TN Pédiatrie > 14. Nephrology > Flashcards

14. Nephrology Flashcards

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1
Q

Name: Common Manifestations of Renal Disease in NEONATE (3)

A
  • Flank Mass
  • Hematuria
  • Anuria/Oliguria
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2
Q

Name: Common Manifestations of Renal Disease in CHILD and ADOLESCENT (8)

A
  • Cola/Red-Coloured Urine
  • Gross Hematuria
  • Edema
  • HTN
  • Polyuria
  • Proteinuria
  • Oliguria
  • Urgency
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3
Q

Name common causes in neonates: Flank Mass (3)

A
  • Hydronephrosis
  • polycystic disease (autosomal dominant or recessive subtypes)
  • tumour
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4
Q

Name common causes in neonates: Hematuria (4)

A
  • Renal vein thrombosis
  • Asphyxia
  • Malformation
  • Trauma
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5
Q

Name common causes in neonates: Anuria/Oliguria (3)

A
  • Bilateral renal agenesis
  • obstruction
  • asphyxia
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6
Q

Name common causes in child/adolescent: Cola/Red-Coloured Urine (3)

A
  • Acute GN (post-streptococcal, HSP, IgA nephropathy, etc.)
  • hemoglobinuria (hemolysis)
  • myoglobinuria (rhabdomyolysis)
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7
Q

Name common causes in child/adolescent: Gross Hematuria (3)

A
  • Urologic disease (nephrolithiasis, trauma, etc.)
  • UTI
  • acute GN
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8
Q

Name common causes in child/adolescent: Edema (5)

A
  • Nephrotic syndrome
  • nephritis
  • acute/chronic renal failure
  • consider cardiac
  • liver disease
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9
Q

Name common causes in child/adolescent: HTN (3)

A
  • GN
  • renal failure
  • dysplasia (consider coarctation, drugs, endocrine causes)
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10
Q

Name common causes in child/adolescent: Polyuria (5)

A
  • DM
  • central and nephrogenic DI
  • renal Fanconi’s syndrome (genetic/metabolic/acquired causes)
  • hypercalcemia
  • polyuric renal failure (renal dysplasia)
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11
Q

Name common causes in child/adolescent: Proteinuria (3)

A
  • Orthostatic
  • nephrotic syndrome (MCD, etc.)
  • GN
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12
Q

Name common causes in child/adolescent: Oliguria (4)

A
  • Dehydration
  • ATN
  • interstitial nephritis
  • acute or chronic kidney disease (i.e. renal failure)
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13
Q

Name common causes in child/adolescent: Urgency (2)

A
  • UTI
  • vulvovaginitis
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14
Q

Name triad of: Hemolytic Uremic Syndrome (3)

A
  • non-immune microangiopathic hemolytic anemia
  • thrombocytopenia
  • acute renal injury
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15
Q

Describe epidemiology: Hemolytic Uremic Syndrome (2)

A
  • annual incidence of 1-2 per 100,000 in Canada
  • most common cause of acute renal failure in children
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16
Q

Describe etiology: Hemolytic Uremic Syndrome (2)

A
  • diarrhea positive HUS: 90% of pediatric HUS from E.coli O157:H7, shiga toxin, or verotoxin
  • diarrhea negative HUS: other bacteria, viruses, drugs, familial/genetic
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17
Q

Describe pathophysiology: Hemolytic Uremic Syndrome (5)

A
  • toxinbinds, invades, and destroys colonic epithelial cells, causing bloody diarrhea
  • toxin enters the systemic circulation, attaches to, and injures endothelial cells (especially in kidney),
  • causing a release of endothelial products (e.g. von Willebrand factor, platelet aggregating factor)
  • platelet/fibrin thrombi form in multiple organ systems (e.g.kidney,pancreas,brain,etc.) resulting in thrombocytopenia
  • RBCs are forced through occluded vessels, resulting in fragmented RBCs (schistocytes) that are removed by the reticuloendothelial system (hemolytic anemia)
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18
Q

Describe clinical features: Hemolytic Uremic Syndrome (7)

A
  • initial presentation of abdominal pain and diarrhea, followed by bloody diarrhea;
  • within 5-7d begins to show signs of anemia, thrombocytopenia, and renal insufficiency
  • pallor
  • jaundice (hemolysis)
  • edema
  • petechiae
  • HTN
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19
Q

Describe investigations: Hemolytic Uremic Syndrome (7)

A
  • CBC (anemia, thrombocytopenia)
  • blood smear (schistocytes)
  • electrolytes
  • renal function
  • urinalysis (microscopic hematuria)
  • stool cultures
  • and verotoxin/shigella toxin assay
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20
Q

Describe management: Hemolytic Uremic Syndrome (4)

A
  • mainly supportive: nutrition, hydration, ventilation (if necessary), blood transfusion for symptomatic anemia
  • monitor electrolytes and renal function: dialysis if electrolyte abnormality (hyperkalemia) cannot be corrected, fluid overload, or uremia
  • steroids are not helpful
  • antibiotics are contraindicated as death of bacteria leads to increased toxin release and worse clinical course
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21
Q
A
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22
Q

Describe prognosis: Hemolytic Uremic Syndrome (2)

A
  • death in <5% of cases,
  • 5-25% long term renal damage (HTN, proteinuria, decreased renalfunction)
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23
Q

Define: Nephritic Syndrome (3)

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A
  • acute or chronic syndrome affecting the kidney, characterized by glomerular injury and inflammation
  • defined by hematuria (>5 RBCs per high-powered microscope field), presence of dysmorphic RBCs, and RBC casts on urinalysis
  • often accompanied by at least one of proteinuria (<50mg/kg/d), edema, HTN, azotemia, and oliguria
24
Q

Describe presentation: Nephritic Syndrome (6)

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A

PHAROH

  • Proteinuria (<50 mg/kg/d)
  • Hematuria
  • Azotemia
  • RBC casts
  • Oliguria
  • HTN
25
Describe epidemiology: Nephritic Syndrome (1)
highest incidence in children aged 5-15 yr old
26
Describe etiology: Nephritic Syndrome (2)
* humoral immune response to a variety of etiologic agents → immunoglobulin deposition → complement activation, leukocyte recruitment, release of growth factors/cytokines → glomerular inflammation and injury → porous podocytes → hematuria + RBC casts ± proteinuria * HTN secondary to fluid retention and increased renin secretion by ischemic kidneys
27
Name: Major Causes of Nephritic Syndrome
28
Describe clinical features: Nephritic Syndrome (3)
* often asymptomatic; some overlap in clinical findings for nephritic and nephrotic syndrome * gross hematuria, mild-moderate edema, oliguria, HTN * signs and symptoms suggestive of underlying systemic causes (e.g.fever,arthralgias,rash,dyspnea, pulmonary hemorrhage)
29
Describe investigation: Nephritic Syndrome (3)
* urine * dipstick (hematuria, 0 to 2+ proteinuria) and microscopy (\>5 RBCs per high-powered microscope field, acanthocytes, RBC casts) * first morning urine protein/creatinine ratio (\<200 mg/mmol) * blood word * CBC, electrolytes, Cr, BUN, albumin * impaired renal function (⬆️ Cr and BUN) resulting in ⬆️ pH and electrolyte abnormalities (hyperkalemia, hyperphosphatemia, hypocalcemia) * mild anemia on CBC (secondary to hematuria) * hypoalbuminemia (secondary to proteinuria) * appropriate investigations to determine etiology: C3/C4 levels, serologic testing for recent streptococcal infection (ASOT, anti-hyaluronidase, anti-streptokinase, anti-NAD, anti-DNAse B), ANA, anti-DNA antibodies, ANCA, serum IgA levels, anti-GBM antibodies * renal biopsy should be considered only in the presence of acute renal failure, no evidence of streptococcal infection, normal C3/C4
30
Describe management: Nephritic Syndrome (3)
* treat underlying cause * symptomatic * renal insufficiency: supportive (dialysis if necessary), proper hydration * HTN: salt and fluid restriction (but not at expense of renal function), ACEI or ARBs for chronic persistent HTN (not acute cases because ACEI or ARBs may decrease GFR further) * edema: salt and fluid restriction, possibly diuretics (avoid if significant intravascular depletion) * corticosteroids if indicated: IgA nephropathy, lupus nephritis,etc.
31
Describe prognosis: Nephritic Syndrome (2)
* dependent on underlying etiology * complications include HTN, heart failure, pulmonary edema, chronic kidney injury (requiring renal transplant)
32
Define: Nephrotic Syndrome (4)
clinical syndrome affecting the kidney, characterized by * significant proteinuria * peripheral edema * hypoalbuminemia * hyperlipidemia
33
Describe epidemiology: Nephrotic Syndrome (1)
highest incidence in children 2-6 yr old, M\>F
34
Name types of Nephrotic Syndrome (3)
* Primary (idopathic) * Secondary * Congenital: congenital nephropathy of the Finnish type, Denys-Drash syndrome,etc.
35
Describe etiology: Nephrotic Syndrome PRIMARY (2)
primary (idiopathic): nephrotic syndrome in the absence of systemic disease (most common cause in pediatrics) * glomerular inflammation ABSENT on renal biopsy: MCD (85%), focal segmental glomerular sclerosis * glomerular inflammation PRESENT on renal biopsy: membranoproliferative GN, IgA nephropathy
36
Describe secondary: Nephrotic Syndrome PRIMARY (6)
nephrotic syndrome associated with systemic disease or due to another process causing glomerular injury (\<10% in pediatrics) * autoimmune: SLE, DM, rheumatoid arthritis * genetic: sickle cell disease, Alport syndrome * infections: hepatitis B/C, post-streptococcal, infective endocarditis, HUS, HIV * malignancies: leukemia, lymphoma * medications: captopril, penicillamine, NSAIDs, antiepileptics * vasculitides: HSP, granulomatosis with polyangiitis
37
Describe clinical features: Nephrotic Syndrome (4)
* non-specific symptoms such as irritability, malaise, fatigue, anorexia, or diarrhea * edema * often first sign; detectable when fluid retention exceeds 3-5% of body weight * starts periorbital and often pretibial → edematous areas are white, soft, and pitting * gravity dependent: periorbital edema ⬇️ and pretibial edema ⬆️ over the day * anasarca may develop (i.e. marked periorbital and peripheral edema, ascites, pleural effusions, scrotal/labial edema) * decrease in effective circulating volume (e.g. tachycardia, HTN, oliguria,etc.) * foamy urine is a possible sign of proteinuria
38
Describe investigation: Nephrotic Syndrome (3)
* urine * urine dipstick (3 to 4+ proteinuria, microscopic hematuria) and microscopy (oval fat bodies,hyaline casts) * first morning urine protein/creatinine ratio (\>200 mg/mmol) * blood work * diagnostic: hypoalbuminemia (\<25 g/L), hyperlipidemia/hypercholesterolemia (total cholesterol \>5 mmol/L) * secondary: electrolytes (hypocalcemia, hyperkalemia, hyponatremia), renal function (⬆️BUN and Cr), coagulation profile (⬇️PTT) * appropriate investigations to rule out secondary causes: CBC, blood smear, C3/C4, ANA, hepatitis B/C titres, ASOT, HIV serology, etc. * consider renal biopsy if: HTN, gross hematuria, ⬇️renal function, low serum C3/C4, no response to steroids after 4 wk of therapy, frequent relapses (\>2 in 6 mo), presentation before first yr of life (high likelihood of congenital nephrotic syndrome), presentation ≥12 yr (rule out more serious renal pathology than MCD)
39
Describe management: Nephrotic Syndrome (7)
* MCD: oral prednisone 2 mg/kg/d (or equivalent) for up to 12 wk → varicella status should be known before starting * consider cytotoxic agents, immunomodulators, or high-dose pulse corticosteroid if steroid resistant * symptomatic * edema: salt and fluid restriction, possibly diuretic (avoid if significant intravascular depletion); furosemide + albumin for anasarca * hyperlipidemia: generally resolves with remission; limit dietary fat intake; consider statin therapy if persistently nephrotic * hypoalbuminemia: IV albumin and furosemide not routinely given; consider if refractory edema * abnormal BP: control BP; fluid resuscitation if severe intravascular depletion; ACEI or ARBs for persistent HTN * diet: no added salt; monitor caloric intake and supplement with Ca2+ and Vit D if on corticosteroids * daily weights and BP to assess therapeutic progress * secondary infections: treat with appropriate antimicrobials; antibioticprophylaxis not recommended; pneumococcal vaccine at diagnosis and varicella vaccine after remission; varicella Ig + acyclovir if exposed while on corticosteroids * secondary hypercoagulability: mobilize, avoid hemoconcentration due to hypovolemia, prompt sepsis occur
40
Name: Side Effects of Long-Term Steroid Use (10)
* Increasedappetite * Weight gain * Dorsal hump * Impaired growth * Behavioural changes * Risk of infection * Salt and water retention * HTN * Bone demineralization * Skin striae
41
Describe prognosis: Nephrotic Syndrome (3)
* generally good: 80% of children responsive to corticosteroids * up to 2/3 experience relapse, often multiple times; sustained remission with normal kidney function usually by adolescence * complications: ⬆️ risk of infections (spontaneous peritonitis, cellulitis, sepsis); hypercoagulability due to decreased intravascular volume and antithrombin III depletion (PE, renal vein thrombosis); intravascular volume depletion, leading to hypotension, shock, renal failure; side effects of drugs
42
Define HTN (1)
sBP and/or dBP ≥95th percentile for sex, age, and height on ≥ 3occasions
43
Define pre-HTN (2)
* sBP and/or dBP ≥90th percentile but \<95th percentile * or BP≥ 120/80 irrespective of age, gender, and height
44
Fill table
45
Describe epidemiology: Hypertension in Childhood (2)
* prevalence: 3-5% for HTN, 7-10% for pre-HTN; M\>F * increasing prevalence of pre-HTN over the last 25 +yr
46
Describe etiology: Primary HTN (3)
* diagnosis of exclusion * most common in older children (≥10 yr), especially if positive family history, overweight, and only mild HTN * responsible for ~90% of cases of HTN in adolescents, rarely in young children
47
Describe etiology: Secondary HTN (2)
* identifiable cause of HTN (most likely etiology depends on age) * responsible for majority of childhood HTN
48
Name: Etiology of Secondary HTN by Age Group
49
Name risk factors primary HTN (6)
* male gender * positive family history * obesity * obstructive sleep apnea * African American * prematurity/LBW
50
Name risk factors secondary HTN (4)
* history of renal disease * abdominal trauma * family history of autoimmune diseases * umbilical artery catheterization
51
Name: Signs of Secondary HTN (6)
* Edema (renal parenchymal disease) * Abdominal or renal bruit (RAS) * Differential 4 limb BP/diminished femoral pulses (coarctation) * Abdominal mass (Wilms’, neuro blastoma) * Goitre/skin changes (hyperthyroidism) * Ambiguous genitalia (CAH)
52
Describe clinical features: Hypertension in childhood (3)
often asymptomatic, but can include * FTT * fatigue * epistaxis
53
Name: symptoms of hypertensive emergency (6)
* neurologic: * headache * seizures * focal complaints * change in mental status * visual disturbances * cardiovascular: * symptoms of MI or heart failure (chest pain, palpitations, cough, SOB)
54
Describe physical exam: Hypertension childhood (7)
* measure BP with correct cuff size * BMI * full neurologic exam * ophthalmoscopy, * precordial exam * peripheral pulses * perfusion status
55
Describe Investigations: Hypertension childhood (6)
* laboratory * urine dipstick for hematuria and/or proteinuria (renal disease), urine catecholamines (pheochromocytoma, neuroblastoma) * blood work: renal function tests (electrolytes, Cr, BUN), consider renin and aldosterone levels (RAS, Conn’s syndrome, Wilms’ tumour) * other specific hormones if indicated on history and physical * imaging: * Echo (coarctation, heart function) * abdomina lU/S (RAS, abdominal mass) * renal radionucleide imaging (renal scarring)
56
Describe management: Hypertension childhood (5)
* treat underlying cause * non-pharmacologic: modify concurrent cardiovascular risk factors (weight reduction,exercise,salt restriction, smoking cessation) * pharmacologic: gradual lowering of BP using thiazide diuretics; no antihypertensives havebeen formally studied in children; if hypertensive emergencies use hydralazine, labetalol, sodium nitroprusside * management of end-organ damage (e.g.retinopathy,LVH) * consider referral to specialist
57
Describe prognosis: Hypertension childhood (5)
end-organ damage (similar to adults) including * LVH * CHF * cerebrovascular insults * renal disease * retinopathy
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