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General Pediatrics Board Review Nephrology Fluids and Electrolytes Acid-BaseUTIHypertension Jeffrey M. Saland, M.D. Chief, Nephrology and Hypertension.

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Presentation on theme: "General Pediatrics Board Review Nephrology Fluids and Electrolytes Acid-BaseUTIHypertension Jeffrey M. Saland, M.D. Chief, Nephrology and Hypertension."— Presentation transcript:

1 General Pediatrics Board Review Nephrology Fluids and Electrolytes Acid-BaseUTIHypertension Jeffrey M. Saland, M.D. Chief, Nephrology and Hypertension Department of Pediatrics Icahn School of Medicine at Mount Sinai

2 Summer Board Review

3 I Don’t Decide What’s On the Boards

4 An 8 year old proudly announces to you that she did a report on jellyfish and they are 96% water. She asks you what is her “percent water?” What is the best estimate of her fluid compartments by percent of body weight? Total Body Water Extracellular Fluid Intracellular Fluid A. 80%45%35% B. 70%30%40% C. 60%20%40% D. 50%20%30% E. Same as the jellyfish 4

5 An 8 year old proudly announces to you that she did a report on jellyfish and they are 96% water. She asks you what is her “percent water?” What is the best estimate of her fluid compartments by percent of body weight? Total Body Water Extracellular Fluid Intracellular Fluid A. 80%45%35% B. 70%30%40% C. 60%20%40% D. 50%20%30% E. Same as the jellyfish 5

6 Composition of Body Fluids Babies are moist– but not quite jellyfish! 6

7 Finberg L. Water and Electrolytes in Pediatrics 1993 (data from Friis- Hansen BJ Pediatrics 1961) ICW ECW TBW 7

8 AgeTotal WaterECWICW 0-1 day days mo mo mo yr yr yr yr yr Distribution of body water as a percentage of body weight Compiled by Finberg, L. from data by BJ Friis-Hansen, Acta Paed Scand 1958 Technique: D 2 O for TBW and thiosulfate for ECW 8

9 TBW = 60% Lean Body Mass: Approx Body Composition > 1 year ICF = 2/3 TBW ECF = 1/3 TBW Plasma = 1/4 ECF (rest is interstitial fluid) Na ~ 13 K ~ 140 Na ~ 140 K ~ 4 Plasma ICF ECF TBW 9

10 A previously healthy 23 kg child is admitted for gingivostomatitis and refusal of oral intake. What is the most appropriate maintenance intravenous fluid prescription? BasePotassiumRate A. 0.9% NSNone65 ml/hr B. D5 ½ 0.9% NS20 mEq/L100 ml/hr C. D5 ½ 0.9% NS20 mEq/L65 ml/hr D. D5 W20 mEq/L50 ml/hr E. D5 ¾ 0.9% NS20 mEq/L65 ml/hr 10

11 A previously healthy 23 kg child is admitted for gingivostomatitis and refusal of oral intake. What is the most appropriate maintenance intravenous fluid prescription? BasePotassiumRate A. 0.9% NSNone65 ml/hr B. D5 ½ 0.9% NS20 mEq/L100 ml/hr C. D5 ½ 0.9% NS20 mEq/L65 ml/hr D. D5 W20 mEq/L50 ml/hr E. D5 ¾ 0.9% NS20 mEq/L65 ml/hr 11

12 What are maintenance fluids? The fluid and electrolytes necessary for a person to remain in net balance over the long term ICF ECF Plasma INTAKE OUTPUT 12

13 Sounds Easy! 13

14 What are maintenance fluids? Barratt M: Pediatric Nephrology 4th Ed

15 What are maintenance fluids? Why did that graph estimate caloric needs? We need to know how many mL of fluid to order, not how many calories! 15

16 Insensible losses: respiratory30 cc / 100 Cal + evaporative not sweat 15 cc / 100 Cal 45 cc / 100 Cal Urine output losses cc / 100 Cal Stool losses 5-10 cc / 100 Cal Growth “loss” 0-15 cc / 100 Cal Water of oxidation (a gain) cc / 100 Cal TOTAL Approximately 100 cc / 100 Cal For the “average” patient, the use of 1 Cal corresponds to the use of 1 mL of water 16

17 Summary “maintenance fluids” Fluid needs are linked to the metabolic rate. Maintenance is approximately insensible plus urine losses. Maintenance fluids of the “average” patient are approximately: 1 st 10 kg:100 cc / kg / day 2 nd 10 kg:50 cc / kg / day the rest:20 cc / kg / day 17

18 Increased INSENSIBLE Losses Fever (each deg > 38):12.5% Prematurity % Radiant warmer % Phototherapy25-50% Increased activity 5-25% Decreased INSENSIBLE Losses Ventilation (humidified air)25-40% Sedation5-25% Decreased activity 5-25% Hypothermia 5-15% Enclosed Incubator 25-50% Changes in the metabolic rate or the environment change insensible fluid loss 18

19 Common / “Community” losses Gastrointestinal: diarrhea, vomiting Activity: sweating, increased ventilation, heat Burns: (even sunburn!) Uncommon / “Nosocomial” losses Drainage (eg chest tube, NG tube, et cetera) Bleeding Pathological renal losses (eg salt wasting, diabetes) These losses are universally hypo- or isotonic Maintenance Fluid DOES NOT Include Abnormal Losses 19

20 Fluid Na (mEq/L) K (mEq/L) Cl (mEq/L) Gastric20–805–20100–150 Pancreatic120–1405–1590–120 Small bowel100–1405–1590–130 Bile120–1405–1580–120 Ileostomy45–1353–1520–115 Diarrhea10–9010–8010–110 Burns Sweat Normal 10–303–1010–35 Cystic fibrosis 50–1305–2550–110 Composition of Various Body Fluids Harriet Lane Handbook 20

21 Na:2-5 mEq / kg /day K:1-2 mEq / kg /day There is a large variability in the intake of Na, and to a lesser extent K, by healthy people. Renal ability to conserve or excrete Na is very large. The ability to conserve or secrete K is also larger than the average variation in intake. “Salt” Maintenance Requirements 21

22 22

23 An 18 month old boy presents to the ER with a history of vomiting and diarrhea for several days. He is lethargic, has poor skin turgor, dry mucus membranes, and has tachycardia. He took 5 ml oral fluid but vomited almost immediately. The next most appropriate step is to: A. Give 20 ml/kg of D5 0.45% NS intravenously over min B. Give 5 ml/kg of D5 0.9% NS intravenously over min C. Give 20 ml/kg of 0.9% NS intravenously over min D. Give 10 ml/kg of 3% NS intravenously over min E. Await serum electrolytes before giving IV fluid 23 6

24 A nearly 1 month old boy has been vomiting his feedings forcefully for 2 days. He is afebrile and has no diarrhea. He had 1 wet diaper in the last day. He appears dehydrated. He eagerly takes fluids but vomits (non-bilious) immediately and while he does so you note “waves” on his abdomen. What is the most likely set of labs? Serum pHSerum NaSerum KSerum Cl A. LowHighLow B. HighNormalHighLow C. HighNormalLow D. NormalLow E. HighLow High 24

25 A nearly 1 month old boy has been vomiting his feedings forcefully for 2 days. He is afebrile and has no diarrhea. He had 1 wet diaper in the last day. He appears dehydrated. He eagerly takes fluids but vomits (non-bilious) immediately and while he does so you note “waves” on his abdomen. What is the most likely set of labs? Serum pHSerum NaSerum KSerum Cl A. LowHighLow B. HighNormalHighLow C. HighNormalLow D. NormalLow E. HighLow High 25

26 MildModerateSevere Weight Loss 5% (infant) 2% (child/adult) 10% (infant) 6% (child/adult) 15% (infant) 9% (child/adult) SensoriumNormal Fussy Lethargic Poor arousability Urine Output hrs w/o UOP range Slight decrease 2-3 hours cc/kg/hr Notable decrease 4-6 hours <0.5 cc/kg/hr Anuric 6-12 hours None Signs & Symptoms of Dehydration I (fairly reliable) Harriet Lane Handbook 26

27 MildModerateSevere Skin turgor or quality 1+ decrease pale 2+ decrease “gray” 3+ decrease mottled Mucus Membranes Dry / “tacky”Drier“parched” Pulse Slightly increased Increased Very increased FontanelleNormalIntermediateSunken EyesNormalIntermediateSunken Blood PressureNormalAbout normalLow Signs & Symptoms of Dehydration II (less reliable) Harriet Lane Handbook 27

28 A 2 year-old presents with a 1 day history diarrhea and a 5% weight loss. Which of the following best represents the distribution of the fluid loss? ExtracellularIntracellular A. 80%20% B. 60%40% C. 40%60% D. 20%80% E. None of the above 28

29 A 2 year-old presents with a 1 day history diarrhea and a 5% weight loss. Which of the following best represents the distribution of the fluid loss? ExtracellularIntracellular A. 80%20% B. 60%40% C. 40%60% D. 20%80% E. None of the above 3 or more days: the correct answer would have been B. The ICF is relatively protected from volume loss. Harriet Lane Handbook 29

30 A nearly 13 month old girl has had diarrhea for 5 days. She has few wet diapers. Her BP is 86/40, pulse is 135. She weighs 9 kg and you estimate she is 10% dehydrated based on clinical parameters. Disregarding Na losses from the ICF, which of the following estimates is best? Total DeficitECF lossICF lossNa Loss A. 900 mL540 ml360 ml75 mEq B mL800 ml200 ml110 mEq C mL400 ml600 ml55 mEq D mL600 ml400 ml85 mEq E. 100 mL80 mL20 mL10 mEq 30

31 A nearly 13 month old girl has had diarrhea for 5 days. She has few wet diapers. Her BP is 86/40, pulse is 135. She weighs 9 kg and you estimate she is 10% dehydrated based on clinical parameters. Disregarding Na losses from the ICF, which of the following estimates is best? Total DeficitECF lossICF lossNa Loss A. 900 mL540 ml360 ml75 mEq B mL800 ml200 ml110 mEq C mL400 ml600 ml55 mEq D mL600 ml400 ml85 mEq E. 100 mL80 mL20 mL10 mEq 31

32 A 13 month old child was seen for a checkup and weighed 10 kg. 10 days later in the ER with gastroenteritis she weighs 9 kg. 10% Dehydration. A liter weighs 1 kg. A pint’s a pound the world around. 32

33 A high school student and her friend have multiple episodes of vomiting and watery diarrhea after sharing lunch from a food cart at the park earlier in the day. Her bp is 95/45 and her pulse increases from 90 to 115 standing. She feels light-headed and has not urinated in the last 6 hours. Which is the most likely type of dehydration? A. Isotonic B. Hypotonic C. Hypertonic D. All are equally likely 33

34 A high school student and her friend have multiple episodes of vomiting and watery diarrhea after sharing lunch from a food cart at the park earlier in the day. Her bp is 95/45 and her pulse increases from 90 to 115 standing. She feels light-headed and has not urinated in the last 6 hours. Which is the most likely type of dehydration? A. Isotonic B. Hypotonic C. Hypertonic D. All are equally likely 34

35 A 14 year old girl is treated with a prolonged course of antibiotics for sinusitis. She develops profuse watery diarrhea that lasts several days. She had not been eating due to abdominal pain but had taken at least 2 liters of a yellow sports drink each day. In the ER, she still appears moderately dehydrated. You diagnose C. Dificile colitis. The most likely type of dehydration is: A. Isotonic B. Hypotonic C. Hypertonic D. All are equally likely 35

36 A 14 year old girl is treated with a prolonged course of antibiotics for sinusitis. She develops profuse watery diarrhea that lasts several days. She had not been eating due to abdominal pain but had taken at least 2 liters of a yellow sports drink each day. In the ER, she still appears moderately dehydrated. You diagnose C. Dificile colitis. The most likely type of dehydration is: A. Isotonic B. Hypotonic C. Hypertonic D. All are equally likely 36

37 A 14 year old boy with cerebral palsy and mental retardation develops fever to 40 °C. He is able to tolerate his usual liquid formula diet by gastric tube. You diagnose him with streptococcal pharyngitis but also note he has very dry mucus membranes and his skin feels thick. Which is the most likely set of lab findings? Serum Na Serum Osm Urine NaUrine Osm A. High LowHigh B. Low High C. High D. LowNormalHigh E. Normal Low 37

38 A 14 year old boy with cerebral palsy and mental retardation develops fever to 40 °C. He is able to tolerate his usual liquid formula diet by gastric tube. You diagnose him with streptococcal pharyngitis but also note he has very dry mucus membranes and his skin feels thick. Which is the most likely set of lab findings? Serum Na Serum Osm Urine NaUrine Osm A. High LowHigh B. Low High C. High D. LowNormalHigh E. Normal Low 38

39 TonicityPlasma Na (mEq/L) IncidenceExample etiologies Iso %diarrhea, vomiting Hyper>15025%A loss PLUS: no thirst or no tolerance for or no access to water Hypo<13015%Any loss PLUS water replacement in excess of solute replacement. Worse if loss had some Na (CF, salt-wasting ) Tonicity Classification of Dehydration 39

40 40

41 A 10 year old boy has high fever and dehydration due to seasonal influenza. He has not urinated in over 24 hours. His serum creatinine is elevated from 0.7 to 1.6. Urine is taken to calculate fractional excretion of Na. Two days later he is rehydrated and has normal urine output and his creatinine is baseline. What best describes his diagnosis and most likely FENa on presentation? A. Acute kidney injury – FENa 3% B. Acute kidney injury – FENa 0.3% C. Pre-renal azotemia – FENa 3% D. Pre-renal azotemia – FENa 0.3% 41 6

42 Consider a child with sepsis and decreased urine output with the following labs: SERUM:Na 124, K 4, Cl 94, Total CO 2 12 Creat 0.8 mg/dL, BUN 40, Glucose 70 URINE: specific gravity 1.030, trace protein, no blood or glucose, small ketones; urine Na 15, creat 40 42

43 FENa is a useful test when: The urine output is low. No current use of diuretics. < 1% (0.01): pre-renal azotemia (“acute renal success”) > 2% (0.02): acute kidney injury (“acute renal failure”) Exceptions: acute GN has low FENa, obstruction can vary 43

44 A 4 year-old girl with a ventriculoperitoneal shunt presents with a week of vague symptoms progressing toward listlessness and decreased speech, finally with a 5 minute seizure. The bulb of the shunt empties with pressure but is slow to refill. She does not appear dehydrated. The most likely set of laboratory findings is: Serum Na mEq/L Urine Na mEq/L Serum Osm mOsm/kg Urine Osm mOsm/kg A B C D E

45 A 4 year-old girl with a ventriculoperitoneal shunt presents with a week of vague symptoms progressing toward listlessness and decreased speech, finally with a 5 minute seizure. The bulb of the shunt empties with pressure but is slow to refill. She does not appear dehydrated. The most likely set of laboratory findings is: Serum Na mEq/L Urine Na mEq/L Serum Osm mOsm/kg Urine Osm mOsm/kg A B C D E

46 SIADH: Too Much ADH Etiologies: CNS disease (hydrocephalus, meningitis, etc) Lung (pneumonia, RSV, etc) Nausea or Pain Cancer or Stem Cell transplantation Drugs (SSRI’s) Should exclude: Thyroid, adrenal, cardiac, or renal disease Volume deficits / dehydration Hyponatremia, inappropriately high urine Osm (>100) Urine Na can be variable– usually “highish” 46

47 A 7 year-old girl presents for secondary enuresis. On review of systems she has significant polyuria, polydipsia, and severe daily headaches that awaken her in the morning. Urinalysis in your office is negative for glucose and ketones. The most likely set of laboratory findings is: Serum Na mEq/L Urine Na mEq/L Serum Osm mOsm/kg Urine Osm mOsm/kg A B C D E

48 A 7 year-old girl presents for secondary enuresis. On review of systems she has significant polyuria, polydipsia, and severe daily headaches that awaken her in the morning. Urinalysis in your office is negative for glucose and ketones. The most likely set of laboratory findings is: Serum Na mEq/L Urine Na mEq/L Serum Osm mOsm/kg Urine Osm mOsm/kg A B C D E

49 Diabetes Insipidus: Not Enough ADH Or ADH not Effective Etiologies: CNS disease (pituitary infiltration, damage) Drugs (lithium) Nephrogenic (V2 receptor or aquaporin defect) Others more rare With access to water, just polyuria, polydipsia Without access to water, hypernatremia, polyuria, polydipsia Hypernatremic dehydration Inappropriately dilute urine Water deprivation test diagnostic but dangerous Response to DDAVP diagnostic of central DI Genetic testing for nephrogenic DI 49

50 An overweight 15 year old girl is admitted with polyuria and severe dehydration. Severe hyperglycemia of 800 mg/dl without ketoacidosis is discovered. Serum electrolytes are significant for Na of 140, K of 4.3, Cl of 98, CO 2 of 19, BUN is 53, Creatinine is 1.6. Which of the following is NOT true? A. Excessive 0.9% NS may exacerbate the situation. B. Serum K can be expected to fall with rehydration C. Serum NA can be expected to rise with rehydration D. Hyperglycemia causes the lab equipment to malfunction and produce falsely low NA values E. Dehydration is the result of osmotic diuresis 50 6

51 Acid / Base Mr. Osborne, may I be excused? My brain is full. 51

52 A 6 month old girl born at term and with no apparent illnesses presents with failure to thrive. She is mildly tachypneic at rest. Lab evaluation is remarkable for serum Na 140, K 2.5, Chloride of 115, bicarbonate of 11 and creatinine of 0.3 mg/dL. Which of the following is most consistent with distal (type I) renal tubular acidosis (RTA)? Urine pH Urine Ca Urine Citrate Urine K Urine Anion Gap (Na + + K + ) - Cl - A 6.5HighLowHigh> 0 (positive) B 6.5Low High> 0 (positive) C < 5.5HighLowHigh< 0 (negative) D > 7HighLowHigh> 0 (positive) E > 7LowHighLow< 0 (negative) 52 ** CORRECTION

53 A 6 month old girl born at term and with no apparent illnesses presents with failure to thrive. She is mildly tachypneic at rest. Lab evaluation is remarkable for serum Na 140, K 2.5, Chloride of 115, bicarbonate of 11 and creatinine of 0.3 mg/dL. Which of the following is most consistent with distal (type I) renal tubular acidosis (RTA)? Urine pH Urine Ca Urine Citrate Urine K Urine Anion Gap (Na + + K + ) - Cl - A 6.5HighLowHigh> 0 (positive) B 6.5Low High> 0 (positive) C < 5.5HighLowHigh< 0 (negative) D > 7HighLowHigh> 0 (positive) E > 7LowHighLow< 0 (negative) 53

54 Renal Tubular Acidosis Associated with growth failure Low anion gap metabolic acidosis May be compensated by pulmonary hyperventilation Urine anion gap should be positive: (Na + + K + ) > Cl - Clinical pearls: Confirm metabolic acidosis with a VBG Distal RTA (type I) is most common Types I and II have hypokalemia Type IV has hyperkalemia (aldosterone defect) Can be treated with bicitra with varying success 54

55 Renal Tubular Acidosis: Urine Anion Gap Na + + K + __– Cl - ____ Anion Gap What is NOT measured is ammonium (NH 4 + ) Carmody, PREP 2011 Na + +K + < Cl - UAG Negative Non-renal acidosis Na + +K + > Cl - UAG Positive RTA 55

56 Renal Tubular Acidosis: Distal vs Proximal 56

57 A Normal anion gap metabolic acidosis B Low anion gap metabolic acidosis C High anion gap metabolic acidosis D High anion gap respiratory alkalosis E None of the above An 8 year-old with type 1 diabetes mellitus is admitted to the ICU with pneumonia. His blood sugar is 450 mg/dL, serum Na is 133, K is 5.1, Cl 95, HCO The most likely acid-base disturbance is: 57

58 Don’t forget– we ASSUMED the pH was low because metabolic acidosis is so likely. We really need a blood gas to know for sure! A Normal anion gap metabolic acidosis B Low anion gap metabolic acidosis C High anion gap metabolic acidosis D High anion gap respiratory alkalosis E None of the above An 8 year-old with type 1 diabetes mellitus is admitted to the ICU with pneumonia. His blood sugar is 450 mg/dL, serum Na is 133, K is 5.1, Cl 95, HCO The most likely acid-base disturbance is: 58

59 High Anion Gap Metabolic Acidosis: M: methanol (and metabolic diseases) U: uremia D:diabetes (ketoacids), d-lactic acidosis P:(paraldehyde); propylene glycol I:Isoniazid, Iron L:Lactate E:Ethanol, Ethylene glycol S:Salicylates 59

60 A 3 day old male is referred to the ER by his pediatrician because he seems mildly lethargic. Electrolytes are Na 140, K 5.6, Cl 105, HCO3 12. He is afebrile, has BP 84/40 and a rr of 52. A blood ammonia level is markedly elevated. The MOST likely arterial blood gas result is: pHpCO 2 paO 2 BE A B C D E None of the above 60

61 A 3 day old male is referred to the ER by his pediatrician because he seems mildly lethargic. Electrolytes are Na 140, K 5.6, Cl 105, HCO3 12. He is afebrile, has BP 84/40 and a rr of 52. A blood ammonia level is markedly elevated. The MOST likely arterial blood gas result is: pHpCO 2 paO 2 BEInterpretation A R. Alkalosis B R. Acidosis C M. Acidosis D M. Alkalosis E None of the above 61

62 A 10 year old girl with ALL and neutropenia after chemotherapy develops shock. She has stable ventilatory status but is mildly tachypneic. Electrolytes and an arterial blood gas is obtained while she is provided isotonic fluid boluses and dopamine infusion is prepared. The most likely results of the ABG and plasma bicarbonate are: pHHCO 3 - pCO 2 paO 2 A B C D E None of the above 62

63 A 10 year old girl with ALL and neutropenia after chemotherapy develops shock. She has stable ventilatory status but is mildly tachypneic. Electrolytes and an arterial blood gas is obtained while she is provided isotonic fluid boluses and dopamine infusion is prepared. The most likely results of the ABG and plasma bicarbonate are: pHHCO 3 - pCO 2 paO 2 Interpretation A R. Alkalosis B M. Acidosis C M. Alkalosis D R. Acidosis E None of the above 63

64 A 10 year old with dilated cardiomyopathy is admitted with pulmonary edema, intubated, and given 72 hours of continuous IV furosemide. The laboratory results return: What is the best interpretation of these results? pHpCO 2 HCO 3 - BEpaO AMetabolic alkalosis due to diuretics BRespiratory alkalosis due to hyperventilation CMetabolic acidosis due to heart failure DRespiratory acidosis due to pulmonary edema ENone of the above / Lab Error 64

65 A 10 year old with dilated cardiomyopathy is admitted with pulmonary edema, intubated, and given 72 hours of continuous IV furosemide. The laboratory results return: What is the best interpretation of these results? pHpCO 2 HCO 3 - BEpaO AMetabolic alkalosis due to diuretics BRespiratory alkalosis due to hyperventilation CMetabolic acidosis due to heart failure DRespiratory acidosis due to pulmonary edema ENone of the above / Lab Error 65

66 A 6 month old boy develops diarrhea for 4 days. He appears dehydrated and is given a bolus of 0.9% NS and promptly produces a generous wet diaper. Electrolytes are obtained with difficulty during the blood draw and return the following values: Na 143, K 7.3, Cl 109, CO 2 14, Ca is 10.1 mg/dl. The next step in management is A Repeat the laboratory tests in 24 hours B Administer intravenous Calcium gluconate C Administer intravenous sodium bicarbonate D Begin intravenous D5 0.45% NS with 20 mEq KCl per liter at 1.5 times maintenance rate E None of the above 66

67 A 6 month old boy develops diarrhea for 4 days. He appears dehydrated and is given a bolus of 0.9% NS and promptly produces a generous wet diaper. Electrolytes are obtained with difficulty during the blood draw and return the following values: Na 143, K 7.3, Cl 109, CO 2 14, Ca is 10.1 mg/dl. The next step in management is A Repeat the laboratory tests in 24 hours B Administer intravenous Calcium gluconate C Administer intravenous sodium bicarbonate D Begin intravenous D5 ½ 0.9% NS with 20 mEq KCl per liter at 1.5 times maintenance rate E None of the above 67

68 A 9 year old boy is chronically treated with oral furosemide for vascular congestion related to dilated cardiomyopathy. All of the following electrolyte disturbances are likely EXCEPT: A Hypokalemia B Hypophosphatemia C Hypocalcemia D Hyponatremia E Hypomagnesemia 68

69 A 9 year old boy is chronically treated with oral furosemide for vascular congestion related to dilated cardiomyopathy. All of the following electrolyte disturbances are likely EXCEPT: A Hypokalemia B Hypophosphatemia C Hypocalcemia D Hyponatremia E Hypomagnesemia 69

70 Hyperkalemia can be induced by all of the following medications EXCEPT: A Intravenous terbutaline B Epinephrine C Angiotensin converting enzyme inhibitor D Hydrochlorthiazide (HCTZ) E Spironolactone 70

71 Hyperkalemia can be induced by all of the following medications EXCEPT: A Intravenous terbutaline B Epinephrine C Angiotensin converting enzyme inhibitor D Hydrochlorthiazide (HCTZ) E Spironolactone 71

72 UTI’s and So on… 72

73 An otherwise healthy, well-grown 4 year-old girl has had 3 febrile UTIs, the first at age 3 years. She has been taking TMP/SMX since the 2 nd UTI. Review of systems reveals constipation. She has occasional enuresis but no frequency or dysuria. Renal sonography and voiding cystourethrogram (VCUG) are normal. Which of the following is likely to be helpful in her evaluation and treatment? A Renal scintigraphy B Evaluation for immunodeficiency C Increase daily fluid intake to 2 – 2.5 liters/day D Prescribe stool softener & a regular bowel routine E Switch prophylaxis to nitrofurantoin 73

74 An otherwise healthy, well-grown 4 year-old girl has had 3 febrile UTIs, the first at age 3 years. She has been taking TMP/SMX since the 2 nd UTI. Review of systems reveals constipation. She has occasional enuresis but no frequency or dysuria. Renal sonography and voiding cystourethrogram (VCUG) are normal. Which of the following is likely to be helpful in her evaluation and treatment? A Renal scintigraphy B Evaluation for immunodeficiency C Increase daily fluid intake to 2 – 2.5 liters/day D Prescribe stool softener & a regular bowel routine E Switch prophylaxis to nitrofurantoin 74

75 A 3 month old male has a febrile UTI with E. Coli. His renal ultrasound is negative. The best test to evaluate for vesicoureteral reflux (VUR) is: A 99 Tc DTPA renal scintigraphy B 99 Tc DMSA renal scintigraphy C Voiding cystourethrogram D Urodynamics study E Magnetic resonance (MR) urogram 75

76 A 3 month old male has a febrile UTI with E. Coli. His renal ultrasound is negative. The best test to evaluate for vesicoureteral reflux (VUR) is: A 99 Tc DTPA renal scintigraphy B 99 Tc DMSA renal scintigraphy C Voiding cystourethrogram D Urodynamics study E Magnetic resonance (MR) urogram 76

77 All of the following statements about UTI are correct EXCEPT: A Under the age of 1 year, the risk of UTI in females is greater than in males B Circumcision of boys does not affect the risk of UTI C The prevalence of UTI in febrile infants under 3 months of age and without an obvious source on clinical examination is 5-10% D The incidence of UTI in patients with abnormal urinary tract anatomy is greater than in those with normal urinary tract anatomy E There is controversy whether a 1 st UTI requires evaluation if a prenatal sonogram was normal. 77

78 All of the following statements about UTI are correct EXCEPT: A Under the age of 1 year, the risk of UTI in females is greater than in males B Circumcision of boys does not affect the risk of UTI C The prevalence of UTI in febrile infants under 3 months of age and without an obvious source on clinical examination is 5-10% D The incidence of UTI in patients with abnormal urinary tract anatomy is greater than in those with normal urinary tract anatomy E There is controversy whether a 1 st UTI requires evaluation if a prenatal sonogram was normal. 78

79 An 8 month old male is found to have grade II VUR on the right and grade IV VUR on the left with mild hydronephrosis. Which of the following are immediately appropriate: A Daily antibiotic prophylaxis B Antibiotic prophylaxis and repeat VCUG in 6 months C Antibiotic prophylaxis and schedule correction of VUR by bilateral endoscopic injection of gel in the bladder wall under the ureteral orifice D Antibiotic prophylaxis and left ureteral reimplant E None of the above 79

80 An 8 month old male is found to have grade II VUR on the right and grade IV VUR on the left with mild hydronephrosis. Which of the following are immediately appropriate: A Daily antibiotic prophylaxis B Antibiotic prophylaxis and repeat VCUG in 6 months C Antibiotic prophylaxis and schedule correction of VUR by bilateral endoscopic injection of gel in the bladder wall under the ureteral orifice D Antibiotic prophylaxis and left ureteral reimplant E None of the above 80

81 Besides fever, signs and symptoms of UTI in infants include: A Irritability B Diarrhea C Difficulty feeding D Jaundice E Any of the above 81

82 Besides fever, signs and symptoms of UTI in infants include: A Irritability B Diarrhea C Difficulty feeding D Jaundice E Any of the above 82

83 An 8 year old boy in the 3 rd grade develops secondary nocturnal enuresis. On review of systems he has constipation. When he was a newborn you had ordered a spinal ultrasound and x-ray after noting a sacral dimple, and both were normal. Urinalysis is negative for leukocyte esterase and nitrates. The next most appropriate steps are: A Renal and bladder ultrasound B Spine MRI and referral to pediatric neurosurgery C Prescribe stool softener & a regular bowel routine D Referral to pediatric urology E Reduce evening fluids & use a bedtime wetting alarm 83

84 An 8 year old boy in the 3 rd grade develops secondary nocturnal enuresis. On review of systems he has constipation. When he was a newborn you had ordered a spinal ultrasound and x-ray after noting a sacral dimple, and both were normal. Urinalysis is negative for leukocyte esterase and nitrates. The next most appropriate steps are: A Renal and bladder ultrasound B Spine MRI and referral to pediatric neurosurgery C Prescribe stool softener & a regular bowel routine D Referral to pediatric urology E Reduce evening fluids & use a bedtime wetting alarm 84

85 Nephrology 85

86 A 3 year-old boy is referred to pediatric nephrology for sudden onset of edema and 4+ proteinuria. True statements about the nephrotic syndrome in this child include: A The majority of children will respond to corticosteroid treatment within 1 week B IV infusion of 25% albumin and furosemide will decrease recovery time C Progression to renal failure is likely D Steroid response is predictive of renal histology E A family history of nephrotic syndrome is common 86

87 A 3 year-old boy is referred to pediatric nephrology for sudden onset of edema and 4+ proteinuria. True statements about the nephrotic syndrome in this child include: A The majority of children will respond to corticosteroid treatment within 1 week B IV infusion of 25% albumin and furosemide will decrease recovery time C Progression to renal failure is likely D Steroid response is predictive of renal histology E A family history of nephrotic syndrome is common 87

88 A 14 year-old overweight girl has proteinuria 100 mg/dL on two separate occasions, first noted during a screening examination for summer camp. The remainder of the urinalysis is normal and the blood pressure is normal. The most appropriate next step in management is: A Request a hemoglobin A 1 C B Renal and bladder ultrasonography C Request a urine culture D Request a first morning urine protein and creatinine E Request a 24 hour urine collection for protein 88

89 A 14 year-old overweight girl has proteinuria 100 mg/dL on two separate occasions, first noted during a screening examination for summer camp. The remainder of the urinalysis is normal and the blood pressure is normal. The most appropriate next step in management is: A Request a hemoglobin A 1 C B Renal and bladder ultrasonography C Request a urine culture D Request a first morning urine protein and creatinine E Request a 24 hour urine collection for protein 89

90 A 14 year old boy has microscopic hematuria on a urinalysis done for a school form. Family history is significant for his mother having microscopic hematuria since childhood. A maternal uncle required dialysis. Which of the following is true of this boy’s condition? A It is associated with conductive hearing loss B It is associated with retinal abnormalities C Immunoglobulin A levels are elevated in 50% of cases D Female carriers are at risk of kidney failure E Skin biopsy may reveal leukocytoclastic vasculitis 90

91 A 14 year old boy has microscopic hematuria on a urinalysis done for a school form. Family history is significant for his mother having microscopic hematuria since childhood. A maternal uncle required dialysis. Which of the following is true of this boy’s condition? A It is associated with conductive hearing loss B It is associated with retinal abnormalities C Immunoglobulin A levels are elevated in 50% of cases D Female carriers are at risk of kidney failure E Skin biopsy may reveal leukocytoclastic vasculitis 91

92 A 14 year old boy has microscopic hematuria on a urinalysis done for a school form. Family history is significant for his father and a paternal grandparent having long-standing microscopic hematuria. There is no family history of kidney failure. There is no proteinuria. Blood pressure, urine calcium, and renal/bladder sonography is normal. Which of the following is true? A There is an elevated risk of kidney stones B Renal biopsy is indicated C The glomerular basement membrane often appears thick by electron microscopic examination. D Female carriers are at risk of kidney failure E None of the above 92

93 A 14 year old boy has microscopic hematuria on a urinalysis done for a school form. Family history is significant for his father and a paternal grandparent having long-standing microscopic hematuria. There is no family history of kidney failure. There is no proteinuria. Blood pressure, urine calcium, and renal/bladder sonography is normal. Which of the following is true? A There is an elevated risk of kidney stones B Renal biopsy is indicated C The glomerular basement membrane often appears thick by electron microscopic examination. D Female carriers are at risk of kidney failure E None of the above 93

94 A 3 day old male infant has been is brought to the ER for blood in the diaper, which the family produces. The diaper has multiple brick-red discolorations in the front. There is no significant perinatal history. Exam finds a vigorous infant in no distress with normal blood pressure. Bagged urinalysis is negative for blood by dipstick and by microscopy. The most likely cause of these findings is: A Hemoglobinuria B Sickle cell trait C Calcium oxalate crystals D Uric acid crystals E Porphyria 94

95 A 3 day old male infant has been is brought to the ER for blood in the diaper, which the family produces. The diaper has multiple brick-red discolorations in the front. There is no significant perinatal history. Exam finds a vigorous infant in no distress with normal blood pressure. Bagged urinalysis is negative for blood by dipstick and by microscopy. The most likely cause of these findings is: A Hemoglobinuria B Sickle cell trait C Calcium oxalate crystals D Uric acid crystals E Porphyria 95

96 Hematuria Red Urine  Hematuria See Harriet Lane list– favorites for the boards! (eg beets, blackberries, urates, rifampin) In reality, red urine that is not blood is not commonly encountered in practice, except maybe red diaper urates. Important uncommon causes: hemoglobinuria myoglobinuria 96

97 A 16 year old boy develops sharp flank pain and gross hematuria. Sonography shows multiple large “soap bubble” cysts in each kidney. The mother reports that her mother, who lived in a developing country, suffered from episodes of painful blood in the urine and died with a kidney disease in her 40’s. Which of the following is true? A The disease is associated with hearing loss B The disease is associated with intracranial aneurysms C An older brother, age 20, has a normal sonogram and therefore does not carry the gene D Both parents are carriers of the gene E This disease is found in about 1 in 5000 people 97

98 A The disease is associated with hearing loss B The disease is associated with intracranial aneurysms C An older brother, age 20, has a normal sonogram and therefore does not carry the gene D Both parents are carriers of the gene E This disease is found in about 1 in 5000 people 98 A 16 year old boy develops sharp flank pain and gross hematuria. Sonography shows multiple large “soap bubble” cysts in each kidney. The mother reports that her mother, who lived in a developing country, suffered from episodes of painful blood in the urine and died with a kidney disease in her 40’s. Which of the following is true?

99 Polycystic Kidney Disease Autosomal Dominant PKD (ADPKD) More commonly affects adults Larger cysts, liver cysts Intracranial aneurysms Mitral valve prolapse, aortic root dilitation Common: affects about 1:1000 Autosomal Recessive PKD (ARPKD) More commonly affects infants Smaller cysts, liver fibrosis (ductal plate malformation) May need liver and/or kidney transplant Rare: affects about 1 in 20,000 99

100 2 days following a fall trip to a farm and apple cider press in the country, a 3 year old boy develops bloody diarrhea which his parents manage at home with fluids. The next week, the is brought to the ER lethargic and pale. He has not urinated in over 8 hours. Lab testing finds WBC of 26,000, hemoglobin of 9.8 g/dL, platelets 65,000, serum creatinine of 1 mg/dL, BUN 54 mg/dL. All of the following statements about this condition are true EXCEPT: A It is precipitated by infection with enteric bacteria producing shiga toxin such as E. Coli O157:H7 B It is preventable by early treatment with antibiotics C End stage renal failure is uncommon D Recurrence is atypical E Hypertension is common and may be severe 100

101 2 days following a fall trip to a farm and apple cider press in the country, a 3 year old boy develops bloody diarrhea which his parents manage at home with fluids. The next week, the is brought to the ER lethargic and pale. He has not urinated in over 8 hours. Lab testing finds WBC of 26,000, hemoglobin of 9.8 g/dL, platelets 65,000, serum creatinine of 1 mg/dL, BUN 54 mg/dL. All of the following statements about this condition are true EXCEPT: A It is precipitated by infection with enteric bacteria producing shiga toxin such as E. Coli O157:H7 B It is preventable by early treatment with antibiotics C End stage renal failure is uncommon D Recurrence is atypical E Hypertension is common and may be severe 101

102 A 4 month old girl is brought to the ER lethargic and pale. She has not urinated in over 8 hours. Lab testing finds WBC of 26,000, hemoglobin of 8.8 g/dL, platelets 56,000, serum creatinine of 1 mg/dL, BUN 54 mg/dL. The blood smear shows schistocytes and helmet cells. True statements about this case include all of the following EXCEPT: A Defective complement system regulation is likely B Hypertension is common and may be severe C End stage renal failure is common D Recurrence is common E Treatment is symptomatic 102

103 A 4 month old girl is brought to the ER lethargic and pale. She has not urinated in over 8 hours. Lab testing finds WBC of 26,000, hemoglobin of 8.8 g/dL, platelets 56,000, serum creatinine of 1 mg/dL, BUN 54 mg/dL. The blood smear shows schistocytes and helmet cells. True statements about this case include all of the following EXCEPT: A Defective complement system regulation is likely B Hypertension is common and may be severe C End stage renal failure is common D Recurrence is common E Treatment is symptomatic 103

104 A 6 year-old girl develops tea-colored urine. Urine dip finds 4+ blood and 3+ protein. There is mild edema present and the blood pressure is 114/74. Review of systems is negative. Her twin brother currently has fever and a sore throat. Which of the following statements is CORRECT? A. Complement C3 & C4 may remain low for 4-6 weeks B. The brother can be protected from the same condition by prompt antibiotic treatment C. The is a high risk of rheumatic heart disease also D. Rapid progression and need for dialysis is uncommon and requires renal bipsy E. Hypertension is uncommon and requires renal biopsy 104 6

105 A 14 year old boy is uncharacteristically tired in the afternoons and appears somewhat pale to his mother. Laboratory findings consistent with chronic kidney disease with decreased glomerular filtration rate (GFR) include: MCV = mean corpuscular volume PTH = parathyroid hormone MCVNaCaPTHHCO 3 - A LowNormalHigh Low B NormalLow High C Normal LowHighLow D High NormalLow E NormalLowNormalLow 105

106 A 14 year old boy is uncharacteristically tired in the afternoons and appears somewhat pale to his mother. Laboratory findings consistent with chronic kidney disease with decreased glomerular filtration rate (GFR) include: MCV = mean corpuscular volume PTH = parathyroid hormone MCVNaCaPTHHCO 3 - A LowNormalHigh Low B NormalLow High C Normal LowHighLow D High NormalLow E NormalLowNormalLow 106

107 A 7 year-old boy with a history of posterior urethral valves and stage 3 CKD has short stature. All of the following factors commonly contribute to short stature in children with CKD EXCEPT: IGF: insulin-like growth factor A Growth hormone deficiency B Resistance to growth hormone C Decreased bioavailability of IGF-1 due to increased IGF binding proteins D Vitamin D deficiency and renal osteodystrophy E Nutritional disturbances 107

108 A 7 year-old boy with a history of posterior urethral valves and stage 3 CKD has short stature. All of the following factors commonly contribute to short stature in children with CKD EXCEPT: IGF: insulin-like growth factor A Growth hormone deficiency B Resistance to growth hormone C Decreased bioavailability of IGF-1 due to increased IGF binding proteins D Vitamin D deficiency and renal osteodystrophy E Nutritional disturbances 108

109 A newborn has a sonogram due to an abnormal prenatal sonogram. The left kidney is bit large but otherwise normal. The right kidney has multiple cystic areas and abnormal cortex. The right side shows no uptake on nuclear renal scan. All of the following statements are correct EXCEPT: A Vesicoureteral reflux is a common finding B Genetic testing is not likely to be useful C The left kidney will eventually develop cysts and fail D There is an increased risk of hypertension E ALL of the above are correct 109

110 A newborn has a sonogram due to an abnormal prenatal sonogram. The left kidney is bit large but otherwise normal. The right kidney has multiple cystic areas and abnormal cortex. The right side shows no uptake on nuclear renal scan. All of the following statements are correct EXCEPT: A Vesicoureteral reflux is a common finding B Genetic testing is not likely to be useful C The left kidney will eventually develop cysts and fail D There is an increased risk of hypertension E ALL of the above are correct 110

111 The parents of a 15 year-old followed in the renal clinic for advancing kidney disease ask your advice about what will happen as his kidneys fail. All of the following are true about End Stage Renal Disease (ESRD) EXCEPT: A A kidney from a live donor is usually better than from a deceased donor. B Hemodialysis does not replace all of the function of the kidneys C Peritoneal dialysis is usually done at home D Nutritional restrictions frequently include potassium, phosphorus, and sodium. E All of the above are true 111

112 The parents of a 15 year-old followed in the renal clinic for advancing kidney disease ask your advice about what will happen as his kidneys fail. All of the following are true about End Stage Renal Disease (ESRD) EXCEPT: A A kidney from a live donor is usually better than from a deceased donor. B Hemodialysis does not replace all of the function of the kidneys C Peritoneal dialysis is usually done at home D Nutritional restrictions frequently include potassium, phosphorus, and sodium. E All of the above are true 112

113 Blood Pressure and Hypertension 113

114 A 9 year-old girl with no symptoms has BP / discovered on a routine physical and confirmed several times. The remainder of her examination is normal. True statements about this case include: A Two additional measurements of BP are required to make the diagnosis of hypertension B The most likely diagnosis is essential hypertension C Best initial treatment is intravenous nicardipine infusion to lower the BP to normal D Normal renal ultrasonography can rule out renal and renovascular causes of hypertension. E The elevated blood pressure is likely long-standing 114

115 A 9 year-old girl with no symptoms has BP / discovered on a routine physical and confirmed several times. The remainder of her examination is normal. True statements about this case include: A Two additional measurements of BP are required to make the diagnosis of hypertension B The most likely diagnosis is essential hypertension C Best initial treatment is intravenous nicardipine infusion to lower the BP to normal D Normal renal ultrasonography can rule out renal and renovascular causes of hypertension. E The elevated blood pressure is likely long-standing 115

116 All of the following statements about normal blood pressure in children are true EXCEPT: A Normal BP increases with age during childhood B Boys normally have higher BP than girls C Normal BP is higher in taller children D Normal BP is higher in overweight and obese children E ALL of the above are true statements 116

117 All of the following statements about normal blood pressure in children are true EXCEPT: A Normal BP increases with age during childhood B Boys normally have higher BP than girls C Normal BP is higher in taller children D Normal BP is higher in overweight and obese children E ALL of the above are true statements Increased BP with height is physiologic and normal. Increased BP with obesity is pathophysiological and abnormal. 117

118 Blood Pressure Tables 118

119 Blood Pressure Tables PEDIATRICS Vol. 114 No. 2 August 2004, pp

120 4 th Report BP Designations PercentileDesignation (Diastolic or Systolic) < 90 th Normal 90 th to 95 th “pre-hypertension” 95 th to 99 th + 5Hypertension (“stage 1”) Over 99 th + 5Severe hypertension (“stage 2”) 120

121 A 9 year-old girl with asymptomatic stage 2 HTN is evaluated first by renal sonography then by magnetic resonance arteriography. A long right-sided renal arterial narrowing with high velocities is suspicious for renal artery stenosis. She was not in the NICU after birth and never had central venous nor arterial access. The MOST likely etiology of this disease is: A Tuberous sclerosis B Neurofibromatosis C Williams Syndrome D Bartter Syndrome E Fibromuscular dysplasia 121

122 A 9 year-old girl with asymptomatic stage 2 HTN is evaluated first by renal sonography then by magnetic resonance arteriography. A long right-sided renal arterial narrowing with high velocities is suspicious for renal artery stenosis. She was not in the NICU after birth and never had central venous nor arterial access. The MOST likely etiology of this disease is: A Tuberous sclerosis B Neurofibromatosis C Williams Syndrome D Bartter Syndrome E Fibromuscular dysplasia 122

123 A 13 year old girl with a BMI in the 96 th percentile is referred for stage 1 HTN. Initial management should include all of the following EXCEPT: A Therapeutic lifestyle changes B Evaluation of lipid levels C Urinalysis D Thorough review of possible diet supplements, over- the-counter medications, caffeine intake, and illicit drug use E Renal angiography 123

124 A 13 year old girl with a BMI in the 96 th percentile is referred for stage 1 HTN. Initial management should include all of the following EXCEPT: A Therapeutic lifestyle changes B Evaluation of lipid levels C Urinalysis D Thorough review of possible diet supplements, over- the-counter medications, caffeine intake, and illicit drug use E Renal angiography 124 Just making a point here– obesity-related HTN is common and frequently responds to diet and exercise (TLC). Don’t forget these other items– all are fair game for questions.

125 Keep Studying and Good Luck! 125


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