Case 4 - urinary symptoms Flashcards
(17 cards)
Baseline invetsigations for ?minimal change disease
Bedside:
* Urinalysis for blood and protein
* Protein:creatinine ratio (early morning sample if poss)
Bloods:
* FBC
* U&E
* Bone profile (inc albumin)
* Varicella zoster immunity status)
Consider complement, hepatitis serology, antistreptolysin O titre, and autoimmune investigations - later
Triad nephrotic syndrome
- Proteinuria (more than 3+ dipstick)
- Hypoalbuminaemia
- Oedema
Other important features of nephrotic syndrome
- Hyperlipidaemia
- High BP - RAAS activated
- Hypercoaguable
Treatment for minimal change disease
- Admit to paeds ward - allow for monitoring of fluid status
- Oral antibiotics - penicillin V for abx prophylaxis to protect against pneumococcal infection
- Oral prednisolone
- Diuretics should only be used if severe worsening oedema/ascites and not hypovolaemic
- Low salt diet
How can oedema with hypovolaemia manifest?
- Tachycardia
- Hypotension
- Cool peripheries
- Prolonged capillary refill
- High Hb
- High urea
Complications of minimal change disease
- Peritonitis
- Compromised immune system - hypogammaglobulinaemia
- Thrombosis - loss of antithrombin III, steroid therapy, high blood viscosity (due to high Ht and hypovolaemia)
- Fluid management - dehydration
- Varicella zoster infection can be very severe if occurs in immunosupressed
Urine dipstick findings for UTI in child
- If leucocyte and nitrite +ve –> start abx
- If just nitrite +ve –> start abx, confirm with culture
- If leucocyte +ve only –> don’t start abx unless good clinical evidence of UTI, confirm with urine culture
- If negative for both - do not start abx, do not send culture, explore other causes
Nitrites are key
Criteria for renal USS in a child with UTI
- Infant under 6 months - USS within 6 weeks
- Atypical UTI
- Recurrent UTI
Define atypical UTI
- Seriously ill
- Poor urine flow
- Abdo/bladder mass
- Raised creatinine
- Septicaemia
- Failure to respond to abx within 48hrs
- Infection with non-e.coli organism
Define recurrent UTI
- 2 or more upper UTI
- 1 upper and one or more lower UTI
- 3 or more lower UTI
Other causes of oedema in childhood (other than nephrotic)
- Increased hydrostatic pressure from sodium and water retention - heart failure, acute glomerulonephritis, renal failure, drugs
- Increased capillary pressure from obstruction - venous obstruction, cirrhosis
- Decreased capillary oncotic pressure - malnutrition, protein losing enteropathy
- Lymphatic obstruction
What can raised urea and Hb suggest in bloods?
Hypovolaemia
What can raised creatinine suggest of ?nephrotic syndrome?
Atypical nephrotic syndrome
Typical presentation of minimal change disease
- Aged 1-11
- Normal creatinine
- Microscopic haematuria
- Normal BP
- Absent FH of nephrotic syndrome
Atypical is opposite - consider discuss with nephrology and biopsy
Differentials for oedema in children
- Heart failure
- Allergic reaction
- Malnutrition - Kwashiokor
Management of childhood UTI
- All children under 3 months –> full septic screen and start immediate abx
- If features of sepsis or upper UTI - admit for IV abx
- Uncomplicated - 3 days of oral abx eg trimethoprim, nitrofurantoin
DMSA scan
- Recommended 4-6 months after infection
- Assess for damage from recurrent or atypical UTI
- Patches of kidneys which do not take up the radioactive material can suggest scarring
