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NU665C/ NU 665C EXAM 2: (NEW 2024/
2025 UPDATE)| QS & AS| GRADE A| 100%
CORRECT (VERIFIED ANSWERS)
Vesicoureteral Reflux - ANS ✓-Retrograde regurgitation of urine from the
bladder into the ureters, and potentially the kidney
1. Grades
-1 - does not reach the renal pelvis; monitor clinically; treat BBD, avoid antibiotic
prophylaxis, avoid yearly US and VCUG; avoid surgery
-2 - extends up to the renal pelvis without dilation; monitor clinically; treat BBD;
consider CAP; consider US and VCUG; consider surgery
-3 - reflux to the renal pelvis with mild to moderate dilation of the ureter and the
renal pelvis; monitor clinically (not alone); treat BBD, CAP; yearly US and VCUG
and consider surgery
-4 and 5 - definite distention of the ureters and renal pelvis and can include
hydronephrosis or reflux into the intrarenal collecting system; monitor clinically
(not alone); treat BBD, CAP, yearly US and VCUG, and consider surgery
-Prophylactic antibiotics to prevent UTI, pyelonephritis, renal injury, and other
sequelae when a child has VUR; recommended when the child has a history of a
febrile UTI, VUR grades 3-5 or for children younger than 1 year old
-Surgery - 4 and 5
Hematuria - ANS ✓-The presence of RBCs in the urine; 5 or more RBCs per HPF
in three consecutive fresh, centrifuged specimens obtained over several weeks
-RBCs in urine, either visible or microscopic; pain varies with many children
experiencing no pain and some reporting discomfort/pain
-Referral for gross hematuria with unclear cause, symptomatic microscopic
hematuria, or persistent asymptomatic hematuria and proteinuria as renal
biopsy may be indicated
-Asymptomatic hematuria requires periodic evaluation every 1-2 years to re-
evaluate for coexisting conditions or proteinuria, and to revisit family history of
hematuria or hearing deficits
-HSP - Henoch-Schonlein purpura - when there is gross hematuria in the
presence of abdominal pain, with or without bloody stools, arthralgias, and
purpuric rash
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-Other causes of hematuria - PSGN, renal disease, UTI, trauma, coagulopathy,
crystalluria, nephrolithiasis; HSP, IgA nephropathy, rhabdo, sickle cell disease,
external irritation , menses
-Always important to ask if the female is menstruating
Proteinuria - ANS ✓-The presence of abnormal levels of protein in the urine;
levels higher than 100-150 in child is abnormal
-Presentation - look at BP, pulse, and RR, edema, abdominal exam, growth and
development
-Isolated - asymptomatic/orthostatic - most common
-Transient - stress-induced; idiopathic, fever, seizure, vigorous exercise,
dehydration, stress, cold exposure
-Findings suggestive of renal disease - change in urine volume, change in urine
color, increased BP or edema, recent strep infection; generalized symptoms -
fever, weight loss, malaise, rash, arthritis, or rash
-Proteinuria with hematuria is more concerning and warrants further evaluation
-If protein on dipstick is trace or 1+ and SG is greater than 1.015, offer
reassurance; monthly recheck of urine for 4-6 months; if persistent - refer to
nephrologist
-If protein is greater than 1+, evaluate for orthostatic proteinuria
-*If first morning urine is 1+ or 2+, do a quantitative 12-24 hour urine protein
excretion test (first morning void) or a random urine total protein-creatinine
ratio and UA with microscope; if positive - refer
-If protein is greater than 2+ evaluate for nephrotic syndrome
-If hematuria - evaluate for nephritis
-*Refer to nephrologist if persistent unexplained nonorthostatic proteinuria. any
hematuria or RBC or WBC casts, polyuria or oliguria, nephrotic levels of protein,
elevated BUN/Cr, elevated BP, systemic complaints (joint pain, rash,
arthralgia)or a child with a family member with history of renal failure, GN,
sensorineural hearing loss or kidney transplant
Nephrotic syndrome - ANS ✓-Due to excessive excretion of protein in urine as a
result of alterations in the integrity of the glomerular filtration barrier
-Prednisone to induce remission and prevent relapses, which can occur as early
as 14 days as evidenced by diuresis. Steroids are continued for 4-6 weeks.
Relapses are treated with a short course of steroids and the patient is weaned as
soon as the proteinuria resolves.
-Working with a nephrologist
Nephritis and glomerulonephritis - ANS ✓-Non-infectious, inflammatory
kidney response characterized by varied degrees of HTN, edema, proteinuria and
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hematuria that is either microscopic or macroscopic with dysmorphic RBCs and
casts
-Glomerulonephritis - diffuse inflammatory changes in the glomeruli; immune-
mediated
-Primary acute form - poststreptococcal glomerulonephritis - most common in
children; streptococcal infection within the last two weeks and has an acute
onset of edema, oliguria, HTN, and gross hematuria
-A latent period of 7-10 days between infection of onset of symptoms; if fewer
than 5 days or more than 14 days, consider other causes
-Abrupt hematuria, reduced urine output, lethargy, anorexia, nausea, vomiting,
abdominal pain, chills, fever, backache (pyelo)
-*When to refer - in all cases - consult with nephrologist;
PSGN treatment is supportive because resolution occurs spontaneously most of
the time
-Children who have oliguria, HTN in the first few days of illness (acute nephritis)
- hospitalization may be required with fluid and sodium limitation and diuretic,
antiHTN and antibiotic treatment if cultures are positive
Hydronephrosis - ANS ✓-Unilateral or bilateral dilation of kidney(s)
-Presentation - nausea, abdominal or flank pain, decreased urine output, FTT,
may be asymptomatic
-Management - Surgery to relieve obstruction, must follow-up long term for
continued assessment of renal function; if spontaneously resolution doesn't
occur within 6-12 months; the longer the obstruction - the less likely renal
function will return to normal
-Surgical repair depending on cause and if spontaneous resolution does not occur
in 6-12 months
Renal Tubular Acidosis - ANS ✓-Defect in normal urine acidification with
resulting persistent metabolic acidosis
-Growth failure, GI complaints, muscle weakness
-Urine pH less than 5.5-5.8, hyperkalemia, serum bicarb less than 16
-Goal - correct acidosis and maintain normal bicarbonate (greater than 20),
which will restore growth and minimize complications
-Oral alkalizing medications - Bicitra, polycitra, sodium bicarbonate, and baking
soda; response helps confirm diagnosis, maximize caloric intake
-Referral to a pediatric nephrologist is necessary for any child who is not growing
well despite treatment, whose lab values are not normalizing with treatment, has
unusual lab results, has type IV RTA, or has any RTA complications
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