Renal & Urology Flashcards
Symptoms of UTI?
fever may be the only symptom
Babies:
fever
lethargy
irritability
poor feeding
vomiting
urinary frequency
Older children:
fever
suprapubic pain/abdo pain
vomiting
dysuria
urinary frequency
incontinence
When to diagnose acute pyelonephritis in children?
if temp is > 38
if there is loin pain or tenderness
Mx of UTIs?
all children <3 months with fever should start immediate IV antibiotics and have full septic screen
> 3 months:
oral antibiotics if otherwise well
IV if signs of pyelonephritis or sepsis
trimethoprim, nitrofurantoin, cefalexin, amoxicillin
Investigations used in recurrent UTIs?
US
DMSA scans
micturating cystourethrogram
When to investigate UTIs further?
all children under 6 months should have US 6wks after their first UTI
(or during the illness if recurrent or atypical bacteria)
all children with recurrent UTIs should have US within 6wks
children with atypical UTIs should have US during the illness
DMSA scans 4-6 months after illness in recurrent or atypical UTIs
MCUG in children <6 months with atypical or recurrent UTIs or FHx of VUR
What is a DMSA scan used for?
to check for scarring of the the kidneys following UTIs
uses radioactive DMSA and a gamma camera to see the uptake by the kidneys
What is a MCUG used for?
to assess for the presence of VUR
catheterise the child, inject contrast and series x-rays to see if there is reflux present
prophylactic ABx usually given for 3 days around the investigation
What is Vesico-ureteric reflux?
when urine has a tendence to flow backwards from the bladder up into the ureters
predisposes the patient to UTIs and scarring
Mx of VUR?
diagnosed with MCUG
mx depends on severity
avoid constipation
avoid an excessively full bladder
prophylactic ABx
surgical input
Exacerbations of vulvovaginitis?
wet nappies
use of chemicals or soaps
tight clothing
poor toilet hygiene
constipation
threadworms
pressure (e.g., horse-riding)
heavily chlorinated pools
Presentation of vulvovaginitis?
soreness
itching
erythema
vaginal discharge
dysuria
constipation
v common pre-puberty (no oestrogen)
often urine dipstick will show leukocytes, leading to UTI misdiagnosis)
What is nephrotic syndrome?
classic triad:
hypalbuminaemia
proteinuria
oedema
+ deranged lipid profile
HTN
hypercoagulability
most common between 2-5
Causes of nephrotic syndrome?
minimal change disease (90%)
secondary to intrinsic kidney disease:
FSGS
membranoproliferative glomerulonephritis
secondary to systemic illness:
HSP
diabetes
infections (HIV, malaria, hepatitis)
What is minimal change disease?
the most common cause of nephrotic syndrome in children
presents with oedema, proteinuria and hypoalbuminemia
no clear cause
Investigations in minimal change disease?
urinalysis (small molecular weight proteins + hyaline casts)
BP
Bloods
renal biopsy and microscopy usually do not detect any abnormalities
Mx of minimal change disease?
corticosteroids (prednisolone)
usually good response
most children make full recovery, however it can recur
Mx of nephrotic syndrome?
high dose steroids
low sodium diet
diuretics for oedema
albumin infusions
antibiotic prophylaxis
high dose steroids given for 4wks and then weaned over 8wks
if steroid resistant -> ACEi, immunosuppressants (cyclosporine, tacrolimus, rituximab)
Response to steroids in nephrotic syndrome?
80% respond - steroid sensitive
80% of steroid sensitive will relapse and need further steroids - steroid dependent
20% are steroid resistant
Complications of nephrotic syndrome?
hypovolaemia (third spacing)
thrombosis
infection (kidneys leak immunoglobulins, immunosuppressant meds)
acute or chronic renal failure
relapse
What is nephritic syndrome?
caused by inflammation in the nephrons of the kidneys
classic triad:
red. in kidney function
haematuria
proteinuria (but less than nephrotic syndrome)
Causes of nephritic syndrome?
post-streptococcal glomerulonephritis
IgA nephropathy (Berger’s disease)
HSP (overlaps with IgA)
What is post-streptococcal glomerulonephritis?
nephritis occurring 1-3wks after b-haemolytic streptococcus infection
(tonsillitis by strep pyogenes)
strep antigens, antibodies and complement gets stuck in the kidneys, causing AKI
Investigations for post-strep GN?
Hx of tonsillitis
throat swab
anti-streptolysin O titres
Mx of post-strep GN?
supportive care
80% full recovery
others -> worsening of renal function:
antihypertensives
diuretics
depending on complications
What is IgA nephropathy?
aka Berger’s disease
related to HSP (IgA vasculitis)
IgA deposits form in the kidneys, causing nephritis
Mx of IgA nephropathy?
supportive treatment
immunosuppressants to slow the progression of the disease
What is haemolytic uraemic syndrome?
classic triad:
microangiopathic haemolytic anaemia
AKI
thrombocytopenia
involves thrombosis of the small vessels caused by the Shiga toxin from either E coli 0157 or shigella infection
What increases the risk of HUS?
treating gastroenteritis with Abx or anti-diarrhoeal
releases the toxin from E coli 0157 or shigella
Presentation of haemolytic uraemic syndrome?
gastroenteritis initially (diarrhoea, which turns bloody after 3 days)
HUS symptoms develop about a week later
fever
abdo pain
lethargy
pallor (haemolysis)
oliguria (AKI)
haematuria (AKI)
HTN (AKI)
bruising (thrombocytopenia)
jaundice (haemolysis)
confusion (uraemia)
Mx of HUS?
stool culture to establish the causative organism
medical emergency - admission
supportive management with:
IV fluids
antihypertensives
blood transfusions
haemodialysis
self-limiting and good recovery by most patients with supportive care
When do most children gain bladder control?
daytime by 2yrs
night time by 3-4yrs
What is primary and secondary nocturnal enuresis?
primary -> child has never been dry at night
secondary -> child who previously was dry for at least 6 months starts bedwetting again
Causes of primary nocturnal enuresis?
normal variation (particularly if FHx)
overactive bladder
fluid intake
failure to wake
psychological distress
secondary causes (constipation, UTI, learning disability or CP)
Mx of primary nocturnal enuresis?
diary
Hx and exam
reassure parents of patients <5
lifestyle changes
encouragement and positive reinforcement
avoid punishment or shame
treat any underlying cause
enuresis alarm
pharmacological treatment
Causes of secondary nocturnal enuresis?
UTI
constipation
T1DM
new psychosocial problems
maltreatment or abuse
Mx of secondary nocturnal enuresis?
establish and treat underlying cause
always be thinking of abuse
Causes of diurnal enuresis?
urge incontinence
stress incontinence
recurrent UTIs
psychosocial problems
constipation
Pharmacological treatment for enuresis?
initiated by a specialist
desmopressin (ADH, taken before bedtime)
oxybutynin (anticholinergic - helpful if urge incontinence)
imipramine (TCA)
What is ARPKD?
AR condition caused by the mutation in the PKHD1 gene on chromosome 6
this gene is responsible for creation and maintenance of the tubules, the epithelial tissue of the kidneys, liver and pancreas
presents in neonates, usually picked up antenatally
Features of ARPKD?
cystic enlargement of collecting ducts
oligohydramnios, pulmonary hypoplasia and Potter syndrome
congenital liver fibrosis
most patients require dialysis within first few days of life and reach end-stage kidney disease before reaching adulthood
What is Potter syndrome?
syndrome caused by lack of amniotic fluid and renal failure in utero
presents with dysmorphic features including underdeveloped ear cartilage, low-set ears, flat nasal bridge and skeletal abnormalities
Complications of ARPKD?
liver failure (fibrosis)
portal HTN
progressive renal failure
HTN
chronic lung disease
Prognosis of ARPKD?
poor
1/3 will die in the neonatal period
1/3 will survive to adulthood but with various co-morbidities
What is multi-cystic dysplastic kidney disease?
separate condition to ARPKD
one kidney is affected and the other is typically normal
rarely bilateral -> death
cystic kidney often atrophies and disappears before 5
What is Wilm’s tumour?
nephroblastoma, tumour that affects the kidneys in children, usually <5yrs
Presentation of Wilm’s tumour?
suspect in any child <5 presenting with abdominal mass
abdo pain
haematuria
lethargy
fever
HTN
weight loss
Diagnosis of Wilm’s tumour?
US initially
biopsy for definitive diagnosis
CT/MRI for staging
Mx of Wilm’s tumour?
nephrectomy
adjuvant chemotherapy
adjuvant radiotherapy if advanced
Prognosis of Wilm’s tumour?
good
90% cure rate if early
mets worsen prognosis
What is a posterior urethral valve?
occurs in newborn boys, where there is tissue at the posterior end of the urethra, causing a bladder outflow obstruction, resulting in hydronephrosis
Presentation of posterior urethral valve?
varies in severity
difficulty urinating
poor stream
chronic urinary retention
palpable bladder
recurrent UTIs
impaired kidney function
severe cases -> bilateral hydronephrosis and oligohydramnios -> pulmonary hypoplasia
Investigations for posterior urethral valve?
severe cases picked up antenatally
abdo US -> enlarged, thickened bladder and bilateral hydronephrosis
MCUG
cystoscopy -> can be used to ablate or remove excess tissue
Mx of posterior urethral valve?
mild -> monitoring
temporary urinary catheter can be inserted while awaiting definitive management
definitive management is ablation or removal, usually during cystoscopy
What are undescended testis?
aka cryptorchidism
affects 5% boys, when the testis are still in the abdomen at birth
Complications of undescended testis remaining undescended?
testicular cancer
infertility
testicular torsion
RFs for undescended testis?
FHx
low birth weight
SGA
prematurity
maternal smoking
Mx of undescended testis?
watch and wait
most cases descend by 3-6 months
orchidopexy between 6-12 months
What are retractile testis?
normal in pre-puberty
testes move out of the scrotum and into the inguinal canal when it is cold or when the cremasteric reflex is activated
occasionally may fully retract and then orchidopexy may be required
What is hypospadias?
condition affecting males, where the urethral meatus is abnormally displaced to the ventral (underside) side of the penis
foreskin is usually developed incorrectly also
What is epispadias?
condition affecting males where the urethral meatus is abnormally displaced to the dorsal (top) side of the penis
foreskin usually developed incorrectly also
Investigations for hypospadias?
usually diagnosed on newborn exam
Mx of hypospadias?
no circumcision allowed as foreskin might be needed in surgical intervention
mild cases might not need any treatment
Sx usually performed at 3-4 months of age
Complications of hypospadias?
difficulty during urination
cosmetic and psychological concerns
sexual dysfunction
What is a hydrocele?
a collection of fluid that forms within the tunica vaginalis and surrounds the testes
simple - fluid is trapped in tunica vaginalis and usually gets reabsorbed over time
communicating - processus vaginalis remains open and the tunica vaginalis is connected to the peritoneal cavity, resulting in fluctuation in size of the hydrocele
Examination of hydrocele?
soft, smooth, non-tender swelling
simple remains one size, communicating can fluctuate
transilluminate with light
DDx of inguinal or scrotal swelling in neonate?
hydrocele
partially descended testis
inguinal hernia
testicular torsion
haematoma
tumours (rare)
Mx of hydroceles?
US to confirm diagnosis and exclude other cause
simple usually resolve within 2yrs, reassurance and sx only if complicated with hernia etc.
communicating - sx operation to remove or ligate the processus vaginalis
