Kidney and Urinary Tract Disorders Flashcards
(65 cards)
1
Q
What are the signs and symptoms of urinary tract infections in children?
A
- Dysuria
- Frequency
- Flank pain
- Offensive smelling urine
- Fever / rigors
- Diarrhoea and Vomiting
- Lethargy / Irritability
- Febrile seizures
- Infants
- Fever
- Poor feeding / faltering growth
- Jaundice
- Septicaemia
- Children
- Abdominal pain / lion tenderness
- Haematuria
- Enuresis
2
Q
What are the appropriate investigations for suspected urinary tract infections in children?
A
-
Urine dip
- Nitrite stick test – very specific
- Leucocyte esterase test
- Urine MC&S = diagnostic
- Imaging not recommended
- Unless atypical or recurrent UTIs = USS à DMSA ± MCUG
- Atypical UTI = USS ± DMSA (<3yo only)
- Recurrent UTI = USS + DMSA
- Unless atypical or recurrent UTIs = USS à DMSA ± MCUG
3
Q
What is the management of urinary tract infections?
A
- <3m = Emergency
- Admit to hospital
- IV Abx for 5-7 days → oral prophylaxis
- Urgent USS should be booked (4-6w)
- >3m Upper UTI
- Consider hospital admission
- IV Abx for 7-10 days
- <6m old when they have 1st UTI = urgent USS should be booked (4-6w)
- >3m Lower UTI
- Oral Abx for 3 days
- Safety net parents → bring child back if they remain unwell after 48 hours (may be atypical)
- <6m old when they have 1st UTI = urgent USS should be booked (4-6w)
4
Q
What is the management of recurrent UTIs in children?
A
- Antibiotic prophylaxis
- USS - during admission if <6m, urgent if >6m
- DMSA scan (routine)
5
Q
What strategies can prevent UTIs?
A
- High fluid intake to produce high urine output
- Regular voiding
- Ensure complete bladder emptying
- Treatment and/or prevention of constipation
- Good perineal hygiene
- Lactobacillus acidophilus probiotic
6
Q
What is Enuresis?
A
Bed-wetting
7
Q
What is the management of primary bedwetting without daytime symptoms <5 years old?
A
- Reassure parents → often resolves by 5yo
- Educate
- Easy access to toilet at night
- Bladder emptying before bed
- Positive reward system
8
Q
What is the management of primary bedwetting without daytime symptoms >5 years old?
A
- Infrequent (<2/week) → offer watch-and-see approach
- Frequent
- 1st line = enuresis alarm, positive reward system - encourage child to help change sheets
- 2nd line = desmopressin (1st line if >7yo or for short-term control (i.e. sleepovers, school trips, etc))
- 3rd line = combination
- Referral to enuresis clinic
- Community paediatrician if bedwetting not responded to 2 courses tx
9
Q
What counselling should be given to parents with a child with primary bed-wetting without daytime symptoms?
A
- Bedwetting not the child/parent’s fault - take a neutral attitude to bedwetting so not to embarrass
- Reason is excess volume that does not wake the child to go to the toilet
- Reassure that pretty much all children become dry with time as their bladder capacity increases and they learn to wake at the sensation of a full bladder
- Child should go to the toilet regularly and before bed
- Avoid caffeine before bed
- Easy access to toilet
- Waterproof mattress or bed pads
- Lifting or waking during the night does not promote long-term dryness
- Positive reward systems - rewards for going to the toilet before bed
- Drink the recommended amount of fluid during the day
- Support groups
10
Q
What is the management of primary bedwetting with daytime symptoms?
A
Referral to enuresis clinic and community paediatrician
11
Q
What are the appropriate investigations for troubling enuresis?
A
- Renal USS
- Urine diary
- Dipsticks
- MCUG
- Urine MC&S
12
Q
What is the management of secondary bedwetting with daytime symptoms?
A
- Primary care management = manage the cause
- UTI
- Constipation
- Secondary care management = manage the cause
- Diabetes
- Recurrent UTI
- Psychological problems
- Family problems
- Developmental, attention or learning difficulties
- Known or suspected physical or neurological problems
13
Q
Define Secondary Bedwetting.
A
Enuresis that occurs after the child has previously been dry at night for 6 months.
14
Q
What are the signs and symptoms of osteosarcoma?
A
- Occurs in end of long bones - 60-75% in the knee
- Relatively painless
- Mass/swelling that restricts movement
- Rapid metastasis to lung
15
Q
What are the appropriate investigations for suspected osteosarcoma?
A
-
X-Ray - bone destruction and formation
- Soft tissue calcification = sunburst appearance
- Elevated periosteum = “Codman’s triangle”
- Biopsy
- CT/PET/MRI
16
Q
What is the management of osteosarcoma?
A
- Specialised sarcoma team (London) management
-
Surgery + Chemotherapy
- Limb-sparing surgery ± amputation
- Post-treatment
- OT
- PT
- Dietician
- Orthotics/prosthetics
- Support group - Sarcoma UK
17
Q
What is the difference between osteosarcoma, Ewing’s sarcoma and chondrosarcoma?
A
- Osteosarcoma = forms bone
- Ewing’s sarcoma = forms mesenchymal tissue (neuroectodermal)
- Chondrosarcoma = forms cartilage (occurs in those >40yo)
18
Q
What is the prognosis of osteosarcoma?
A
60% 5-year survival
19
Q
What is Nephrotic syndrome?
A
- Low albumin
- Peripheral oedema
- Proteinuria
20
Q
What is the most common cause of nephrotic syndrome?
A
Minimal Change Disease - 90%
21
Q
What are the signs and symptoms of nephrotic syndrome?
A
- 1st = Peri-orbital oedema - often misdiagnosed as allergy
- 2nd = Other delayed features of oedema + Features of underlying diagnosis
22
Q
What are the types of nephrotic syndrome?
A
- Steroid-sensitive nephrotic syndrome - 80-95%
- Steroid-resistant nephrotic syndrome
23
Q
What are the appropriate investigations for suspected nephrotic syndrome?
A
- Urine
- Dipstick
- MC&S
- Sodium
- Bloods
- Urea
- U&Es
- FBC
- ESR
- Creatinine
- Albumin
- Complement levels (C3, C4)
- Anti-streptolysin O or Anti-DNase B titres - recent streptococcal throat infection
- HBV, HCV, malaria screen
24
Q
What is the management of nephrotic syndrome?
A
- 1st = Oral prednisolone for 4-6 weeks - reduced dose from 4+ weeks
- Renal histology of steroid-sensitive nephrotic syndrome = normal on light microscopy
- However, on electron microscopy, fusion of podocytes is seen (minimal change disease)
- 2nd (steroid-resistant or atypical) = specialised renal biopsy and care
25
What are the main complications of nephrotic syndrome?
* **Risk of thrombosis** → loss of AT-III in the urine = hypercoagulable state
* **Risk of infection** → loss of immunoglobulin in urine
* **Hypercholesterolaemia** → urinary albumin loss → less oncotic pressure → hepatic cholesterol synthesis
26
What are the causes of childhood acute glomerulonephritis?
* Minimal change disease
* Focal-segmental glomerulosclerosis
* Membranous - more common in adults
* *Post-infectious (streptococcus in children)*
* *Vasculitis (SLE, ANCA +ve)*
* *IgA nephropathy (adults, but includes HSP in children)*
* *Mesangiocapillary glomerulonephritis*
* *Goodpasture’s*
27
What is Minimal change disease?
Change to the glomeruli, usually from an idiopathic cause but can be due to drugs or infection
* Normal renal function, complement and BP
* Most common in 2-4 year olds
* 90% of nephrotic syndrome
* Usually responds to high dose prednisolone
28
What is Focal segmental glomerulonephritis?
Segmental scarring and foot process fusion.
* Hypertension and impaired renal function
* Common in older children
* 50% respond to steroids
29
What is Membranous nephropathy?
Widespread thickening, granular deposits of Ig and complement.
* More common in adults
30
What are the signs and symptoms of acute glomerulonephritits?
* Nephrotic syndrome
* Low albumin
* Peripheral oedema
* Proteinuria
* Nephritic syndrome
* Haematuria
* Hypertension
* Proteinuria
* **Decreased urine output and volume overload**
* **Oedema**
* **Hypertension**
* **Seizures**
31
What are the appropriate investigations for suspected acute glomerulonephritis?
* Urine
* Dipstick
* MC&S
* Sodium
* Bloods
* Urea
* U&Es
* FBC
* ESR
* Creatinine
* Albumin
* Complement levels (C3, C4)
* **Anti-streptolysin O** or **Anti-DNase B titres** - *recent streptococcal throat infection*
* HBV, HCV, malaria screen
32
What is the management of acute glomerulonephritis?
* Depends on type, severity and complications
* Minimal change = Nephrotic Syndrome = **Corticosteroids**
* Focal-segmental = depends on cause
* **Corticosteroids**
* Immunosuppressive drugs
* Plasmapheresis
* ACE inhibitors and ARBs
* Diuretics
* Diet change
* Membranous = Supportive, ACEi and ARBs
* **Correct water and electrolyte balances**
* Treat oedema → **diuretics and potassium supplement**
* **BP management**
* **Dietary advice and/or Lipid lowering therapy**
33
What is IgA Vasculitis?
Small-vessel vasculitis in which complexes of IgA and C3 are deposited on arterioles, capillaries, and venules.
* AKA - Henoch-Schonelin Purpura
34
What is the most common cause of vasculitis in children?
IgA vasculitis → particularly in boys aged between 3-10yo
35
What are the signs and symptoms of IgA vasculitis?
* **Purpuric Rash** (100%)
* Extensor surface of legs, arms, buttocks, ankles - spares trunk
* Maculopapular
* **Arthralgia** and Periarticular oedema (60-80%):
* Large Joints
* Joint pain and swelling of knees and ankles
* **Abdominal pain** (60%)
* Colicky abdominal pain
* Haematemesis, melena, intussusception
* **Glomerulonephritis** (20-60% → 97% within 3m of onset)
* Microscopic or macroscopic haematuria
* Nephrotic syndrome - rare
* Recent URTI
* Winter time
36
What are the appropriate investigations for IgA vasculitis?
* 1st
* **FBC**
* **Clotting screen**
* **Urine dipstick**
* **U&Es**
* Urinalysis
* RBCs
* Proteinuria
* Urea
* Creatinine
* 24hr protein → rule out meningococcal sepsis
* Increased IgA
* Normal coagulation
* Follow-up → BP measurements and urine dipstick (haematuria)
37
What is the management of IgA vasculitis?
* **Most cases = resolve spontaneously within 4 weeks**
* Symptomatic management:
* Joint pain → **NSAIDs**
* Scrotal involvement or severe oedema or severe abdominal pain = **oral prednisolone**
* Renal involvement:
* **IV corticosteroids** - nephrotic-range proteinuria and those with declining renal function
* Renal transplant may be considered in end-stage renal disease
38
What are the complications of IgA vasculitis?
* Testicular pain (rare)
* Arthritis of knees
* Intussusception
* Acute/Chronic renal failure
* Pancreatitis
39
What are the most common causes of acute renal failure in children in the UK?
* **Haemolytic Uraemic Syndrome (HUS)**
* Acute Tubular Necrosis – *usually in context of organ failure in ITU or after cardiac surgery*
40
Define Haemolytic Uraemic Syndrome.
Microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury.
41
What are the signs and symptoms of haemolytic uraemic syndrome?
* **Diarrhoea - some times bloody**
* **Known E. coli or food poisoning**
* Most common cause = Shiga toxin from haemorrhagic E. coli O157 (infectious diarrhoea)
* More common \<5 years old
* **Requires admission**
* On investigations
* Schistocytes on blood film
* Distorted erythrocytes → MAHA → schistocytes
42
What are the signs and symptoms of renal failure in childhood?
* Oliguria or anuria
* Discoloured urine – brown
* Oedema – feet, legs, abdo, weight gain
* Fatigue / Lethargy
* N&V
43
What are the indicatiosn fo rreferral to urology in childhood renal failure?
* Signs/findings of Post-renal cause
* Pyonephrosis
* Obstructed solitary kidney
* Bilateral upper urinary tract obstruction
* Complications of AKI caused by urological obstruction
* Requires assessment of the site of obstruction (i.e. PUV, VUJ obstruction, etc.)
* Relief can be achieved by nephrostomy or catheterisation
44
What are the appropriate investigations for childhood renal failure?
* **Renal USS** - might identify obstruction
* CKD = small kidneys
* AKI = large, bright kidneys with loss of cortical medullary differentiation
* Bloods → FBC, U&Es, Urea
45
What is the management of renal failure in a child?
* **Diuretics PRN + Fluid restriction** → treat fluid overload/oedema whilst awaiting dialysis
* Unless cause in hypovolaemic → **fluid replacement and circulatory support**
* **Dialysis** – *indicated if failure of conservative management, multisystem failure or one of the following:*
* Refractory hyperkalaemia
* Refractory fluid overload
* Metabolic acidosis
* Uraemic symptoms (encephalopathy, nausea, pruritis, malaise, pericarditis)
* CKD stage 5 (GFR \<15mL/min)
46
What are the signs and symptoms of uraemia?
* Encephalopathy
* Nausea
* Pruritis
* Malaise
* Pericarditis
47
What is Phimosis?
Inability to retract foreskin, “tight” foreskin.
* Physiological at birth
* 1yo → 50% have a non-retractable foreskin
* 4yo → 10%
* 17yo → 1%
* If persistent to puberty = increase risk of infection and issues with urination and intercourse
48
What is the management of phimosis?
* \<2yo = Reassure + Review in 6 months + Personal hygiene promotion
* \>2yo = Circumcision or Topical steroid creams - *depending on severity*
49
What is balantis xerotica obliterans (BXO)?
Pathological phimosis = scarring of foreskin → rare before 5y
* S/S
* Haematuria
* Painful erections
* Recurrent UTI
* Weak stream
* Swelling
* Redness
* Tenderness
50
What is Paraphimosis?
Foreskin becomes trapped in the retracted position proximal to swollen glans.
* Restricting blood flow to head of penis → penis turns dark purple → urological emergency
51
What is the management of Paraphimosis?
* 1st line
* Adequate analgesia
* Attempt to reduce foreskin - gentle compression with saline soaked swab
* 2nd line = Emergency referral to urologist
52
What is Hypospadias?
Wrongly positioned meatus (ventral in hypospadias; dorsal in epispadias)
* Features
* **Ventral foramen ± Hooded foreskin**
* **Foreskin not fused ventrally ± Chordee**
* End-membrane
53
What is the management of hypospadias?
* Do nothing - *surgery is not mandatory*
* Hypospadias repair surgery (after 3 months)
* *No circumcision should be done prior as skin required*
54
What is Balanoposthitis?
Inflamed/purulent discharge from foreskin - *single attacks common*
55
What is the management of Balanoposthitis?
* Warm baths
* Broad spectrum Abx
* Recurrent = Circumcision
56
What are the risk factors for testicular torsion?
* Undescended testes
* ‘Clapper bell’ testis - *testes free hanging on spermatic cord*
* 11-30yo → 16 is the mean age
* *Must be ruled out in any-aged boy with an acute abdomen*
57
Describe torsion of appendix testes.
* **Pain evolves over multiple days**
* Surgery often needed as cannot be distinguished from true torsion
* **Blue dot** on superior pole of the testes = torsion of appendix testes → no surgery - only simple analgesia
* More common than testicular torsion
58
What are the signs and symptoms of testicular torsion?
* Redness
* Oedema
* **N&V**
* **Sudden onset pain** – localised in testis or in the abdomen
* One testicle higher than the other
59
What are the appropriate investigations for suspected testicular torsion?
* **Doppler USS - cannot delay surgery**
* Lifting testes **increases** pain
* Epididymitis = **relieves** pain (Prehn’s sign)
60
What is the management of testicular torsion?
* **Surgical Emergency**
* **Exploratory surgery ± Bilateral orchiopexy ± Orchidectomy ± Fixation of contralateral testes**
* \<6hrs = 90-100% saved
* \>24hrs = 0-10% saved
* Supportive care
* Analgesia
* Sedation
* Antiemetics
61
What is a Nephroblastoma (Wilm's tumour)?
Undifferentiated mesodermal tumour of intermediate cell mass – primitive renal tubules and mesenchymal cells
* Most common intra-abdominal tumour of childhood
* 2nd most common cancer of childhood - *after ALL*
* *\<5yo (80%) – often 3yo*
* *95% unilateral*
* *1-2% familial /FHx*
62
What is associated with nephroblastoma?
* Beckwith-Wiedemann syndrome - *specific body parts overgrow, usually present at birth*
* WAGR syndrome - *Wilm’s tumour, Aniridia, Genitourinary malformations, Retardation*
* Hemihypertrophy
* 33% with a loss-of-function mutation in the WT1 gene on chromosome 11
63
What are the signs and symptoms of a nephroblastoma?
* **Asymptomatic abdominal mass -** *most common*
* **Painless haematuria**
* Abdominal pain
* Anorexia
* Anaemia - from haemorrhage into mass
* Hypertension
64
What are the appropriate investigations for suspected nephroblastoma?
* **USS**
* **CT/MRI**
* *Staging 1-5*
* *1 = limited to kidney, completely excisable*
* *2 = not limited to kidney, completely excisable*
* *3 = not limited to kidney, not completely excisable*
* *4 = spread beyond abdomen, haematogenous metastasis*
* *5 = bilateral (each tumour graded separately)*
* Avoid biopsy → can worsen the condition
65
What is the management of a nephroblastoma?
* **Nephrectomy** + **chemotherapy** ± **Radiotherapy prior to surgery** (advanced disease)
* 80% cure rate
