlein purpura present?

A

Purpuric rash – from buttocks downwards stereotypically

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16
Q

What is haemolytic uraemic syndrome

A

A non-AI microangiopathic haemolytic anaemia (MAHA).

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17
Q

What is HUS caused by?

A

E.coli 0157:H7 which producesshiga toxin

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18
Q

What toxin does E.coli 0157:H7 produce to cause HUS?

A

shiga toxin

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19
Q

How does HUS cause damage to endothelial cells in the vessels in the kidneys?

A

fibrin mesh formation    that damages RBCs

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20
Q

Presentation of HUS

A

diarrhoea followed by MAHA and renal impairment (AKI)

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21
Q

Management of HUS

A

supportive, plasma exchange, eculizumab (a C5 inhibitor monoclonal antibody)

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22
Q

HUS/TTP Triad/Pentad

A
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23
Q

What is Wilm’s Tumour

A

A nephroblastoma which typically presents in children.

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24
Q

2nd most common childhood malignancy

A

Wilm’s Tumour (nephroblastoma)

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25
Q

Presentation of Wilm’s tumour

A

abdominal mass (unilateral in 95% cases), occasionally haematuria

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26
Q

Unilateral abdominal mass in a child

A

Wilm’s tumour (nephroblastoma)

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27
Q

Investigations for Wilm’s Tumour

A

Examination
US doppler - rule out IVC and renal vein involvement
Microscopy – small undifferentiated blue cells, primitive renal tubule formation

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28
Q

What is seen on microscopy in a Wilm’s Tumour?

A

Microscopy – small undifferentiated blue cells, primitive renal tubule formation

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29
Q

Managemnt of Wilm’s tumour

A

urgent paeds review within 48h

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30
Q

Small undifferentiated blue cells, primitive renal tubule formation on microscopy

A

Wilm’s tumour

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31
Q

What is enuresis?

A

Bedwetting in the absence of congenital or acquired defects of the nervous system or urinary tract.

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32
Q

When do most children achieve day and night dryness?

A

by 3-4 years old

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33
Q

Types of enuresis

A

Primary: child never achieved continence (can be with or without daytime symptoms)
Secondary: bedwetting occurs after a child has achieved sustained continence >6months

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34
Q

Primary enuresis

A

child never achieved continence (can be with or without daytime symptoms)

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35
Q

Secondary enuresis

A

bedwetting occurs after a child has achieved sustained continence >6months

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36
Q

Table showing possible causes of enuresis

A
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37
Q

Red flags to ask for in secondary enuresis

A

ask about psychological/family problems

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38
Q

Investigations for enuresis

A

clinical diagnosis, urine MC&S to rule out UTI, urine dip to rule out diabetes

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39
Q

Management of enuresis

A

Primary enuresis + day and night sx → refer to paeds urology
Night sx only → manage in community

Conservative – reduce fluid intake, regular emptying, star charts for actions not outcomes
Enuresis alarm – high success rate and lower relapse than meds
Desmopressin – synthetic ADH replacement, good for short term control or if above fail

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40
Q

How is primary enuresis + day and night sx managed?

A

refer to paeds urology

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41
Q

How are night Sx of enuresis only managed?

A

In community

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42
Q

Order of enuresis management

A

Conservative – reduce fluid intake, regular emptying, star charts for actions not outcomes
Enuresis alarm – high success rate and lower relapse than meds
Desmopressin – synthetic ADH replacement, good for short term control or if above fail

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43
Q

PACES: What is the conservative management of enuresis?

A

reduce fluid intake, regular emptying, star charts for actions not outcomes

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44
Q

Management of nocturnal enuresis in children <5 years (without daytime symptoms)

A

Reassure that parents that many children under 5 years wet the bed and this usually resolves without intervention
Ensure easy access to the toilet at night (e.g. potty near bed)
Encourage bladder emptying before bed
Consider a positive reward system

45
Q

Management of nocturnal enuresis in children >5 years (without daytime symptoms)

A

If bedwetting is infrequent (< 2 per week) reassure the parents and offer watch-and-wait approach
If long-term treatment is required:
First-Line: Enuresis Alarm with Positive Reward System
Second-Line: Desmopressin

NOTE: fluid should be restricted 1 hour before desmopressin until 8 hours afterwards
It may also be considered when rapid or short-term control is required (e.g. school trips)
TCAs and antimuscarinics may be considered in special cases

46
Q

What is the vesicoureteral reflex?

A

abnormal backflow of urine from the bladder into the ureter and kidney.

47
Q

How does the vesicoureteral reflex increase likelihood of UTI?

A

abnormal backflow of urine from the bladder into the ureter and kidney –> more likely to retain bacteria

NOTE: found in around 30% of children who present with a UTI

48
Q

Presentation of vesicoureteral reflex

A

Antenatal period: hydronephrosis on ultrasound
Recurrent childhood UTI
Reflux nephropathy - chronic pyelonephritis secondary to VUR

49
Q

What is seen on US in vesicoureteral reflux?

A

Hydronephrosis

50
Q

What condition can vesicoureteral reflux cause recurrance?

A

childhood UTI

51
Q

What is Reflux nephropathy?

A

Chronic pyelonephritic secondary to VUR

52
Q

What does Micturating cystourethrogram (MCUG) do?

A

assess how the urine flows

53
Q

What does the DMSA do?

A

looks for renal scarring, routine referral within 4-6m

54
Q

When are children referred for DMSA?

A

Routine referral 4-6m alongside US for UTI if: recurrent UTI sx or <3yo with atypical UTI

55
Q

Flow charts showing UTI investigation

A
56
Q

What does DMSA look for?

A

hydronephrosis and parenchymal defects

57
Q

Who is MCUG done in?

A

children <6 months –> underlying structural disorders of renal tract e.g. reflux nephropathy

58
Q

What is epididymitis/orchitis?

A

Infection of epididymis/testis due to STI (chlamydia/gonorrhoea, teens), or bladder (E.coli, younger kids).

59
Q

What causes Epididymitis/orchitis?

A

STI (chlamydia/gonorrhoea, teens), or bladder (E.coli, younger kids).

60
Q

Presentation of epididymitis/orchitis

A

unilateral testicular pain and swelling, urethral discharge may be present

61
Q

Investigation of epididymitis/orchitis

A

MUST EXCLUDE TORSION, urine MC&S, NAAT

62
Q

What must be excluded if considering a diagnosis of epididymitis/orchitis?

A

TESTICULAR TORSION

NOTE: USE EXPLORATORY LAPAROTOMY TO EXCLUDE

63
Q

What is the management of epididymitis/orchitis caused by UTI?

A

E.coli most likely so treat empirically with a quinolone (e.g. Ofloxacin) for 2 weeks

64
Q

What is the management of epididymitis/orchitis caused by STI?

A

if cause unknown IM Cef 500mg + PO Doxy 100mg BD for 10-14days

65
Q

What is hypospadias?

A

Congenital defect in which the urethral meatus is not present at the tip of the glans and is instead found along the ventral surface of the penis.

66
Q

When is hypospadias typically noted?

A

On neonatal examination

67
Q

Management of hypospadias

A

Surgery is NOT mandatory
May be performed on functional or cosmetic grounds (after 3 months)
Ultimate functional aim of surgery is to allow boys to pass urine in a straight line whilst standing and to have a straight erection
IMPORTANT: boys with hypospadias should NOT be circumcised before repair, because the skin is important for the repair

68
Q

Key point in the management of hypospadias

A

IMPORTANT: boys with hypospadias should NOT be circumcised before repair, because the skin is important for the repair

69
Q

What is phimosis? How does it present?

A

inability to retract foreskin covering glans penis

Non-retractile foreskin +/- ballooning during micturiong and <2yo→ physiological phimosis

70
Q

PACES: Advice to give if patient has phimosis

A

 Do not attempt to retract the foreskin to clean under it, if it is still fixed.

71
Q

What is balanitis? WHat typically causes it?

A

inflammation of glans penis +/- underside of foreskin

Typically caused by bacterial or candidal infection, but can also be dermatological (dermatitis, psoriasis etc)

72
Q

How does balanitis present?

A

Swab under foreskin and do an STI screen (esp if high risk)

73
Q

Management of balanitis

A

 Clean penis with warm lukewarm water regularly; do not use soap,baby wipes as these may irritate the area.
 Nappies should be changed frequently
 NHS leaflet for balanitis care should be provided
 Hydrocortisone considered for severe symptoms, and specific abx/clotrimazole if organism identified

74
Q

What should be avoided in the management of balanitis? What should be used instead?

A

do not use soap,baby wipes as these may irritate the area, clean with lukewarm water instead

75
Q

PACES: Advice for balanitis

A

 NHS leaflet for balanitis care should be provided

76
Q

What medication may be offered in balanitis?

A

 Hydrocortisone considered for severe symptoms, and specific abx/clotrimazole if organism identified

77
Q

What is cryptorchidism?

A

Incomplete descent of one or both testes from abdomen, through the inguinal canal and into the scrotum.

78
Q

Types of cryptorchidism

A

True undescended testis—the testislies along the normal path of descent in the abdomen or inguinal region but hasneverbeen present in the scrotum.
Ectopic testis —the testis lies outside of the normal path of descent and outside the scrotum, for example in the femoral region, perineum, penile shaft, oropposite hemiscrotum.
Ascending testis —the testis has previously been present in the scrotum but hasthen moved to a higher position over time.
Absent or atrophic testis— the testisis in the scrotum at birth but later disappears causinga non-palpable testis.

79
Q

True undescending tesis

A

the testislies along the normal path of descent in the abdomen or inguinal region but hasneverbeen present in the scrotum.

80
Q

Ectopic testis

A

the testis lies outside of the normal path of descent and outside the scrotum, for example in the femoral region, perineum, penile shaft, oropposite hemiscrotum.

81
Q

Ascending testis

A

the testis has previously been present in the scrotum but hasthen moved to a higher position over time

82
Q

Absent or atrophic testis

A

the testisis in the scrotum at birth but later disappears causinga non-palpable testis

83
Q

the testislies along the normal path of descent in the abdomen or inguinal region but hasneverbeen present in the scrotum.

A

True undescended testis

84
Q

the testis lies outside of the normal path of descent and outside the scrotum, for example in the femoral region, perineum, penile shaft, oropposite hemiscrotum.

A

Ectopic testis

85
Q

the testis has previously been present in the scrotum but hasthen moved to a higher position over time

A

Ascending testis

86
Q

the testisis in the scrotum at birth but later disappears causinga non-palpable testis

A

Absent or atrophic testis

87
Q

Complications of cryoptorchidism

A

Impaired fertility, increased risk of testicular cancer in the undescended testis, and increased risk of testicular torsion and inguinal hernia.

88
Q

Biggest complication of cryptorchidism

A

Infertility

89
Q

How to differentiate between types of cryptorchidism on investigation?

A

Hypospadias → disorder of sexual development
Bilateral + ambiguous genitalia → Congenital Adrenal Hyperplasia
Can attempt to manipulate an inguinal testes into scrotum, if it moves back into canal → retractile testis
If unpalpable to unable to manipulate → undescended tests
Contralateral testis is atrophied → testicular absence or atrophy

90
Q

Management of cryptorchidism

A

Disorder of sexual development or bilateral at birth → urgent referral to paeds in 24h (ix endocrine and genetics)
Unilateral at birth → review at 6-8w
Bilateral at 6-8w → urgent 2 week referral to paeds urology
Unilateral at 6-8w → reexamine at 4-5 months → still unilateral → urgent referral to paeds urology to be seen by 6m old

91
Q

Management of cryptorchidism if bilateral at birth or coexisting disorders of sexual development (e.g. hypospadias)

A

urgent referral to paeds in 24h (ix endocrine and genetics)

92
Q

Management of cryptorchidism if unilateral at birth

A

review at 6-8 weeks

93
Q

Management of bilateral cryptorchidism at 6-8 weeks

A

urgent 2 week referral to paeds urology

94
Q

Management of unilateral cryptorchidism at 6-8 weeks

A

reexamine at 4-5 months → still unilateral → urgent referral to paeds urology to be seen by 6m old

95
Q

What is testicular torsion? Who is it most common with?

A

Testicle rotates twisting the spermatic cord that brings blood to the scrotum causing ischaemia. Most common between males ages 12-18

96
Q

Presentation of testicular torsion

A

Very tender, hot, swollen SINGLE testis
Cremasteric reflex lost (doesn’t exclude TT if this isn’t seen if TT is top dx)
Elevation of testis doesn’t ease pain (negative Prehn’s sign)

97
Q

Investigation of testicular torsion

A

urgent surgical exploration

98
Q

Management of testicular torsion

A

BILATERAL fixation (orchidopexy) and possible orchidectomy
Salvage rate 90-100% if <6h
Salvage rate 0-12% if >24h

99
Q

How do UTIs present in infants?

A

Poor feeding
Foul-smelling urine
Fever
Irritability
Febrile convulsions

100
Q

How do UTIs present in children?

A

Dysuria
Urinary frequency and urgency
Lower abdominal pain
Foul-smelling urine
Enuresis

101
Q

Investigations for UTIs in children

A

Bedside
Urine dipstick and MC&S

Bloods
Blood gas if concerns of sepsis

102
Q

Management of UTIs in infants <3 months

A

ALL infants < 3 months of agewith suspicion or a UTI or if seriously ill should be referred IMMEDIATELY to hospital
IV antibiotics (e.g. co-amoxiclav) for at least 5-7 days
This should be followed by oral prophylaxis

103
Q

Management of infants aged >3 months with UTIs and children with acute pyelonephritis/upper UTI

A

Oral antibiotics
First-Line: Cefalexin, Co-Amoxiclav

If oral cannot be used, give IV antibiotics
First-Line: co-amoxiclav, ceftriaxone, ciprofloxacin, cefuroxime, amikacin or gentamicin

104
Q

What are first line oral ABs in infants with UTIs?

A

Cefalexin, Co-Amoxiclav

105
Q

Features of pyelonephritis

A

Bacteriuria + fever > 38 degrees
Bacteriuria + loin pain/tenderness

106
Q

Features of cystitis/lower UTI

A

Dysuria but NO systemic symptoms

107
Q

Management of children with cystitis/lower UTI

A

Oral antibiotics
First-Line: Trimethoprim, Nitrofurantoin
Second-Line: Amoxicillin, Cefalexin

108
Q

What are first line ABs in children with cystitis/lower UTI?

A

First-Line: Trimethoprim, Nitrofurantoin

IF FEATURES OF PYELONEPHRITIS –> USE Cefalexin or co-amox

109
Q

PACES: Advice to give for infants/children with UTIs

A

Seek medical attention if the child is still unwell after 24-48 hours of antibiotic treatment
Encourage adequate fluid intake

Paeds (14 decks)

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