Peds - Nephrology and Urology

proteinuria, hypoalbuminemia, hypercholesterolemia, barrier, permeability, proteinuria, serum, oncotic, edema, lipoprotein, elevated

Nephrotic Syndrome

• Characterized by:

  • Persistent heavy _________ (>40 mg/m2/hr or >2-3/m2/24hr)

  • __________ (albumin <3g/dL)

  • ____________ (>250 mg/dL)

  • Edema

• Pathogenesis

  • Alteration in normal glomerular cellular/basement membrane ________ → increased glomerular _________ → massive __________ → decreased ______ proteins → decreased plasma ________ pressure → fluid shifts from vascular to __________ compartments → ________

  • Hypoproteinemia → stimulates hepatic _________ synthesis → _________ serum lipids/lipoproteins

systemic, idiopathic, minimal change, foot, minimal, glomerulosclerosis, hypocomplementemia, failure, steroid

Primary Nephrotic Syndrome

• Nephrotic syndrome w/o _________ disease

• __________ Nephrotic Syndrome

  • Most common form in children (90% of cases between 1-10 y/o and 50% >10 y/o)

  • ________ _______ Disease (MC type)

    • Renal biopsy → diffuse ____ process effacement and ________ changes

  • Focal Segmental ______________

  • Membranoproliferative Glomerulonephritis

    • _____________ w/ signs of glomerular disease

    • Typically persistent w/ high likelihood of progression to renal _________

• Majority are _______ responsive

systemic, injury, lupus, purpura, chronic, allergic, renal

Secondary Nephrotic Syndrome

• Nephrotic syndrome associated w/ ________ diseases or secondary to another process that causes glomerular _______

• Examples

  • Systemic ______ erythematous

  • Henoch-Schonlein ________

  • Polyangitis and other vasculitides

  • _______ infections (hep B, hep C, malaria, HIV)

  • _______ reactions

  • Diabetes

  • Amyloidosis

  • Malignancies

  • CHF, constrictive pericarditis

  • ______ vein thrombosis

periorbital, lower, edema, anascarca, dehydration, HTN

Nephrotic Syndrome Symptoms

• __________ edema

• _______ extremity edema

• _______ of scrotum, penis, or labia

• __________

  • Generalized edema including significant peripheral edema and ascites

• Anorexia, malaise, abdominal pain

• S/S of ________

• ____ and hematuria may or may not be present

protein, morning, 2.0, cholesterol, albumin, C3, secondary, biopsy, steroid

Nephrotic Syndrome Diagnosis

• Urinalysis (+ ______)

• First _______ void (protein to creatinine ratio)

  • > ___ indicates nephrotic range

• Electrolytes

• BUN/creatinine

• _________ (high)

• _________ (low)

• __

  • Low serum C3 implies a lesion other than multiple change disease (MCD)

• Other tests → work up for secondary causes if needed

• Renal ______ → if children >12 y/o, suspect something other than MCD, or in those who don’t improve with ________ therapy

prednisone, salt, loop, beta blockers, absence, complement, normal

Nephrotic Syndrome Treatment

• Steroid therapy (__________) since MCD is most common

• Edema

  • may treat with ____ restriction and/or ____ diuretics

• HTN

  • ______ _______, CCB, or ACE-i

• Minimal Change Disease

  • Characterized by the _____ of HTN and hematuria as well as normal _________ levels and _______ renal function

RBCs, gross, microscopic, glomerular, tubulointerstitial, lower

Hematuria

• Definition

  • Presence of ____ in the urine

  • ______ → visible to the naked eye

  • ________ → detected on UA or by microscope (>3-5 RBCs/high power field)

• Location

  • ____________

    • glomerulonephritis, structural disorder (Alport syndrome), hemolytic uremic syndrome

  • __________

    • nephritis, vascular (sickle cell), structural (Wilms tumor, trauma)

  • ______ urinary tract

    • Cystitis, injury

hematuria, HTN, oliguria, renal

Immune-Mediated Glomerulonephritis

• Sx of glomerular disease

  • _________

  • Proteinuria

  • ____

  • Edema

  • _________

  • _______ insufficiency

poststreptococcal

What is the most common acute cause of immune-mediated glomerulonephritis?

IgA Nephropathy

What is the MC overall and chronic cause of immune-mediated glomerulonephritis?

>, strep pharyngitis, impetigo, hematuria, nephritic, antistreptococcal, persistent, gross, URI, GI, treatment

Immune-Mediated Glomerulonephritis

• Poststreptococcal GN (MC acute cause)

  • MC in children 2-12 y/o; Males _ Females

  • Develops 5-21 days after ____ ___________ or 4-6 weeks after __________

  • Asx ________ to full blown _______ syndrome

  • __________ antibodies (ASO) can support recent infection

• IgA Nephropathy (MC overall and chronic cause)

  • _________ microscopic hematuria w/ episodes of _______ hematuria with or w/o proteinuria

  • Often precipitated by ___ or __ illness

  • __________ generally not needed

Alport, X, sensorineural, ocular, progressive, microscopic, thin, autosomal, progressive, good

Structural Glomerular Disease

• _________ Syndrome

  • Recessive _-linked disorder

  • Males > Females

  • Sx in Males

    • Hematuria accompanied by high frequency ___________ hearing loss, _______ abnormalities, and __________ renal failure

  • Sx in Females

    • Benign course w/ just ___________ hematuria

• _____ basement membrane disease

  • ____________ dominant condition

  • Not typically ___________

  • _____ prognosis

hemolytic, thrombocytopenia, renal, 5, shiga, e coli, meds, complement, diarrhea, pallor, petechiae, dehydration

Hemolytic Uremic Syndrome

• Triad → ___________ anemia, ___________, ______ injury

• Epidemiology → MC in children <_ y/o

• Etiology

  • _______ toxin producing _ ____ (MC cause)

  • Atypical → other infections (S. pneumoniae, HIV), _____, genetic or acquired defects in __________ regulation, etc

• Symptoms

  • Prodromal Illness → abd pain, vomiting, blood in _________

  • Weakness/lethargy, oliguria/anuria

  • _______

  • __________

  • S/S of _________

hemoglobin, Coombs, platelets, helmet, elevated, PT/PTT, transfusion, electrolytes, dialysis

HUS

• Diagnosis

  • CBC and peripheral blood smear

    • Low _________ (neg _______ test)

    • Low _________

    • Schistocytes and ________ cells

  • UA → hematuria/proteinuria

  • BMP → ________ BUN/creatinine

  • Other possible labs

    • Coag studies (___/____)

    • Stool studies (culture, ELISA)

• Treatment

  • RBC and platelet ________

  • Fluids/_________

  • ___________

uncircumcised, females, E coli, female, emptying, VUR, hygiene, fever, frequency

UTI

• Epidemiology

  • MC in _________ males < 3 mo

  • MC in _______ > 6 mo

• Etiology → _ ____, Klebsiella, Proteus

• Risk Factors

  • _________ gender, Caucasian race, uncircumcised

  • Condition that interferes with bladder ___________

    • Constipation, ___, urinary tract obstruction, neurogenic bladder

  • Poor _________

• Symptoms

  • _________ → may be the only symptom

  • Dysuria

  • _________/urgency

  • Incontinence

urine culture, cath, clean, US, febrile, recurrent, growth

UTI

• Diagnosis

  • _________ ________ (gold standard)

    • ______ in those not toilet trained

    • ________ catch urine in toilet trained

      • Clean catch positive: >100,000 CFU/mL

      • Cath positive: >50,000 CFU/mL

      • Suprapubic positive: 1000 CFU/mL

  • Urinalysis

  • Indications for RB __

    • Children <2 y/o w/ 1st _______ UTI

    • Children of any age with ________ febrile UTIs

    • Children of any age w/ a UTI who have a FHx of renal or urologic disease, poor ______, or HTN

    • Children who don’t respond as expected to antimicrobial therapy

amoxicillin, cefixime, 2, urosepsis, oral, fail

UTI Treatment

• Start empiric therapy if the likelihood of UTI is high

  • Uncomplicated cystitis → _________, trimethoprim-sulfamethoxazole, cephalexin

  • Complicated cystitis → __________, cefdinir, ceftriaxone

• Indications for hospitalization or IV Abx

  • < _ mo of age

  • Possible __________ (toxic appearing, hypotension, etc)

  • Immunocompromised

  • Inability to take _____ meds (vomiting)

  • Lack adequate f/u

  • ______ outpatient therapy

retrograde, UVJ, short, growth, high, close, obstruction, >, >

Vesicoureteral Reflux

• ________ passage of urine from the bladder into the upper urinary tract

• Primary

  • Most common

  • Incompetent or inadequate closure of the ___

    • Congenitally ____ intravesicle ureter

    • Spontaneously resolves with patient ______

• Secondary

  • Abnormally ____ voiding pressure in the bladder which results in failure of the UVJ to ______ during bladder contraction

    • Associated w/ anatomic or functional bladder _________

• Epidemiology

  • Caucasian _ AA

  • Female _ Male

RNC, VCUG, 1, 2, 3, 4, 5

VUR Diagnosis

• Voiding cystourethrogram (VCUG) or radionucleotide cystogram (____)

  • _______ preferred

• Grade _ → reflux only fills the ureter w/o dilation

• Grade _ → reflux fills the ureter and the collecting system w/o dilation

• Grade _ → reflux fills and mildly dilates the ureter and the collecting system with mild blunting of the calicies

• Grade _ → reflux fills and grossly dilates the ureter and the collecting system w/ blunting of the calices. Some tortuosity of the ureter is also present

• Grade _ → massive reflux grossly dilates the collecting system. All the calices are blunted w/ a loss of papillary impression, and intrarenal reflux may be present. There is significant ureteral dilation and tortuosity.

pyelonephritis, damage, dysfunction, surveillance, prophylactic, TMP-SMZ, cephalexin, antibiotic, surgery

VUR Treatment

• Goals

  • Prevent recurrent _________ or UTIs

  • Prevent further renal _______

  • ID and Tx children w/ bladder or bowel _______

• Grade I-II

  • Toilet trained → __________

  • Not toilet trained → _________ antibiotics

• Antibiotic Prophylaxis

  • >2 mo → ___-___ or nitrofurantoin

  • <2 mo → ________, ampicillin, amoxicillin

• Grade III-V

  • ________ prophylaxis

  • ________ indications

    • Continued grade IV/V beyond 2-3 y/o

    • Children who fail medical therapy

    • Children who have side effects from continuous antibiotics

    • Those who are noncompliant with meds and f/u

>, 5, night, yearly, never, 6, stressful, dysfunction, medical, UTI, evening, constipation, DM, insipidus

Nocturnal Enuresis

• Epidemiology

  • Boys _ Girls

  • 15% of children > _ y/o still have enuresis (typically at _____) → tends to decrease about 15% ________

• Primary (most common)

  • Children who have _______ achieved a period of nighttime dryness

• Secondary

  • Children develop enuresis after a dry period of at least _ mo

  • Usually after _______ event (parental divorce, birth of sibling)

• Diagnosis

  • Determine if bowel/bladder ________ or underlying ________ problem present

    • Can get a good idea w/ Hx

    • Daytime wetting, ___ sx, fluid intake (too much in _______), stooling hx (_________, withholding), personal and fam medical Hx (DM, neuro issues)

  • UA

    • Screen for ___, diabetes _______, UTI

spontaneous, motivational, sticker, alarm, wake, contraction, desmopressin

Nocturnal Enuresis Treatment

• Education/Reassurance

  • High rate of __________ resolution

• ________ Therapy → ______ chart

• Enuresis _______ (1st line)

  • Helps child learn to _____ or inhibit bladder _________

• ___________

  • Synthetic antidiuretic hormone