Renal/urology Flashcards
What are the symptoms of a UTI?
Older children- dysuria, frequency, abdominal (especially loin) pain, vomiting
Young babies and neonates- lethargy and irritability
How is the diagnosis of acute pyelonephritis made?
A temperature greater than 38 degrees
Loin pain or tenderness
What are you looking for on a urine dipstick?
Nitrites (gram negative bacteria convert nitrates into nitrites) Leucocyte esterase (shows the amount of leucocytes there are)
If neither are present then the patient is unlikely to have a UTI
Send a MSU to the lab to be cultures and have sensitivity testing if both are present.
What is the management of UTIs?
All children should under 3 months with a fever should start immediate IV Abx (ceftriaxone) and have a full septic screen- blood cultures, bloods and lactate, lumbar puncture.
Typical Abx choices: trimethoprim, nitrofurantoin, cefalexin, amoxicillin
How do you investigate recurrent UTIs?
Children under 6 months with their first UTI should have an Abdominal US scan within 6 weeks or during the illness if there are recurrent UTIs or atypical bacteria.
Children with recurrent UTIs should have an abdominal US within 6 weeks
Children with atypical UTIs should have an abdominal US during the illness
When do you do a Dimercaptosuccinic acid scan?
These should be used 4-6 months after the illness to assess for damage from recurrent or atypical UTIs.
What does the DMSA involve?
Works by injecting isotope into a childs vein which is then absorbed by the kidney, the scan shows function and location and scarring of the kidneys.
What is vesico ureteric reflex?
This is where urine has a tendency to flow from the bladder back into the ureters, this predisposes patients to developing Upper UTIs and subsequent renal scarring.
How is vesicoureteric reflex diagnosed?
Micturating cystourethrogram
What is the management of vesico ureteric reflex?
It depends on the severity .avoid constipation .avoid excessively full bladder .prophylactic Abx .surgical input from paediatric urology
When is micturating cystourethrogram used?
Used to investigate atypical or recurrent UTIs in children under 6 months
Used when there is a family history of VUR
Dilatation of ureter on US
Poor urinary flow
What does micturating cystourethrogram involve?
It involves catheterising the child and injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing back into the ureters. Children are usually given Abx for around 3 days around the time of investigation.
What is vulvovaginitis and what is it caused by?
Inflammation and irritation of the vulva and vagina, it is a common condition affecting between 3 and 10 year olds.
It can be exarcebated by wet nappies, chlorinated pools, use of soaps, tight clothing, poor toilet hygiene, constipation, threadworms, pressure on the area.
Why is vulvovaginitis much less common after puberty?
Oestrogen helps keep the skin and vaginal mucosa healthy and resistant to infection.
What would vulvovaginitis present with?
Erythema Itchiness Discharge Dysuria Constipation Urine dipstick may show leucocytes and therefore it may be misdiagnosed as UTI
What is the management of vulvovaginitis?
Avoid washing with soaps/chemicals
Avoid perfumed or antiseptic products
Good toiler hygiene
Keep area dry
Emollients such as sudocreme can sooth area
Loose cotton clothing
Treating constipation and worms where applicable
Avoiding activities that exacerbate the problem
What is nephrotic syndrome?
This is when the basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine. It is most common between 2 and 5 years.
How does nephrotic syndrome present?
Classic triad of:
Low serum albumin (hypoalbuminaemia)
High urine protein content (more than 3+ proteins on urine dipstick)
Oedema
Why may children with nephrotic syndrome be dehydrated?
This is because the oedema represents all the fluid going into 3rd fluid spaces, so there is less in the intravascular system.
Other than the classic triad of nephrotic syndrome, what other important features are there in terms of nephrotic syndrome?
. Hypercoagulability
. High blood pressure
. Deranged lipid profile- high levels of cholesterol, triglycerides, low density lipoproteins
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
Causing over 90% of cases in children under ten
Other than minimal change disease, what can cause nephrotic syndrome?
It can be secondary to intrinsic kidney disease- focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis
It can also be secondary to an underlying systemic illness:
Diabetes
Infection (HIV, hepatitis, malaria)
Henoch schonlein purpura
What is the management of nephrotic syndrome?
Management is with corticosteroids (prednisolone) the prognosis is good and most children make a full recovery.
Low salt diet
Diuretics to treat the oedema
Albumin infusions can be required in severe hypoalbuminaemia
Antibiotic prophylaxis given in severe cases (due to the oedema and ascites)
In nephrotic syndrome, how long should steroids be given for?
High dose steroids should be given for 4 weeks and then gradually weaned over the next 8 weeks.
Steroid sensitive= children who respond to steroids (80% of children respond)
Steroid dependent= patients that struggle to wean steroids due to relapses
Steroid resistant= patients that do not respond to steroids
Steroid resistant children are children with nephrotic syndrome who do not respond to steroids, what should you give in these cases?
ACE inhibitors and immunosuppresants (cyclosporine, tacrolimus, rituximab).
What are the complications of nephrotic syndrome?
Hypovolaemia- occurs as fluid leaks from the intravascular space into the interstitial space causing oedema and low blood pressure.
Spontaneous bacterial peritonitis
Thrombosis (proteins that normally prevent blood clotting are lost in the kidneys)
Infection as kidneys leak immunoglobulins (weakens the capacity of the immune system)
Relapses
Acute or chronic kidney failure
What are the signs of a UTI?
Fever
Poor feeding and vomiting (may be the only signs in a neonate)
Jaundice (especially in neonates)
Sepsis
What investigations are done for UTI?
Urine dip, urine for MC&S
Bloods (FBC, U and Es, increased CRP) and blood cultures
Ultrasound to identify pyelonephritis and structural defects and other imaging (if atypical or recurrent then do during active infection, however if just typical UTI do in 6 weeks)
What are the risk factors for UTI?
Constipation Female sex Incomplete emptying VUR Structural defect in the urinary tract
What is the management of UTI?
Antibiotics - initially empirical then guided by MC&S results
Antipyretics for fever and analgesia for pain
In terms of long term management then those with recurrent UTIS, and those with severe VUR then prophylactic abx can be used
Preventative measures include encouraging good hygiene, regular voiding, high oral intake
Also treat constipation if present
What is reflux nephropathy?
This is renal damage due to the retrograde flow of urine from the bladder to the upper renal tract.
What causes reflux nephropathy?
Incompetence at the vesicoureteric junction Secondary to obstruction (posterior urethral valve) Neurogenic bladder (fails to void adequately)
What is the pathophysiology behind reflux nephropathy?
. Reflux of urine Leading to . Recurrent upper UTI Leading to . Scarring (neohropathy) Leading to . HTN And eventual . CKD
What is the diagnostic investigation for reflux nephropathy?
MCUG
DMSA is also used to look for scarring
How do you manage reflux nephropathy?
Varies depending on the grade of disease
If its mild then they can have observation and advice on identifying features of infection
If its moderate then antibiotic prophylaxis can be given to prevent further damage to the kidneys due to infection
If its severe then surgical repair
In 80% of children spontaneous regression is seen
What is nephrotic syndrome?
Triad of features which is caused by damage to the basement membrane of the glomerulus, it is not diagnosis in itself instead it is seen as a consequence of other diseases affecting the kidney.
What are the primary causes of nephrotic syndrome?
Minimal change disease= most common
Primary focal glomerulosclerosis
Membranoproliferative glomerulonephritis
Idiopathic
What are the secondary causes of nephrotic syndrome?
SLE
HSP (remember a potential case of this in PAU, boy presenting with blood in stools however he did not have a purpuric rash/other vasculitis)
Chronic infections (hepatitis, HIV, malaria)
Diabetes
What are the consequences of nephrotic syndrome?
Hypercholesterolaemia
Hypopvolaemia
Thrombosis Risk
Infection risk
Why is there a thrombosis risk in nephrotic syndrome?
There is a hypercoagulable state due to loss of proteins such as antithrombin via. The kidneys and raised haematocrit from hypovolaemia
Why are people with nephrotic syndrome more likely to develop infections?
They are especially at risk to encapsulated organisms, because of urinary loss of complement and immunoglobulins (both are proteins)
Why do patients with nephrotic syndrome have hypercholesterolaemia?
Low protein levels triggers the liver to synthesise lipids
What are the risk factors for nephrotic syndrome?
Male sex
Asian ethnicity
Resp tract infections
Family history
How do you diagnose nephrotic syndrome?
You can do a rapid diagnosis which will show the following... Proteinuria >3g/day Hypoproteinaemia (albumin<25g/l) Oedema Hyperlipidaemia
What would you find on examination of a child with nephrotic syndrome?
Periorbital oedema is an early sign!
+/- scrotal oedema, +/- ascites, +/- peripheral
Pulmonary oedema or pleural effusion with respiratory distress may be present
When would you do a renal biopsy for nephrotic syndrome?
If the patient was steroid resistant or had atypical features.
What is the management of nephrotic syndrome?
High dose pred- 60mg/ day for 4 weeks then at a reduced dose for a further 4 weeks
If they dont respond to steroids then they have a biopsy (normally they don’t because 80% is minimal change)
What is nephritic syndrome?
This is a consequence of glomerulonephritis and is characterised by haematuria, proteinuria, renal failure and hypertension.
What are the main causes of nephritic syndrome?
Post streptococcal glomerulonephritis (most common and caused by group A strep)
IgA nephropathy
Henoch schonlein purpura
Glomerular basement membrane disease (alport and goodpasture)
What is the classic findings in post streptococcal glomerulonephritis?
. C3 is low but C4 is normal
. ASOT is positive
What is henloch schonlein purpura?
IgA/IgG/complement complexes are deposited in organs causing vasculitis and multisystem symptoms
Typically a boy aged 3-10 in winter after an URTI (saw in PAU with Jo)
Abdo pain, joint pain, rash on legs
What are the risk factors for nephritic syndrome?
Male sex
Preceding viral illness/URTI
Preceding throat infection
What are the signs and symptoms of nephritic syndrome?
Symptoms- haematuria, oliguria, feeling non specifically unwell, coca cola urine
Signs- hypertension, oedema (peripheral, peri orbital, pulmonary oedema features)
What would the differential diagnosis for nephritic syndrome be?
Anything that causes blood in urine . UTI Trauma Renal stones Tumours Renal vein thrombosis Bleeding disorders Sickle cell disease TB
What is the management of nephritic syndrome?
Impaired renal function (electrolytes and renal function need to be closely monitored, if in renal failure then consider ITU and renal filtration/dialysis)
Hypertension- ACE-I, CCB
Fluid overload- oral fluid and salt intake should be restricted, consider dialysis if severe peripheral or pulmonary oedema
Treating the underlying pathology - for PSGN then it is supportive measures only, if IgA nephropathy use ACE-I or steroids if persistent
HSP- generally supportive (if renal failure then steroids can be given)
What is enuresis?
Involuntary loss of urine, typically nocturnal, beyond developmental age of 5.
It can be primary- they have never achieved continence
It can be secondary- incontinence in a child that has previously been continent for at least 6 months
What are the primary and secondary causes of enuresis?
Primary- bladder sphincter dysfunction, neurogenic bladder, dysfunctional voidkng
Reflux nephropathy or posterior urethral valve
What questions would you want to ask in a history of enuresis?
Characteristics- is the enuresis in the daytime, nighttime or both
Ask about bowel habit
Ask about stress/sleeping habits
Ask about FH
Ask about polyuria, polydipsia and drinking habits and caffeine intake
What investigations would you do for enuresis?
Urine dip to exclude infection
Blood sugar and ketones to exclude diabetes mellitus
Imaging - not for primary but for secondary and diurnal, imaging is with urodynamics +/- spinal imaging if possible
What would the differentials for enuresis be?
DM
Diabetes insipidus
UTI
Sleep disorders
How do you treat enuresis?
If secondary to organic pathology then treating the organic pathology usually solves it
If no organic then can use positive reinforcement techniques
Failing the positive reinforcement techniques then enuresis alarms can be affective
Evening fluid restriction is helpful
If triggered by stress- psychological support
Med management RARELY used as recurrence occurs when they stop medications
What is hypospodias?
The failure of the urethral folds to close over the urethral groove, so the urethra opens proximal to the meatus
What is the management of hypospodias?
Surgical correction at around 2 years
Aim to have the urethral opening in the meatus so they can micturate normally
Must not be circumcised
What is cryptorchidism?
The failure of the testes to follow normal route of descent, they may be absent, intra abdominal or in the inguinal canal.
How would you investigate cryptochidism?
USS to identify where they are
How do you treat cryptochidism?
Surgical correction (orchidopexy) at 1 year of age (fertility deteriorates the later the corrective surgery is performed
Education and surveillance for malignancy
Counselling on infertility risk in adulthood
What are retractile testes?
Excessive cremasteric reflex causes the testes to retract into the inguinal canal. They will spontaneously descend back into the scrotum in the warm or can be manipulated back, they are normal and common but require follow up until puberty to ensure they do not become ascending (fixed outside the scrotum).
