MRCPCH Clinicals > Renal > Flashcards

Renal Flashcards

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1
Q

Name the 4 different types of renal replacement therapy

A

1) Peritoneal dialysis
2) Haemodialysis
3) Continuous renal replacement therapy = continuous haemodiafiltration
4) Renal transplant

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2
Q

When would peritoneal dialysis be considered?

A

For infants and young children
No vascular access needed
Gentle haemodynamic shifts

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3
Q

What are the indications for renal replacement therapy?

A

Acute:
Acidosis
Electrolyte imbalance (hyperkalaemia)
Intoxication
Overload
Uraemia (encephalopathy, pericarditis, bleeding)

Chronic:
ESKD (end stage kidney disease)
Symptomatic uraemia
Growth failure

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4
Q

Name 3 signs of steroid overuse

A

Skin atrophy
Striae
Cushingoid features: moon face, truncal obesity, buffalo hump
Growth suppression
Proximal myopathy
Recurrent/severe infections

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5
Q

An oblique scar below the ribs on the lateral aspect of the abdomen. What is this scar and its indications?

A

Flank/loin scar

Indications:
- Nephrectomy
- Pyeloplasty
- Open renal surgery

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6
Q

A suprapubic transverse scar. What is the name of this scar and its indications?

A

Lower abdominal scar/pfannenstiel

Indications:
Renal transplant (recipient incision)
Bladder surgery

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7
Q

Oblique or transverse scar over RIF.

Name of scar and indications.

A

Right iliac fossa scar

Indications:
Renal transplant
Differentiate from appendicectomy by context and palpable kidney

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8
Q

Midline scar from epigastric to umbilical region.

Name scar and indications.

A

Upper abdominal midline scar

Indications:
Major abdominal surgery
Rarely renal tumour surgery e.g. Wilms tumour extension

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9
Q

If renal transplant suspected, what else would you like to know?

A

Check BP - HTN
Ask about urine output and if reduced
Ask about immunosuppression adherence (tacrolimus levels)
Assess for graft tenderness
Rising creatinine

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10
Q

What are the complication of a renal transplant?

A

Can be classified into early, intermediate and late

Early:
- Surgical: bleeding/haematoma, vascular thrombosis
- Delayed graft function
- Infection

Intermediate (1-6 months):
- Acute rejection (rising creatinine, reduced UO, graft tenderness, fever)
- Infection: CMV, EBV - PTLD (post-transplant lymphoproliferative disorder), BK virus nephropathy

Late (> 6 months):
- Chronic rejection
- Infection
- HTN
- Diabetes mellitus

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11
Q

2 year old boy presents with macroglossia, ear lobe creases, a scar over his umbilicus and has hepatosplenomegaly. He had a history of neonatal hypoglycaemia. What is the diagnosis, differentials and management?

A

Dx: Beckwith Wiedemann syndrome

DDx:
Sotos syndrome
Weaver syndrome
MPS
Congenital hypothyroidism

Mx:
Medical
- Tumour screening: abdominal US every 3 months until 8 years; AFP every 3 months until 4 years (increased risk of embryonal tumours e.g. Wilms tumour, hepatoblastoma, neuroblastoma) - tumour risk decreases with age
- General paediatrician
- Paediatric surgery: omphalocoele
- Community paediatrician
- Clinical geneticist

PT/OT
EHCP - SENCO

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12
Q

Name 3 causes of a renal mass

A

Malignant:
- Wilm’s tumour (2-5 years) - painless abdominal mass w/ haematuria, HTN
- Renal cell carcinoma

Cystic renal disease:
- Multicystic dysplastic kidney
- AD or AR polycystic kidney disease

Obstructive/hydronephrosis
- PUJ obstruction
- Posterior urethral valves

Infective/inflammatory

Traumatic:
- Renal haematoma

Renal transplant

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13
Q

What syndrome is associated with Wilms tumour?

A

Beckwith-Wiedemann syndrome
WAGR syndrome (Wilms, Aniridia, genitourinary anomalies, developmental delay)

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14
Q

Name 3 causes of microscopic haematuria

A

Glomerular cause:
- IgA nephropathy/HSP
- Post-streptococcal glomerulonephritis
- Alport syndrome

Urological cause:
- UTI
- Kidney stones
- Trauma

Benign causes:
- Exercise-induced
- Febrile illness

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15
Q

What would indicate a glomerular cause of microscopic haematuria?

A

Proteinuria
HTN
Red cell casts
Dysmorphic RBCs
Oedema

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16
Q

What investigations would you send if microscopic haematuria was present?

A

Repeat urine dipstick
Urine microscopy
Urine protein:creatinine ratio
BP
Renal function

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17
Q

Name 3 causes of macroscopic haematuria

A

Glomerular causes:
Inflammatory/immune
- Post-streptoccocal glomerulonephritis
- IgA nephropathy
- HSP (IgA vasculitis)

Hereditary:
- Alport syndrome

Non-glomerular causes:
- Infection: UTI/pyelonephritis
- Stones

Structural/obstructive:
- Hydronephrosis
- PUJ obstruction

Tumour:
Wilms tumour

Trauma

Coagulation disorders

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18
Q

In the context of macroscopic haematuria, what clinical signs would indicate a glomerular cause?

A

Cola-coloured urine
Proteinuria
HTN
Oedema
Red cell cases

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19
Q

What investigations would you do for macroscopic haematuria?

A

Urine dipstick + microscopy
BP
U&E
Urine PCR
US KUB

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20
Q

How would you perform a nutritional assessment?

A

Anthropometry: weight, height/length, BMI (2 or older), head circumference (< 2y)
Mid-arm circumference (muscle mass)
Triceps skin-fold thickness (subcutaneous)

Dietary intake: meal pattern; 24 hour dietary recall

Clinical examination

Medical history: chronic disease, medications, recurrent infections, developmental delay

Social history: food insecurity, cultural practices

Bloods:
- FBC, Iron studies, vitamin D, U&E, LFTs, coeliac screen, inflammatory markers

Functional assessment

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21
Q

A 3 year old boy presents with puffiness to his ankles and frothy urine. He has protein ++++ on dipstick with low albumin. Diagnosis, differentials and management?

A

Nephrotic syndrome

DDx:
Primary cause:
- Minimal change disease (most common)
- FSGS = focal segmental glomerulosclerosis

Secondary cause:
- Infection (hepatitis)
- SLE
- Drugs (NSAIDs)

Mx
- Bedside Ix: urine dipstick, urine protein:creatinine ratio
- Bloods: low albumin, raised cholesterol

Medical:
- PO prednislone - if responds well, good prognosis; if resistant: higher CKD risk
- Salt restriction
- Fluid management

Follow-up:
- Urine dipsticks at home
- Monitor growth and BP
- Steroid side effects
- Vaccination (pneumococcal)

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22
Q

What are the complications of nephrotic syndrome?

A

Infection: SBP
Thrombosis: Renal vein thrombosis
AKI
Hyperlipidaemia

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23
Q

What are some relapse triggers for nephrotic syndrome?

A

Viral infections
Non-adherence
Immunisations

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24
Q

Why are children with nephrotic syndrome at an increased risk of spontaneous bacterial peritonitis?

A

Loss of immune proteins in the urine and ascites acting as a culture medium

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25
Name 3 causes of nephrotic syndrome
Glomerular: - Minimal change disease (most common) - FSGS Secondary cause: - SLE - Infection - Drugs (NSAID)
26
How would you explain nephrotic syndrome to a parent?
The filters in the kidneys are leaking protein into the urine which normally shouldn't happen. As the protein is being lost, fluid can leak out of the blood vessels and collect in the face, tummy or legs hence the swelling The good news is that in most children, this is caused by minimal change disease which usually responds very well to steroids. The steroids help stop the kidneys leaking protein. Safety net: while your child has nephrotic syndrome, they are more prone to infections. So if you notice fever, tummy pain, vomiting or generally seems unwell, you must seek medical attention We’ll show you how to check your child’s urine at home with simple dipsticks and we’ll monitor their growth, blood pressure, and any side effects of treatment. Many children do have relapses, often triggered by infections, but most grow out of this condition over time and go on to have normal kidney function.
27
When would you refer to renal in the context of nephrotic syndrome?
Steroid resistant (no remission after 4 weeks of treatment) < 1y (congenital nephrotic syndrome) or > 12 y Gross haematuria HTN Renal impairment Low complement Vasculitic features (rash, arthropathy) 2 X consecutive relapses on steroids OR relapse within stopping prednisolone within 2 weeks
28
3 year old presents with a painless abdominal mass, weight loss and haematuria. Name diagnosis, differentials and management.
Diagnosis: Wilm's tumour DDx: Neuroblastoma Hydronephrosis Multicystic dysplastic kidney Management: Bedside: obs incl BP, urine dip, palpate lightly (risk of tumour rupture) Bloods: FBC, U&Es, LFTs Imaging: US Abdomen; CT/MRI abdomen for staging; CXR/CT chest for lung metastases FNA/mass biopsy MDT: - Surgeons (nephrectomy) - Chemotherapy +/- radiotherapy
29
How would you tell the difference between Wilms and neuroblastoma on examination?
Neuroblastoma can cross the midline whereas Wilms cannot Wilms would have HTN; neuroblastoma would not
30
2 year old child presents with abdominal pain, weight loss and fever. O/E: you palpate an abdominal mass that crosses the midline. What is the diagnosis, differentials and management?
Dx: Neuroblastoma = malignant tumour of the sympathetic nervous system arising from neural crest cells, most commonly from adrenal medulla - Often presents with metastatic disease DDx: Wilms tumour Ix: - Bloods: FBC (for pancytopenia) - Urine VMA/HVA (raised catecholamine metabolites) - Imaging: US abdomen, CT/MRI, MIBG scan - Tissue biopsy (bone marrow) Mx: - Risk-stratified: surgery, chemotherapy, radiotherapy, immunotherapy
31
Name some clinical signs indicative of metastatic disease in context of neuroblastoma
Bone pain Limp Pancytopenia (bone marrow infiltration) Periorbital ecchymoses (racoon eyes) Proptosis
32
Describe CKD staging
Stages 1-5: 1 = eGFR 90 or more = kidney damage with normal function 2 = eGFR 60-89 3a = eGFR 45-59; 3b = eGFR 30-44 4 = eGFR 15-29 5 = < 15 = end stage kidney disease
33
Name 3 causes of CKD
Congenital anomalies of renal tract: - Renal dysplasia - Reflux nephropathy (VUR) - Posterior urethral valves Glomerular disease: - Nephrotic syndrome (steroid-resistant) - IgA nephropathy - HSP nephritis Hereditary: - Polycystic kidney disease - Alport syndrome Systemic: - SCC
34
What is the classic triad of nephritis?
Haematuria HTN Oedema
35
What is nephritis?
Inflammation of the glomeruli --> haematuria, HTN, reduced GFR, variable proteinuria -> oedema
36
Name 3 causes of nephritis
Post-streptococcal glomerulonephritis IgA nephropathy HSP (IgA vasculitis) SLE
37
3 year old boy presents with cola-coloured urine, HTN and oedema. He had just recovered from a sore throat 2 weeks ago. What is your diagnosis, differentials and management?
Dx: Post-streptococcal glomerulonephritis DDx: IgA nephropathy Lupus nephritis Ix: - Observation: check BP - Urine dip - Urine protein:creatinine ration - Bloods: U&Es, complement (low C3 in PSGN), ASOT Mx: - Fluid and salt restriction - Antihypertensives
38
What is the main difference between nephritis and nephrotic syndrome?
Nephritis = inflammation of kidneys Nephrotic syndrome = protein loss from kidneys Complement often low in nephritic syndrome vs normal in nephrotic syndrome
39
6 year old presents to ED with abdominal pain, oedema, bruising/petechiae. He had a history of bloody diarrhoea and vomiting 10 days ago. What is the diagnosis, differential and management?
Haemolytic Uraemic syndrome - Triggered by Shiga-toxin producing E. coli (normally 0157) Ix: - Urine dip - Stool culture/PCR for E coli 0157 - Bloods: FBC (low Hb + platelets), blood film, U&Es, LDH, Haptoglobin Mx: - Supportive: fluid management; dialysis if required; blood transfusion if symptomatic anaemia - Avoid antibiotics, antimotility agents
40
In a child < 3 months, what is the management of a UTI?
Admit and treat w/ Abx as per Trust guidelines
41
What is the imaging required for infants < 6 months with a UTI that responds well to treatment within 48 hours?
US KUB within 6 weeks - If abnormal, consider MCUG
42
What is the imaging required for infants < 6 months with an atypical UTI?
US KUB during acute infection DMSA 4-6 months after MCUG
43
What is the imaging required for infants < 6 months with recurrent UTI?
US KUB during acute infection DMSA 4-6 months after MCUG
44
What features indicate an atypical UTI?
Severe/systemic illness Poor urine flow Abdominal/bladder mass Raised creatinine/AKI No response to antibiotics within 48 hours Non-E. coli organism e.g. Proteus, Pseudomonas, Klebsiella
45
What is the imaging required for infants 6 months - 3 years with a UTI which responds well to treatment within 48 hours?
No imaging required
46
What is the imaging required for infants 6 months - 3 years with an atypical UTI?
US KUB during acute infection DMSA 4-6 months after
47
What is the imaging required for infants 6 months - 3 years with recurrent UTI?
US KUB within 6 weeks DMSA 4-6 months after
48
What is the purpose of a MCUG?
Assesses vesicoureteric reflux, urethral anatomy, bladder outlet obstruction Indications: suspected VUR, posterior urethral valves, recurrent/atypical UTI with abnormal US, poor urine flow
49
How is a MCUG done?
Catheterised Contrast injected XR images during voiding
50
What is the purpose of DMSA scan?
Assesses renal cortical damage/scarring - Usually done 4-6 months after infection
51
How is a DMSA scan done?
IV radioactive tracer administered Static nuclear medicine scan
52
What is the imaging required for children 3 years and older with a UTI that responds well to treatment within 48 hours?
No imaging required
53
What is the imaging required for children 3 years and older with an atypical UTI?
US KUB during acute infection
54
What is the imaging required for children 3 years and older with recurrent UTI?
US KUB < 6 weeks DMSA 4-6 months after
55
What is the antibiotic regime for a) upper UTI and b) lower UTI?
a) Abx for ~10 days b) Abx for ~3 days According to Trust guidelines
56
A 14 year old presents with microscopic haematuria. O/E: he has b/l ballotable kidneys. BP 130/90 mmHg. He has a family history of a kidney issue (he can't remember what it is). What is the most likely diagnosis, investigations and management?
Autosomal dominant polycystic kidney disease Ix: Bedside: Urine dip, urine MC&S, full set of observations Blood: Genetic testing, renal function Imaging: US KUB (enlarged kidneys with cysts); US Abdomen (liver cysts) Mx: Medical; - BP control w/ ACEi - Treat UTIs - Monitor renal function - Family screening (ADPKD) - Transplant planning if CKD
57
What are the causes of renal failure? Name the 3 broad categories and examples in each.
Pre-renal: - Dehydration - Sepsis - Drugs (NSAIDs, ACEi) Renal: - Glomerular: glomerulonephritis (PSGN, IgA nephropathy, Lupus nephritis); nephrotic syndrome; HUS - Tubular: Acute tubular necrosis - Vascular: renal vein thrombosis Post-renal causes: - Posterior urethral valves (boys) - PUJ obstruction - Neurogenic bladder
58
What are the causes of CKD? Name 3
Congenital anomalies of kidney and urinary tract - Renal dysplasia - Reflux nephropathy - Posterior urethral valves - PUJ obstruction Glomerular disease: - Steroid resistant nephrotic syndrome - IgA nephropathy - Lupus nephritis Hereditary/genetic: - Alport syndrome - Polycystic kidney disease Post AKI - HUS
59
What is renal osteodystrophy and how does that lead to weak, deformed bones?
Caused by CKD - Causes reduced phosphate excretion - Reduced calcium absorption - Secondary hyperparathyroidism - Increased bone turnover and abnormal mineralisation
60
What is the management of osteodystrophy?
- Dietary phosphate restriction - Phosphate binders e.g. calcium carbonate - Active vitamin D (alfacalcidol/calcitriol) - Optimise CKD management
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