Paediatrics > Renal > Flashcards

Renal Flashcards

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1
Q

What is oedema?

A

Increase in interstitial fluid

Swelling, pitting oedema, facial puffiness, ascites, pleural effusions, pulmonary oedema

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2
Q

What can cause oedema?

A

Lymph drainage problems (lymphoedema) - congenital/blockage
Venous drainage and pressure problems - venous obstruction (eg venous thrombosis)
Lowered oncotic pressure - low albumin/protein
Salt and water retention

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3
Q

What can cause lowered oncotic pressure?

A

Malnutrition
Decreased production - liver
Increased loss - gut/kidney (nephrotic syndrome)

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4
Q

What can cause salt and water retention?

A

Kidney impaired GFR

Heart failure

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5
Q

What is nephrotic syndrome?

A

Damaged podocytes leading to loss of protein through podocyte processes

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6
Q

What is the classic triad of symptoms in nephrotic syndrome?

A

Heavy proteinuria (frothy urine)
Hypoalbuminaemia
Oedema

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7
Q

How is protein level determined in nephrotic syndrome investigations?

A

Urine dipstick - semi-quantitative levels

First morning urine protein:creatinine

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8
Q

What levels of protein show nephrotic syndrome?

A

No definite level that is nephrotic

  • Normal < 20mg/mmol
  • > 600mg/mmol likely to produce hypoalbuminaemia but occurs at lower levels
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9
Q

What is hypoalbuminaemia?

A

Normal range 35-45g/L
Fluid retention and oedema usually with albumin < 25-30g/L but not strict cut off
Serum albumin linked to fluid retention
Other protein losses responsible for other complications eg infection, thrombosis

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10
Q

What is the oedema in nephrotic syndrome like?

A

Pitting oedema

Gravitational

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11
Q

What are the 3 types of nephrotic syndrome?

A

Congenital NS < 1 year
Steroid sensitive NS
Steroid resistant NS

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12
Q

What are the symptoms of steroid sensitive NS?

A 
Normal BP
No macroscopic haematuria
Normal renal function
No features to suggest nephritis
Respond to steroids
Minimal change on histology
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13
Q

In whom is steroid sensitive NS more common?

A

Peak age of onset 2-5
M > F
Higher incidence in those from African sub-continent

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14
Q

What causes steroid sensitive NS?

A

? Immunological aetiology

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15
Q

What is the prognosis of steroid sensitive NS?

A

Recurrent relapses in 80%
- Of these 50% have frequent relapses - problems associated with steroid usage over prolonged periods of time
5% continue into adult life
Normal renal function if steroid responsive

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16
Q

How is steroid sensitive NS treated?

A

Standard course of prednisolone for first episode - 60mg/m2 for 4 weeks, then 40mg/m2 on alternate days for 4 weeks
Other considerations - Na and water moderation, diuretics, penicillin as can get very unwell with infection, measles and varicella immunity and pneumococcal immunisation

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17
Q

What are the symptoms of steroid resistant NS?

A 
Elevated BP
Haematuria
Impaired renal function
Features may suggest nephritis
Failure to respond to steroids
Histology - various underlying glomerulopathy, basement membrane abnormalities
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18
Q

What is acute glomerulonephritis?

A

Inflammation of kidneys

Haematuria (macroscopic), proteinuria (varying degree), impaired GFR, salt and water retention

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19
Q

What does impaired GFR lead to?

A

Rising creatinine

Salt and water retention

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20
Q

What does salt and water retention lead to?

A

Hypertension

Oedema

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21
Q

What often causes acute glomerulonephritis?

A

Post-streptococcal infection
Often nasopharnygeal or skin infection
Group A beta-haemolytic strep nephritogenic strains
Antigen-antibody complexes form in glomerulus causing complement activation and glomerular injury

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22
Q

When does nephritis happen post infection?

A

Around 10 days

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23
Q

What are the signs of clinical nephritis?

A

Haematuria - swelling, decreased urine output

Oedema, hypertension, signs of CVS overload

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24
Q

How is acute glomerulonephritis managed?

A

Fluid balance - measurement of input and output, fluid moderation, diuretics, salt restriction
Correction of other imbalances - K+, acidosis
Dialysis if needed (uncommon)
Penicillin - treatment of strep infection

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25
What is the prognosis of glomerulonephritis?
95% full recovery Not recurrent No long term implication of renal function if full recovery
26
What investigations should you do for acute glomerulonephritis?
FBC - mild, normochromic normocytic anaemia U&Es - increased urea and creatinine, hyperkalaemia, acidosis Immunology - raised ASOT/anti-DNAse B titre, low C3/4 Throat/other swabs Urinalysis - haematuria (macroscopic), proteinuria, microscopy (RBC cast)
27
What are the different causes of AKI?
Pre-renal Renal Post-renal
28
What is Henoch-Schonlein purpura?
Clinical diagnosis based on rash - purpuric rash - red raised rash over legs and/or buttocks Vasculitis affecting several organs
29
What organs does HSP affect?
Skin Joints Gut Kidneys
30
What are the symptoms of HSP?
``` Rash - purpuric Arthritis Abdominal pain Faecal blood Proteinuria and haematuria ```
31
What affect can HSP have on the kidneys?
``` Haematuria/proteinuria Nephrotic syndrome Acute nephritis Renal impairment Hypertension ```
32
Why does HSP caused nephritis?
IgA deposition
33
What type of nephrotic syndrome can HSP cause?
Either steroid sensitive/resistant | If resistant then may need alternative immunosuppression and/or other anti-proteinuric measures
34
What is the prognosis of HSP?
Variable | May be ESRD
35
What should you do with a child who has had HSP?
Monitor bloods and urine after diagnosis to check for kidney problems
36
What is a UTI?
Infection of the urinary tract with growth of bacteria within the urinary tract 10^5 organisms/ml growth on culture 2 types - acute pyelonephritis (upper), acute cystitis (lower)
37
How common are UTIs in children?
``` 3-5% girls and 1-2% boys Can cause significant acute illness 50% rate of recurrence 50% structural abnormality presenting symptom Heavy burden on NHS and families ```
38
What are the long term complications of UTI in children?
Kidney scarring Hypertension CKD
39
What are the common symptoms and signs in infants < 3 months with UTI?
Fever, vomiting, lethargy, irritability Less commonly - poor feeding, failure to thrive Even less commonly - abdominal pain, jaundice, haematuria, offensive urine
40
What are the common symptoms and signs of UTI in preverbal children > 3 months?
Fever Less commonly - abdominal pain, loin tenderness, vomiting, poor feeding Even less commonly - lethargy, irritability, haematuria, offensive urine, failure to thrive
41
What are the common symptoms and signs of UTI in verbal children?
Frequency, dysuria Less commonly - dysfunction voiding, changes to continence, abdominal pain, loin tenderness Even less commonly - fever, malaise, vomiting, haematuria, offensive urine, cloudy urine
42
When should you take a urine sample from a child?
With S&S of UTI With unexplained fever > 38 With alternative site of infection but who remain unwell All infants < 3 months with suspected UTI referred to paediatric specialist care and urine should be sent for M & C
43
How do you collect a urine sample from a child?
MSU if able to urinate on command Clean catch recommended method Urine collection pads Catheter sample/suprapubic aspiration - before SPA need USS guidance to demonstrate presence of urine in bladder Don't delay treatment to seriously ill children for urine sample Need to specify how urine was collected
44
How can you do urine analysis?
Visual inspection Dipstick - nitrites, leucocyte esterase M, C & S
45
How do you interpret microscopy results?
Bacteruria and pyuria positive - regarded as having UTI Bacteruria positive, pyuria negative - regarded as having UTI Bacteruria negative and pyuria positive - antibiotic treatment only commenced if clinically UTI (could be partially treated UTI) Bateruria and pyuria negative - UTI excluded 10^5 organisms/ml of single bacteria on clean catch/MSU OR any growth on SPA
46
What is the most common type of bacteria causing UTI?
E coli | Proteus - more common in boys
47
What bacteria may indicate structural abnormality?
Pseudomonas
48
Which children need admission for IV antibiotics?
< 3 months - any child Systemically unwell Significant risk factors
49
How do you treat an infant < 3 months that is systemically well?
Minimum 2-4 days IV antibiotics followed by oral for 3 days | Advice to return if no better at 24-48 hours for reassessment
50
How do you treat an infant < 3 months that is systemically unwell (fever > 38 +/- loin pain/tenderness)?
Minimum 2-4 days IV antibiotics followed by oral 7-10 days (consider IV according to clinical judgement - use lower threshold for IV antibiotics in younger children, those with significant risk factors and severly ill)
51
What constitutes an atypical UTI?
``` Septicaemia/requires IV antibiotics Non-E coli UTI Poor urine flow Abdominal mass/bladder mass Raised creatinine Failure to respond to treatment with suitable antibiotics within 48 hours ```
52
What constitutes a recurrent UTI?
2/more UTI episodes at least one episode with systemic S&S | 3/more UTI without systemic S&S
53
When should you investigate further for structural abnormalities or scarring/damage to kidneys?
Atypical or recurrent UTI
54
What is the first line investigation for a UTI?
USS of renal tract - Non-invasive - Observer dependent - Size and drainage of kidneys and bladder - Good for ?obstruction
55
What is the second line investigation after USS for UTI and when do you do it?
Micturating cystourethrogram (MCUG) - Done if abnormalities detected on USS - Vesicoureteric reflux - retrograde flow of urine from bladder into ureter/pelvicalyceal system/intrarenal, severity graded on level of reflux and associated dilatation, I-V - IV and V most severe with urine backing up into kidneys, associated with UTI/renal abnormalities - Bladder - Posterior urethra
56
What is the third line investigation for UTI after USS and MCUG?
DMSA scan - dimercaptosuccinic acid - Radionuclide imaging - Relative renal function of each kidney - Renal scarring and extent of scarring
57
When should you give children a general paediatric follow up appointment?
All children < 3 months Children of any age systemically unwell Children with recurrent UTI Address dysfunctional elimination syndromes and constipation Include height, weight, BP and routine testing for proteinuria
58
Name 2 possible causes of UTI
``` E coli Enterobacter Klebsiella Proteus Pseudomonas Enterococcus ```
59
Name 2 antibiotics you could use to treat UTI
Trimethoprim Amoxicillin Cephalosporin (Nitrofurantoin)
60
What further investigations could you do in a child with UTI?
USS of urinary tract depending on age DMSA if atypical MCUG if atypical or doesn't respond to treatment
61
What does USS of urinary tract tell you?
Structural abnormalities
62
What does DMSA scan tell you?
Function and location of kidneys
63
What does MCUG tell you?
Shows how well bladder functions
64
What factors affect your choice of investigation in UTI?
Age of child - < 6 months, 6 months to 3 years, > 3 years Recurrent/atypical infection How well responds to treatment
65
What are the causes of proteinuria in children?
``` Non-pathological - Transient - Fever - Exercise - UTI Orthostatic - checking at the end of the da and stood upright Pathological - Nephrotic syndrome - CKD - Glomerulonephritis - Tubular interstitial nephritis ```
66
What is the diagnostic criteria for nephrotic syndrome?
Heavy proteinuria > 3+ Urine protein/creatinine ratio > 250mg/mmol Hypoalbuminaemia < 20g/l
67
What initial investigations do you have for nephrotic syndrome?
BP Urine dip - protein + blood, protein:creatinine ratio 24 hour urine collection Urine microscopy FBC, clotting, ESR, U&E, albumin, cholesterol, blood glucose, bone profile, chicken pox status
68
What are the possible causes of nephrotic syndrome?
Minimal change disease > 90% Focal segmental glomerulosclerosis Membranous glomerular disease Membranous nephropathy
69
How would you treat nephrotic syndrome?
``` Prednisolone 60mg/m2 for 4 weeks then wean Maintenance pred PPI cover Low salt diet Penicillin V + imms Antihypertensives Fluid balance ```
70
What is the prognosis of nephrotic syndrome?
Most respond to steroids - 80% 50% recurrent relapse 0.5-1% mortality
Paediatrics
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