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Flashcards in Pediatric Nephrology Deck (37)
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What’s red flag signs/components of history for nephrology issues in children?

History of:
- hematuria
- proteinuria
- abdominal/costovertebral angle/flank pain
- recent serious pain or trauma
- sudden weight gain or edema
- complicated birth (especially oligodendrogliomas/polyhydramnios)
- **congenital anomalies with eyes/ears or external genitalia (this is common)


How to take BP in children

Right upper extremity and the cuff should cover 2/3rds of the child’s upper arm.
- peripheral pulses should also be palpable

**should also always palpate the abdomen, even this has nothing to do with BP**

***should have BP measured every year starting at 3 yrs***


Labs to observe for urinary function in children

BUN:creatinine ratio
- normal = 10:1
- increases with urine flow decreases, obstruction and dehydration

**most single reliable indicator of GFR is the serum level of creatinine**


What are the basic 3 steps in a routine urinalysis?

Gross inspection

Dipstick screening

Microscopic examination


What does smoky-brown or tea-colored urine imply?

- this is indicative of stagnated blood that is decomposed with its iron oxidized


What are causes of frank hematuria (very bright red urine)


Kidney stones


Strenuous exercise


Secondary HTN and children

Most common in younger children
- most often caused by renal abnormalities (if they have elevated BP, need to check for renal or CV abnormalities)
- severely elevated BP (stage 2) and symptomatic HTN suggest secondary HTN more in children

Causes includes: 10%
- glomerulonephritis
- VUR/ obstruction nephropathy
- congenital abnormalities of urinary tract

**renovascular HTN accounts for 90% of secondary HTN**


Prune belly
“eagle-Barrett syndrome”

Congenital abnormality where a child is born without abdominal musculature
- also shows renal and Urinary tract abnormalities
- **75% of these cases present with dilated ureters and VUR
- may also show cryptochidism
- may also show intestinal malrotation

**wayyyy more common in boys (20x more)**

***major determinant of prognosis = degree of cystic renal dysplasia***

Treatment = early orchiopexy and just monitor


(Undescended testies)

*very common male pediatric disorders, especially in premature children (33%)*
- 75% will spontaneously descend by 3 months. If they dont by 6 months (but especially by 15months ) probably need surgery

**uncorrected cryptochidism = increased risk of infertility and testicular malignancies**

To check for this, must check the placement and turgor of the testicles on all physical exams for infants and well check ups

Treatment = surgery after 6 months-18 months
- never use hormonal therapy


When should a disorder of sex development be suspected always?

In a phenotypic male with bilateral non palpable testies
- in this case it could be a virilized female with congenital adrenal hyperplasia

Risk always goes up the less palpable the testicles are


Congenital adrenal hyperplasia (CAH)

Is a autosomal recessive disorder of cortisol biosynthesis (usually deficiency)
- causes an increase in the secretion of adrenocorticotropic hormone (ACTH) which in turn leads to adrenal hyperplasia and increases in intermediate metabolites production

Usually leads to precocious puberty in males and sexual infantilism in females
- will change the infants genitalia if not corrected (females will have enlarged clitoris which looked like a penis, and males will have either normal looking or cryptochidism

**can be life threatening since uncorrected cortisol deficiencies can lead to low aldosterone production = salt-wasting and hyponatremia**
- is termed simple virilizing disease if the aldosterone is not reduced.


What is the most common cause of CAH

21-hydroxylase deficiency
- this enzyme is required for the synthesis of cortisol and aldosterone
- if you dont have this enzyme, cortisol and aldosterone turns into testosterone


Symptoms of serious CAH

Usually present by 10-14 days of age

Progressive weight loss






Hypoglycemia and hyponatremia*


* = most dangerous and will lead to shock if not corrected


Postnatal androgen excess

Untreated CAH deficiency produces this
- * harder to see in males since they will appear normal and don’t usually develop adrenal insufficiency

- rapid somatic growth and accelerated skeletal maturation with premature closure of epiphyseal plates(look super tall when young, but short at adulthood)
- increase pubic and axillary hair for their age
- premature acne and deep voice
- enlarged penis/scrotum with normal testie size


What ages are UTIs most common in children?

First year = #1
- male:female ratio = 2.8:5.4
(Females more likely to get it)
- **if a male is going to get a UTI, It is far more common in the 1st year of life
- **more common in uncircumcised males
- first UTI females is usually by the age of 5yrs old

Beyond first year male:female ratio = 1:10

**commonly presents with a fever with NO OTHER symptoms**


Pathogenesis of UTI in children

Almost all are ascending infections and arise from fecal flora

If not treated will cause pyelonephritis over time

Common causes
- dysfunctional voiding (leads to increase risk of bacterial colonization)
- constipation
- urinary tract obstruction
- neurogenic bladder
- poor sanitation
- sexual activity


Future consequences of pyelonephritis at a young age

Inflammatory response and scar formation of pyelonephritis can lead to:
- renal failure


Pyelonephritis rates are highest in younger children at what he group?

Younger than 2yrs old
- **always check the urinary tract if a patient presents febrile and no other symptoms


Clinical findings of UTI in young children

Nonspecific signs all around:
- fever
- hypothermia
- jaundice
- poor feeding
- irritability
- vomiting
- failure to thrive
- septic symptoms
- abdominal pain
- vomiting
- pain while urination
- enuresis/ high levels of accidents

**almost never shows CVA tenderness if pyelonephritis**

**urine often is strong foul smelling and cloudy on appearance**


Laboratory findings of UTI

Pyuria (> 5 WBCs/Hpf)

Leukocyte esterase positive

Nitrite positive
- **70% with UTI will show a NEGATIVE test**
- this is because kids pee a lot so bacteria doesnt have the time to produce nitrites

****GOLD STANDARD = UA culture
- takes a while though and difficult as well to make sure its not contaminated
- if UA culture shows >100,000 cfu = definitive infection of that pathogen


What are techniques to increase good specimen collection?

Catch in midstream

Separate labia in girls and retract foreskin in boys

Super younger patients/infants = bladder catheterization or suprapubic collection is almost always needed to avoid contamination

DONT send a bagged urine culture = almost always contaminates


Why should you presume pyelonephritis in any children that is febrile and has a confirmed primary/secondary UTI?

Because pyelonephritis is the most dangerous result of a UTI with long term effects
- leads to increased renal scarring and CKD risk


What kind of imaging should be done in all newborns to screen for urinalysis abnormalities

- recommended in children of 2-24 months
- screen kidneys,ureters, bladder


is a VCUG required in all cases of initial UTI?

- is really only 100% indicated if ultrasound suggests hydronephrosis is present or if a child has recurrent febrile UTIs (not on the first one)

**because we attempt to minimize VCUG use, educated parents to return for evaluation of subsequent fevers (rate of renal scarring increases between days 2-3 of a fever)
- scarring also increases with # of overall episodes of pyelonephritis and high grade VUR**


What is the fever cut off for any newborn?

100.4 F (38C)


Why does a infant who is less than 60 days that has a fever automatically get cultures and referred to critical care?

They dont have their own innate immune system
- living off of mothers antibodies


What drugs are first line theropy in children <36 months who have a UTI?

Cephalexin or ceftriaxone
- 10 day does with 12.5-25 mg per dose
- **cephalexin for cystitis especially

2nd Line= SMX-TMP


What drugs are first line therapy in children 36 months-18 yrs months who have a UTI?

Cystitis = cephalexin

Pyelonephritis = cephalexin or ceftriaxone

2nd option = SMX-TMP

**only changes are dosage
3-11yrs = 12.5 mg
12 -18yrs = 25 mg


When do you usually have to give ceftriaxone over cephalexin in UTIs?

If the kid wont take oral cephalexin
- have to give IM ceftriaxone


What are second-line therapies that are only used in resistant/refractory UTIs in children?

Cystitis = nitrofurantoin or cefixime

Pyelonephritis = cefixime

**can also give ciprofloxacin at any point, however FDA warning = decreased growth and increased risk fo tendon ruptures (so last line)**

***dont give nitrofurantoin to pregnant adolescents or patients with pyelonephritis***