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Y2 Clinical Pathology > Kidney and urinary tract pathology > Flashcards

Kidney and urinary tract pathology Flashcards

1
Q

What is pathogenisis

A

What is the mechanism causing the disease

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2
Q

What is aetiology

A

What causes the disease

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3
Q

What is epidemiology

A

Who gets the disease

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4
Q

What is renal cell carcinoma

A

Cancer of the kidney that arises from the renal tubular epithelium

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5
Q

What are the most common types of renal cell carcinoma

A 
Clear cell (75%)
Papillary (10%)
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6
Q

What is the epidemiology of renal cell carcinoma

A 
60yo+
Male > female
Family history
PMH of:
-Obesity
-Smoking
-NSAID use
-ESRF and on dialysis
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7
Q

What are paraneoplastic syndromes

A

Signs and symptoms that are not related to local effects of the primary or metastatic tumours
Develop as a result of either:
-proteins/ hormones secreted by tumour cells
-immune cross reactivity between tumour cells and normal tissues

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8
Q

What are the clinical features of renal cell carcinoma

A

Local primary tumour effects:

  • Haematuria
  • Abdominal pain

Effects of distant metastases:

  • Lung mets-> SOB etc
  • Bone mets -> bone pain etc

Paraneoplastic syndromes:

  • PNS are common in RCC and include:
  • weight loss (cancer cachexia)
  • Hypertension (renin)
  • Polycythemia (EPO)
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9
Q

What is Wilms’ tumour and who gets it

A

Nephroblastoma
Cancer of the kidney that arises from the nephroblasts (cells that develop into the kidney in embryological development)
Children under 5

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10
Q

What are the clinical features of Wilm’s tumour

A

Abdominal distention
Haematuria
Mets are rare
PNS are rare

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11
Q

What is urolithiasis

A

Urinary tract calculi/ stones

Stones forming in the lumen of the urinary tract, anywhere from renal calyx to bladder

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12
Q

What are the types of urolithiasis

A 
Calcium stones (70%)
Urate stones (5%)
Cystine stones (1%)
Struvite stones (15%) (magnesium ammonium phosphate)
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13
Q

What causes each type of urolithiasis

A

Too high a concentration of a solute in the urine
Calcium: hypercalcemia
Urate: gout, malignancy (high cell turnover)
Cystine: congenital cystinuria (kidneys unable to reabsorb amino acids)
Struvite: urinary tract infection

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14
Q

What are the clinical features of urolithiasis

A 
Pain:
-Ureter: loin to groin
-Bladder: lower abdominal
-Urethra: dysuria
Haematuria (blood in urine)
Symptoms of complications
Obstruction leads to renal impairment 
Urinary stasis leads to infection
Local trauma leads to squamous metaphase and then SCC risk
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15
Q

What is dysuria

A

Painful urination

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16
Q

What is vesicoureteral reflux (VUR)

A

When urine flows backwards from the bladder to the ureter rather than from the bladder to the urethra

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17
Q

What is the epidemiology of VUR

A

Young people especially <2yo

Those with family history of VUR

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18
Q

What is the aetiology of VUR

A

Congenital abnormality of vesicoureteric junction

Shorter intramural ureter

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19
Q

What is the pathogenesis of VUR

A

Ureter enters bladder at abnormal angle -> dysfunction of vesicoureteric junction -> when voiding, urine flows the wrong way

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20
Q

What are the clinical features of VUR

A

Usually asymptomatic
Only symptoms of complications
Stasis: UTI
Back pressure and ascending infection - renal damage

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21
Q

What are the clinical features of urothelial carcinoma

A 
Haematuria
Frequency, urgency, dysuria, urinary obstruction
Lung mets - SOB
Bone mets - bone pain
Liver mets - jaundice
PNS are rare
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22
Q

What is urothelial carcinoma

A

Transitional cell carcinoma
Cancer of urothelial epithelium
Accounts for >90% of bladder cancer

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23
Q

What is the epidemiology of urothelial carcinoma

A 
Adults aged >60yo
M>F
Smokers
Exposure to certain industrial chemicals
Family history
Treatment for other Cancer (pelvic radiotherapy, cyclophosphamide)
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24
Q

What is a neurogenic bladder

A

Inability to properly empty the bladder due to neurological damage
Two types:
-Spastic if damage to brain or spinal cord (UMN)
Flaccid if damage to peripheral nerves (LMN)

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25
Q

What causes neurogenic bladder

A

UMN damage:

  • stroke
  • MS
  • Spinal injury

LMN damage:

  • Pregnancy
  • Diabetes
  • Alcohol
  • B12 deficiency
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26
Q

What are the clinical features of neurogenic bladder

A

Symptoms of lack of control of bladder emptying:

  • Urinary retention
  • Abdominal distention
  • Incontinence
  • Urge
  • Frequency

Symptoms related to complications:
-Stasis -> UTI -> dysuria
-Stasis -> urinary stones -> haematuria
Inability to empty bladder -> bladder distention -> hydroureter -> hyronephrosis -> renal function impairment -> oedema

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27
Q

What is benign prostatic hyperplasia

A

Increased number of both stroll and glandular cells in the prostate
Know by patients as an enlarged prostate

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28
Q

What is the epidemiology of benign prostatic hyperplasia

A

Old men
Obesity
Diabetes
Family history

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29
Q

What are the clinical features of benign prostatic hyperplasia

A

Lower urinary tract symptoms:

  • Hesitancy or urgency
  • Poor/ intermittent stream
  • straining
  • prolonged micturition (peeing)
  • Incomplete bladder emptying
  • Dribbling
  • Frequency
  • Incontinence
  • Nocturia (waking in night to pee)
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30
Q

What is prostatic adenocarcinoma

A

Cancer of the glandular epithelium in the prostate

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31
Q

What is the epidemiology of prostatic adenocarcinoma

A

Old men
Black men
Family history (inc BRCA1 /2)
Pesticide exposure

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32
Q

What are the clinical features of prostatic adenocarcinoma

A

Lower urinary tract symptoms
Bone mets -> bone pain
PNS are rare

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33
Q

What is cryptochidism

A

Undescended testis where the testis is not in the scrotum

Types based on site of testis

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34
Q

Who gets cryptorchidism

A

Premature babies

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35
Q

What are the clinical features of cryptorchidism

A 
Empty scrotum
May resolve spontaneously or may develop complications:
-infertility
-hernias
-testicular cancer risk
-testicular torsion
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36
Q

What is seminoma

A

Malignant neoplasm of the testis arising from the germ cells in seminiferous tubules
Most common type of testicular cancer

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37
Q

Which forms of primary testicular tumour have a bad prognosis and so need more aggressive treatment

A 
Teratoma
Choriocarcinoma
Yolk sac
Embryonal
Lymphoma
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38
Q

Which forms of primary testicular tumour have a good prognosis and so need less aggressive treatment

A

Classic seminoma
Spermatocytic seminoma
Leydig cell tumour (usually benign)
Sertoli cell tumour (usually benign)

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39
Q

What is the epidemiology of seminoma

A

Young men 25 - 45 yo
family history
Crytorchidism regardless of whether it was surgically corrected or only affected the other testis

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40
Q

What are the clinical features of seminoma

A

Testicular lump, swelling, pain
Lung mets - SOB
LN mets - back pain
Gynecomastia (BHCG)

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41
Q

What are the complications of Urinary tract obstruction

A

Irreversible renal impairment and secondary VUR due to back pressures
Infection and calculi formation due to urinary stasis

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42
Q

What are the renal functions

A

Eliminate metabolic waste products
Regulate fluid/electrolyte balance
Regulate acid-base balance
Produce hormones

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43
Q

What hormones are produced by the kidneys and what do they do

A

Renin: fluid balance (RAAS)
Erythropoietin: stimulates erythrocyte production

44
Q

How does acute renal failure present

A

Unwell

Rapid rise in creatinine and urea

45
Q

How does nephrotic syndrome present

A 
Always due to damage to glomerulus
Oedema
Proteinuria
Hypoalbuminaemia
\+/- hypertension
\+/- hyperlipidaemia
46
Q

How does acute nephritis (nephritic syndrome) present

A 
Oedema
Proteinuria
Haematuria
Hypertension
Renal failure
47
Q

How does chronic renal failure present

A

Slow decline in renal function

48
Q

How is renal pathology diagnosed

A

Renal physician: clinical history, examination
Biochemist: Blood tests (urea, creatinine), Urine analysis (Protein, blood, electrolytes)
Pathologist: Renal biopsy (Light microscopy, immunofluorescence, electron microscopy)
Urologist: Cytoscopy (obstruction, haematuria)
Radiologist: Radiology (obstruction, kidney size, structural abnormalities)

49
Q

What is the blood flow of renal system

A 
Branches of renal artery
Afferent arteriole
Glomerulus (capillary bed- network of capillaries)
Efferent arteriole
Branches of renal vein
50
Q

What is thrombotic microangiopathy

A

Thrombi in capillaries/arterioles

Endothelial damage by bacterial toxins, drugs, complement or clotting system abnormalities

51
Q

What is vasculitis

A

Acute/chronic vessel wall inflammation with lumen obliteration
Various types affect different calibre vessels

52
Q

What causes vascular damage

A 
Hypertension
Diabetes
Atheroma
Thrombotic microangiopathy
Vasculitis
53
Q

What are the complications of nephrotic syndrome

A

Infection

Thrombosis

54
Q

What are the common causes of nephrotic syndrome

A

Adults:

  • Membranous nephropathy
  • Focal segmental glomerulosclerosis (FSGS)
  • Minimal change disease
  • Diabetes
  • Lupus nephritis
  • Amyloid

Children:

  • Minimal change disease (commonest)
  • Focal segmental glomerulosclerosis
  • Other causes are rare
55
Q

What are the various possible causes of FSGS

A

Idiopathic or genetic
Heroin use
HIV
Male more than female

56
Q

What are the causes of acute nephritis

A

Adults:

  • Post infective glomerulonephritis
  • IgA nephropathy
  • Vasculitis
  • SLE

Children:

  • Post infective glomerulonephritis
  • IgA nephropathy
  • Henoch-Schönlein purpura (specific IgA nephropathy)
  • Haemolytic-uraemic syndrome
57
Q

How does acute renal failure present

A 
Anuria/oliguria (<400ml/24h)
Raised creatinine and urea
Malaise
Fatigue
Nausea
Vomiting
Arrhythmias
58
Q

What are the causes of acute renal failure

A

Pre-renal: reduced blood flow to kidney (severe dehydration, hypotension (bleed, septic shock, LVF)) (renal biopsy unhelpful)
Renal: damage to kidney (renal biopsy can be helpful)
Post-renal: urinary tract obstruction (urinary tract tumours, pelvic tumour, calculi, prostatic enlargement) (renal biopsy unhelpful)

59
Q

What are the adult causes of acute renal failure

A

Vasculitis

Acute interstitial nephritis/ tubulointerstitial nephritis (tubular damage with inflammation usually due to drugs)

60
Q

What are the children causes of acute renal failure

A

PIGN
Henoch-Schönlein Purpura
Haemolytic uraemia syndrome
Acute interstitial nephritis

61
Q

What are potential complications of acute renal failure

A 
Cardiac failure (fluid overload)
Arrhythmias (electrolyte imbalance)
GI bleeding (multifactorial)
Jaundice (hepatic venous congestion)
Infection (especially lung and urinary tract)
62
Q

What is chronic renal failure

A

Permanently reduced GFR

Reduced number of functional nephrons

63
Q

What are the stages of chronic renal failure

A

Stage 1: Normal/increased GFR (>90ml/min/1.73m2)
Stage 2: Mild GFR reduction (60-89ml/min/1.73m2)
Stage 3: Moderate GFR reduction (30-59ml/min/1.73m2)
Stage 4: severe GFR reduction (15-29ml/min/1.73m2)
Stage 5: Kidney failure (GFR <15ml/min/1.73m2 or dialysis)

64
Q

What chronic conditions cause chronic renal failure

A

Adults:
-Dibetes

Children:
-Developmental abnormalities/ malformations

Both:

  • Glomerulonephritis
  • Reflux nephropathy (repeated infections/scarring)
65
Q

What is isolated proteinuria and what causes it

A 
No allied haematuria, renal failure or oedema
May be benign
May be due to renal disease:
Adult: FSGS, DM, SLE
Children: FSGS, HSP
66
Q

What causes isolated haematuria

A

IgA nephropathy
Thin basement membrane disease
Alport hereditary nephropathy

67
Q

What are the mechanisms of damage to kidneys due to hyperglycaemia in diabetics

A

Damaged basement membrane thickens and glomerulus produces excess extracellular matrix (nodules)
Small vessel damage causes ischaemia and tubular damage

68
Q

What is a myeloma

A

Plasma cell tumour
Excess Ig deposit in tubules cause inflammation and fibrosis
Renal tubule loss causes irreversible decline in renal function

69
Q

What is a UTI

A

An infection of any part of the urinary system

70
Q

What is an infection

A

The invasion of body tissues by a pathogenic organism which causes an immune response, giving rise to symptoms

71
Q

What causes a UTI

A

Usually an endogenous bacteria which has got in the wrong place and invaded

72
Q

Who are at higher risk of UTIs

A 
Female
Pregnant
Patients with:
-Prostatic hypertrophy 
-Stones 
-Strictures
-Neoplasia 
-Residual urine 
Urological instrumentation (including catheters)
Sexual intercourse
Fistulae: Recto-vesical, vesico-vaginal
Congenital abnormalities: vesico- ureteric reflux
73
Q

Which areas of the Urinary tract have bacteria and which are sterile

A

Sterile: kidney, ureter and usually the bladder (sometimes not though)
Colonised: urethra (perineal flora)

74
Q

What makes up perineal flora

A

Skin flora: mainly coagulase negative staphylococci
Lower GI tract flora:
-internal colonising bacteria found on skin around relevant orifice
-Anaerobic bacteria
-Aerobic bacteria
–Enterobacterales (coliforms, enteric gram negative bacilli)
–Gram positive cocci
—Enterococcus spp

75
Q

What is asymptomatic bacteriuria

A

No symptoms of a urinary tract infection but cultured urine sample grows a single organism in significant numbers

76
Q

What are the symptoms of cystitis (lower UTI) and who is most likely to contract it

A 
Dysuria
Frequency
Urgency
Supra-pubic pain or tenderness
Polyuria, nocturne, haematuria
More common in women
77
Q

What are the symptoms of an infection of the kidney or renal pelvis

A 
Dysuria
Frequency
Urgency
Supra-pubic pain or tenderness
Polyuria, nocturne, haematuria
More common in women
Loin/abdominal pain or tenderness
Fever
Signs of systemic infection:
-rigors, nausea, vomiting diarrhoea
-Elevated CRP, WBC
78
Q

What is a complicated UTI

A 
Underlying abnormality to structure or function
Urinary stasis
Presence of foreign body:
-catheter/other device/renal calculi
-biofilm
-Children <10-12
-Men <65
79
Q

What is Urosepsis

A

Systemic signs of infection related to any underlying urinary source of infection

80
Q

What are other causes of urethritis

A

STIs (gonorrhoea)
Thrush can cause irritation and symptoms such as dysuria
Urethral syndrome

81
Q

What is urethral syndrome

A

Symptoms of Lower UTI without infection

82
Q

What are the types of Urinary tract abscesses

A

Perinephric

Intra-renal

83
Q

What is prostatitis

A

Inflammation of prostate

84
Q

How does acute bacterial prostatitis present

A

Lower urinary tract symptoms
Fever
Tender tense prostate on PR palpation
Acute retention

85
Q

What are the risk factors for acute bacterial prostatitis

A

Procedures involving the prostate:
-Trans-urethral resection of prostate (TURP)
-Trans-rectal ultra-sound guided (TRUS biopsy)
Indwelling urinary catheter

86
Q

Which pathogens usually cause acute bacterial prostatitis

A

Typically normal urinary pathogens (E.coli)

Can be caused by S. aureus

87
Q

How does chronic prostatitis present

A

Pain inland around the perineum and genitalia
Lower urinary tract symptoms
Enlarged or tender prostate on examination

88
Q

What causes chronic prostatitis and how are the causes distinguished

A

> 90% due to chronic pelvic pain syndrome:

  • Negative urinary culture
  • Non-bacterial

Chronic bacterial prostatitis:

  • Recurrent UTIs with the same organism
  • Asymptomatic in-between
89
Q

What are the points of clinical tests

A

To confirm clinical suspicion
To find out the pathogen and how best to treat it
Monitor response

90
Q

What is imaging used for in UTIs

A

Is the Urinary tract anatomically normal?
Are there stones?
Is there an abscess

91
Q

What are the microbiological investigations available for UTIs

A

Dipsticks/Ward tests? Urinalysis

Laboratory testing of urine samples

92
Q

What do the ideal renal function tests do

A

Detect renal damage
Monitor functional damage
Distinguish between impairment and failure

93
Q

How is it known when the kidney functioning system is broken

A

No urine output
Clinical symptoms
Tests

94
Q

What is the flow for kidney function

A

Input arterial-> filter -> processor -> output venous/ output urine

95
Q

What are the lab tests for renal function

A 
Glomerular filtration rate
eGFR
creatinine clearance
plasma creatinine
plasma urea
urine volume
urine urea
urine sodium
urine protein
urine glucose
haematuria
96
Q

What is Oliguria

A

Abnormally low urine volume

24 hour volume less than 400ml

97
Q

When is a patient considered anuric

A

No or little urine, less than 100ml/24hr

98
Q

When does a patient have polyuria

A

Urine volume greater than 3 litres per day and not drinking.

99
Q

Which factors influence plasma urea conc

A 
GIT protein
Liver amino acids
Tissue protein
Distribution volume
Kidney reabsorption excretion
Kidney filtration
100
Q

What does urea excretion show

A

60% of urea is usually excreted with the rest being absorbed passively by the renal tubules
Rate of reabsorption depends on rate of tubular flow
More urea is reabsorbed if the flow rate is slow as there is more time for urea to diffuse into the peritubular capillaries
Tubular flow rate is slow when there is renal hypoperfusion

101
Q

What causes increased plasma urea

A 
GI bleed
Trauma
Renal hypoperfusion
Decreased RBF
Decreased ECFV
Acute renal impairment
Chronic renal disease
Post-renal obstruction calculus tumour
102
Q

What is the normal range of plasma creatinine and when should it be measured

A

50-140 umol/l

8 hours after a meal as evidence of increased conc after meat ingestion

103
Q

What does an increase in plasma creatinine mean

A

GFR decreased a large amount

In chronic renal disease it may increase to as high as 1000umol/l

104
Q

How do physicians predict when a patient will require dialysis or transplantation

A

Plot the reciprocal of the plasma creatinine conc which is linear and then extrapolate

105
Q

When is Glomerular filtration rate measured

A

No often as requires patient to come to hospital
People considering donating a kidney whilst alive
Before administering a potentially toxic drug before chemo

106
Q

How is GFR measured

A

Used to be by calculating the clearance of insulin but now radioactive substances are used

107
Q

How is creatinine clearance measured

A

(Urine creatinine conc m/mol/l x urine volume)/ plasma creatinine conc umol/l

Y2 Clinical Pathology (11 decks)

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