Renal Flashcards
(37 cards)
How may a child with a UTI present?
What is important about children with UTI’s?
Classic Sx:
- Dysuria
- Frequency (how many wet nappies?)
- Flank pain
- Recurrent UTIs
- Offensive, cloudy urine
- D&V, rigors, fever, enuresis
Infants:
- Fever
- Vomiting
- Irritability, lethargy
- Poor feeding/growth
- Jaundice
- Sepsis
- Febrile seizures
Note: up to 50% have structural abnormalities of the urinary tract e.g. VUR
What investigations would you do in a child with suspected UTI?
Ix:
- > Obs + Exam
- > *Urine dip (nitrite stick test which v specific, leucocyte esterase test which is less specific/will be +ve in children without UTI and balanitis/vulvovaginitis also)
- > Urine MC+S - Diagnose UTI (Bacteriuria)
- > Imaging only indicated unless atypical or recurrent (USS + DMSA** (only in <3yo if atypical)
- Clean catch preferably for urine collection, if not then urine collection pads, if not then catheter samples/suprapubic aspiration
- *DMSA looks at renal scarring
How may you distinguish an upper and a lower UTI clinically?
Upper/pyelonephritis:
- Bacteriruria + fever >38 degrees
- Bacteriuria + loin pain/tenderness
Lower/cystitis:
- Anything else i.e. bacteriuria/dysuria but NO systemic symptoms
How would you manage a child with a UTI: i) Neonates and children under 3m? ii) Children 3m+ ? iii) Recurrent UTI's? How may you advise avoiding UTIs?
Note: always say that antibiotic choice is guided by local guidelines/resistance patterns [below is NICE guidance]
i) Under 3m:
- Low threshold for admission + full sepsis screen
- IV ABx - Cefotaxime/Gent, and Ampicillin and then switched to oral when cultures negative/clinical improvement
- Refer to paediatric specialist
- Urgent USS should be booked for within 4-6w
ii) 3m+
- Consider admission
- IV ABx 7-10d out of:
–> Co-amoxiclav
–> Ceftriaxone
–> Cefuroxime
–> Gentamicin
- OR Oral Abx for 7-10d, or 3d if 13+
–> Cephalexin
–> Co-amoxiclav
–> Trimethoprim
–> Ciprofloxacin
for 7-10 days if stable
- If <6m when they have their first UTI then urgent USS should be booked (4-6w)
- Safety net
Recurrent UTI
- Scans: USS, MCUG (structure) and DMSA for scarring and reflux
- Refer to specialist
- Abx prophylaxis?
Medical measures to prevent UTI:
- High fluid intake to produce increased output
- Ensure complete bladder emptying
- Good perineal hygiene
- Regular voiding
- Treating/preventing constipation
- Probiotics (lactobacillus acidophilus)
When is a child normally potty trained/dry by night and day?
Potty training started around 2.5y but varies between children
- > Dry by day - by 4yo
- > Dry by day and night - by 5yo (most by 3-4y)
What is the difference between primary and secondary bedwetting?
What Ix would you do (if indicated)?
Primary:
-> Child has never been dry before
Secondary
-> Enuresis occurring after child has previously been dry for 6 months
Ix: -> Abdominal exam, rule out DDx -> Urine diary -> Urine MC+S, Dipstick Other: -> Renal USS -> MCUG
How would you manage primary enuresis (without or with daytime symptoms)?
With daytime Sx:
-> Referral to enuresis clinic, community paediatrician
Without daytime Sx:
- <5yo
= 1st line is conservative education:
–> encourage and easy access to toilet (bedside potty)
–> reduce fluids before bed, no caffeine
–> positive reward system
–> reassure parents that often resolves by 5y (as bladder capacity increases and learn to wake at the sensation of a full bladder) - if not can try other options
–> support of leaflets/site: ERIC)
- > 5yo
= 1st line is conservative + enuresis alarm (wakes child when wet)
= 2nd line is desmopressin (1st line if >7yo OR requires short-term control e.g. a trip)
= 3rd line = combination
= Referral to enuresis clinic, community paediatrician if bedwetting hasn’t responded to 2 courses of treatment
What are some causes of secondary bedwetting?
Causes include:
- UTI, recurrent UTI
- Constipation
Secondary care Mx:
- Diabetes
- Psychological problems, developmental delay/LD
- Neurological/physical problems
- Family issues
What is Wilm’s tumour? Who does it tend to affect?
AKA Nephroblastoma (undifferentiated mesodermal tumour of intermediate cell mass - primitive renal tubules and mesenchymal cells)
- > Most common intra-abdominal tumour of childhood (2nd most common cancer in children after ALL)
- > 80% are <5y, often 3yo children
- > 95% unilateral
- > 1-2% have FHx
What are some associations with Wilm’s tumour?
- Beckwith-Wiedmann syndrome (specific parts of the body overgrow, presenting at birth e..g islet cell hyperplasia)
- WAGR syndrome (Wilms, Aniridia, GU malformations, mental retardation)
- Hemihypertrophy
- 33% with a loss of function mutation on WT1 gene on X11
How may a child with Wilm’s tumour present?
Sx:
- Asymptomatic abdominal mass (painless, smooth, firm)
- Painless haematuria
- Less commonly: abode pain, anaemia due to haemorrhage into the mass, distension
- RF e.g. FHx, Congenital syndromes
How would you Ix and stage Wilm’s tumours? How would you Mx it? What is its prognosis? What should you avoid?
Ix:
- > USS
- > CT/MRI for spread
- > Avoid biopsy as may worsen condition
- > Bloods - FBC, Cr/Urea, LFTs
Staging if 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 (LN and other organs)
5 = bilateral (each tumour graded separately
Mx:
- Nephrectomy + chemotherapy (+radiotherapy before surgery if advanced disease)
- 80% cure rate
What is phimosis? Is it always physiological and why is it important?
Inability to retract foreskin
Physiological at birth:
-> By 1y, 50% have non-retractable foreskin
-> By 4y only 10% do
-> by 17y, only 1% do
If persistent to puberty, it can increase the risk of infection + cause issues with urination and intercourse
How is phimosis managed?
note: what is Balanitis Xerotica Obliterans (BXO)
Mx:
<2y = reassure and review in 6m and promote personal hygeine (clean the external surface normally, don’t need to physically/forcibly retract foreskin until separates itself)
> 2y = circumcision or topical steroid cream depending on severity
BXO = pathological phimosis where there is scarring of the foreskin (rare before 5y)
-> haematuria, painful erections, recurrent UTI, weak stream, redness, tenderness
What is Paraphimosis and how is it managed?
Paraphimosis - where the foreskin is trapped in the retracted position, proximal to the swollen glans = EMERGENCY [restricted blood to head of the penis –> turns purple]
Mx:
- Analgesia (local/nerve block) + attempt to reduce foreskin with gentle compression and saline soaked swab
- Emergency referral to urologist + surgery if required (ischaemia, necrosis, prev interventions failed)
What is hypospadias (+epispadias) and how does it present? What is the management for it?
Hypospadias = wrongly positioned meatus (ventral in hypospadias, dorsal in epispadias)
Features:
- Ventral foramen
- Hooded foreskin
- Chordee (ventral curvature)
Mx:
- No intervention required but can do surgery (after 3m) –> aim for urinating in a straight line when standing and straight erections
- HOWEVER, advise NO circumcision as the skin is required for the repair
What is balanoposthitis and how is it managed?
balanoposthitis = inflamed/purulent discharge from the foreskin
- single episodes common
- managed by warm baths, broad spectrum Abx (if recurrent, then circumcision)
What is testicular torsion and who does it tend to affect (RFs)? What is another form of torsion?
Torsion
- Urological emergency where there is twisting of the testicle on the spermatic cord (processus vaginalis) causing ischaemia of the testes
- Post-pubertal age most commonly affected i.e. 16y but ranges from 11-30y
- RF = undescended testes, ‘clapper bell’ testes (on the side)
- MUST be excluded in any boy with acute abdomen
NOTE: Torsion of the appendix testes (Hyatid of Morgani) is more common but the pain evolves over MULTIPLE days.
-> Often surgery is needed as can’t distinguish between true torsion but if a BLUE dot is seen over the superior pole of the testes then no surgery may be required/just analgesia
How would someone with TT present?
Sx:
- SUDDEN onset pain; localised to testis or in abdomen
- N+ V
- Redness
- Oedema
How would you Ix and Mx suspected TT? What is its prognosis?
Ix:
- Clinical Dx
- -> [lifting testes increases pain whereas in epididymitis it reduces pain - Prehn’s sign]
- Doppler USS (but this shouldn’t delay surgery)
Mx:
- Urgent urological/paeds surgery referral + NBM
- Exploratory surgery with bilateral orchidiopexy vs orchidectomy, and fixation of contralateral testes**
- Supportive care (analgesia/sedation/antiemetics)
note:
- If caught within <6h then >90% saved whereas if <24h then <10% saved
*Process: Raphe incision -> untort testes -> watch reperfusion in warm saline -> decide if orchidectomy needed
How can renal disease (AKI) be categorised?
AKI Stage 1:
= Increase ≥26 µmol/L serum Cr; or by 1.5-1.9x the reference sCr
= Urine output <0.5mL/kg/hr, 6-12hr
AKI Stage 2:
= Increase 2.0-2.9x the reference sCr
= UO <0.5mL/kg/hr, ≥12hr
AKI Stage 3:
= Increase ≥354 µmol/L; or by ≥3x the reference sCr
= UO <0.3mL/kg/hr, ≥24hr
or Anuric for ≥12hr
What is orthostatic proteinuria? How would you assess it?
Common transient cause of proteinuria
- measure urine PCR (protein:Cr ratio) in a series of early morning specimens
What is nephrotic syndrome? What is the most common cause of it in children?
How would a child present?
Triad of: low albumin, peripheral oedema and proteinuria
–> Most commonly = Minimal Change Disease in kids (90%; children aged 2-4y)
Sx:
- 1st sign is peri-orbital oedema (often misdiagnosed as allergy)
- 2nd is other delayed features of oedema i.e. leg swelling, features of underlying diagnosis
How would you Ix and manage suspected nephrotic syndrome?
Ix:
- Urine dip
- Urine MC+S
- Bloods - FBC, ESR/CRP, Cr, Albumin, Complement [C3,C4]
- Anti-streptolysin O or anti-DNase B titres (recent strep throat infection)
- HBV, HCV, malaria screen
- [renal biopsy but normally in kids, only if unresponsive to steroids]
Mx:
1st line:
–> Oral 60mg/m2 prednisolone for 4-6w, reducing the dose from 4w
–> Fluid restricted and low salt diet
–> If advanced, may require albumin and furosemide
2nd line:
- -> specialised renal biopsy
- -> unresponsive to steroids/atypical - CNIs and methylprednisolone
[Renal histology shows steroid sensitive nephrotic syndrome (normal on light microscopy) but electron microscopy shows fusion of podocytes (MCD)]
Complications:
- > Thrombosis (loss of AT-III in urine)
- > Infection (loss of Ig in urine)
- > Hypercholesteraemia (due to urinary albumin loss)
