1
Q
What might cause AKI in children? *commonly
A
pre-renal - gastroenteritis, blood loss, insensible losses, burns, sepsis, DKA, anaphylaxis *most common in children
2
Q
what features may be present in the history to suggest AKI as a cause?
A
- D+V, fluid or blood loss may suggest pre-renal
- acute gastroenteritis with dehydration and shock
- oedema
- blood in urine
- generally unwell
- fever
3
Q
what are some key signs noticed to support AKI?
A
- oedema
- haematuria
- hypertension
- signs of sepsis
- hyperkalaemia signs
- hyperventilating to balance metabolic acidosis
4
Q
how might you investigate AKI?
A
- urine dipstick - blood
- U&E - sodium and potassium
- renal USS
- urinalysis
- CT-KUB is stone suspected
- blood gas for acidosis state
5
Q
how might you manage an AKI?
A
- fluid therapy - monitor, don’t give potassium containing fluids
- optimise medication
- hyperkalaemia treatment - calcium gluconate
- metabolic acidosis treated with sodium bicarbonate
- manage hypertension
- dialysis considered in those with multi organ failure and haemofiltration
6
Q
when might you consider dialysis?
A
- failure of conservative management
- hyperkalaemia
- severe hyponatraemia or hypernatraemia
- pulmonary oedema or severe hypertension due to volume overload
- severe metabolic acidosis
- multisystem failure
7
Q
what might cause CKD in a child?
A
congenital anomalies of kidney and urinary tract, then glomerular disease, familial, systemic diseases affecting kidneys, tubulointerstitial diseases etc
8
Q
how might CKD present?
A
- abnormal antenatal scan
- anorexia
- lethargy
- polydipsia, polyuria
- faltering growth
*Many children with chronic kidney disease have had their renal disease detected before birth by antenatal ultrasound or have previously identified renal disease
9
Q
how might you investigate CKD?
A
- urinalysis - protein
- U&E
- FBC
- USS
- biopsy
10
Q
how might you manage CKD?
A
- nutrition: calorie supplements, NG, restrict protein
- prevent renal osteodystrophy
- control salt and water balance
- human recombinant erythropoietin
- growth hormone
- bicarbonate supplements
- transplant or dialysis
11
Q
what causes UTI in child? what are some RF?
A
- bacterial from GI tract - E.coli (85%), Klebsiella and staphylococcus saprophyticus
- RF: under 1, female (under 3m boys), previous UTI, sexual abuse, constipation, immunosuppression
12
Q
how might UTI present?
A
fever
babies: lethargy, irritable, vomiting, poor feed, increased frequency
abdo pain and loin tenderness
temp, HR, RR, CRT, pyelonephritis
13
Q
how might you investigate UTI?
A
- infants microscopy and cultures within 24h if temp over 38c
- clean catch urine sample, urine collection pads
- urine dipstick - in leukocyte esterase and nitrites positive send for cultures
- nitrites better than leukocytes
- imaging - USS, micturating cystography gold standard for reflux
- recurrent UTI - investigate for underlying cause with USS, DMSA, VUR, MCUG
14
Q
how are UTI managed in children?
A
- all under 3 with fever - IV abx ceftriaxone, full septic screen, blood cultures, bloods and lactate and lumbar puncture
- oral Abx if over 3m - trimethoprim, nitrofurantoin
- pyelonephritis - IV Abx
15
Q
how are UTI prevented in children?
A
- use the potty more often
- time child’s potty sessions - as in not to hold pee, empty bladder every 2-3h
- empty bladder completely
- proper wiping - front to back
- stay hydrated
- avoid constipation
- choice of clothing - cotton underpants, avoid nylon or tight fitted
- no bubble baths
16
Q
what could cause haematuria?
A
- UTI
- irritation to meatus or perineum
- wilms
- nephrolithiasis
- GN
- IgA nephropathy
- FSGS
- alport
- trauma
- sickle cell
- exercise
- HUS
17
Q
what are some red flags for haematuria?
A
- Abnormal renal function
- Proteinuria 2+ or more on the dipstick, please send a urine protein/creatinine ratio
- Signs of fluid overload: peripheral oedema, ascites, elevated JVP, pulmonary oedema
- Hypertension
- Persistent frank/macroscopic haematuria with no cause identified after baseline investigations
18
Q
what is the physiology of controlling urination? what age?
A
- daytime urination by 2 years
- night time urination by 3-4 years
19
Q
what causes primary nocturnal enuresis?
A
- development variation esp if <5
- overactive bladder
- fluids before bed
- failure to wake up
- psych distress
*chronic constipations, UTI, LD, CP
20
Q
how would you manage primary nocturnal enuresis?
A
- reassure parents of children <5 years
- lifestyle changes
- reduce fluid intake in evenings
- pass urine before bed
- ensure easy access to toilet
- encouragement and positive reinforcement
- treat underlying causes e.g. constipation
- enuresis alarms
- pharmacological treatment
21
Q
what could cause secondary nocturnal enuresis?
A
- urinary tract infection
- constipation
- type 1 diabetes
- new psychosocial problems
- e.g. stress in family or school life
- maltreatment
22
Q
when would you suspect abuse regarding enuresis?
A
- deliberate bedwetting
- punishment for bedwetting (despite parental education)
- unexplained secondary nocturnal enuresis
23
Q
what are some risk factors for enuresis?
A
- family history
- male gender
- developmental delay (physical or intellectual\0
- constipation, faecal incontinence
- ADHD, ASD, anxiety, depression, conduct disorders
- sleep apnoea
24
Q
what is an enuresis alarm?
A
- makes a noise at the first sign of bed wetting
- this wakes up the child and stops them from urinating
25
what are some limitations of an enuresis alarm?
- equires a high level of training and commitment
- needs to be used consistently for a prolonged period e.g. at least 3 months
- may add to burden and frustration
26
what are some pharmacological tx for enuresis?
- desmopressin to reduce volume produced by kidneys
- oxybutynin to reduce contractility of bladder
- impramine to relax bladder
27
what is the pathophysiology of nephrotic syndrome?
**basement membrane** in the **glomerulus** becomes highly permeable to protein, allowing **proteins to leak** from the blood into the urine
**podocytes** become flattened and allow leakage
28
how is nephrotic syndrome managed?
- high dose steroids
- low salt diet
- diuretics
- albumin infusion
- abx prophylaxis
29
what is nephritic syndrome?
- Nephritis refers to inflammation within the nephrons of the kidneys
- and nephritic syndrome is a consequence of glomerulonephritis
30
how is nephritic syndrome managed?
- monitoring of electrolytes, consider intensive care
- antihypertensives
- fluid restriction, consider dialysis
- IgA nephropathy, HSP mx
31
what is HUS?
thrombosis in small blood vessels throughout the body, usually triggered by shiga toxins from E. coli O157 or shigella
32
what is the triad of HUS?
- microangiopathic haemolytic anaemia
- acute kidney injury
- thrombocytopenia (low platelets)
33
what is the pathophysiology of HUS?
- formation of blood clots consumes platelets, leading to thrombocytopenia
- blood flow through the kidney is affected by thrombi and damaged RBCs causing AKI
- MAHA involves haemolysis due to pathology in small vessels (microangiopathy)
- tiny thrombi partially obstruct the small blood vessels and churn the RBCs as they pass through, causing them to rupture
34
how is HUS investigated?
stool culture
FBC
blood smear
U&E
clotting
PCR for shiga
LDH
biopsy
35
how is HUS managed?
- self limiting with supportive
hypovolaemia, hypertension mx
red cell transfusion
short term dialysis or transplant
plasma exchange
36
what does the underlying pathology of PKD case?
mutation in the polycystic kidney and hepatic disease 1 (PKHD1) gene on chromosome 6
1. Cystic enlargement of the renal collecting ducts
2. Oligohydramnios, pulmonary hypoplasia and Potter syndrome
3. Congenital liver fibrosis
37
how does PKD present?
- ARPKD usually presents in the antenatal period with the following seen on antenatal scans.
1. oligohydramnios and
2. polycystic kidneys
38
how is PKD managed?
- Patients may require renal dialysis within the first few days of life.
- Most patients develop end stage renal failure before reaching adulthood
39
what is Wilms tumour?
tumour affecting the kidney in children, typically <5 years old
40
when would you suspect Wilms?
should be considered in any child <5 years with a mass in the abdomen
- abdominal pain
- haematuria
- lethargy
- fever
- hypertension
- weight loss
41
how would you investigate Wilms?
- abdominal USS, CT, MRI
- FBC, U&E, urinalysis
- CXR
- LFT
- bone profile
42
how is WIlms managed?
- surgical excision of tumour and nephrectomy
- adjuvant treatment depending on stage and metastasis:
- adjuvant chemotherapy
- adjuvant radiotherapy
43
what is the pathophysiology of a posterior urethral valve?
tissue at the proximal end of the urethra causes obstruction of urine output
obstruction causes back pressure into the bladders and ureter causing hydronephrosis
restriction of outflow of urine means the bladder cannot fully empty, increasing the risk of UTIs
44
how might a posterior urethral valve present?
- asymptomatic
- difficulty urinating
- weak urinary stream
- chronic urinary retention
- palpable bladder
- recurrent UTIs
- impaired kidney function
45
how is a posterior urethral valve investigated?
- antenatal with oligohydramnios and hydronephrosis
- abdo USS
- micturating cystourethrogram: shows location of the extra urethral tissue and reflux of urine back into the bladder
- cystoscopy
46
how is a posterior urethral valve managed?
- simple cases can be observed and monitored
- temporary management
- temporary urinary catheter
- bypasses the valve
- definitive management
- ablation or removal of extra tissue
- usually during cystoscopy
Y4 Paediatrics
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