Urology

Question 1

Investigation for nephrotic syndrome***

Answer 1

> Blood

• FBC: Hb, WCC and Hct
• BUSE/ Cr
• LFT: hypoalbuminemia <25g/L
• Serum complement level: decrease C3, 4 in SLE
• Serum ASOT and anti-DNAse B: exclude PSGN

> Urine

• Urine dipstick: proteinuria
• 24 hour urine collection
• UFEME + C&S

> Renal biopsy (Main indication = steroid resistant nephrotic syndrome)

Question 2

4 classical features of nephrotic syndrome

Answer 2

• Edema
• Proteinuria: 24-h urine protein >40 mg/m2/hr or spot urine protein:creatinine index of >200mg/mmol
• Hypoalbuminemia <25g/L
• Hypercholesterolemia
• Only require both proteinuria and hypoalbuminemia for diagnosis

Question 3

Etiology of nephrotic syndrome

Answer 3

> Primary - Most common >90% in <10 y/o

• Minimal change disease (<5 y/o) - 80-90%
• Primary focal glomerulosclerosis
• Congenital (family hx of Alport syndrome)
• Primary idiopathic nephrotic syndrome

> Secondary

• Autoimmune ds (eg: HSP, SLE)
• Diabetic nephropathy
• Amyloidosis
• PSGN
• Chronic infection (eg: Hep B, C, HIV)

Question 4

Management algo of nephrotic syndrome***

Answer 4

1. Initial ep
   - Prednisolone 60mg/m2/day for 4 weeks
   - If response -> 40mg/m2/alternate day for 4 weeks, then taper over 4 weeks and stop
   - If no response -> renal biopsy
2. Relapse
   - Prednisolone 60mg/m2/day till remission
   - 40mg/m2/alternate day for 4 weeks then stop
3. Frequent relapse
   - Reinduce as (2) + low dose alternate day Prednisolone for 6 months
4. Relapse while on Pred
   - Treat as (3) if not steroid toxic
   - Consider cyclophosphamide if steroid toxic
5. Relapse post cyclophosphamide
   - As for (2) and (3) if not steroid toxic
   - Refer specialist for steroid sparring agents

Question 5

General management for nephrotic syndrome***

Answer 5

• Penicillin V is recommended at diagnosis and during relapse to prevent infection
• Careful assessment of the hemodynamic status
• Human albumin can be used at symptomatic grossly edematous states with IV frusemide to produce diuresis
• Fluid restriction not recommended except chronic edematous

Question 6

Complication of nephrotic syndrome**

Answer 6

• Hypovolemia
• Thrombosis
• Infection
• Hypercholesterolemia
• Renal failure

Question 7

Management for nephritic syndrome***

Answer 7

• Penicillin V for 10 days: to eliminate B-hemolytic strep
• Fluid restriction: to control edema and circulatory overload
• Diuretics (eg: Frusemide): for pulmonary edema

Question 8

Complication of nephritis syndrome and how to manage

***

Answer 8

> Hypertensive encephalopathy
- Anti-HPT to reduce mean arterial pressure by approx 25% over the first 24 hour

> Pulmonary edema

• O2 support if necessary
• IV Frusemide, fluid restriction
• Consider dialysis if no response to diuretics

> Acute renal failure
- Treat cause and complication?

Question 9

Pathophysiology of IgA nephropathy

Answer 9

• (Onset within 24 hours after URTI)
• Immune complexes deposit into glomerulus from circulation, leading to inflammation and proliferation of cells in glomerulus
• Inflammatory process damages capillary walls, leading to abnormal permeability to RBC or proteins

Question 10

ECG changes in hyperkalemia

Answer 10

• Tall, tented T waves
• Prolonged PR interval
• Widened QRS complexes
• VF or asystole

(Peads protocol)

Question 11

Description of impetigo*

Answer 11

• Non-bullous impetigo (most common form)
• Begins as papules -> vesicles surrounded by erythema -> pustules -> enlarge and rapidly break down to form thick, adherent crusts with characteristic golden appearance
• Seen in group A strep (eg: strep. pyogenes) and S. aureus infection

Question 12

Investigation for nephritic syndrome***

Answer 12

• Urinalyses and culture: hematuria, proteinuria, RBC cast, pyuria
• Bacteriological and serological evidence: raised ASOT, anti-DNAse B, throat/ skin swab
• Renal function test: blood urea, electrolyte and serum creatinine
• FBC: anemia, leukocytosis
• Complement level: C3 low, C4 normal

Question 13

Nephrotic vs Nephritic syndrome*

Answer 13

> Nephrotic syndrome

• Frothy urine, edema, xanthelasma
• Urinalysis: proteinuria (++++), frothy appearance

> Nephritic syndrome

• Hematuria, uremic symptoms
• Urinalysis: hematuria, proteinuria (mild), red cell casts

Question 14

Pathogenesis of PSGN

Answer 14

• Deposition of circulating immune complex induced by GAS in glomerular
• Trigger complement activation and inflammation in the glomerular

Question 15

Definition for hypertension in children

Answer 15

• Auscultatory-confirmed BP reading >= 95th percentiles on 3 different occasion (oscillometric tend to give higher BP reading)

Question 16

Definition of nephrotic symptoms

• Remission
• Relapse
• Frequent relapse
• Steroid-resistant
• Steroid dependent

Answer 16

> Remission
- Urine dipstick is trace or nil for 2 consecutive days within 28 days

> Relapse

• Urine albumin excretion >40mg/m2/hour OR
• Urine dipsticks of ≥2+ for 3 consecutive days

> Frequent relapse

• ≥2 relapses within 6 months of initial diagnosis OR
• ≥4 relapses within any 12 month period

> Steroid-resistant
- Failure to achieve remission despite 4 weeks treatment with prednisolone at 60mg/m2/day

> Steroid dependence

• ≥2 consecutive relapse occurring during steroid taper OR
• Within 14 days of the cessation of steroids