B&B Renal: Other Flashcards
1
Q
Cystitis
UTIs
A
Bladder infection
* Lower urinary tract
2
Q
Pyelonephritis
UTIs
A
Kidney infection
* Upper urinary tract
3
Q
UTI
Etiology
A
- E. coli: 75-90% of cases
- Proteus mirabilis
* Urease-producing –> struvite kidney stones - Klebsiella pneumoniae
- Staphylococcus saprophyticus
- Enterococcus faecalis
Typically enteric bacteria
4
Q
- Dysuria
- Frequnecy
- Urgency
- Suprapubic pain
- No systemic symptoms
- Usually normal plasma WBC count
Signs & Symptoms
A
Cystitis
5
Q
- Systemic symptoms: fever, chills
- Flank pain
- CVA tenderness
- Urine: hematuria; WBC casts
Signs & Symptoms
A
Pyelonephritis
Ascending infection –> will also have cystitis symptoms
6
Q
UTI
Diagnosis
A
- Urinalysis
- Cloudy urine
- Leukocyte esterase –> produced by WBCs in urine
- Nitrites –> 90% of UTI bugs convert nitrates to nitrites
- > 10 WBC/hpf
- Urine culture
- > 100,000 CFUs
7
Q
UTI
Risk Factors
A
- Women: 10x more likely than men
* Shorter urethra, closer to fecal flora - Sexual activity
- Urinary catheterization
- Diabetes
- Pregnancy
- Infants with vesicoureteral reflux
- Abnormal insertion of ureters into bladder
- Chronic backflow of urine back into ureters
- Urinary obstruction
- Anatomic abnormalities in children
- Bladder tumors in adults
- Enlarged prostate in older mens
8
Q
UTI
Treatment
A
Fluoroquinolones: ciprofloxacin, levofloxacin, ofloxacin
* Nitrofurantoin: used in pregnancy
9
Q
Chronic Pyelonephritis
UTIs
A
- Consequence of recurrent pyelonephritis
- Children w/ vesicoureteral reflux
- Adults w/ recurrent kidney stones
- Results in kidney injury
- Corticomedullary scarring
- Blunted calyces
- Renal thyroidization: tubules contain eosinophilic material, look like thyroid on LM
10
Q
Cystic Kidney Diseases
A
- Multicystic Dysplastic Kidney
- Autosomal Recessive PKD
- Autosomal Dominant PKD
- Medullary Cystic Kidney Disease
PKD = Polycystic Kidney Disease
11
Q
Multicystic Dysplastic Kidney
Cystic kidney Diseases
A
Abnormal ureteric bud-mesenchyme interaction in gestation
* Kidney replaced with cysts
* No / little functioning renal tissue
* Absent ureter
* Unilateral –> remaining kidney hypertrophies
* Bilateral –> Potter’s syndrome
* Oligohydramnios
* Failure of lung maturation
* Compression of face / limbs
* Not compatible with life
* Spontaneous congenital abnormality
* Not-inherited, unlike other cystic kidney diseases
12
Q
Autosomal Recessive PKD
PKD
A
- Occurs in infants; rare
- Bilateral –> Potter’s syndrome
- Renal failure
- High BP
- Key associations:
* Liver disease: fibrosis, cysts
* Portal hypertension: ascites
13
Q
Autosomal Dominant PKD
PKD
A
- Occurs in adults; more common
- Microscopic cysts present at birth
- Cysts are too small to visualize with U/S
- Kidneys appear normal at birth
- Cysts develop over many years
- Inherited mutation: APKD1 or APKD2 gene
- Key assocation
- Berry aneurysm –> subarachnoid hemorrhage
- Liver cysts
- Mitral valve prolapse
14
Q
- Young adult
- High BP
- Hematuria
- Renal failure
- Fx of sudden death (aneurysm)
Presentation
A
Autosomal Dominant PKD
15
Q
Medullary Cystic Kidney Disease
Cystic Kidney Diseases
A
- Autosomal dominant disorder
- Cysts develop in medullary collecting ducts
- Most patients do not have cysts
- Fibrosis of kidneys –> small, shrunken kidneys
- Kidneys are enlarged in other cystic diseases
- Often associated with early-onset gout
- Due to inability to properly filter uric acid
- Renal failure
16
Q
Types of Kidney Stones
Kidney Stones
A
- Calcium
- Struvite
- Urate
- Cystine
17
Q
- Flank pain (between ribs & hip)
- Colicky pain (waxes & wanes in severity)
- Hematuria
Signs & Symptoms
A
Kidney Stones
18
Q
Kidney Stones
Risk Factors
A
- High amount of stone substance in blood
- Hypercalcemia
- Hyperuricemia
- Low urine volume
- Usually from dehydration
- Increases concentration of urine substances
19
Q
Calcium Stones
Kidney Stones
A
- Most common type of kidney stone (80%)
- Calcium oxalate: most common
- Calcium phosphate
- Key risk factors:
- Hypercalcemia
- High oxalate levels in blood
- Radiopaque –> visible on X-Ray, CT
20
Q
Calcium Stones
Risk Factors
A
Most common etiology: idiopathic hypercalciuria
* Hypercalcemia (hyperparathyroidism)
* High oxalate levels
* Crohn’s disease
* Gastric bypass patients
* Ethylene glycol –> produces oxalate
* Vitamin C abuse –> produces oxalate
21
Q
Calcium Stones
Treatment
A
- Most stones pass on their own
- Larger stones that do not pass require surgery
- Recurrent stone formers may take prophylactics
* TZ diuretics: decrease Ca2+ in urine
* Citrate: binds Ca2+, inhibits stone formation
22
Q
Dietary Sodium
Calcium Stones
A
- Sodium balance
- Sodium intake increases ECV –> turns off RAAS
- Inactive RAAS decreases Na+ resorption in PCT
- Decreased Na+ resorption reduces Ca2+ resorption in PCT
- More serum [Na] = more urine [Ca]
- High Na diet –> increased risk of stone
- Low Na diet –> prevents stone formation
23
Q
Struvite Stones
Kidney Stones
A
- 2nd most common type of kidney stone: 15%
- NH3-Mg-PO4 stones
- Consequence of UTI
- Urease-positive bacteria: Proteus, Staph, Klebsiella
- All hydrolyze urea to ammonia
- Alkaline urine –> promotes stone formation
- Can form staghorn calculi
- Stones form a cast of renal pelvis & calyces
- Cannot pass on their own –> require surgery
- Untreated –> bacterial reservoir
* Results in recurrent infections
- Radiopaque –> visible on X-Ray, CT
24
Q
- UTI symptoms: dysuria, frequency
- Mild flank pain
- Hematuria
- Large, branching staghorn stone on imaging
Presentation
A
Staghorn Calculi
25
Uric Acid Stones
| Kidney Stones
* Caused by high uric acid in urine or acidic urine
* H+ + Urate- --> Uric Acid
* Lowest urine pH is in distal tubule / CD
* Radiolucent stones --> not visible on X-Ray
* Can see with CT scan
26
Uric Acid Stones
| Risk Factors
* High uric acid levels
* Gout
* Leukemia
* Myeloproliferative disease
* Acidic urine --> precipitates uric acid
* Chronic diarrhea
* More common in hot, arid climates
* Low urine volume & pH more common
27
Uric Acid Stones
| Treatment
Dissolve stone
* Hydration
* Alkalization of urine: HCO3-
28
Cystine Stone
| Kidney Stones
* Seen in children with cystinuria
* Tubular defect --> impaired cystine resorption
* Also form staghorn calculi
* Treatment: hydration & alkalinzation of urine
29
Renal & Bladder Tumors
| Urinary Tract Tumors
1. Renal Cell Carcinoma (RCC)
2. Wilms' Tumor
3. Renal Angiomyolipoma
4. Transitional Cell / Urothelial Carcinoma (TCC / UC)
5. Squamous Cell Carcinoma (SCC)
6. Adenocarcinoma
30
Most common kidney tumor
* Epithelial tumor
* Commonly arises from proximal tubule cells
| Renal Tumors
RCC
31
1. Sex: M > F
2. Age: 50-70 years
3. Cigarette smoking
4. Obesity
| Risk Factors
RCC
32
* Classic triad (< 10% of patient):
* Hematuria
* Palpable abdominal mass
* Flank pain
* Many patients have fever, weight loss
* Many pts are asymptomatic until advanced disease
* 25% have mets / advanced disease at presentation
| Presentation
RCC
33
* Invades renal vein
* Can block drainage of spermatic vein on left
* Left varicocele = classic finding
* Not right --> R. spermatic drains directly to IVC
* Spreads through venous system
* Common sites for mets:
* Lungs
* Bone
* Can also spread to retroperitoneal lymph nodes
| Spread / Metastases
RCC
34
* Polycythemia --> increased Hct
* EPO production by tumor
* Hypercalcemia
* Tumor production of PTH-related peptide
* Increased Ca resorption from bone
* Hypertension
* Renin production by tumor
* Cushing's Syndrome
* ACTH production by tumor
* Look for weight gain, HTN, hyperglycemia
| Paraneoplastic Syndromes
RCC
35
Most common type of RCC
| Pathology
Clear cell carcinoma
* Cells filled with glycogen & lipids
36
RCC
| Genetics
Associated with chromosome 3 gene deletion
* Von-Hippel-Lindau (VHL) gene
* Sporadic mutation
* Single tumor
* Older patient, usually smoker
* Inherited mutation
* Younger patient
* Multiple, bilateral tumors
37
VHL Disease
| RCC
Autosomal dominant VHL gene inactivation
* Diffuse tumors:
* RCC
* Cerebellar hemangioblastoma
* Retinal hemangioblastoma
38
RCC
| Treatment
* Surgical resection in early disease
* Poorly responsive to CTX / radiation
* Recombinant cytokine: IL-2
* Side effects: hypotension, fevers, chills
39
Most common renal malignancy of young children
* Proliferation of metanephric mesenchyme
* Embryonic glomerular structures
| Renal Tumors
Wilms' Tumor
40
Wilms' Tumor
| Genetics
Associated with loss of function mutation in chromosome 11
* WT1 tumor suppressor gene
* May be sporadic, often part of a syndrome
41
WAGR Syndrome
| Wilms' Tumor
WT1 gene deletion in chromosome 11
* Wilms' tumor
* Aniridia = absence of iris
* Visual problems
* Genital anomalies
* Cryptorchidism
* Ambiguous genitalia
* Mental retardation
42
Benign tumor of blood vessels, smooth muscle, and fat in young children
* Associated with tuberous sclerosis
| Renal Tumors
Renal Angiomyolipoma
43
Most common tumor of urinary tract system
* Most common type of bladder cancer
* Locations:
* Bladder: most common
* Also can occur in renal calyces, pelvis, ureters
* Often multifocal & recurrent
* "Field defect": damage to entire urothelium
| Urinary Tract Tumors
Transitional Cell Carcinoma (TCC)
44
* Smoking
* Cyclophosphamide
* Phanacetin
* Aniline dyes (hair dyes)
* Workplace exposures:
* Rubber, textiles, leather
* Naphthaline (industrial solvent)
* Painters, machinists, printers
| Risk Factors
TCC
45
TCC
| Diagnosis
Cytoscopy & biopsy
46
TCC
| Treatment
* Surgical resection
* Radiation
* CTX: combination Tx with platinum-based regimens
* Cisplatin
* Carboplatin
47
SCC
| Bladder Cancers
* Rare bladder cancer
* Requires chronic inflammation of bladder
* Key risk factors:
* Recurrent kidney stones / cystitis
* UTI with *Schistosoma haemotobium*
48
*Schistosoma haematobium*
| SCC
Trematode found in Africa & Middle East (Egypt)
* Acquired from freshwater containing larvae
* Penetrate skin & migrate to liver for maturation
* Adult infect bladder
* Usually causes hematuria
* Chronic bladder infection can result in SCC
49
Adenocarcinoma
| Bladder Cancers
* Very rare bladder cancer
* Glandular prolieration in bladder
* Occurs in special circumstances
* Urachal remnant
* Long history of cystitis
* Bladder exstrophy
50
* Syndrome caused by muscle necrosis
* Can lead to renal failure & death
Rhabdomyolysis
51
Causes of Muscle Damage
| Rhabdomyolysis
1. Intense physical exercise --> especially if dehydrated
2. Crush injuries: trauma
3. Drugs: statins, fibrates
52
Muscle Contents
| Rhabdomyolysis
* Creatine kinase
* Elevated levels are hallmark of rhabdo
* Aldolase
* LDH
* AST / ALT
53
Muscle Contents
| Rhabdomyolysis
* Creatine kinase
* Elevated levels are hallmark of rhabdo
* Aldolase, LDH, AST / ALT
* Potassium & phosphate
* Hyperkalemia & hyperphosphatemia in rhabdo
* Purines --> metabolized to uric acid in liver
* Can lead to hyperuricemia
* Myoglobin --> binds oxygen for use by muscle
* Contains heme
54
Renal Toxicity
| Myoglobin
* Obstructs tubules
* Toxic to proximal tubular cells
* Vasoconstriction --> especially in medulla
* Leads to hypoxia
55
* Muscle pain
* Weakness
* Dark urine
| Presentation
Rhabdomyolysis
* Dark urine due to myoglobin
56
Rhabdomyolysis
| Diagnosis
* Creatine kinase
* Normal: <250 IU/L
* Rhabdo: >1,000 IU/L
* Urinalysis for heme
* Positive dipstick = hemoglobin or myoglobin
* Microscopy for RBCs
* No evidence of RBCs
