Pediatric Nephrology Flashcards by Scott Mitchell

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)

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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

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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

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What are the basic 3 steps in a routine urinalysis?

Gross inspection

Dipstick screening

Microscopic examination

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

Glomerulonephritis

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

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

Trauma

Kidney stones

UTI’s

Strenuous exercise

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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
HUS
congenital abnormalities of urinary tract

renovascular HTN accounts for 90% of secondary HTN

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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

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Cryptochidism

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

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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

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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.

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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

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Symptoms of serious CAH

Usually present by 10-14 days of age

Progressive weight loss

Anorexia

Vomiting

Dehydration

Weakness

Hypotension*

Hypoglycemia and hyponatremia*

Hyperkalemia*

= most dangerous and will lead to shock if not corrected

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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

Signs:

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

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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

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Pathogenesis of UTI in children

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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

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Inflammatory response and scar formation of pyelonephritis can lead to:

CKD
HTN
renal failure

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

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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

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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

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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?

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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?

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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

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Ultrasound

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

is a VCUG required in all cases of initial UTI?

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NO
- 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***

Vesicoureteral Reflux (VUR)

**Most common urinary tract abnormality in children congenial condition in which the normal value mechanism at the UV is impaired - causes reflux of urine in the bladder into the ureter or kidneys - very strong genetic component Rates = 1-3% in healthy kids; 30-50% in children who have UTIs Higher the grade = higher the renal scarring risks

Treatment of VUR

Prophylaxis a management for children at high risks of renal injuries (<1yr) - also if febrile UTIs occur at any point

Posterior urethral valves (PUV)

** most common cause of severe obstructive uropathy in young children (almost always males)** Urethral valves appear leaflet like and fan dismally from the prostatic urethra to the external urinalysis sphincter (essentially back flows urine when kids try to pee) * *30% will experience end-stage renal disease of chronic renal insufficiency** - 50% will experience VUR Shows mild-major hydronephrosis on imaging - also symptoms= frequent UTIs, inability to void or pee **must get VCUG to diagnosis**

Acute scrotum/testicular torsion

* *is a urological surgical emergency until proven otherwise** - MUST rule out torsion of the spermatic cord in males (causes ischemia of testies with 4-6hrs if not corrected) * *testicular torsion is the most common cause of severe scrotal pain in males >12yrs - caused by inadequate fixation of testies - requires immediate surgery - shows a “bell-clapper” deformity Symptoms: - acute onset or pain and swelling in scrotum - dysuria/fever may signal infection as well - previous UTIs and any trauma at all in history is important to get

What is the time frame of a testicular torsion where irreversible loss of spermatogenesis occurs?

4-6hrs | - testicle will still live but cant produce sperm

What are the results of BP readings in adolescents > or equal to 13 yrs old

Normal BP = <120/<80 Elevated BP = 120-129/<80 Stage 1 HTN = 130-139/80-89 Stage 2 HTN = >140/90

What is the #1 sign for coarctation of the aorta in a child with HTN?

Gradient HTN between upper and lower body BPs: - upper extremity = HTN - lower extremity = low BP

Pediatric Nephrology Flashcards

(37 cards)