Kidneys and Urinary Tract Disorders Flashcards
UTI: epidemiology and presentation
Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood
Presentation in childhood depends on age:
- infants: poor feeding, vomiting, irritability
- younger children: abdominal pain, fever, dysuria
- older children: dysuria, frequency, haematuria
- features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness
NICE guidelines for checking urine sample in a child, urine collection method, when to send for a culture
NICE guidelines for checking urine sample in a child
- if there are any symptoms or signs suggestive or a UTI
- with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
- with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)
Urine collection method
- clean catch is preferable
- if not possible then urine collection pads should be used
- cotton wool balls, gauze and sanitary towels are not suitable
- invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible
send for a culture:
- < 3 years old
- recurrent UTI
- suspected pyelonephritis
- risk of serious illness
- unresponsive to tx within 24 - 48 hours
- when clinical symptoms and dipstick results do not correlate
UTI mx
- infants less than 3 months old should be referred immediately to a paediatrician
children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
- antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
- advise parents to return if still unwell 24-48 hours later
What are recurrent UTIs
2 or more episodes UTI with acute pyelonephritis/upper UTI
1 episode of UTI with acute pyelonephritis/upper UTI plus one or more episode of UTI with cystitis/lower UTI
3 or more episodes of UTI with cystitis/lower UTI
Nocturnal enuresis meaning and 2 types
‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’. Most dry day and night by age of 5 years, children dry by day only by age of 4 years
Primary (never achieved continence), secondary (dry for at least 6 months before)
Nocturnal enuresis Ix and Mx
Primary <5 = reassure and self-limiting, easy access to toilet (e.g. potty near bed), encourage bladder emptying before bed, positive reward system
Primary >5 = infrequenct (<2/w) reassure and watch-and-see, star/reward chart, no punishment
- Long term = enuresis alarm (1st line) w/ positive reward system, desmopressin (2nd line)
- REFER to 2o care/enuresis clinic
Desmopressin = fluid restrict 1 hr before until 8 hr after. Used 2ns line and for rapid/short-term control
REFER = if not responded to 2 courses of tx, to 2o care (enuresis clinic/community paediatrician)
Secondary causes (need specialised referral bar UTI and constipation) = diabetes, recurrent UTI, psychological and family problems, developmental/attention/learning difficulties, known or suspected physical or neurological problems
Ix = look for possible causes
Features of atypical UTI
what investigation and when
Features of atypical UTI:
- *CATFISH**
- Creatinine
- Abdo/bladder mass
- Terribly ill
- Flow problems
- Infected with non-ecoli organisms
- Septicaemia
- Halted/no response to suitable abx >48 hours
Ix = USS during acute admission when there are signs of an atypical UTI in infants under 6 months
Nephrotic syndrome features
proteinuria (> 1 g/m2 per 24 hours)
hypoalbuminaemia (< 25 g/l)
oedema
hyperlipidaemia
lipiduria
hypercoaguable state (loss of AT III/protein C/S) although loss of clotting factors
predisposition to infection (due to loss of Ig)
loss of TBG (lower levels of thyroxine)
- 80% are diagnosed <6 years
- 80% have a relapse
- 80% are minimal change disease
- 80% are steroid responsive
Most common nephrotic syndrome in children?
Minimal change disease
Minimal change glomerulonephritis (2-5 years age) nearly always presents as nephrotic syndrome, accounting for 80% of cases in children and 25% in adults. The majority of cases are idiopathic and respond well to steroids
- drugs: NSAIDs, rifampicin
- Hodgkin’s lymphoma, thymoma
- infectious mononucleosis
other glomerulitis’ (nephritic)
1-2 DAY post infection -> igA
1-2 week post infection -> post strep
Nephrotic vs nephritic syndrome
Vesicoureteric reflux (VUR) what is it? pathophysiology
abnormal backflow of urine from bladder into ureter and kidney
predisposition to UTI (30% of children with UTI)
→ renal scarring
VUR presentation and ix
features:
- antenatal = hydronephrosis on USS
- recurrent childhood UTI
- reflux nephropathy = ‘chronic pyelonephritis 2o to VUR’, commonest cause of chronic pyelonephritis, renal scar may produce increased quanities of renin causing HTN
Ix
- micturating cystourethrogram (GOLD-STANDARD)
- DMSA for renal scaring
How do we grade VUR
