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7. CP - Kidney and Urinary Tract Disease > (32) Renal System Disease 2 > Flashcards

(32) Renal System Disease 2 Flashcards

1
Q

What is obstructive uropathy?

A

Obstruction of the urinary tract - can occur anywhere from renal pelvis to urethral meatus

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2
Q

Obstructive uropathy can be… (classifications)

A
  • chronic or acute
  • unilateral or bilateral (rare)
  • intrinsic or extrinsic
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3
Q

What are the types of obstruction that can occur in the renal pelvis?

A
  • calculi
  • tumours
  • ureteropelvic strictures
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4
Q

Give an example of a type of renal pelvis calculi

A

Staghorn calculus

  • large and difficult to remove
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5
Q

What happens when there is a ureteral stricture?

A

The kidney and ureter becomes distended above the stricture

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6
Q

What are types of intrinsic ureter obstructions that can occur?

A
  • calculi
  • tumours
  • clots
  • sloughed papillae
  • inflammation
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7
Q

What are the types of extrinsic ureter obstructions that can occur?

A
  • pregnancy
  • tumours (eg. cervix)
  • retroperitoneal fibrosis
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8
Q

What can occur at the vesicoureteral junction to cause obstruction?

A

Vesicoureteral reflux (defective valve causing reflux of urine up ureter)

  • only seen in male patients
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9
Q

At what areas can urinary tract obstruction occur?

A
  • renal pelvis
  • ureter (intrinsic and extrinsic)
  • bladder
  • urethra
  • prostate
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10
Q

Give examples of obstruction that can occur at the level of the bladder

A
  • calculi

- tumours

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11
Q

Give examples of obstruction that can occur at the level of the urethra

A
  • posterior urethral valve stricture

- tumours (rare)

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12
Q

What conditions of the prostate may cause urinary tract obstruction?

A
  • hyperplasia
  • carcinoma
  • prostatitis

(surrounds urethra so enlargement may cause blockage)

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13
Q

What are the types of obstruction that occur within the lumen of the urinary tract?

A
  • urinary calculi
  • strictures
  • neoplasia
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14
Q

Give 3 classifications of strictures

A
  • post-procedural
  • post-infective
  • congenital
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15
Q

What are the types of obstruction that occur due to abnormalities of the wall of the urinary tract?

A
  • neoplasia (benign or malignant)

- congenital anatomical abnormalities

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16
Q

What are the types of obstruction that occur due to external compression?

A
  • tumours outside of the urinary tract
  • inflammatory conditions (retroperitoneal fibrosis)
  • pregnancy
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17
Q

What are the types of obstruction that can be classified as functional obstruction?

A
  • neurological conditions

- severe reflux

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18
Q

What is the typical sequelae of urinary tract obstruction?

A
  • infection (cystitis, ascending pyelonephritis)
  • stone/calculi formation (both cause and result of obstruction)
  • kidney damage (acute or chronic)
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19
Q

The consequences of urinary tract obstruction depend on…

A
  • site of obstruction
  • degree of obstruction
  • duration of obstruction
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20
Q

Give an example of a consequence of urethral obstruction (bladder outlet obstruction)

A

Detrusor hypertrophy and trabeculation

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21
Q

Give examples of consequences of ureteric obstruction

A
  • hydroureter (whole system dilated and kidneys shrunken and scarred)
  • hydronephrosis (dilated calyces and pelvis and cortical atrophy)
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22
Q

What are the resulting consequences of acute complete obstruction?

A
  • reduction in GFR
  • mild dilatation and mild cortical atrophy

CAN CAUSE ACUTE RENAL FAILURE

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23
Q

Give 2 potential pathways following partial/intermittent obstruction

A
  • continued GFR
  • dilatation of pelvis and calyces

OR

  • filtrate passes back into interstitium
  • compression of medulla
  • impaired concentrating ability
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24
Q

What is the end result following partial or intermittent obstruction?

A

Eventual cortical atrophy, fall in renal filtration, and renal failure

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25
Q

How does acute bilateral obstruction present?

A
  • pain
  • acute renal failure
  • anuria
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26
Q

How does chronic unilateral obstruction present?

A
  • asymptomatic initially

- cortical atrophy and reduced renal function if unresolved

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27
Q

How does bilateral partial obstruction present?

A

Initially polyuric with progressive renal scarring and impairment

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28
Q

What does polyuric mean?

A

Excessive passage of urine

eg. in diabetes

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29
Q

What is the word for the formation of renal calculi?

A

Urolithiasis

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30
Q

How many people does urolithiasis/renal calculi affect?

A

7-10% of the population - increasing

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31
Q

Which gender is affected more by renal calculi/urolithiasis?

A

Male predominance

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32
Q

What is the peak onset age for renal calculi?

A

20-30

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33
Q

Where do renal stones form?

A

Can form anywhere in the urinary tract but most commonly in the kidney

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34
Q

What is the pathogenesis behind renal calculi?

A
  • excess of substances which may precipitate out eg. Ca+
  • change in urine constituents causing precipitation of substances eg. change in pH
  • poor urine output (supersaturation)
  • decreased citrate levels
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35
Q

What are the different types of stones (classified by composition)?

A
  • calcium stones
  • struvite stones
  • urate stones
  • cystine stones

Different stone types arise for different reasons

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36
Q

What is the most common type of renal stone by composition?

A

Calcium stones (70%)

37
Q

What do calcium stones consist of?

A

Calcium oxate +/- calcium phosphate

38
Q

What do struvite stones consist of?

A

(15%) - magnesium ammonium phosphate

39
Q

What do urate stones consist of?

A

(5%) - uric acid

40
Q

The most commonly identified cause of calcium stones is what?

A

Hypercalciuria

41
Q

Caclium stones are most commonly caused by hypercalciuria which is due to…

A
  • hypercalcaemia
  • excessive absorption of intestinal Ca+
  • inability to reabsorb tubular Ca+
  • idiopathic
42
Q

Hypercalcaemia may lead to hypercalciuria which causes calcium stones. What are the causes of hypercalcaemia?

A
  • bone disease
  • PTH excess
  • sarcoidosis
43
Q

What are the other risk factors (other than hypercalciuria) for calcium stones?

A
  • gout (forms a core for Ca+ crystal formation)

- hyperoxaluria (hereditary, excess dietary intake)

44
Q

What is hyperoxaluria?

A

An excessive urinary excretion of oxalate. Patients often have calcium oxalate kidney stones. It is sometimes called Bird’s disease.

45
Q

What are the stages in the formation of struvite stones

A
  • urease produced by bacterial infection (proteus)
  • urease converts urea to ammonia
  • causes rise in urine pH
  • precipitation of of magnesium ammonium phosphate salts
  • large staghorn calculi
46
Q

Most staghorn calculi are what type of urinary stone?

A

Struvite stones

47
Q

What are the causes of urate stones?

A
  • hyperuricaemia (gout, patients with high cell turnover eg. leukaemia)
  • idiopathic
48
Q

When do cystine stones occur?

A
  • rare

- occur in presence of inability of kidneys to reabsorb amino acids

49
Q

What is the gold standard investigation for renal calculi?

A

Non-contrast CT scanning (sensitivity of >95%)

50
Q

What investigation would you use for renal calculi in pregnancy or where CT not possible?

A

Ultrasound (30-67% sensitive)

51
Q

When would you used ultrasound for renal calculi?

A

In pregnancy or where CT is not possible

52
Q

Other than CT and ultrasound, name another investigation for renal calculi

A

Intravenous urography (70% sensitive for stones)

53
Q

What is the possible sequelae in renal calculi?

A
  • obstruction
  • haematuria
  • infection
  • squamous metaplasia/squamous cell carcinoma
54
Q

Renal cell carcinomas make up what proportion of cancers?

A

3%

55
Q

The vast majority of renal carcinomas are…

A

Clear cell

56
Q

Most renal carcinomas are clear cell but rarer variants include..

A

Papillary and chromophobe cell

57
Q

What is the peak age for renal cell carcinoma?

A

65-80

58
Q

Which gender is affected more by renal cell carcinoma?

A

Male > female (3:2)

59
Q

What are the risk factors for renal carcinoma?

A
  • tobacco
  • obesity
  • hypertension
  • oestrogens
  • acquired cystic kidney disease (due to chronic renal failure)
  • asbestos exposure
60
Q

What is the most common of several cancer syndromes in RCC?

A

Von Hippel-Lindau syndrome

61
Q

What is the VHL gene required for?

A

Breakdown of Hypoxia Inducible Factor-1 (HIF-1) oncogene

62
Q

What does loss of VHL gene function cause?

A

Cell growth and increased cell survival

63
Q

VHL gene mutations are commonly identified in what cancers?

A

Tumours develop in kidneys, blood vessels, pancreas

Commonly identified in clear cell renal cell carcinoma

64
Q

What are the local symptoms of renal carcinoma?

A
  • haematuria
  • palpable abdominal mass
  • costovertebral pain

(late presentation - systemic symptoms or metastases 25%)
- paraneoplastic syndromes

65
Q

What are paraneoplastic syndromes?

A

Clinical syndromes caused by tumours

  • not related to the tissue that the tumour arose from
  • not related to invasion by the tumour itself or its metastases
66
Q

What are the paraneoplastic syndromes associated with RCC?

A
  • Cushing’s syndrome
  • hypercalcaemia
  • polycythaemia
67
Q

What is Cushing’s syndrome?

A

Prolonged exposure to cortisol (excess ACTH stimulating adrenal cortex to produce high levels of cortisol)

68
Q

What is polycythaemia?

A

Abnormally increased concentration of haemoglobin in the blood, either through reduction of plasma volume or increase in red cell number (related to erythropoietin)

69
Q

What is erythropoetin?

A

Hormone secreted by the kidneys that increases the rate of production of red blood cells in response to falling levels of oxygen in the tissues

70
Q

Which hormones are the paraneoplastic syndromes related to RCC related with?

A

Cushing’s syndrome - ACTH

Hypercalcaemia - parathyroid hormone related peptide

Polycythaemia - erythropoietin

71
Q

Describe the morphology of RCC in clear cell RCC

A
  • well defined yellow tumours
  • often with haemorrhagic areas
  • may extend into perinephric fat or into renal vein
72
Q

Describe the morphology of RCC in papillary RCC

A
  • more cystic

- more likely to be multiple

73
Q

Describe the microscopy in clear cell RCC

A
  • clear cells
  • delicate vasculature
  • usually small bland nuclei
74
Q

Describe the microscopy in papillary RCC

A
  • cuboidal, foamy cells

- surrounding fibrovascular cores often containing foamy macrophages or calcium

75
Q

What is the average 5 year survival for RCC?

A

45%

76
Q

What is the 5 year survival for RCC if organ confined?

A

> 70%

77
Q

What is the 5 year survival for tumours extending into perinephric fat or renal vein?

A

50%

78
Q

What is the 5 year survival for RCC with distant metastases?

A

Very poor prognosis (

79
Q

95% of bladder tumours are what type?

A

Urothelial cell carcinoma

80
Q

Where do urothelial cell carcinomas arise from?

A

The specialised multilayered epithelium - most common in bladder but may arise anywhere from renal pelvis to urethra

81
Q

What are the risk factors for urothelial cell carcinoma?

A
  • age
  • gender (male>female)
  • carcinogens:
  • smoking
  • arylamines
  • cyclophosphamide
  • radiotherapy
82
Q

What is the most common sign of urothelial cell carcinoma?

A

Haematuria

83
Q

How does urothelial cell carcinoma present?

A
  • haematuria
  • urinary frequency
  • pain on urination
  • urinary tract obstruction
84
Q

What is urothelial cell carcinoma also known as?

A

Transitional cell carcinoma

85
Q

What are the different histological patterns in TCC?

A
  • papilloma-papillary carcinoma
  • invasive papillary carcinoma
  • flat non-invasive carcinoma (CIS)
  • flat invasive carcinoma
86
Q

Describe the T staging in bladder carcinoma (depth of invasion)

A 
Ta = noninvasive, papillary
Tis = carcinoma in situ (nonivasive, flat)
T1 = lamina propria invasion
T2 = muscularis propria invasion
T3a = microscopic extra-vesicle invasion 
T3b = grossly apparent extra-vesicle invasion
T4 = invades adjacent structures
87
Q

Describe the prognosis in TCC/UCC?

A
  • recurrences are common
  • outcome depends on grade and stage
  • poor prognosis for metastatic disease
88
Q

How does grade affect prognosis for TCC/UCC?

A

Low grade TCC = 98% alive at 5 years

89
Q

How does stage affect prognosis for TCC/UCC?

A

Muscle invasion = 60% 5 year survival

7. CP - Kidney and Urinary Tract Disease (5 decks)

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