Paediatrics > Renal > Flashcards

Renal Flashcards

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1
Q

Features of Potter’s Syndrome

A 
Pulmonary Hypoplasia
Low set ears
Beaked Nose
Prominent epicanthic folds
Downwards slanting eyes
Limb Deformity
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2
Q

Mechanism of Multicystic Dysplastic Kidney

A

Failure of union of the uterine bud with nephrogenic mesenchyme

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3
Q

Management of Multicystic Dysplastic Kidney

A

50% involuted by aged 2

Nephrectomy indications: very large/ hypertension develops

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4
Q

Causes of large Cystic Kidneys

A

Autosomal recessive/dominant polycystic Kidney disease
Multicystic Dysplastic Kidney
Tuberous Sclerosis

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5
Q

Presentation of Autosomal dominant polycystic kidney disease

A

Childhood hypertension

Renal failure in adulthood

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6
Q

Extra Renal feature of Autosomal Dominant Polycystic Kidneys

A

Cysts in liver and pancreas
Cerebral Aneurysm
Mitral Valve prolapse

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7
Q

Abnormal Caudal migration of the kidneys results in…

A

Horseshoe kidney or pelvic kidney

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8
Q

Duplex System is due to?

A

Premature division of the uterine bud

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9
Q

Complications of duplex system

A

Lower pole moiety- Reflux

Upper pole moiety- Ectopic drainage to urethra or vagina, prolapse into bladder, obstruction urging flow

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10
Q

Features of Absent Musculature Syndrome (Prune Belly)

A

Wrinkled appearance of abdomen
Large Bladder
Dilated Ureters
Crytorchidism

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11
Q

Site of urinary tract obstruction

A

Pelviuretric Junction
Vesicoureteric Junction
Bladder Neck
Urethra

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12
Q

Features of bilateral hydronehritis

A

Hydronephrosis
Hydroureters
Thickened bladder wall
Diverticula

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13
Q

Management of urinary tract anomalies

A

Start prophylactic antibiotics
US within 24hours, in males with bilateral hydronephrosis
-Normal: US repeat at 2-3 months, stop Abx
-Abnormal: MCUG and surgery
US within 4-6 weeks, in females or unilateral hydronephrosis
- Normal: US repeat at 2-3 months, stop Abx
-Abnormal: Further Ix

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14
Q

Renal Function Assessment in children

A 
Plasma creatinine concentration: 
eGFR
Insulin/EDTA GFR
Creatinine Clearance
Plasma Urea Concnetration
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15
Q

Radiological Investigation of Kidneys and Urinary Tract

A

Ultrasound: anatomy
DMSA scan: renal scarring (2 months after UTI- sensitive)
MCUG: detects reflux and urethral obstruction
MAG3 renogram (Children over 4 years): detects reflux, given with furosemide
Plain abdominal X-ray: spinal abnormalities

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16
Q

Features of UTI in infants

A 
Offensive Urine
Septicaemia
Jaundice
Poor Feeding
Lethargy
Irritability
Vomitting
Fever
Febrile siezure
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17
Q

Features of UTI in children

A 
Secondary Enuresis
Dysuria
Frequency
Urgency
Abdominal Pain
Loin Tenderness
Fever
Anorexia
Lethargy
Vommitting and Diarrhoea
Haematuria
Cloudy Urine
Febrile Seizure
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18
Q

dDx Dysuria

A

Girls- Cystitis or Vulvitis

Boys- Balanitis (Uncircumcised)

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19
Q

Collection of Urine Samples

A 
Clean catch sample (recommended method)
Adhesive plastic bag
Urethral catheter
Suprapubic aspiration (fine needle inserted above pubic symphysis under US guidance)
Midstream sample- Older children
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20
Q

Dipstick Interpretation

A

Nitrate- positive indicates UTI
Leukocyte- present in fever without UTI, balanitis, and cystitis
Blood/Protein/Glucose- not UTI specific

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21
Q

Predisposing factors UTI

A

Renal or urinary tract abnormality
Incomplete Bladder emptying
Vesicoureteric reflux

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22
Q

Incomplete bladder emptying factors

A 
Infrequent voiding
Vulvitis
Incomplete micturition 
Obstruction from constipation
Neuropathic bladder
Vesicoureteric reflux
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23
Q

Anatomy of vesicoureteric reflux

A

Anomaly of vesicoureteric junctions
Ureters displaced laterally
Ureters enter bladder directly
Shorted or absent intramural course

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24
Q

Complications of vesicoureteric reflux

A

Incomplete Bladder emptying
Increased risk of infection
Risk of pyelonephritis
Renal damage due to pressure transmission

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25
Features Atypical UTIs
``` Seriously ill or septicaemia Poor urine flow Abdominal or Bladder Mass Raised Creatinine Failure to respond to Abx within 48hrs Non-E.coli organism ```
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Mx UTI Infants <3 months
Immediate referral to hospital IV Abx .e.g. Co-amoxiclav for 5-7 days Oral prophylaxis
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Mx Pyelonephritis Children >3m
Oral Abx .e.g. Trimethoprim 7days | OR IV Abx .e.g. Co-amoxiclav 2-4 days + oral (total course 7days)
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Mx Simple UTI Child >3m
Oral Abx .e.g. Trimethoprim or Nitrofurantoin 3 days
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Prevention of UTIs
``` High fluid intake Regular voiding Complete bladder emptying- sitting on toilet/double voiding Treatment of constipation Good Perineal hygiene Lactobacillus Acidophilus (pro-biotic) Antibiotic prophylaxis ```
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UTI Abx prophylaxis
Children <2-3years with congenital abnormality/upper UTI/reflux Continue until out of nappies Trimethoprim 2mg/Kg NOCHE
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Follow-up recurrent UTIs, reflux and scarring
Urine dipstick in any non-specific infection Long term low dose Abx prophylaxis Circumcision in boys Anti-VUR surgery in progressive scarring Annual blood pressure in renal defects Urinalysis to check proteinuria (CKD) Regular assessment renal growth and function
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Causes of daytime enuresis
``` Lack of attention to bladder sensation Detrusor instability Bladder neck weakness Neuropathic bladder UTI/Diabetes Constipation Ectopic ureter ```
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Signs of neuropathic bladder
``` Distended bladder Abnormal perineal sensation Abnormal anal tone Abnormal leg reflexes and gait Sensory loss in S2-S4 ```
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Typical Hx of ectopic ureter
Girls who are dry by day but with wetting on morning waking | Pooling of urine from vaginal ureter opening
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Ix for daytime enuresis
``` Urine dipstick, and MCS US- ?incomplete bladder emptying and thickening of bladder wall Urodynamics X-ray- ?vertebral abnormality MRI- ?cord tethering ```
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Mx daytime enuresis
``` Star charts Bladder training Pelvic floor exercises Constipation treatment Urine alarm Anticholinergics .e.g. Oxybutynin ```
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Causes secondary enuresis
Emotional upset (most common) UTI Diabetes (osmotic diuresis) Renal concentrating disorder .e.g. Sickle cell, CKD, DI
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Ix secondary enuresis
UDS- infection, glycosaria, proteinuria Early morning osmalality Formal water deprivation test US renal tract
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Physiological proteinuria
Febrile illnesses | After exercise
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Normal protein:creatinine
<20mg/mmol early morning sample
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Causes of proteinuria
``` Orthostatic proteinuria Glomerular abnormality: -Minimal change disease -Glomerulonephritis -Abnormal glomerular basement membrane Increased glomerular filtration pressure Reduced renal mass in CKD Hypertension Tubular proteinuria ```
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Features of nephrotic syndrome
Periorbital odema esp. on waking Scrotal, vulva, leg, ankle odema Ascites Breathlessness: abdominal distension and pleural effusion Infection .e.g. Peritonitis, septic arthritis, sepsis (loss of Ig)
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Systemic disease associated with nephrotic syndrome
HSP Vasculitides .e.g SLE Infection .e.g. malaria Allergens .e.g. bee sting
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Epidemiology steroid sensitive nephrotic syndrome
Age 1-10 years More common in boys Asian children Associated with atopy
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Biochemistry steroid sensitive nephrotic syndrome
No macroscopic haematuria Normal BP Normal complement levels Normal renal function
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Management steroid sensitive nephrotic syndrome
Oral corticosteroids .e.g. prednisolone 60mg/m^2 daily Reduce dose to 40mg/m^2 after 4 weeks alternate days Wean after 8 weeks
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Histology steroid sensitive nephrotic syndrome
Normal on light microscopy Electron microscopy- fusion of specialised epithelial cells investing glomerular capillaries Minimal change disease
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Complication of nephrotic syndrome
Hypovolaemia Thrombosis Infection Hypercholestrolaemia
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Mx hypovolaemia in nephrotic syndrome
IV 0.9% saline or 4.5% albumin solution | IV 20% albumin with furosemide if severe
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Complications of albumin
Precipitates pulmonary odema and hypertension from fluid overload
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Prognosis of nephrotic syndrome
1/3 resolve spontaneous 1/3 infrequent relapses 1/3 steroid dependant with frequent relapses Identified by parents on urine testing
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Steroid sparing agents in relapsing nephrotic syndrome
Levamisole- immunomodulator Cyclophosphamide- alkylating agents Tacrolimus/cephalosporin A- calcineurin inhibitors Mycophenolate mofetil- immunosuppressant Rituximab- Anti B cell monoclonal antibody
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Mx steroid resistant nephrotic syndrome
Diuretic therapy Salt restriction Angiotensin-converting enzyme inhibitors NSAIDs
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Epidemiology Congenital nephrotic syndrome
``` Presents in first 3 months of life RARE Recessively inherited Consanguinity and Finnish populations High mortality ```
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Cx Congenital nephrotic syndrome
Hypoalbuminemia- high mortality
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Mx congenital nephrotic syndrome
Unilateral nephrectomy for albumin control | Dialysis for stage 5 CKD continued until transplant
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Ix nephrotic syndrome
``` Urine protein FBC and ESR Urea, electrolytes, creatinine, albumin Complement C3 and C4 Anti-streptolysin O or anti-DNAase B titres/throat swab Urine MCS Urinary sodium concentration Hep B and hep C screening Malaria screening (foreign travel) ```
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Steroid resistant nephrotic syndrome
Focal segmental glomerulosclerosis Mesangiocapillary glomerulonephritis Membranous nephropathy
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Focal segmental glomeruloscleosis features
Most common steroid resistant nephrotic syndrome 30% progress to renal failure Mx: cyclophosphamide, cyclosporin, tacrolimus, rituximab Recurrence post-transplant common
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Mesangiocapillary glomerulonephritis feature
More common in older children Haematuria Low complement level Decline in renal function over years
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Membranous nephropathy
Associated with hep B and SLE | Usually remits spontaneously within 5 years
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Non glomerular causes of haematuria
``` Infection Trauma Stones Tumours Sickle cell disease Bleeding disorders Renal vein thrombosis Hypercalciuria ```
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Glomerular causes of haematuria
``` Acute nephritis (with proteinuria) Chronic glomerulonephritis IgA nephropathy Familial nephritis .e.g. Alport Thin basement membrane ```
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Indications for renal biopsy in haematuria
Significant persistent proteinuria Recurrent macroscopic haematuria Renal function in abnormal Abnormal complement levels
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Glomerular haematuria features
Brown urine Deformed red cells Casts Associated with proteinuria
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Lower urinary tract haematuria features
Red urine Occurs at beginning or end of urinary stream Unusual in children
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Ix haematuria
Urine MCS Protein and calcium excretion Kidney and urinary tract US Plasma urea, electrolytes, creatinine, calcium, phosphate, albumin FBC, platelet, coagulation screen, sickle cell screen
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Ix Glomerula haematuria
ESR, complement levels, anti-DNA antibodies Hep B and C screen Throat swab and antitreptolysin O/anti-DNAase titres Renal biopsy Test mothers urine and hearing test (Alports)
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Causes of Acute nephritis
Post infectious .e.g. strep Vasculitis .e.g. HSP, SLE, Wegners, polyarteritis nodose, microscopic polyarteritis IgA nephropathy and mesangiocapillary glomerulonephritis Antiglomerular basement membrane disease (Goodpastures)
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Acute nephritis presentation
``` Decreased urine output Volume overload Hypertension- seizures Periorbital odema Haematuria Proteinuria ```
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Post-strep nephritis features
Follows sore throat or skin infection Raise strep titre or culture Low C3 returning to normal after 3-4 weeks
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Henoch-Schonein Pupura Presentation
``` Purpuric rash affecting extensor surfaces Arthralgia Periarticular oedema Abdominal pain Glomerulonephritis Boys aged 3-10 years ```
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Henoch-Schonein Purpura Pathology
Genetic predisposition and antigen exposure | IgA and IgG complex activate complement and precipitate inflammation
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HSP Rash
``` Symmetrical distribution Buttocks, extensor surfaces of arms and legs Ankles Trunk sparing Urticarial initially Progression to maculopapular Characteristically palpable ```
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HSP Arthralgia
Knees and Ankles | Periarticular oedema
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HSP Abdominal Pain
Colicky Melaena and haematemesis Mx: corticosteroids
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Cx Henoch Schonlein Purpura
``` Interssusception Ileus Protein loosing eneteropathy Orchitis CNS involvement ```
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HSP Renal Involvement
Common | Haematuria +/- proteinuria
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Risk factors for CKD in HSP
Heavy proteinuria Oedema Hypertension Deteriorating renal function
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IgA nephropathy presentation
Macroscopic haematuria URTI Treat as HSP
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Alport syndrome
X linked recessive condition CKD by early adulthood Neural deafness and ocular defects Maternal haematuria
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Causes Hypertension
``` Renal Coarctation of the aorta Catecholamine excess: pheochromocytoma/neuroblastoma Endocrine Essential hypertension ```
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Presentation hypertension
``` Vomiting Headaches Facial palsy Hypertensive retinopathy Convulsions Proteinuria Faltering growth Cardiac failure Paroxysmal palpations/sweating (pheochromocytoma) ```
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Causes unilateral palpable kidneys
``` Multicystic kidneys Compensatory hypertrophy Obstructed hydronephrosis Renal tumour .e.g. Wilms Renal vein thrombosis ```
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Causes bilateral palpable kidneys
Polycystic kidney disease Tuberous sclerosis Renal vein thrombosis
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Predisposing factors renal calculi
UTI esp. proteus Structural anomalies of urinary tract Metabolic abnormalities Hypercalcaemia - calcium stones
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Presentation renal calculi
``` Haematuria Loin pain Abdominal pain UTI Passage of a stone ```
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Mx renal calculi
Passage spontaneously Lithotripsy Surgical removal High fluid intake
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Complication of furosemide therapy in neonates
Nephrocalcinosis
90
Causes Fanconi syndrome- metabolic
``` Cystinosis Glycogen storage disorders Lowe syndrome Galactosaemia Fructose intolerance Tyrosinaemia Wilson disease ```
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Causes Fanconi syndrome- acquired
Heavy metals Drugs and toxins Vitamin D deficiency
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Defition Fanconi Syndrome
Generalised proximal tubular dysfunction
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Presentation Fanconi Syndrome
``` Polydipsia Polyuria Salt depletion Dehydration Hypercalcaemic metabolic acidosis Rickets Poor/faltering growth ```
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Urinary electrolyte loss in Fanconi syndrome
``` Amino acids Glucose Phosphate Bicarbonate Sodium Calcium Potassium Magnesium ```
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Classification of AKI
Pre-renal Renal: salt and water retention, blood/protiein/casts in urine Post-renal: urinary obstruction
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Management of AKI
Monitoring of circulation and fluid balance
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Ix in AKI
US: - obstruction of urinary tract - small kidneys in CKD - large bright kidneys in CKD
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Pre-renal acute failure features
Hypovolaemia | Low secretion of sodium
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Cx Pre-renal Acute failure
Acute tubular injury and necrosis
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Features Acute Renal Failure
Circulatory overload | Most commonly HUS and acute tubular injury
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Causes of acute tubular injury
Cardiac surgery | Multisystem failure in ICU
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Mx Acute Renal failure
Restriction of fluid intake High calorie, normal protein feed Renal biopsy
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Causes of Pre-Renal AKI
Hypovolaemia | Circulatory failure
104
Causes of Renal AKI
Vascular .e.g. HUS, vasculitis, emboli, renal vein thrombosis Tubular: acute necrosis, ischaemia, toxic, obstructive Glomerulonephritis Interstitial nephritis Pyelonephritis
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Causes of Post-renal AKI
Obstruction
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Dialysis indications in AKI
``` Failure of conservative management Hyperkalaemia Severe hyper/hypo-natraemia Pulmonary oedema Severe hypertension Severe metabolic acidosis Multisystem failure ```
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Proximal tubule transport defects
Glycosuria- asymptomatic (glucose) Cystinuria- renal calculi (cystine amino acids) Vitamin D resistant rickets (phosphate) Pseudohypoparathyroidism- obesity, depressed nasal bridge, short fingers (phosphate) Hyperuricosuria- renal calculi (uric acid) Renal tubular acidosis- metabolic acidosis, alkaline urine, faltering growth (bicarbonate) Hypercalciuria- renal calculi (calcium)
108
Bartter syndrome
``` Chloride transporter defect Loop of Henle Hypokalaemic metabolic acidosis Hypercalciuria Normal bp Raised renin Polydipsia Polyuria Faltering Growth ```
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Nephrogenic Diabetes Insipidus
Polydipsia Polyuria Fever Faltering growth
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Haemolytic Uraemic Syndrome Triad
Acute renal failure Microangiopathic haemolytic anaemia Thrombocytopenia
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Typical HUS features
Follows GI infection (verocytotoxin E.coli- farm animal or uncooked beef) Diarrheal prodrome Persistent proteinuria Cx: htn and CKD
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Mx metabolic acidosis in renal failure
Sodium bicarbonate
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Mx hyperphosphataemia in renal failure
Calcium carbonate | Dietary restriction
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Mx hyperkalaemia in renal failure
``` Calcium gluconate in ECG changes Salbutamol (neb or IV) Calcium exchange resin Glucose and insulin Dietary restriction Dialysis ```
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Features Atypical HUS
No diarrheal prodrome Frequent relapses High risk htn and CKD
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Mx Atypical HUS
Eculizumab: Monoclonal anti-terminal complement antibody | Plasma exchange
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Features CKD
``` Anorexia Lethargy Polydipsia Polyuria Faltering growth/growth failure Bony deformity (renal osteodystrophy) Hypertension Acute-on-Chronic renal failure (dehydration/infection) Proteinuria Normochromic, normocytic anaemia ```
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Staging CKD
``` I >90ml/min II 60-90ml/min III 30-60ml/min IV 15-30 ml/min V <15ml/min ```
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Mx CKD
``` Calorie supplementation and NG feeds Phosphate restriction Calcium carbonate as phosphate binder Vitamin D supplementation Salt supplementation Free access to water Bicarbonate supplements Recombinant human erythopoetin- subcut Growth hormone supplementation ```
120
Renal Transplant Criteria
Weight >10kg | Risk of renal vein thrombosis
121
Immunosuppression with transplantation
Tacrolimus Mycophenolate Mofetil Prednisolone
Paediatrics
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