nephrology and urology

acute kidney injury

rapid-onset disease of the kidneys resulting in a failure to produce urine

-BBB disruption from uremic toxins and inflammatory mediators

-HTN, depleted cardiac ATP

-impaired monocyte and cytokine production

short term effects of pediatric AKI

-worse neurocognitive outcomes

-weight loss with preserved muscle mass

-lon term cardiac morbidity and mortality

-pulmonary edema, ARDS, BPD

long term outcomes of pediatric AKI

-crush injury, prolonged immobilization, high voltage electrical injuries, severe burns, compartment syndrome, strenuous physical activity

-infections, hyperthermia

-use of amphetamines, cocaine, or alcohol

-meds including statins, colchicine, propopfol

-toxins like snake venom, wasp, and bee stings

causes of rhabdomyolysis

muscle pain, muscle weakness, and dark urine

-elevated CK

signs of rhabdomyolyssi

-prevent kidney injury with intensive fluid resuscitation

-correcting electrolyte abnormalities

-ID underlying cause

management of rhabdomyolysis

-PSGN

-vasculitis, lupus

-Hep B, Hep C+

-anti-GBM disease

syndromes of nephritic syndrome

->95th percentile + 30 mmHg without symptoms/signs of end organ damage

-in adolescents >180/120

define a pediatric hypertensive urgency

>95th percentlie + 30 mmHg associated with encephalopathy (A, vision, changes, neuro symptoms)

->180/120 in adolescent and teenss

define a pediatric hypertensive emergency

oral: nifedipine

management of hypertensive urgency

-Hypoalbuminemia due to losses from urinary excretion

-edema from loss of oncotic pressure--> facial edema upon waking up, non-pitting edema

-hyperlipidemia: liver starts manufacturing cholesterol in respsonses to hypoalbuminemia

clinical signs of nephrotic syndrome

Renal: chronic kidney disease, glomerulonephritis, polycystic kidney disease, renal artery stenosis

Endocrine: hyperthyroidism, Cushing syndrome, pheochromocytoma, congenital adrenal hyperplasia

Cardiovascular: coarctation of the aorta

Medications: corticosteroids, stimulants, oral contraceptives

secondary causes of HTN

fever, exercise, dehydration, stress s

causes of transient (benign) proteinuria

A rapid decline in kidney function over hours to days, resulting in the inability to excrete nitrogenous waste products, maintain fluid/electrolyte balance, and regulate acid-base status.

define acute kidney injury

↑ Serum creatinine by ≥0.3 mg/dL within 48 hrs, or

↑ Serum creatinine to ≥1.5 × baseline within 7 days, or

Urine output

pediatric criteria of acute kidney injury

Hypertension

Altered mental status (uremia, encephalopathy)

Arrhythmias (hyperkalemia)

signs of acute kidney injury

dehydration, shock, HF

causes of pre-renal AKI

obstructive neuropathy

cause of post-renal AKI

Manage fluid balance (avoid overload but ensure perfusion)

Treat electrolyte abnormalities (esp. hyperkalemia: calcium gluconate, insulin + glucose, albuterol, dialysis if needed)

Correct acidosis if severe

primary managemet of AKI

Control BP (ACE inhibitors/ARBs)

Manage proteinuria

Correct anemia (iron, erythropoiesis-stimulating agents)

Manage bone-mineral disorders (phosphate binders, vitamin D analogs)

Optimize nutrition for growth

management of CKD

GFR

GFR indication for dialysis or transplant

Post-streptococcal glomerulonephritis (PSGN) - most common worldwide

IgA nephropathy (Berger disease) - hematuria within 1-2 days of infection

Henoch-Schönlein purpura (IgA vasculitis) - purpura, abdominal pain, arthralgia

Lupus nephritis

Membranoproliferative GN

Rapidly progressive GN (rare in children, but severe

common pediatric causes of nephritic syndrome

PSGN, MPGN

low C3 is indicative of what nephritic syndromes

Fluid & salt restriction to control edema and hypertension

Loop diuretics (e.g., furosemide) for significant fluid overload

Antihypertensives (calcium channel blockers, beta-blockers) if needed

Careful monitoring of fluid balance, weight, electrolytes

mainstay treatment of nephritic syndrome

ACE inhibitors or ARBs (renal protective; avoid in pregnancy)

Long-acting calcium channel blockers

Thiazide diuretics

Beta-blockers (less commonly first-line in children)

first line HTN drugs in pediatrics

nephrotic syndrome

in nephritic or nephrotic syndrome can you become hypercoaguable due to loss of antithrombin III

nephrotic syndrome

foamy urine is indicative of

40 mg/m²/hr or urine protein/creatinine ratio >2-3, or ≥3+ on dipstick

nephrotic range protein level

oval fat bodies

nephrotic syndrome

minimal change didesase

most common cause of nephrotic syndrome in children

minimal change disease

Focal segmental glomerulosclerosis (FSGS), membranous nephropathy, secondary causes (SLE, infections, Henoch-Schönlein purpura, hepatitis B, HIV)

causes of nephrotic syndrome in pediatrics

Fluid and salt restriction during edema phase

Diuretics (e.g., furosemide) for symptomatic edema, with caution

Monitor weight, urine output, electrolytes

management of nephrotic syndrome principles

oral corticosteroids

first line treatment of minimal change disease

Hemolytic Uremic Syndrome

a condition that can occur when the small blood vessels in your kiddney become damaged and inflamed

-bloody diarrhea, adominal pain, fever

initial signs of hemolytic uremic syndrome

E. coli O157:H7

etiology of HUS

Microangiopathic hemolytic anemia (Coombs-negative)

Thrombocytopenia

Acute kidney injury (AKI

triad of hemolytic uremic syndrome

hemolytic uremic syndrome

most common cause of AKI in young children

-fluid management

-HTN management

-anemia tx with PRBC

-no abx or anti-motility agents!

mainstay management of typical HUS

Atypical Hemolytic Uremic Syndrome

HUS without the diarrheal prodrome

- can occur due to inherited disorder of complement regulation

- Triggered by pregnancy or infection

Neisseria gonorrhoeae

Often asymptomatic in females

Purulent discharge, dysuria, cervical motion tenderness

Pharyngitis, conjunctivitis possible

Trichomonas vaginalis

Frothy, yellow-green discharge

Vulvar irritation, strawberry cervix

metronidazole

management of trichomonas

Primary: painless chancre

Secondary: rash (palms/soles), mucous patches, lymphadenopathy

Tertiary: neurologic, cardiac, gummas

describe the presentation of syphilis

Uretopelvic Junction Obstruction

blockage somewhere between the renal pelvis and the ureter

most common cause of hydronephrosis in neonates

ureterocele

Cystic dilation of the distal ureter within the bladder wall (often associated with duplicated collecting systems)

febrile UTIs in infants/children

most common presenting symptom of ureterocele

UPJ obstruction

mosst common cause of antenatal hyrdonephrosis

posterior urethral valves

irregular thin membranes of tissue located within the male posterior urethra that do not allow urine to exit the urethra

cobra head sign

Dilatation of the distal ureter which may be seen in patients with ureteroceles.

vesicoureteral reflux

backflow of urine from the bladder into the ureters

-usually due to congenital defect of vesicoureteral valve

1. dilation of pelvis

2. papillae flatten

3. decreased parenchyma width

4. atrophy of cortex

5. umbrella with rim of atrophy/fibrosis

sequential changes associated with hydronephrosis

hypospadias

incomplete urethral development leading to malpositioning of the urethral meatus anywhere along the ventral surface

E. coli

80% of UTIs are caused by

fever, FTT, feeding problms, hyperbilirubinemia

signs of UTI in neonate

in

indication for VCUG

testicular torsion

twisting of the spermatic cord causing decreased blood flow to the testis

bell clapper deformity

the condition in which the patient lacks the normal posterior fixation of the testis and epididymis to the scrotal wall

-allows twisting of spermatic cordd

testicular torsion

absent cremasteric reflex indicates

phimosis

narrowing of the opening of the prepuce over the glans penis

-a normal variant if congenital

poor hygiene or chronic irritation---> fibrotic ring of tissue close to the opening of the prepuce

acquiredd phimosis is often result of

phimosis

inability to retract the foreskin fully back over glans

-never a urologic emergency, unless ther is an obstructed urinary stream

-manage with manual stretching, steroid creams, circumcision

treatment of phimosis

Paraphimosis

entrapment of retracted foreskin behindd the corona of glans peniss

urologic emergency!

manual reduction attempt immediately

-dorsal slit or circumcision

treatment of paraphimosis

prematurity, family hx

inguinal hernias in pediatric pts are more common in

inguinal hernia

bowel sounds iin the scrotum are strongly suggestive of

silk glove sign

indirect hernia sac in pediatric patient

the sac feels like a finger of a silk glove when rolled under the examiners finger

cryptorchidism

failure of testes to descend ffrom intra-abdominal into scrotum

Do not circumcise (foreskin may be needed for repair)

Surgical repair usually between 6-18 months

management of hyposppadias

tender, firm mass, vomiting

signs of incarcerated hernia

Refer to urology if not descended by 6 months

Orchidopexy ideally by 12 months to reduce infertility/malignancy risk

management of cryptorchidism

Fusion of labia minora; may cause urinary dribbling, recurrent vulvovaginitis

presentation of labial adhesions

Asymptomatic: observe (often resolves spontaneously)

Symptomatic: topical estrogen cream ± gentle separation

management of labial adhesions

Neonates: mucocolpos (vaginal bulge) from maternal estrogen

Adolescents: primary amenorrhea, cyclic pelvic pain, bulging bluish hymen

presentation of imperforate hymen