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PAEDS RENAL Flashcards

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1
Q

PROTEINURIA
What is proteinuria?

A
  • Persistent proteinuria is significant + should be quantified by measuring the urine protein/creatinine ratio in an early morning sample
  • Protein should not exceed <20mg/mmol of creatinine
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2
Q

PROTEINURIA
What are some causes of proteinuria?

A
  • Transient (febrile illness, after exercise = no investigation)
  • Nephrotic syndrome
  • HTN
  • Tubular proteinuria
  • Increased glomerular perfusion pressure
  • Reduced renal mass
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3
Q

HSP
What is Henoch-Schönlein purpura (HSP)?

A
  • IgA mediated small vessel vasculitis leading to inflammation affecting the skin, joints, GI tract + kidneys
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4
Q

HSP
what is the pathophysiology?

A

deposition of immunoglobulin A (IgA) in affected vessels leads to inflammation and subsequent tissue damage

it is often reported 10 days after URTI

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5
Q

HSP
What is the clinical presentation of HSP?

A

SYMPTOMS
- joint pain
- abdominal pain
- bloody stools
- haematuria

SIGNS
- palpable purpuric rash (typically on legs)
- joint swelling
- joint tenderness

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6
Q

HSP
What are some investigations for HSP?

A
  • serum U&Es = may have rising creatinine
  • serum clotting screen
  • urinalysis = proteinuria, haematuria + RBC cast cells
  • stool analysis

to consider
- skin biopsy
- renal biopsy

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7
Q

HSP
What might happen if proteinuria becomes severe in HSP?
What would you monitor?

A
  • Nephrotic syndrome
  • BP + serum albumin
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8
Q

HSP
What is the management of HSP?

A

1st line:
- supportive care (rest, hydration + monitoring for complications
- NSAIDs (for pain relief + joint symptoms, use with caution in renal injury)

2nd line
- corticosteroids
- immunosuppressive agents (AZATHIOPRINE or CYCLOPHOSPHAMIDE)

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9
Q

HAEMOLYTIC URAEMIC SYNDROME
What is haemolytic uraemic syndrome (HUS)?

A
  • Thrombosis within small blood vessels throughout the body, usually triggered by a bacterial toxin (shiga)
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10
Q

HAEMOLYTIC URAEMIC SYNDROME
What is the classic HUS triad?

A
  • Microangiopathic haemolytic anaemia (due to RBC destruction)
  • AKI (kidneys fail to excrete waste products like urea)
  • Thrombocytopenia
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11
Q

HAEMOLYTIC URAEMIC SYNDROME
What are some causes of HUS?

A
  • Mostly E. Coli 0157 producing Shiga toxin, can be Shigella (?Petting zoo)
  • Use of Abx + antimotility agents to treat gastroenteritis caused by these pathogens can increase risk of HUS
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12
Q

HAEMOLYTIC URAEMIC SYNDROME
What is the clinical presentation of HUS?

A

SYMPTOMS
- bloody diarrhoea
- fever
- abdominal pain
- vomiting
- reduced urine output

SIGNS
- dehydrated (delayed CRT, tachycardic/hypotensive, mottled skin)
- pyrexia
- pallor

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13
Q

HAEMOLYTIC URAEMIC SYNDROME
What are some investigations for HUS?

A
  • FBC = anaemia, thrombocytopaenia
  • blood film = schistocytes due to microangiopathic haemolysis
  • LDH = raised
  • LFTs = raised bilirubin
  • urinalysis = microscopic haematuria + proteinuria
  • U&Es = raised creatinine + reduced eGFR, often hyperkalaemia
  • stool culture = e.coli 0157:H7
  • PCR shiga toxin
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14
Q

HAEMOLYTIC URAEMIC SYNDROME
What is the management of HUS?

A

SUPPORTIVE
- IV fluids
- red cell transfusion
- dialysis (if refractory acidosis, hyperkalaemia, fluid overload or oliguria)

2ND LINE
- antibiotics (only in non-e.coli HUS)
- plasma exchange
- eculizimab

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15
Q

HAEMATURIA
How can you differentiate the source of haematuria based on its presentation?

A
  • Glomerular = brown urine, deformed red cells, presence of casts, often with proteinuria
  • Lower urinary tract = red urine, occurs at beginning or end of stream, not accompanied by proteinuria
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16
Q

HAEMATURIA
What is the most common cause of haematuria?
What are the other 2 broad causes?

A
  • UTI
  • Glomerular or non-glomerular
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17
Q

HAEMATURIA
What are some glomerular causes of haematuria?

A
  • Acute/chronic glomerulonephritis,
  • IgA nephropathy,
  • familial nephritis,
  • post-strep glomerulonephritis,
  • HSP,
  • goodpasture’s
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18
Q

HAEMATURIA
What investigations for haematuria should all patients get?

A
  • Urinalysis + urine MC&S
  • FBC, platelets, clotting + sickle cell screen
  • U+Es, creatinine, albumin, Ca2+, phosphate
  • USS kidneys + urinary tract
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19
Q

HAEMATURIA
What investigations would you do if you suspected glomerular haematuria?

A
  • ESR, C3/4 + anti-DNA antibodies
  • Throat swab + antistreptolysin O/anti-DNAse B titres
  • Hepatitis B/C screen
  • Renal biopsy if recurrent haematuria, abnormal renal function/complement levels or significant persistent proteinuria
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20
Q

HYPOSPADIAS
What is hypospadias?

A
  • Urethral meatus is abnormally displaced posteriorly on the penis
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21
Q

HYPOSPADIAS
What is the clinical presentation of hypospadias?

A
  • Ventral urethral meatus
  • Hooded prepuce
  • Chordee (ventral or downwards curvature of the penis in more severe forms)
  • Usually identified during NIPE
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22
Q

HYPOSPADIAS
What is the management of hypospadias?

A
  • Do NOT circumcise as foreskin often needed for later reconstructive surgery
  • Refer to paediatric specialist urologist
  • Mild cases may not require any treatment
  • Surgery done 3-4 months of age to correct position of meatus + straighten penis
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23
Q

UTI
What is a urinary tract infection (UTI)?

A
  • Growth of bacteria within the urinary tract (>10^5 single organism/ml)
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24
Q

UTI
When is a UTI classified as atypical?

A

CATFISH
- creatinine raised
- abdominal or bladder mass
- terribly ill
- flow or urine poor
- infection non-e.coli
- sepsis
- halted response to antibiotics >48hrs

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25
UTI What are some causes of UTI?
- #1 = E. coli, often from bowel contamination - Proteus (M>F, predisposes to formation of phosphate stones in urine) - Pseudomonas (may indicates structural abnormality)
26
UTI What is a complication of E. Coli which might make it difficult to treat?
- Can become resistant to penicillin by producing beta-lactamase (ESBL E. Coli) which breakdown the beta lactam part of Abx making it ineffective
27
UTI What are some risk factors for UTI?
- Incomplete bladder emptying - Vesico-ureteric reflux - Structural abnormality (horseshoe kidney, ureteric strictures) - Inadequate toilet hygiene
28
UTI What is the clinical presentation of UTI in infants?
SYMPTOMS - dysuria - frequency - lower abdominal pain - new onset bedwetting - vomiting - loss of appetite SIGNS - fever - suprapubic tenderness - flank tenderness (in pyelonephritis)
29
UTI What are some investigations for UTI?
URINALYSIS - if nitrites + leukocyte positive = treat as UTI - if nitrites + leukocytes negative = UTI unlikely - if nitrites positive but leukocytes negative = treat as UTI + send MS+C - urine microscopy + culture to consider - USS kidney + bladder - micturating cystourethrogram - DMSA renal scan
30
UTI In terms of performing ultrasounds scans in UTI, what are the guidelines?
- USS within 6w if 1st UTI + <6m but responds well to Tx within 48h or during illness if recurrent or atypical bacteria
31
UTI What are some complications of UTI?
- Recurrent kidney infections can cause renal scarring predisposing to HTN, chronic renal failure + even pregnancy complications later in life
32
UTI What is the supportive management of UTI?
- Good fluid intake, analgesia - Wipe front>back - Regular voiding + ensure complete bladder emptying
33
UTI Admission criteria for UTI?
- Admission if <3m, systemically unwell or significant risk factors
34
UTI What is the management of UTI for >3m with upper UTI?
?Admission for IV, if not PO co-amoxiclav or cefalexin for 7–10d
35
UTI What is a recurrent UTI?
- ≥2 UTIs with ≥1 with systemic Sx (or ≥3 without)
36
UT ABNORMALITIES Name 6 urinary tract abnormalities
- Renal agenesis - Multicystic dysplastic kidney - Polycystic kidney disease - Pelvic/horseshoe kidney - Posterior urethral valves - Prune-belly syndrome
37
UT ABNORMALITIES What is renal agenesis?
- Absence of both kidneys
38
UT ABNORMALITIES What are some other consequences of oligohydramnios in renal agenesis?
- Pulmonary hypoplasia > respiratory failure - Limb deformities such as severe talipes
39
UT ABNORMALITIES What is multicystic dysplastic kidney?
- Non-functioning structure with large fluid-filled cysts with no renal tissue or connection with bladder
40
UT ABNORMALITIES What is the management of multicystic dysplastic kidney? What is a complication?
- Half involuted by 2y + nephrectomy only indicated if very large or HTN - No urine production so if bilateral > Potter syndrome
41
UT ABNORMALITIES How does polycystic kidney disease differ from MDK?
- Some renal function remained in polycystic kidney disease
42
UT ABNORMALITIES How might autosomal recessive polycystic kidney disease present?
- Antenatal USS or with abdo masses or renal failure - Neonates may develop Potter syndrome secondary to oligohydramnios
43
UT ABNORMALITIES What is pelvic/horseshoe kidney?
- Abnormal caudal migration when the lower poles are fused in the midline
44
UT ABNORMALITIES What is posterior urethral valves? What is a consequence?
- Tissue at proximal end of urethra causes obstruction to urinary outflow, M>F - Back pressure into bladder, ureters + up to kidneys > hydronephrosis - Also prevents complete bladder emptying > risk of UTI
45
UT ABNORMALITIES How can posterior urethral valves present in utero? What is a complication of posterior urethral valves?
- Oligohydramnios + potentially pulmonary hypoplasia - Risk of dysplastic kidneys, at its worse if bilateral could lead to potter syndrome
46
UT ABNORMALITIES What is Prune-belly syndrome?
- Absent musculature leading to large bladder + Dilated ureters (megacystis-megaureters) + cryptorchidism
47
UT ABNORMALITIES What are the 2 first steps in management of urinary tract abnormalities? How is the management split after that?
- Antenatal Dx + start prophylactic Abx to prevent UTI - Bilateral hydronephrosis and/or dilated lower urinary tract in a male - Unilateral hydronephrosis in male or any anomaly in female
48
UT ABNORMALITIES What is the management of bilateral hydronephrosis and/or dilated lower urinary tract in a male?
- Bilateral seen in bladder neck obstruction or posterior urethral valves - USS within 48h of birth to exclude posterior urethral valves – Abnormal = MCUG + surgery if required (ablation during cystoscopy) – Normal = stop Abx, repeat USS after 2-3m
49
UT ABNORMALITIES What is the management of unilateral hydronephrosis in male or any anomaly in female?
- Unilateral seen in pelviureteric or vesicoureteric junction obstruction - Abnormal = further investigations - Normal = stop Abx, repeat USS after 2-3m
50
ACUTE KIDNEY INJURY What is acute kidney injury (AKI)? What is it characterised by?
- Spectrum of potentially reversible, reduction in renal function - Rapid rise in creatinine + development of oliguria (<0.5ml/kg/h)
51
ACUTE KIDNEY INJURY What are the 3 broad causes of AKI?
- Pre-renal (most common cause in children) - Renal - Post-renal
52
ACUTE KIDNEY INJURY What are some pre-renal causes of AKI?
- Hypovolaemia = nephrotic syndrome, haemorrhage, sepsis, burns - Circulatory failure
53
ACUTE KIDNEY INJURY What are some renal causes of AKI?
- Vascular = HUS, vasculitis, embolus) - Glomerular = glomerulonephritis - Interstitial = interstitial nephritis, pyelonephritis - Tubular = acute tubular necrosis
54
ACUTE KIDNEY INJURY What are some post-renal causes of AKI?
- Obstruction = congenital like posterior urethral valve or acquired like blocked urinary catheter
55
ACUTE KIDNEY INJURY What are some investigations for AKI?
- FBC, U+Es (high urea), high creatinine, USS to identify if obstruction - Can have hyperkalaemia, hyperphosphataemia + metabolic acidosis
56
ACUTE KIDNEY INJURY What is the management of AKI?
- Maintain strict fluid balance (IV fluids if hypovolaemic, restrict if overload) - If failure of conservative Mx, severe electrolyte disturbances or acidosis then ?dialysis
57
CHRONIC KIDNEY DISEASE What are some causes of chronic kidney disease (CKD)?
- Structural malformations (congenital dysplastic kidney) - Glomerulonephritis - Hereditary nephropathies - Systemic diseases
58
CHRONIC KIDNEY DISEASE What is the clinical presentation of CKD?
- Failure to thrive, anorexia + vomiting - HTN, acute-on-chronic renal failure, anaemia - Bony deformities from renal osteodystrophy - Incidental proteinuria, polydipsia + polyuria
59
CHRONIC KIDNEY DISEASE What are some investigations for CKD?
- Monitor growth - FBC = anaemia due to reduced EPO - U+Es + electrolytes (Ca2+ low, phosphate high)
60
CHRONIC KIDNEY DISEASE What is the management of CKD?
- Diet + NG or gastrostomy feeding may be needed for normal growth - Phosphate restriction + activated vitamin D to prevent renal osteodystrophy - May need recombinant growth hormone - Recombinant erythropoietin to prevent anaemia - Dialysis + transplantation if in ESRF (GFR <15ml/min/1.73m^2)
61
VESICOURETERIC REFLUX what is it?
retrograde flow of urine from the bladder into the upper urinary tract it is usually congenital
62
VESICOURETERIC REFLUX how is it graded?
graded using International Reflux Study grading system
63
VESICOURETERIC REFLUX how is it diagnosed?
- micturating cystourethrogram: radiocontrast medium introduced to catheterised bladder, reflux is detected on voiding - indirect cystogram
64
VESICOURETERIC REFLUX what is the management?
aim is to prevent renal scarring - antibiotic prophylaxis (low dose nitrofurantoin or trimethoprim) - surgery - not commonly recommended
65
NEPHROTIC SYNDROME what can cause minimal change disease?
- NSAIDs, - Hodgkin's lymphoma, - infectious mononucleosis
66
NEPHROTIC SYNDROME Who does minimal change disease present in?
- M>F, - commoner in Asian children than Caucasians, - do not progress to renal failure
67
NEPHRITIC SYNDROME What is the pathophysiology of post-streptococcal glomerulonephritis?
Immune complexes made up of streptococcal antigens, antibodies + complement proteins get stuck in glomeruli > inflammation
68
HSP What is the epidemiology of Henoch-Schönlein purpura (HSP)?
3-10y, M>F + peaks during winter, preceded by URTI or gastroenteritis
69
HYPOSPADIAS What is epispadias?
Meatus displayed anteriorly on top of the penis
70
HAEMATURIA What are some non-glomerular causes of haematuria?
- Wilm's tumour, - trauma, - stones (esp if FHx), - sickle cell disease - other bleeding disorders
71
UTI How can UTIs be differentiated anatomically?
- Upper tract infection involves the kidneys (pyelonephritis) + associated with fever, loin pain/tenderness - Lower tract infection involves bladder (cystitis) + low-grade fever with urinary Sx
72
UTI What are the investigations for recurrent + atypical UTIs?
- USS within 6w in all children with recurrent UTIs - DMSA (dimercaptosuccinic acid) scan (renal scarring 4-6m) - Micturating cystourethrogram (<6m) if FHx of vesico-ureteric reflux, dilatation of ureter on USS, poor urinary flow (catheterise + inject contrast into bladder)
73
UTI What is the clinical presentation of UTI in children?
- Loin/abdo (suprapubic) pain, - fever (± rigors), - febrile convulsions, - increased frequency, - dysuria, - haematuria, - recurrent enuresis, - offensive urine
74
UTI What is the management of children under 3m in UTI?
ALL children <3m + fever get immediate IV cefuroxime + full septic screen (blood cultures, FBC, CRP lactate, LP etc)
75
UTI What is the management of UTI for ESBL E. Coli?
Meropenem
76
UTI What is the management of UTI for >3m with lower UTI?
3d PO trimethoprim, nitrofurantoin, amoxicillin or cephalosporin with follow-up if still unwell after 24-48h
77
UT ABNORMALITIES What is a serious complication of renal agenesis and how does that present?
- Absence of both kidneys causes severe oligohydramnios + hence foetal compression from reduced foetal urine excretion - this can cause Potter syndrome (fatal) - - Low-set ears, beaked nose, prominent epicanthic folds + downward slant to eyes
78
UT ABNORMALITIES What causes multicystic dysplastic kidney?
Failure of union of ureteric bud with nephrogenic mesenchyme
79
UT ABNORMALITIES What are the two types of polycystic kidney disease?
- AD = HTN, haematuria in childhood with renal failure in adulthood - AR = defect on chromosome 6 that encodes fibrocystin, protein for normal renal tubule development
80
UT ABNORMALITIES What are some complications of autosomal recessive polycystic kidney disease?
Often liver involvement with portal + interlobular fibrosis
81
UT ABNORMALITIES What is a complication of pelvic/horseshoe kidney?
Abnormal position can predispose to infection or obstruction to urinary outflow
82
PYELONEPHRITIS what are the risk factors?
- vesicoureteral reflux (VUR) = most common + most important - previous history of UTI - siblings with a history of UTI - female sex - indwelling urinary catheter - intact prepuce in boys - structural abnormalities of the kidneys and lower urinary tract
83
PYELONEPHRITIS what is the pathophysiology?
pyelonephritis occurs after faecal flora colonize the urethra and ascend into the bladder and kidney
84
PYELONEPHRITIS what is the most common causative organism?
E.coli = 80% of cases
85
PYELONEPHRITIS what is the clinical presentation?
- 25% have no clinical signs - 50% present with only flank pain toddlers = fever and irritability, poor feeding, lethargy, abdominal pain older children = fever, vomiting, flank pain, dysuria, urgency, increased frequency
86
PYELONEPHRITIS What are the investigations?
- urine microscopy and culture - CT KUB with contrast
87
PYELONEPHRITIS what is the management?
- empirical antibiotics (co-amoxiclav or cefalexin) then targeted based on cultures - severe = hospitalisation and IV antibiotics
88
PYELONEPHRITIS how can it be prevented?
children <2yrs diagnosed with a UTI should have a renal USS
89
PYELONEPHRITIS what are the complications?
- recurrence - renal scarring - hypertension
90
NOCTURNAL ENURESIS what is it?
bedwetting during sleep
91
NOCTURNAL ENURESIS what are the different types?
- Primary nocturnal enuresis = never been consistently dry at night - Secondary nocturnal enuresis = previously been dry for >6 months - Monosymptomatic = only has symptoms at night - Non-monosymptomatic = daytime wetting symptoms as well as night time wetting
92
NOCTURNAL ENURESIS what are the causes?
- not waking to bladder signals - inadequate levels of vasopressin (ADH) - overactive bladder - constipation - UTIs - Family history - Anxiety/stress - poor bedtime routines
93
NOCTURNAL ENURESIS what is the presentation of inadequate levels of vasopressin?
- large volumes of urine passed at night - wet in the early part of the night - wet more than once per night
94
NOCTURNAL ENURESIS what is the presentation of an overactive bladder?
- damp patches that occur at night also occur during the day - the volume of urine passed is variable - children often wake after wetting at night
95
NOCTURNAL ENURESIS what are the investigations?
- physical examination (back, genitalia + lower limbs) - urinalysis + MS&C - bladder scan - uroflowmetry - ultrasound
96
NOCTURNAL ENURESIS what supportive care can be given to help?
- motivation, support and patience - drinking enough - drinking regularly - stopping drinks before bed - avoid drinks that avoid the bladder - regular timed toileting - establish a bedtime routine - refrain from using nappies - avoid lifting child out of bed before they are awake - treat and prevent constipation
97
NOCTURNAL ENURESIS what is the medical management?
- antibiotics for infection - laxatives for constipation - alarms - desmopressin - anticholinergic medications (oxybutynin + tolterodine) for detrusor relaxation
98
ALPORT'S SYNDROME what is it?
A genetic disorder which damages glomeruli resulting in gradual loss of kidney function and CKD
99
ALPORT'S SYNDROME what are the 3 types?
X-linked Alport syndrome (XLAS) Autosomal recessive Alport syndrome (ARAS) Autosomal dominant Alport syndrome (ADAS)
100
ALPORT SYNDROME what is the clinical presentation?
- haematuria - oedema - hypertension - loss of kidney function - progressive hearing loss - proteinuria - vision problems
101
ALPORT SYNDROME what is the management?
ACE inhibitors dialysis kidney transplant
102
ALPORT SYNDROME what are the investigations?
- genetic testing - tissue biopsy - urinalysis - hearing tests
103
PHIMOSIS what is it?
- non-retractile foreskin and/or ballooning during micturition in a child under 2
104
PHIMOSIS what is the managment?
- expectant management - do not force retraction (can cause scar formation) - personal hygiene is important - if recurrent infection then treatment is considered

MY REVISION - ALL PHASES (36 decks)

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