Renal/Urology Flashcards
Acute epididymitis s/sx and etiology
- S/sx: unilateral pain, scrotal swelling and erythema
- Etiology: prepubertal boys is most commonly postviral, sexually active adolescents most common is STI
Reflux nephropathy
- History of recurrent infections and small kidneys
- Hypertension, proteinuria, albuminuria
Orthostatic proteinuria
Increased urinary protein excretion during the day when the patient is active and normal excretion when supine/asleep for 2 hours (need a first morning urine)
UTI diagnosis guidelines
- Needs to be cath specimen in kids less than 2
- > 50,000 CFUs of a single pathogen and/or suspicious UA
Treatment of UTI
- E. coli is most common bug
- IV: 3rd gen cephalosporins (cefotax or rocephin) or gent
- PO: cephalosporin, augmentin, or bactrim
- Treat for 7-14 days
- Renal ultrasound indicated for febrile infants (< 2)
Hemolytic uremic syndrome micro
- Shiga toxin from E. coli 0157:H7
HUS signs/symptoms
- Bloody diarrhea
- Microangiopathic hemolytic anemia, thrombocytopenia
- Elevated creatinine/BUN
- Seizures/neuro symptoms
- Rash: purpura, ecchymoses
Preferred treatment choice for renal replacement in CKD
- Renal transplant
- Has lower morbidity and improved growth if this can happen before dialysis is required
Clinical feature of orchitis
- Testicular pain and swelling (gradual onset)
- Fever, dysuria, urethral discharge, N/V, urinary frequency
- Exam: redness and swelling over the affected testicle
- Associated with STIs in adolescent/young adults and MUMPS!!
Triad of acute glomerulonephritis
Cola colored urine, hypertension, azotemia
Glomrerulonephritis type with low C3 and low C4
Lupus related
Glomrerulonephritis type with low C3 and normal C4
Postinfectious GN or membranoproliferative GN
Presentation of Wilm’s Tumor
Mom giving kid a bath and felt a mass on their side (peak age is 3 years)
- Highly curable (90% survival over 4 years)
Symptoms of Wilm’s Tumor
- Painless abdominal mass
- Hypertension
- Hematuria
- Hemihypertrophy
- Aniridia
Syndromes associated with Wilm’s Tumor
- Beckwith Weidmann
Imaging/treatment of Wilm’s Tumor
- Does not calcify on xray
- Nephrectomy? with chemo and radiation
Diagnosis of microscopic hematuria
- 5 or more RBCs per HPF
- Transient hematuria can be caused by trauma, exercise, or fever
- Repeat the UA in a few weeks if only have microscopic hematuria (can be present in 2-3% of school aged kids that goes away)
Benign familial hematuria workup
- If family history and no other symptoms, nothing to do
- Just need to monitor for hypertension and proteinuria
Athlete with gross hematuria with UA with < 5 RBCs on microscopic exam
Myoglobinuria
Workup for persistent microscopic hematuria
- Check a urine Ca/Cr ratio –> if elevated then need 24 hour urine calcium to diagnose hypercalciuria
- If Ca/Cr ratio is normal then need more workup
- Sickle cell disease can be a cause of hematuria
Cause of red diaper in a newborn
- Urate crystals
- Need to check a UA but will likely be normal
GFR equation
Height (cm) x 0.413 / serum Cr
Reason why infants might not have nitrites with UTI
Nitrite takes 4 hours to develop and infants pee more than that
Red urine that is dipstick positive but RBC negative on microscopy
Hemoglobinuria or myoglobinuria
Painless tea or coke colored urine with RBC casts
Glomerular disease
Bright red urine with clots
Structural anatomical abnoramlity including kidney stones
Causes of benign protein in urinalysis
Fever, exercise, alkaline urine, concentrated urine
Symptoms of kidney stones
Hematuria, abdominal/flank pain, urinary frequency, dysuria, maybe fever
Risks for kidney stones
- Most common are calcium stones
- Distal RTA, hypercalciuria (hyperparathyroidism, hypercalcemia, loop diuretics), carbonic anhydrase inhibitors, infection, excessive sodium ingestion, excessive animal protein ingestion
Benign orthostatic proteinuria symptoms
- Proteinuria increased when active and exercise
- Need a first morning urine (protein/creatinine ratio < 0.2)
- Common in adolescents
- Usually < 1 gram per day
Kidney stone workup
Plain x-ray (will miss uric acid stones, small stones, or stones overlying bone)
Ultrasound
Metabolic workup
CT scan (this is the BEST diagnostic tool)
Definition of nephrotic syndrome
- Heavy proteinuria (UPC > 2)
- Hypoalbuminemia
- Edema
- Hyperlipidemia (cholesterol around 400)
Kidney stone treatment
- < 5 mm usually pass on their own
- If larger than that may require percutaneous nephrolihotomy
- Long term increase fluid intake and restrict salt intake, may also need a thiazide diuretic
Minimal change nephrotic syndrome symptoms
- Present at age 2-6
- Edema, anasarca, can have intercurrent illness
Minimal change nephrotic syndrome labs
- Proteinuria +/- hematuria
- Normal Cr/BP
- Hypoalbuminemia, hypercholesterolemia
- Normal C3 and negative ANA
Treatment for minimal change disease
- Supportive: salt restriction, diuretics, free water restriction, albumin/lasix if intravascularly dry
- Pharmacologic: steroids (response to steroids is most important prognostic factor)
Congenital nephrotic syndrome symptoms and genetics
- In the first 3 months of life
- Fetal proteinuria –> elevated AFP
- These kids are steroid resistant leading to ESRD and require a transplant
- Genetics: nephrin, NPHS1, on chromosome 19
Hematuria, bilateral sensorineural hearing loss, ocular defects, renal failure
- Alport syndrome
- X linked dominant so mostly in boys
- Females can be asymptomatic carriers
Denys-Drashs yndrome
- Hypertension, gonadoblastoma
Wilms tumor, male pseudohermaphroditism - Infantile nephrotic syndrome
- WT1, choromsome 11
Multicystic dysplastic kidney disease symptoms and diagnosis
- Unilateral flank mass in a neonate
- More common in boys (but girls that have it are more likely to have bilateral)
- 50% of the time associated with other urinary tract anomalies: UPJ obstruction, VUR, posterior urethral valves
- Can be found prenatally with oligohydramnios
- Need renal ultrasound to confirm then need a VCUG to assess for other anomalies
Autosomal recessive polycystic kidney disease symptoms
- Bilateral kidney masses
- Chronic portal hypertension (hematemesis, palpable liver, thrombocytopenia, splenomegaly)
Post infectious glomerulonephritis symptoms
- 7-21 days after infection
- Hypertension (can be severe and labile)
- Edema
- Decreased GFR
- Rarely progresses to CKD
Post infectious glomerulonephritis labs
- VERY LOW C3 (normalizes around 2 months after, if it doesn’t normalize think about MPGN)
- Normal C4, normal ANA
- Strep: ASO, anti DNAse B
- Staph: anti teichoic acid antibodies
- Proteinuria: improves over 1-2 months
- Microscopic hematuria can persist for 18-24 months
What is a normal C3 level
Around 100
Ureterocele symptoms
Think of UTI symptoms
- Dysuria, hematuria, and/or abdominal pain
- MCC urinary retention in fmeales
- Can lead to urinary tract obstruction
Acute glomerulonephritis biopsy findings
Subepithelial humps and PMNs
Membranoproliferative glomerulonephritis biopsy findings
Subendothelial deposits and double contour GBM (tram tracking)
Lumus glomerulonephritis labs and biopsy
- Low C3 and Low C4, positive ANA
- Biopsy: Full house Immunofluorscopy (IgG, IgA, IgM, C3, C1q, fibrinogen, properidin)
IgA nephropathy symptoms
- Happens WHEN YOU’RE SICK or just a couple days after (and can recur with minor illnesses)
- Gross painless hematuria
- Common in adolescents (not less than 10)
- Rarely progresses to CKD but if it does, can recur in alllograft
IgA nephropathy labs and biopsy findings
- Mesangial deposits on biopsy
- Normal C3, normal C4, negative ANA, hematuria and proteinuria
- Persistent proteinuria correlates with worsening/progressive disease
Reason to not place a foley with gross ureteral bleeding
Can cause a false tract or urethral stricture
Causes of urethral strictures
Trauma, recent surgical procedure (iatrogenic), infections (gonorrhea)
Newborn with bilateral hydronephrosis, undescended testicles, poor anterior abdominal wall musculature
- Prune belly syndrome
- Have posterior urethral valves –> need immediate VCUG if bilateral hydronephrosis in males
Newborn male with palpable bladder and wake urinary stream
Posterior urethral valves
A girl who is always wetting her pants despite thorough workup
Ectopic urethral opening
Unstable bladder management
- Have daytime urinary frequency but no symptoms at night (leg crossing/squatting during the day)
- Tx: timed voiding to avoid UTIs, can use anticholinergic agents if needed
UTI organisms
- E coli is most common
- Others: Klebsiella, enterococcus, adenovirus
- Can be associated with constipation
Test after first febrile UTI
- Renal ultrasound
- If second febrile UTI or US is abnormal then need VCUG
UTI prophylactic antibiotics
- Amoxicillin (esp in infants)
- Bactrim
- Nitrofurantoin
Complications of nephrotic syndrome
- Hypercoagulability: due to increased fibrinogen, factor V and VII, and increased platelets
- Hypercholesterolemia: due to increased VLDL production
- Immunodeficiency: due to immunoglobulins lost
- Hypocalcemia: due to low albumin
- Hyponatremia
- Vascular thrombosis
- Peritonitis (pneumococcal most commonly)
- Other pneumococcal infections (due to hypogammaglobulinemia)
Minimal change disease patient who then gets hematuria
Concern for vascular thrombosis
Risk factors for worse prognosis in nephrotic syndrome
- Age > 10
- Persistent or gross hematuria
- Hypertension
- Renal insufficiency
- Low C3 complement levels
Focal segmental glomerulosclerosis (FSGS) symptoms
- Common in teenagers
- Nephrotic syndrome symptoms
- Leads to progressive renal failure
- NORMAL C3
Pre-renal acute renal failure
- FeNA will be low (< 1%)
- Urine osmolality will be high
- Causes: blood or fluid losses, cardiac disease
Intrinsic acute renal failure
- FeNa will be high (> 1%) and urine osmolality will be low
- Causes: ATN, interstitial nephritis, HUS, glomerulonephritis, nephrotoxic drugs
Nephrotoxic drugs
Aminoglycosides Cyclosporine Tacrolimus Cisplatin Carboplatin Ifosfamide Ibuprofen Aspirin Omeprazole
Complications of chronic kidney disease
- Growth failure (nutrition problems and bone mineralization abnormalities)
- Anemia (decreased EPO production)
- Metabolic acidosis (bicarb loss)
- Uremia (elevated BUN –> need to restrict protein intake)
- Hypertension (salt/water restriction helps)
- Neurological abnormalities
- Secondary hyperparathryroidism (low vitamin D –> decreased calcium absorption –> elevated PTH)
- Increased phosphorus (leads to additional hypocalcemia)
Indications for treatment with erythropoietin
- Hemoglobin less than 8 in CKD
- Complications: polycythemia –> hypertension and thrombosis
Creatinine level changes in peds patients
- Higher in newborns due to maternal creatinine levels
- Increase with age due to increased muscle mass with growth
Treatment for pheochromocytoma hypertension
- Alpha blocker (phenoxybenzamine)
- Don’t use a beta blocker because it can lead to a paradoxical increase in BP
- Surgical resection will help the BP
Symptoms of inguinal hernia
- Bulge in supapubic or scrotal area that increases in size with crying
- Incarcerated –> irritability, tender abdomen, vomiting
Painless scrotal swelling that transilluminates
Hydrocele
Left sided scrotal swelling, heavy sensation, bag of worms, decreases when patient lies down
Varicocele
Facts about undescended testicles
- Bringing it down can improve fertility but doesn’t eliminate risk of malignancy
- Descended testicle on opposite side has increased malignancy risk but not as high as the undescended
When to refer for undescended testicles
- Refer by 3-6 months of age
- Repair by 12-18 months
Symptoms of retractile testes
Non-palpable testicle, try to re-examine in frog leg position
- Can be retractile that re-ascends and stays there so this would need to be referred to urology
Nonpalpable testes in newborn workup
- Testicular ultrasound prior to discharge home
- Urologic referall
- Could be presentation of ambiguous genitalia or CAH
Syndromes associated with hypospadias
- Russell Silver syndrome
- Laurence-Moon-Biedl Syndrome
- Opitz Syndrome
- Beckwith Wiedemann syndrome
**NO CIRC in patients with hypospadias, should be corrected surgically at 6 months
Micropenis associations
- Prader Willi syndrome
- Kallmann sydrome
- GH deficiency
- Septo-optic dysplasia
- Hypoglycemia
- Penis length less than 2.5 cm (1 inch) –> do endocrine/genetic workup
Symptoms of testicular torsion
- Sudden severe scrotal pain
- No cremasteric reflex (it is already elevated)
- Can be unilateral or bilateral
- Need urgent ultrasound with doppler
Symptoms of phimosis
- Inability to retract foreskin in a kiddo older than age 3
- Tx with topical steroid cream and gentle retraction
Firm, painless solid scrotal mass workup
Testicular cancer
- Bilateral ultrasound
- LDH, b-HCG, AFP
High risk factors: cryptorchidism, gonadal dysgenesis, family history, klinefelter syndrome
