Nephrology and Genitourinary

Question 1

What causes Henoch-Schonlein purpura?

Answer 1

Antigen exposure post URTI causes increased IgA which disrupts IgG synthesis
IgA and IgG react to form complexes which deposit in affected organs

Question 2

How does HSP present?

Answer 2

Urticarial –> purpuric rash over buttocks, arms, legs and ankles

Arthralgia - knees and ankles

Periarticular oedema

Colicky stomach pain

Haematemesis and malaena

Haematuria and proteinuria

Ileus, protein losing enteropathy, orchitis

Question 3

How is HSP managed?

Answer 3

Abdo and testicular USS - obstruction

Barium enema

Question 4

What are the long term complications of HSP?

Answer 4

Proteinuria may result in nephrotic syndrome
RF: oedema, hypertension and deteriorating renal function

Children are followed up for a year to detect persistent anomalies

Question 5

What is nephrotic syndrome and what causes it?

Answer 5

Heavy proteinuria –> low plasma albumin and oedema

HSP
SLE
Malaria
Allergens

Question 6

What are the presenting features of nephrotic syndrome?

Answer 6

Periorbital oedema
Scrotal/vulval, leg and ankle oedema
Ascites
Breathlessness due to pleural effusions and abdo distension

Question 7

What is steroid sensitive nephrotic syndrome?

Answer 7

85-90%
Boys>girls
ASIAN
Oral corticosteroids make urine free of protein
Doesn't progress to renal failure

1/3 resolve
1/3 infrequently relapse
1/3 frequently relapse

Question 8

What are complications of nephrotic syndrome?

Answer 8

Hypovolaemia - intravascular compartment becomes depleted –> abdo pain and fainting

Thrombosis - hypercoaguable state due to urinary loss of antithrombin

Hypercholesterolaemia

Infection

Question 9

What is steroid resistant nephrotic syndrome?

Answer 9

Referral to paediatric nephrologist after 4-8 weeks

Diuretics, salt restriction, ACE inhibitors and NSAIDs

Question 10

What is congenital nephrotic syndrome?

Answer 10

Presents in first 3 months of life
FINNS and INCEST

Hypoalbuminaemia –> mortality
Kidney may need removing

Question 11

What organisms cause UTIs?

Answer 11

E. coli
Klebsiella
Proteus
Pseudomonas (indicates structural abnormalities)
Strep faecalis

Question 12

What are causes of haematuria?

Answer 12

Infection
Trauma
Stones
Tumours
Sickle cell disease
Bleeding disorders
Renal vein thrombosis
Hypercalciuria

Glomerulonephritis
IgA nephropathy
Familial nephritis
Thin basement membrane disease

Question 13

How does a UTI present in an infant?

Answer 13

Fever
Vomiting
Lethargy and irritability
Poor feeding
Jaundice
Septicaemia
Offensive urine
Febrile convulsions

Question 14

How does a UTI present in a child?

Answer 14

Dysuria and frequency
Abdo pain or loin tenderness
Fever +/- rigors
Lethargy and anorexia
Vomiting and diarrhoea
Haematuria
Febrile convulsions

Question 15

How are urine dipsticks interpreted?

Answer 15

Nitrates (N) - produced by bacteria
Leukocyte esterase (LE) - tests for WBC

N+ve LE+ve = UTI

N+ve LE-ve = start Abx and wait for cultures

N-ve LE+ve = start Abx if clinical picture matches

Question 16

How are atypical and recurrent UTIs investigated?

Answer 16

USS during acute infection

DMSA after infection

Question 17

What is vesicoureteric reflux?

Answer 17

RED HAIRED GIRLS
Development anomaly of the junction
Ureters are displaced laterally and enter directly into bladder
Severity ranges from mild to intrarenal reflux and renal scarring

Question 18

How does an acute kidney injury present in childhood?

Answer 18

Oliguria (less than 0.5ml/kg)

Question 19

What are the most common causes of AKI in childhood?

Answer 19

Prerenal

• hypovolaemia (burns, sepsis, gastroenteritis, haemorrhage, nephrotic syndrome)
• circulatory failure

Renal (salt and water retention, proteinuria)

• vascular
• tubular
• glomerular
• interstitial

Post renal
- obstruction

Question 20

How is an AKI managed?

Answer 20

Check fluid balance and circulation
USS for masses or renal obstruction

Prerenal - fluid replacement

Renal - restrict fluid intake, diuretic

Post renal - catheter, surgery

Question 21

When is dialysis indicated in AKI?

Answer 21

Failure of conservative management
Hyperkalaemia
Severe hypo/hypernatraemia
Pulmonary oedema
Severe acidosis

Question 22

What are the stages of chronic kidney disease?

Answer 22

Stage 1: GFR >90
Stage 2: GFR 60-89
Stage 3: GFR 30-59
Stage 4: GFR 12-29
Stage 5 GFR

Question 23

What are the presenting features of CKD?

Answer 23

Anorexia/lethargy
Polydipsia and polyuria
Failure to thrive
Bone deformities
Hypertension
\+ acute renal failure
Proteinuria

Question 24

What are the most common causes of acute glomerulonephritis?

Answer 24

Follows strep throat/skin infection

Vasculitis (SLE, Wegener’s, HSP)

IgA nephropathy

Anti-glomerular basement membrane disease

Question 25

What happens in glomerulonephritis?

Answer 25

Damaged glomerular cells restricts filtration --> Decreased urine output and volume overload Hypertension --> seizures Oedema Haematuria and proteinuria

Question 26

How is the cause of glomerulonephritis diagnosed?

Answer 26

Post-strep Low C3 Positive ASO and Anti-DNAase B Otherwise renal biopsy and USS

Question 27

What causes haemolytic uraemic syndrome?

Answer 27

Secondary to GI infection with E. coli 0157 Prodrome of bloody diarrhoea Toxins of organism enters GI mucosa and localises to endothelial cells of kidney --> intravascular thrombogenesis

Question 28

What are the abnormalities which define HUS?

Answer 28

Acute renal failure Microangiopathic haemolytic anaemia Thrombocytopenia

Question 29

What are the risks with non-diarrhoea associated HUS?

Answer 29

May be familial and frequently relapses High risk of hypertension Chronic renal failure Mortality

Question 30

What are the common causes of HTN in children?

Answer 30

Renal - renal parenchymal disease - renal artery stenosis - polycystic kidneys - renal tumour Coarctation of the aorta Catecholamine excess - phaechromocytoma (tumour of adrenals) - neuroblastoma Endocrine - CAH - Cushing's or corticosteroid treatment - hyperthyroidism

Question 31

How does HTN present?

Answer 31

``` Vomiting Headaches Facial palsy Hypertensive retinopathy Convulsions Cardiac failure Failure to thrive ```

Question 32

How is pyelonephritis treated?

Answer 32

``` Consider referral to paediatric specialist Oral Abx (co-amoxiclav) for 7-10 days IV Abx (ceftriaxone) for 2-4 days then oral ```

Question 33

How is cystitis treated?

Answer 33

Oral Abx (trimethoprim, nitrofurantoin) for 3 days

Question 34

How does urinary tract anomalies present?

Answer 34

Absence of both kidneys --> severe oligohydramnios Multicystic dysplastic kidney - non functioning kidney Polycystic kidney disease - both kidneys affected but some function is maintained Pelvic or horseshoe shaped kidneys - predisposed to infection/obstructs drainage Duplex system - bifid pelvis -> two ureters Hydronephrosis - dilation and swelling of kidney due to back pressure

Question 35

How does the male urethra develop differently in hypospadias?

Answer 35

Occurs in proximal to distal direction under influence of testosterone Urethral opening lies proximal to normal position

Question 36

How does IgA nephropathy present?

Answer 36

Similar to HSP but restricted to kidney | Macroscopic haematuria after URTI

Question 37

How does neuropathic bladder present?

Answer 37

Urinary incontinence - the need to urinate frequently and with urgency UTI - urine is held in bladder for too long Kidney injury - high pressure caused by urine backlog Kidney stones - pain, haematuria, fever Erectile dysfunction

Question 38

How is vulvo-vaginitis managed?

Answer 38

Hygiene, avoidance of bubble baths and loose fitting underwear Oestrogen cream helps atrophic tissue