CLMD - Renal Topics in Pediatrics

Question 1

Definition of normal BP for children aged 1-13 years old (in terms of percentile)

Answer 1

Normal BP: < 90th percentile

Question 2

Trained healthcare professionals in the office setting should make a dx of HTN if a child or adolescent has auscultatory confirmed BP readings >95th percentile at ____ different visits

Answer 2

3

Question 3

What clinical intervention is indicated for children with elevated BP regardless of its severity whether it was initial or subsequent measurement?

Answer 3

Lifestyle counseling (weight and nutrition)

Question 4

When should a pediatric HTN pt be referred for emergency care?

Answer 4

If pt is symptomatic or BP is >30 mm Hg above the 95th percentile

Question 5

T/F: primary HTN is the predominant cause of HTN in US children

Answer 5

True

Question 6

The severity of BP elevation is similar between primary and secondary, however, diastolic HTN is predictive of ____ cause

Answer 6

Secondary

[systolic HTN is predictive of primary HTN]

Question 7

What are some secondary causes for pediatric HTN?

Answer 7

Renal parenchymal disease or renal structural abnormalities

Renovascular disease

Aortic coarctation (occurs with various syndromes including neurofibromatosis, williams, alagille, takayasu arteritis, etc.)

Various drugs (decongestants, caffiene, NSAIDs, stimulants, contraception, steroids, TCAs, cocaine)

Question 8

What is the difference between white-coat HTN and masked HTN?

What is the recommendation in either case?

Answer 8

White-coat HTN: pt with BP levels >95th percentile in clinic, but normotensive outside clinical setting

Masked HTN: pt with BP levels >95th percentile outside the clinic, but normotensive in clinical setting

Ambulatory blood pressure monitoring (ABPM) helpful in either case

Question 9

Describe Karotkoff sounds used in BP measurement

Answer 9

1st sound: Systolic BP
2nd sound
3rd sound
4th sound: becomes muffled
5th sound: silence, pressure drops below diastolic BP

[in some kids, 4th sound never goes away, so muffled sound is used as DBP]

Question 10

In older, school age children, prevalence of primary HTN has increased hand-in-hand with the ____ epidemic

Answer 10

Obesity

Question 11

______ is the most prominent evidence of target-organ damage in children and adolescents with HTN, and establishes the chronicity of their high blood pressure

Answer 11

Left Ventricular Hypertrophy (LVH) — so get an echocardiogram to determine their chronicity

Question 12

A blood pressure cuff that is too small causes an artificially ____ BP

Answer 12

High

[a blood pressure cuff that is too large causes an artificially low BP]

Question 13

Clinical definition of hematuria

Answer 13

Presence of 5+ RBCs per hpf in 3 consecutive fresh, centrifuged specimens obtained over the span of a few weeks

Can be gross or microscopic

Question 14

A positive urine dipstick for hematuria may occur with no RBCs presence, thus what is an important test you must always order with your UA?

Answer 14

Microscopy

Question 15

What are some things that cause discoloration of urine that may mislead you to think hematuria?

Answer 15

Drugs: rifampin, nitrofurantoin, pyridium, sulfa drugs

Foods: beets, rhubarb, fruit juice

Dehydration in newborns — uric acid crystals in urine of newborn cause brick red color in diaper

Bilirubin

Question 16

When are UAs done as part of normal pediatric check ups?

Answer 16

Often done at 5 y/o checkup

Often done as part of pre-participation physical

Question 17

What urinary findings regarding RBC casts, morphology, proteinuria, clots, and color likely suggest a glomerular source for hematuria?

Answer 17

RBC casts may be present, RBCs are dysmorphic, proteinuria may be present, no clots, color may be red or brown

[if the cause is extra-glomerular, RBC casts will be absent, RBCs appear uniform, no proteinuria, clots may be present, color may be red]

Question 18

Hematuria is not as ominous as hematuria and ____ together

Answer 18

Proteinuria

Question 19

Signs and symptoms of post infectious acute glomerulonephritis

Answer 19

Recent strep throat followed by:

Gross hematuria with glomerular involvement

HTN

Swelling/edema

Elevated ASO titer

Low serum complement C3

Question 20

What type of renal involvement should be associated with lupus? What is the most common type?

Answer 20

Glomerulonephritis

Most common is mesangial proliferative lupus nephritis

Question 21

Signs and symptoms of HSP

Answer 21

Gross hematuria
Abdominal pain
May have bloody stools
Purpura present over buttocks, lower legs, elbows
Hives
Emesis and nausea
Diarrhea

Question 22

The development of ____ along with hematuria in HSP patients is prognostically indicative of potential long term renal damage

Answer 22

Proteinuria

Question 23

Patients with asymptomatic, isolated hematuria rarely have significant renal disease. 25% of pts will no long demonstrate hematuria if followed for 5 years. Ask FH questions to r/o Benign Familial Hematuria (thin basement membrane disease); these pts should be regularly monitored for ____ and _____

Answer 23

Proteinuria; HTN

Question 24

What electrolyte abnormality causes asymptomatic microscopic hematuria?

Answer 24

Hypercalcuria

[urine Ca-to-creatinine ratio of more than 0.2 — indicative of excess Ca excretion]

Question 25

Host factors that influence predisposition to UTI in children

Answer 25

Age (boys < 1 yr, girls < 4 yrs) Lack of circumcision Female Race/ethnicity: caucasian 2-4x higher risk than AA Genetic predisposition Urinary obstruction Bladder and bowel dysfunction

Question 26

Causes of urinary obstruction in kids

Answer 26

Anatomic: Posterior urethral valves (boys only) Ureteropelvic junction obstruction Cysts or ureteroceles Neurologic: Myelomeningocele with neurogenic bladder Functional: Bladder or bowel dysfunction

Question 27

How is urine specimen obtained in children when UTI is suspected? When are bag samples ok to be used?

Answer 27

If child can void on command, a clean-catch urine may be obtained Otherwise utilize catheterization or suprapubic aspiration Bag samples are only helpful if negative, they are NOT appropriate for culture

Question 28

Criteria for dx of UTI

Answer 28

If by clean catch — presence of both pyuria and 50,000+ colonies/mL of single organism If by catheter — pyuria and colony count of 50,000 CPM or 10,000-50,000 CPM confirmed by repeat If by suprapubic aspiration — pyuria and ANY growth on culture

Question 29

What result on UA indicates presence of WBCs? Certain types of bacteria?

Answer 29

Leukocyte esterase indicates WBCs Nitrites indicate certain types of bacteria (including E.coli—most common)

Question 30

If you are going to treat empirically for UTI, what should you choose?

Answer 30

If not acutely ill and tolerating PO, use oral abx: cephalosporin (cefixime or cefdinir), fluoroquinolones can be used If acutely ill or not tolerating PO, IV abx: 3rd gen cephalosporin (ceftriaxone) — add ampicillin if enterococcus suspected If afebrile, tx for 3-10 days; if febrile, tx for 10-14 days

Question 31

When do you image a child’s urinary tract?

Answer 31

In boys with first UTI, common practice is to do renal and bladder US AND VCUG In girls with first UTI, both VCUG and US are ONLY done if there are symptoms of chronic renal disease, high fever, pathogen other than E.coli, poor growth and HTN, or urologic anomaly suspected

Question 32

After the second UTI in children, a VCUG is often done looking for evidence of ______ ______ which can be graded 1-5. This condition is notorious for causing renal ______

Answer 32

Vesicoureteral reflux; scarring [VUR that is graded anywhere from 3-5 requires urologic consult and probably surgery]

Question 33

What is renal scarring? What are long term complications?

Answer 33

Loss of renal parenchyma between calyces and renal capsule Long term complications can be HTN, decreased renal function, proteinuria, endstage renal disease

Question 34

When does the child’s primary care provider refer to a specialist?

Answer 34

In cases of dilating VUR (III-V) If obstructive uropathy is present When renal abnormalities are identified When kidney function is impaired If a pt is hypertensive If bowel and bladder dysfunction is refractory to primary care measures