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RENAL/UROLOGY PAEDS Flashcards

1
Q

UTI PAEDS presentation

A

Babies: Fever, lethargy, irritability, vomiting, poor feeding, urinary frequency
Older infants/children: fever, abdo pain, vomiting, dysuria, frequency, incontinence

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2
Q

Urine dipstick: Presence of nitrites

A

Gram negative bacteria (e.g. E.Coli)

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3
Q

Urine dipstick: Presence of Leukocytes

A

Significant levels of leukocytes in urine suggest inflammation or infection
Don’t treat for UTI if only leukocytes present - unless clinically indicated

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4
Q

UTI: Antibiotics

A

All children under 3 months with a fever: start on IV abx (e.g. ceftriaxone), full septic screen, blood cultures, bloods, lactate. Consider LP

Children over 3 months: Oral abx if they are otherwise well (if signs of sepsis —> admission + IV abx)

  • Trimethoprim
  • Nitrofurantoin
  • Cefalexin
  • Amoxicillin
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5
Q

Investigations for recurrent UTIs

A

USS
DMSA (dimercaptosuccinic acid) scan - 4-6 months after illness to assess for damage from recurrent or atypical UTIs
MCUG (micturating cystourethrogram)

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6
Q

Vesicoureteral reflux (VUR)

A

Urine flows from the bladder back into ureters
Predisposes patient to developing UTIs and subsequent renal scarring
Diagnosed using MICTURATING CYSTOURETHROGRAM

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7
Q

Vulvo vaginitis: Precipitants

A 
Wet nappies 
CLeaning/soaps use in area
Tight clothing that traps moisture in the area 
Poor toilet hygiene 
Constipation 
Threadworms 
Pressure on area (e.g. horse riding) 
Heavily chlorinated pools
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8
Q

Why is vulvovaginitis better after puberty?

A

OEstrogen helps keep skin and vaginal mucosa healthy and resistant to infection
Commonly affects girls aged 3-10 yrs

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9
Q

Vulvovaginitis presentation

A 
Soreness
Itching 
Erythema around labia 
Vaginal discharge 
Dysuria 
Constipation
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10
Q

Vulvovaginitis MANAGEMENT

A

No medical treatment often required. Simple measures to improve symptoms.
E.g. avoid washing with soap/chemicals, good toilet hygiene, emollients e.g. sudacrem, loose cotton clothing, treat any constipation, avoid activities that exacerbate problem

Oestrogen cream in very severe cases

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11
Q

NEPHROTIC SYNDROME features (triad + 3 others)

A
  1. Low serum albumin
  2. High urine protein conc.
  3. Oedema
  4. Deranged lipid profile
  5. High BP
  6. Hyper-coagulability
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12
Q

Nephrotic syndrome: what is it?

A

When the BM in the glomerulus becomes highly permeable to protein.
Frothy urine
Generalised oedema
Pallor

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13
Q

Nephrotic syndrome: cause (primary)

A

Most common cause in children: MINIMAL CHANGE DISEASE

- accounting for 90% of cases in children U10

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14
Q

Nephrotic syndrome: causes (secondary)

A

Secondary to intrinsic kidney disease

  • focal segmental glomerulosclerosis
  • membranoproliferative glomerulonephritis

Secondary to underlying systemic illness

  • Henoch-schonlein purpura (HSP)
  • Diabetes
  • infection (HIV, Hepatitis, malaria)
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15
Q

Minimal change disease: management

A

Corticosteroids (prednisolone)

Most children make full recovery, it may reoccur

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16
Q

Nephrotic syndrome: Management

A

High dose steroids - given for 4w then slowly weaned off for 8w
Low salt diet
Diuretics (for oedema)
Albumin infusions may be required if severe hypoalbuminaemia
Antibiotic prophylaxis (in severe cases)

If steroid resistant - ACEi, immunosuppressants (e.g. tacrolimus, cyclosporine, rituximab)

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17
Q

Nephrotic syndrome: complications

A

Hypovolaemia: fluid goes from intravascular space —> interstitial space (oedema and low BP)
Thrombosis: proteins that normally prevent blood clotting are lost in the kidneys, liver responds to low-albumin by producing pro-thrombotic proteins
Infection: kidneys leak immunoglobulins, exacerbated by treatment with immunosuppressants e.g. steroids
Acute or chronic renal failure
Relapse

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18
Q

Common causes of nephritis in children

A 
Post-streptococcal glomerulonephritis 
IgA Nephropathy (Berger’s disease)
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19
Q

Post-streptococcal glomerulonephritis: Cause

A

Occurs 1-3 weeks after beta haemolytic streptococcus infection (e.g. tonsillitis caused by strep pyogenes)
Immune complexes made of streptococcal antigens, antibodies, complement proteins get stuck in glomeruli of the kidneys causing inflammation
Inflammation —> reduction in kidney function —> AKI

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20
Q

Post-streptococcal glomerulonephritis: management

A

Supportive, 80% make full recovery

Some patients develop a progressive worsening of their renal function

May need treatment with: antihypertensive medication and diuretics if they develop complications

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21
Q

IgA nephropathy: Causes

A

Condition related to henoch-schonlein purpura (IgA vasculitis)
IgA deposits in the nephrons of kidney causes inflammation

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22
Q

IgA nephropathy: renal biopsy/histology

A

IgA deposits and glomerular mesangial proliferation

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23
Q

IgA nephropathy: Management

A

Supportive

Immunosuppressant meds to slow progression of disease (e.g. steroids and cyclophosphamide)

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24
Q

Haemolytic uraemia syndrome: what is it?

A

Thrombosis within small blood vessels throughout the body

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25
Haemolytic uraemia syndrome: cause
Usually caused by bacterial toxin = SHIGA TOXIN | Produced by the E. Coli 0157 bacteria or shigella
26
Haemolytic uraemia syndrome: TRIAD
1. Haemolytic anaemia 2. AKI 4. Thrombocytopenia
27
Haemolytic uraemia syndrome: Risk factors
Use of antibiotics and anti-motility medications (e.g. loperamide) to treat gastroenteritis caused by the causative pathogens increases the risk of developing HUS
28
Haemolytic uraemia syndrome: Presentation
E. Coli 0157 usually causes gastroenteritis + bloody diarrhoea Sx of HUS typically start 5 days after the onset of diarrhoea - reduced urine output, haematuria or dark brown urine, abdo pain, lethargy and irritability, confusion, oedema, HTN, bruising
29
Haemolytic uraemia syndrome: Management
``` MEDICAL EMERGENCY (10% mortality) Self limiting, supportive management Renal and paed specialist Renal dialysis may be needed Antihypertensives Careful maintenance of fluids Blood transfusions if required ```
30
When should NOCTURAL ENURESIS stop
3-4 years
31
When should DIURNAL ENURESIS stop
Should be able to control daytime urination by 2 years
32
Primary noctural enuresis: causes
(Means never managed to be completely dry at night) Most common = variation in normal development (particularly if child younger than 5) - parents just need reassurance Other causes: - Overactive bladder, fluid intake prior to bedtimes, psychological distress, chronic constipation, UTI, learning disability, cerebral palsy
33
Primary noctural enuresis: Establishing cause
2 week bladder diary (diary of toileting, fluid intake, bed wetting) - identify patterns Thorough history Exclude underlying physical / psychological causes
34
Primary noctural enuresis: Management
- Reassure parents of pt under 5 - lifestyle changes - encouragement + positive reinforcement - treat underlying/exacerbating factors (e.g. constipation) - Enuresis alarms - Pharmacological treatment
35
Secondary noctural enuresis: definition
When child starts bed wetting after they have previously been dry for at least 6 months
36
Secondary noctural enuresis: causes
More indicative of an underlying illness - UTI - Constipation - T1 DM - New psychological problems - Maltreatment (consider safeguarding)
37
Diurnal enuresis: types of incontinence
Urge incontinence | Stress incontinence
38
Enuresis alarm
Device that makes a noise at the first sign of bet wetting, waking the child up and stopping them from urinating Needs to be used consistently for a prolonged period (at least 3 months)
39
Enuresis: Pharmacological treatment
DESMOPRESSIN: reduces volume of urine produced by the kidneys (similar to anti-diuretic hormone). Taken at bedtime to reduce noctural enuresis. OXYBUTININ: Anticholinergic, reduces contractility of the bladder. Helpful with overactive bladder causing urge incontinence. IMIPRAMINE: tricyclic antidepressant,
40
Type of POLYCYSTIC KIDNEY DISEASE that presents in children
There are 2 types of PKD: 1. Autosomal recessive polycystic kidney disease (ARPKD) —> presents in neonates and usually picked up on antenatal ultrasounds 2. Autosomal dominant PKD - presents later in life usually adults
41
PKD: Features
Cystic enlargement of the renal collecting ducts Oligohydramnios (lack of amniotic fluid - caused by reduced urine production by foetus) —> pulmonary hypoplasia (resp. Failure short after birth) and potters syndrome (dysmorphic features) Congenial liver fibrosis
42
ARPKD: Ongoing problems throughout life
``` Liver failure due to liver fibrosis Portal hypertension —> oesophageal varices Progressive renal failure Hypertension due to renal failure Chronic lung disease ```
43
Multicystic dysplastic kidney (MCDK): definition
Where one of babies kidneys made up of lots of cysts, but other kidney is normal In rare cases it can be bilateral —> death in infancy Single good kidney to prone to problems (e.g. UTIs, hypertension, CKD later in life) No treatment required
44
WILMS TUMOUR: definition
Tumour affecting the kidneys in children
45
WILMS TUMOUR: Presentation
``` Consider in a pt. Under 5 yrs presenting with a mass in the abdomen. Signs/Sx: - Abdo pain - haematuria - lethargy - fever - hypertension - weight loss ```
46
WILMS TUMOUR: Diagnosis
Ultrasound of abdo CT/MRI to stage tumour Biopsy - histology and definitive diagnosis
47
WILMS TUMOUR: Management
SURGERY: Surgical excision of tumour and nephrectomy of affected kidney ADJUVANT TREATMENT: chemo/radio therapy
48
Posterior urethral valve: definition
Where there is tissue at the proximal end of the urethra (closest to the bladder) that causes obstruction to urine outflow Occurs in newborn boys
49
Posterior urethral valve: consequences
Obstruction of urine outflow —> hydronephrosis from backward flow pressure Severe cases can cause obstruction in developing foetus —> bilateral hydronephrosis and oligohydramnios (low amniotic fluid volume) —> pulmonary hypoplasia + resp. Failure short after birth
50
Posterior urethral valve: Presentation
Can vary in severity - difficulty urinating - weak urinary stream - chronic urinary retention - palpable bladder - recurrent UTIs - impaired kidney function
51
Posterior urethral valve: Investigations
``` Abdo USS Micturating cystourethrogram (MCUG) - shows location of extra urethral tissue and reflux of urine back into the bladder Cystoscopy: to get a view of the tissue/ used to ablate the tissue ```
52
Posterior urethral valve: Management
Mild: observed and monitored A temporary urinary catheter could be inserted to bypass the valve whilst awaiting definitive management Definitive management: ablation or removal of the extra urethral tissue, usually during cystoscopy
53
Undescended testis: risk factors
``` FH do undescended testis Low birth weight Small for gestational age Prematurity Maternal smoking during pregnancy ```
54
Undescended testis: Management
Watch and wait in newborns - most cases testis will descend in first 3-6 months ORCHIDOPEXY (surgical correction of undescended testis) - should be carried out between 6-12 months
55
Undescended testis: consequences
If undescended in older children or after puberty, higher risk of: Testicular torsion Infertility Testicular cancer
56
Retractile testicles: explanation
Normal variant - where the testes move out the scrotum into inguinal canal when it is cold or the cremasteric reflex is activated Occasionally may fully retract and require surgical correction
57
Hypospadias: definition
Urethral meatus in males abnormally placed posterior on the penis Usually foreskin is abnormally placed to match the position of the meatus Congential condition
58
Hypospadias: Complications
Difficulty directing urine Cosmetic and psychological concerns Sexual dysfunction
59
Hypospadias: Management
Mild cases may not require any treatment Surgery usually performed at 3-4 months of age Surgery aims to correct the position of the meatus and straighten the penis
60
Hydrocele: definition
Collection of fluid within tunica vaginal is surrounding testes SIMPLE HYDROCELE: common in new board males, usually resolves COMMUNICATING HYDROCELE: tunica vaginal is around testis connected with peritoneal cavity via PROCESSUS VAGINALIS. - allowing fluid to travel from the peritoneal cavity into the Hydrocele
61
Hydrocele: examination
Soft, smooth, non-tender swelling around one testes In front of and below testicle TRANSILLUMINATE
62
Differential diagnoses for a scrotal/inguinal swelling in a neonate
``` Hydrocele Partially descended testes Inguinal hernia Testicular torsion Haematoma Tumours (rare) ```
63
Hydrocele: Management
Simple ones: usually resolve within 2 years without having lasting negative affects Communicating: surgery to ligate the processus vaginalis

PAEDIATRICS (18 decks)

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