Nephrology

Question 1

nephrotic syndrome

Question 2

kidney stones

Question 3

epidemiology kidney stones

Answer 3

Uncommon and rare in childhood.
Incidence in childhood is unknown, estimated to be approximately 2 children per million UK population per year.
The most common types of calculi in children are calcium phosphate and struvite.

Question 4

UTI

Question 5

UTI children

Answer 5

n children, 7% of girls and 2% of boys will have had a urinary tract infection by age 7 years
Common causes of UTIs are E.Coli (about 85% or more), Klebsiella species and Staphylococcus saprophyticus

Question 6

risk factors for children UTI

Answer 6

Age below one year
Female – however in children under 3 months UTIs are more common in boys than girls
Caucasian race
Previous UTI
Voiding dysfunction
Vesicoureteral reflex (VUR) – this is the reflux of urine from the bladder into the ureter (can be unilateral or bilateral), Around 33% of infants and children who have a urinary tract infection have VUR.
Sexual abuse – can cause urinary symptoms but infection is uncommon
Spinal abnormalities
Constipation
Immunosuppression

Question 7

hx UTI <3mths

Answer 7

Vomiting
Fever
Lethargy
Poor feeding
Failure to thrive

Question 8

other clinical features UTI

Answer 8

Increased frequency
Painful urination
There may also be dysfunctional voiding, changes in continence, abdominal pain and loin tenderness.

Less common symptoms may include vomiting, fever, malaise, haematuria, offensive smelling urine and cloudy urine.

Question 13

examination UTI

Answer 13

Temperature
Heart rate
Respiratory rate
Capillary refill time
Acute pyelonephritis/upper UTI should be suspected in children with:

temperature of 38oC or higher and bacteriuria
temperature lower than 38oC with loin pain/tenderness and bacteriuria
If no systemic symptoms but bacteriuria present then cystitis/lower UTI should be considered.

Throat and cervical nodes
Abdomen – look for constipation, masses and tender or palpable kidney
Back – look for stigmata of spina bifida or sacral agenesis
Genitalia – look for phismosis, labial adhesions, vulvitis, or epdidymo-orchitis

Question 13

imaging in children UTI

Answer 13

see table

Question 13

ddx UTI children

Answer 13

vulvovaginitis
kawasaki disease
voiding dysfunction

Question 13

indications investigations UTI

Answer 13

All infants with an unexplained temperature of 38oC or more should have their urine sent for microscopy and culture within 24 hours.

A clean catch urine sample is the recommended method for urine collection
f leukocyte esterase and nitrites are positive then send the urine sample for microscopy and culture.
If leukocyte esterase and nitrites are negative then do not send a sample unless symptoms suggest acute pyelonephritis, the UTI is recurrent, or the clinical picture does not correlate with the dipstick findings

Question 14

atypical UTI features children

Answer 14

Poor urine flow
Abdominal or bladder mass
Raised creatinine
Sepsis
Failure to respond to treatment within 48 hours
Non-E.Coli organism

Question 18

definition of recurrent UTI

Answer 18

Two or more episodes of upper UTI (pyelonephritis)
One episode of upper UTI and one episode of lower UTI
Three episodes of lower UTI

Question 18

> 3mths UTI management children

Answer 18

Treat with oral antibiotics for 3 days. Trimethoprim, Nitrofurantoin, a cephalosporin or Amoxicillin may be suitable

Question 18

<3 mths UTi management

Answer 18

All infants younger than 3 months with a suspected UTI should be referred immediately to the care of a paediatric specialist for urine analysis and treatment with parenteral antibiotics

Question 19

children >3mths pyelonephtitis tx

Answer 19

referral-
Whether the child is vomiting, think about whether they can tolerate oral antibiotics
Inadequate fluid intake – 50-75% of usual volume or no wet nappy for 12 hours
Factors that may affect a carer’s ability to look after the child or confidence that the carer will be able to identify deteriorating symptoms
If referral is not appropriate treat with oral antibiotics, ciprofloxacin or co-amoxiclav for 7-10 days

Question 20

advice for parents UTI management

Answer 20

importance of completing the course of treatment to parents/carers
Recommend paracetamol for pain relief
Give information on adequate fluid intake and the importance of this
Advise parents/carers that the child should not be expected to delay voiding and have access to clean toilets
Constipation should be addressed

Question 21

complications UTI

Answer 21

renal scarring/dmaage
HTN
renal insufficiency and failure

Question 22

recurrence of UTI more common in

Answer 22

Younger children – aged less than 6 months
Girls compared to boys
VUR grade 3-5
Voiding abnormalities