GU Flashcards
Name the two groupings of glomerulonephritis?
Quickly define each of the groupings
Nephrotic Syndrome - proteinuria w/ hypoalbuminaemia and oedema (greater than 3.5g/day)
Nephritic Syndrome - haematuria w/ oliguria and HTN (less than 3.5g/day)
What are the 4 primary nephrotic syndrome diseases?
What is the normal race associated with each?
Minimal change glomerulonephritis (children & adults)
Focal segmental glomerulosclerosis (black)
Membranous glomerulonephritis (Caucasian)
Membranoproliferative glomerulonephritis (Caucasian)
What are the 5 secondary causes for nephrotic syndrome?
What is the characteristic property of urine with high protein?
What biochemical disorder of the blood is common with nephrotic syndrome?
Diabetes Amyloidosis SLE Infections Malignancy (DASIM)
Frothy urine
Hypercholesterolaemia
Minimal change glomerulonephritis: Association with what disease? H&E? EM? IF? Note on prognosis
Association with Hodgkin’s lymphoma
Normal on H&E
Effacement of foot processes on EM
No immune complexes - no IF stainined
Children generally respond well to steroids, good prognosis
Focal segmental glomerulosclerosis: Association with what 2 diseases and \_\_ use? H&E? EM? Better or worse prognosis than MCD?
Association with HIV, sickle cell disease and heroin use
Focal and segmental sclerosis on H&E
Effacement of foot processes on EM
No immune complexes, no IF
Poorer response to steroids, will often progress to CKD
Membranous glomerulonephritis:
H&E?
EM?
IF?
Thick glomerular basement membrane on H&E
Spike and dome on EM
Positive granular IF
Membranoproliferative glomerulonephritis:
H&E?
EM?
IF?
Note on T1 vs T2?
Thick glomerular basement membrane on H&E
Tram track on EM
Positive granular IF
T1: “tram-tracks”, HBV & HCV, subendothelial
T2: association with C3 nephritic factor, intramembranous
What does RPGN stand for? Associated shape? What are the three possibilities in IF - what does this tell us about the diagnosis?
Rapidly progressive glomerulonephritis
Crescent shape on biopsy - macrophages and fibrin
Linear - Goodpasture’s
Granular - glomerulonephritis
Negative (pauci-immune) - ANCA vasculitis
What is Berger disease?
Presents in?
What category of diseases does it come under?
IgA nephropathy - deposition of IgA complexes in the mesangium of the kidney
Presents in children
Nephritic syndrome
Acute infections glomerulonephritis:
What is the common bacteria?
What particular protein will these carry?
Treatment is ___?
Group A beta-haemolytic strep infection of skin (impetigo) or pharynx
M protein - virulence factor
Treatment is supportive
Which specific cells does a renal cell carcinoma usually arise from?
Kidney tubules - specifically, proximal convoluted tubule
How would a renal cell carcinoma look on gross exam and microscopy?
Gross - yellow mass
Microscopy - polygonal clear (cytoplasm and lipid filled) cells
What are the two pathways for renal cancer? What population does each present in? What is the presentation in each? Main risk factor in each?
HEREDITARY pathway
younger patients, bilateral cancer
Von Hippel-Lindau Disease (also affects the cerebellum) - affecting VHL tumour suppressor gene
SPORADIC pathway
older patients, solitary cancer
Strong association with smoking
What is usual triad in the presentation of renal cell carcinoma?
What other general cancer symptoms could be seen?
What is the staging system in renal cell carcinoma?
Haematuria, palpable mass, flank pain - all 3 together is rare
Fever, weight loss and malaise
TNM system
What are examples of the paraneoplastic syndromes often seen in renal cell carcinoma?
A varicocele of what can sometimes be seen in renal cell carcinoma?
Production of:
EPO, renin, PTHrP, ACTH
LEFT sided varicocele of testicle - left spermatic vein drains into left renal vein (unlike right spermatic vein)
What is a angiomyolipoma?
Comprised of what 3 things?
A common benign tumour of kidneys
Blood vessels, smooth muscle and adipose tissue
What is Wilm’s tumour? - comprised of mostly ___?
Can also have ___ present? (3)
Normal presentation?
Association with what mutation and syndrome?
Malignant kidney tumour often affecting young children
Mostly blastema
Also: stroma, tubules, primitive glomeruli
Association with WT1 mutation and WAGR syndrome
Where can a urothelial carcinoma occur? Where does it most commonly occur?
What is the major risk factor? One more risk factor?
Classical presentation?
Can occur in urothelial lining of…
BLADDER (most common), RENAL PELVIS, URETER, URETHRA
Major risk factor: cigarette smoke
Also: cyclophosphamide
Classic presentation is haematuria
Two growth pathways in urothelial carcinoma?
Comparitive prognosis of each? p53 involvement?
Why is urothelial carcinoma often multifocal and recurring?
Papillary growth - low grade, high grade, invasion - often p53 independent
Flat growth - high grade, invasion (no low grade) - often p53 dependent
Field defect - smoking affects numerous cells
What are the two non-urothelial carncers of the lower urinary tract?
Basic description of each?
Squamous cell carcinoma - requires squamous metaplsaia
Chronic cystitis, Schistosoma, Chronic kidney stones
Adenocarcinoma - malignant proliferation of glands
Often arising from urachal remnant (dome of bladder)
What are the three major risk factors for prostate cancer?
Increasing Age
Family history - BRCA1 and BRCA2
Ethnicity (Afro-Caribbean increased, Far east uncommon)
What type of cancer is the majority of prostate cancer?
Two other very rare types?
Which are of the prostate does it usually grow in? (3 areas and percentage?)
Adenocarcinoma
Transitional cell carcinoma
Small cell prostate cancer
Peripheral (70%), transitional zone (20%), central zone (10%)
How does prostate cancer usually present?
Generic cancer symptoms? (3)
LUTS? (3)
Metastatic disease? (1)
Asymptomatic
Malaise, weight loss, anaemia
LUTS: heistancy, poor flow, dysuria, haematuria
Lower back pain from metastatic disease
What is the specific histological grading system for prostate cancer? - briefly describe the scoring
4 basic treatment strategies?
Gleason grading system -
2 most common cell patterns are scored from 1-5, and the numbers are added for 2-10 score
Active surveillance - minimise treatment, in low risk patients
Radical prostatectomy - used in fit patients with localised cancer
Radiotherapy - localised and advanced cancer
Hormone therapy (leuprolide) - used to reduce testosterone
Where do most testicular cancers arise from?
How many are seminomas vs non-seminomas?
From germ cell tumours
60% seminomas, 40% non-seminomas
How does testicular cancer present? 1 major points, 3 minor points
Mass in testicle +/- pain
Dull ache may be present
Post-pubertal gynecomastia
Impotence
Physical exam of testicular cancer would show?
Key point to differentiate it from differentials?
What scan is used?
Two serum markers check for?
Physical examination - suspicious masses are often firm and non-fluctuating
Don’t transilluminate -differentiate from Torsion, Epididymitis, Hydrocele
Ultrasound
Serum markers - alphafetoprotein (AFP) and human chorionic gonadotrophin (HCG)
Is a biopsy done on testicular cancer?
What is the general management timelines for testicular cancer?
Prognosis is…?
No - might spread the cancer
Radical inguinal orciectomy completed - looked at
Cancer is staged then surveillance and chemotherapy may be done
Good prognosis (5 year survival rate = 95%)
What is the major hormone driving BPH?
Is there an increased risk of cancer in BPH?
What two components of the prostate are enlarged?
What zone is usually enlarged?
Dihydrotestosterone (DHT)
No increased risk of cancer
Stroma and glands are increased
Transitional zone - surrounds urethra
Mjaor risk factor for BPH? Explain why this risk factor occurs
Another risk factor?
Increasing age
5-alpha-reductase increases with age - more DHT
Smoking
Using the FUN WISE mneumonic - name the 3 storage symptoms and 4 voiding symptoms of BPH.
What other two urine-related symptoms may be present?
Frequency, urgency, nocturia
Weak stream, intermittency, straining, emptying incomplete
Microscopic haematuria and dysuria may be present
3 complications of BPH? Why is urinalayis often done with BPH?
Hydronephrosis, infections, stones
Can rule out the main ddx - UTI
What is the conservative management of BPH?
What is the name of the surgery done?
Reduce caffiene and alcohol, bladder retraining
Transurethral resection of prostate
What are the 3 medications that can be used for BPH?
Drug name/names?
How do they work?
Alpha-1 blockers: relaxes smooth muscle - terazosin, doxazosin
5-alpha-reductase inhibitors: stop DHT formation - finasteride
Anticholinergics may be used for overactive bladder
What are the two major causes of CKD? Name 3 other kidney related causes? Name 3 other non-kidney related causes? What long term medication use? \_\_\_ can develop into CKD
Hypertension, Diabetes
Chronic glomerulonephritis, Cystic disease, Obstructive uropathy
SLE, RA, HIV
NSAIDs
AKI into CKD
How does early CKD present? Later presentation: General (2) Encephalopathy (1) Haematological (1)
Asymptomatic
Nausea, loss of appetite
Asterixis
Anaemia
Diagnostic definition of CKD?
What does accelerated CKD mean?
GFR <60ml/minute per 1.73m^2, for 3 months or more
Accelerated - 25% or more decrease in GFR within 12 months
What are the stages of CKD and related GFR ranges?
What else is used to determine CKD prognosis?
1 = >90 ml/minute/1.72m^2 2 = 60-90 ml/minute/1.72m^2 3a = 45-60 ml/minute/1.72m^2 3b = 30-45 ml/minute/1.72m^2 4 = 15-30 ml/minute/1.72m^2 5 = <15 ml/minute/1.72m^2
Albuminuria is also considered - placed into 3 stages
Main principle in CKD management?
Options if ESRF is reached?
Treat the cause
Dialysis or Kidney transplant
Name the 3 most common bacterial STIs. What bacteria causes each?
4 other viral STIs?
Chlamydia - Chlamydia trachomatis
Gonorrhoea - Neisseria gonorrhoeae
Syphillis - Treponema pallidum
Herpes (HSV), Genital Warts (HPV), HIV, Hep B
How does chlamydia and gonorrhoea present in males (2) vs females (3)?
Males: Dysuria and urethral discharge
Females: Non-specific
Dysuria, discharge, menstural irregularity
How is chlamydia diagnosed? Samples are from?
Nucleic Acid Amplification Tests (NAAT) e.g, PCR
Females - self-collected vaginal swab
Males - first void urine
Normal population for chlamydia vs gonorrhoea? Which of these commonly has asymptomatic carriage?
Chlamydia is most common in women & young adults
Gonorrhoea is more common in men & has a wider age range
Asymptomatic carriage of chlamydia is more common than gonorrhoea
How is gonorrhoea diagnosed?
Taken from where? (3)
Microscopy of gram-stained smears of genital secretions, looking for gram negative diplococci
Male urethra, female endocervix, rectum
Treatment of bacterial STIs: 2 involved in all of them? Chlamydia? Gonorrhoea? Syphilis?
Partner management, test for other STIs
Azithromycin or Doxycycline
Azithromycin AND Ceftriaxone
Penicillin (injecion)
What are the 2 major stages of syphilis?
What are the 3 big complications of syphilis?
Early infectious syphilis (within 2 years) Late syphilis (over 2 years)
Gumma, neurosyphilis, cardiovascular complications
What are the 3 stages within EARLY SYPHILIS?
What are the symptoms of syphilis and how do these change within early syphilis?
Primary: Primary chancre (painless) often on genitalia, but depends on transmission route
Secondary: 6-8 weeks after
Non-itchy maculopapular rash
Generalised lymphadenopathy
Mouth ulcers
Latent: (early latent)
How can syphilis be transmitted?
What are the diagnosis methods for syphilis?
BODY FLUIDS:
Sexual contact, needles, direct contact with lesion
VERTICAL TRANSMISSION:
Can cause congenital syphilis
Diagnosis:
Early moist lesions - sample
Normal diagnosis - serology and particle agglutination test
2 classifications of UTIs?
From there can be either ____ or ____?
Uncomplicated - non-pregnant women
Complication - pregnant, men, catheters, children, etc…
Asymptomatic or symptomatic
Name the most common cause of UTIs? Renal stones one? Hospital one? Young women one? 2 others?
E. coli >50% of cases Proteus - renal stone Klebsiella - hospital/catheter Staph. saprophyticus - young women Staph. aureus and Enterococci
Symptoms of UTI:
3 lower tract
3 upper tract
What would be found on urine dipstick?
Dysuria and frequency, haematuria
Fever and haematuria, possible sepsis?
Nitrate, Leukocytes, Blood?
Management of UTI:
Asymptomatic in >65
Uncomplicated - what 2?
Complicated - ?
Do not treat
Trimethoprim OR Nitrofurantoin - MSU not needed, dipstick only
Complicated - send MSU sample, longer antibiotic course
Risk factors for UTI:
Can you name 5 out of 8?
Female Frequency sex Catheter Pregnancy Circumcision Diabetes Urine retention Obstruction - eg, BPH
Typical population for pyelonephritis?
Triad of symptoms?
Normal treatment?
Women younger than 35
Loin pain, fever, pyuria (vomiting?)
Co-amoxiclav for 14 days
3 categories of AKI aetiology?
Name 3 examples within each category
Pre-renal: Hypovolaemia, Shocks, CHF
Post-renal: BPH, Kidney stones, intra-abdominal tumours
Intra-renal: Acute Tubular Necrosis, Glomerulonephritis, Acute Interstitial Nephritis
Name the two groups of medications you can’t give to someone with impaired kidney function. Explain the mechanism behind this
NSAIDs- inhibit COX enzymes, stop prostaglandin synthesis needed for vasodilation of the afferent arteriole
ACEi/ARB- stop the RAAS system from maintaining the blood pressure needed to perfuse the kidney
Acute Tubular Necrosis:
What part of the nephron does it affect most?
2 causes? Examples from one the of the main causes?
What happens to the damaged cells?
Affects PCT the most
Ischaemia
Nephrotoxins - aminoglycosides, lead (heavy metals), anti-freeze, radiocontrast dye
Cells slough off - causes blockages in nephrons and brown spots I the urine
Diagnosis of AKI: 3 guidelines. How many of these 3 needed?
Any 1 or these 3
- Rise in Creatinine > 26 micromol/L in 48 hrs
- Rise in Creatinine < 50% of lowest figure in last 6 months)
- Urine output < 0.5ml/kg/hr for >6 consecutive hours
What is the major emergency in AKI?
ECG findings? How do these progress?
3 different medication managements?
Hyperkalaemia - > 6mmol/L
ECG:
First - tall, peaked T waves
Second - small P waves, prolonged PR and QRS
Third - arrhythmia
Insulin + Dextrose
Calcium gluconate
Salbutamol
Usual BUN:Cr ratio? How does it change in pre-renal, post-renal and intra-renal AKI?
5-20:1
Pre-renal >20:1
Activation of RAAS - more water and salt reabsorption
Intra-renal <20:1
General reabsorption is impaired
Post-renal
>20:1 initially (fluid build-up)
<20:1 later (epithelial cell damage)
What is the classic age for kidney stones? But age is getting ____
Males vs Females?
Is recurrence common? Main advice after treatment?
Male > Female 2:1
Commonest age is 30-50, but getting younger (teenagers now)
Yes - recurrence is common, drink lots of water
What is the two most common types of renal stones? (how much) Which is most common? Colour? X-ray? Acidic or alkaline?
80% are calcium based
Calcium oxalate: more common, black/dark brown, radiopaque on X-RAY, acidic
Calcium phosphate: less common, dirty white, radiopaque on X-RAY, alkaline
Other than calcium stones, name 4 other stones:
10% - name, colour, x-ray
5-10% - name, when, made of, shape, x-ray, colour
1% - name, condition
<1% - name
10% uric acid - red-brown, radiolucent
5-10% struvite (infection stones - Mg, Amm, Phos, from urease positive bacteria, staghorn, radiopaque, dirty white)
Cystine (congenital condition - COLA)
Xanthine stones
One line description of how renal stones form?
Most common cause of renal stone formation?
Rarer cause?
Supersaturation of solutes results in precipitation and crystals forming
Most common cause - idiopathic (probably dehydration)
Rarely hypercalcaemia via primary hyperparathyroidism
Name 4 of 6 risk factors for renal stones?
Male, 20-50, Caucasian/Asian, High Protein & Salt, Family History, Oxalate-rich foods
Presentation of renal colic: Often \_\_? Pain - site? onset? radiation? character? severe? 2 other symptoms? Urine may have \_\_\_\_? What 2 LUTS may be present?
Often asymptomatic
Pain is classically sudden onset, waking up patient, radiation to groin, colicky, severe
Fever
Nausea and vomiting
Haematuria (visible or no visible)
LUTS - frequency and urgency
What is the gold-standard scan for kidney stones?
What other scans may be done?
Name 3 complications of renal stones?
Main differential to look out for?
Non-contrast CT scan - kidney, ureter, bladder
NCCT-KUB
Ultrasound, X-rays
AKI, hydronephrosis, pyonephrosis (pus)
Ruptured AAA
4 management stratigies in kidney stone disease?
Conservative - many will pass on their own, pain management and anti-emetic
Medical expulsion therapy - CCBs or alpha-blockers
Shockwave lithotripsy
Surgery or stent placement
What is hydronephrosis? Difference from hydroureter? General aetiology - hydronephrosis is caused by \_\_\_ 4 causes in adults? 2 in antenatal babies?
Build-up of urine inside kidney causes swelling
Hydroureter - ureter only
Hydronephrosis - ureter and kidney
Caused by urinary retention
Kidney stones, BPH, Urethral strictures, Cancers
Vesicouretral reflux, congenital ureterpelvic junctin obstruction
Testicular/scrotal lump differential:
What is done to confirm diagnosis?
5 differentials w/ description
History, Transilluminate, Ultrasound Scan
Testicular cancer - non-tender, from testicle, hard without transillumination, 15-40
Hydrocele - fluid build-up in the tunica vaginalis
Varicocele - swollen, pampiniform venous plexus, “bag of worms”
Epididymal cyst - sac of fluid at the epidydmis
Testicular torsion - emergency, extremely tender, often triggered by activity, needs surgery
Two major forms of cystic kidney disease?
Population it affects?
Associated genes?
Autosomal Dominant Polycystic Kidney Disease - adults, PKD1 and PKD2 (polycystin)
ARPKD - children, PKHD1
How might someone with ADPKD present? (4)
Screening - affected relative
Severe loin pain - cyst haemorrhage
Hypertension
Gross haematuria following trauma
