Kidneys

Question 1

What does a triad of loin pain, loin mass and haematuria indicate?

Answer 1

Kidney tumour: renal cell carcinoma (triad only occur in 10-15 % ) - mostly non-urological findings

Question 2

Name 7 causes and risk factors CKD

Answer 2

• Diabetes
. Ht
• age-related decline. Elderly
• glomerulonephritis
• medications eg NSAIDs, PPI, lithium
• polycystic kidney disease
• smoking

Question 3

Name 8 signs and symptoms ckd

Answer 3

Usually asymptomatic! But can present with
• pruritis (itching)
• loss appetite
• nausea
• oedema
• muscle cramps
• peripheral neuropathy
• pallor
• ht

Question 4

Name 4 nb investigations if suspect CKD

Answer 4

• EGFR using u&e. 2 tests 3 months apart to confirm diagnosis
• proteinuria using urine albumin: creatinine ratio (acr). ≥ 3 mg/ MMOL significant
• haematuria on dipstick (investigate further for malignancy)
. Renal ultrasound

Question 5

Define kidney failure

Answer 5

Kidney function drops below 15% , losing ability to remove waste and balance fluids, causing overload of toxins in body.

Question 6

Which bone # can cause renal injury?

Answer 6

12th rib

Question 7

Define glomerulonephritis

Answer 7

Renal disease characterised by inflammation and damage to glomeruli, allowing protein and blood to leak into the urine

Question 8

Define nephrotic syndrome

Answer 8

Massive proteinuria (≥3,5g/day) and hypoalbuminaemia (serum albumin ≤ 30 g / L )

Question 9

Define nephritic syndrome (5)

Answer 9

• Haematuria
• mild to moderate proteinuria < 3.5g/L/day
• hypertension
• Oliguria
• red cell casts in urine

Question 10

Classification of glomerulonephritis and some examples (6)

Answer 10

Non-proliferative: typically present with nephrotic syndrome
• minimal change glomerulonephritis, common in paeds
• focal segmental glomeruloscerosis FSGS, common in adults
• membranous glomerulonephritis associated with hep B, malaria, SLE

Proliferative: typically present with nephritic syndrome
• IgA rephropathy (Berger’s disease) must common in adults, after URTI
• post- infectious glomerulonephritis: streptococcal
• membranoproliferative glomerulonephritis: immune mediated
• anti-glomerular basement membrane antibody disease (anti-GBM) ( goodpasture syndrome)

Question 11

Name 4 mechanical congenital causes hydronephrosis

Answer 11

• antenatal hydronephrosis,
• post urethral valves,
• PUJO,
• VUR

Question 12

Name 10 mechanical acquired causes hydronephrosis

Answer 12

intrinsic:
• trauma, 
• inflammation and bleeding, 
• calculi, 
• urologic neoplasms, 
• BPH, 
• urethral stricture, 
• phimosis , 
• previous uro surgery

extrinsic:
• trauma, 
• neoplasms (uterine fibroid, Colorectal, uterine, cervical, lymphoma), 
• aortic aneurysm, 
• pregnancy gravid uterus

Question 13

Name 6 functional causes hydronephrosis

Answer 13

• neuropathic: neurogenic bladder, diabetic neuropathy, spinal cord disease
• Pharmacologic: anticholinergics, alpha adrenergic agonists
• hormonal: pregnancy (progesterone decreases ureteral tone)

Question 14

Urgent treatment of hydronephrosis if necessary?

Answer 14

Percutaneous nephrostomy tube or ureteral stent to relieve pressure

Question 15

Classification and types of renal stones ? (5)

Answer 15

Radio-opaque
• calcium oxalate and calcium phosphate 75-85%
• struvite (infection) 5-10%
. Cystine 1 %

Non -opaque
• Uric and 5-10%
. Indinavir

Question 16

Etiology and risk factors calcium oxalate/phosphate renal stones? (6)

Answer 16

• Hypercalcaemia
• hypercalciuria
• hyperoxaluria
• hyperuricosuria 25% (uric acid)
• low levels “inhibitors” ie hypocitraturia , hypomagnaesemia precipitate calcium and oxalate crystals in urine
• high dietary sodium, decreased urinary proteins, high urine ph and low volume eg gi water loss, hyperparathyroid, obesity, gout, dm

Question 17

Pathogenesis struvite renal stones? (6)

Answer 17

• UTI Infection with urea-splitting /producing organisms: proteus, pseudomonas, klebsiella, mycoplasma, S aureus, serratia, providencia
• urea broken down to ammonia
• alkaline urinary ph
• precipitation in urine of many proteins, pus cells and organisms forming matrix of stone
• Crystalline part of stone (magnesium, ammonium, phosphate) laid down on matrix
• if stone is formed and infection persist → “staghorn” configuration

Question 18

Name 7 factors and etiology associated with uric acid stone formation

Answer 18

• Low urine volume, dehydration, chronic diarrhea
• low urine ph
• diet purine rich foods: red meat
• hyperuricosuria with or without hyperuricemia
• gout
• high rate cell turnover or cell death eg leukemia, cytotoxic drugs
• drugs eg ASA aspirin, thiazides

Question 19

How is uric acid formed?

Answer 19

Product of purine metabolism

Question 20

Pathogenesis and etiology cystine stones?

Answer 20

Rare autosomal recessive aminoaciduria (cystine, ornithine, lysine, arginine cola) due to defect in small bowel mucosal and renal tubular absorption

Question 21

Pathogenesis and etiology indinavir stones?

Answer 21

• Indinavir= protease intribitor used in HIV rx

* soft stones, non-opaque

Question 22

Name 3 complications renal calculus

Answer 22

• UTI:pyelonephritis, pyonephrosis, perinephric abscesses and fistulae
• obstruction: hydronephrosis, renal failure
• chronic irritation: leukoplakia leading to SCC of renal pelvis

Question 23

Clinical presentation renal stones? (4)

Answer 23

• Haematuria
• pain due to urinary obstruction and upstream distension
- non colicky: flank pain from renal capsular distention
-Colicky: stretching of collecting system or ureter
• complications eg UTI, hydronephrosis, cancer
• infective stones may be “silent”

Question 24

Special investigations for renal stones? (6)

Answer 24

• Urine MCS
• abdominal xr: most stones radio-opaque except uric acid and indinavir
-Calcium stones round, irregular border
- struvite “staghorn”
-Cystine ground -glass
• IVP: stone site, obstruction extent, kidney function, anatomical abnormality eg PUJO
• metabolic evaluation, exclude primary hyper parathyroidism
• 24 hour urine in recurrent calcium stone formers
• stone analysis

Question 25

General treatment measures renal stones? (4)

Answer 25

• High fluid intake
• reduced salt intake (hypercalciuria)
• reduce red meat intake
• don’t restrict calcium intake! May cause hyperoxaluria
• analgesics (NSAIDs), antiemetic

Question 26

Medical Treatment uric acid stones

Answer 26

• General measures eg increase fluids
• First line = urine alkalinisation ph 6,5-7 for stone dissolution using bicarb and potassium citrate. Allopurinol (xanthine oxidase inhibitor) if hyperuricaemia

Question 27

Medical Treatment calcium renal stones (4)

Answer 27

• General measures eg increase fluids
• calcium oxalate stones
-Thiazides for normocalcaemic hypercalciuria
-Potassium citrate for hypocitraturia
• calcium phosphate
-Cellulose phosphate, orthophosphate for absorptive causes
. Calcium struvite
- antibiotics and surgical removal

Question 28

Treatment struvite renal stones

Answer 28

• Antibiotics 6 weeks
• surgical removal:
- percutaneous nephrolithotomy pcnl
-Open surgery for staghorn calculus

Question 29

Medical Treatment cystine renal stones

Answer 29

• General measures eg increase fluid intake
• “ extreme “ urine alkalanisation > 7,4 using bicarb, potassium citrate and
• penicillamine -form complex with cystine, prevention
Eswl not effective!

Question 30

Name 5 surgical treatment options for renal stones

Answer 30

• Extracorporeal shock wave lithotripsy eswl: for small stones < 2cm, fragments passed in urine
• percutaneous nephrolithotomy pcnl: > 2cm, removed with suction or forceps. Nephrostomy tube next few days. Used for most stones
• Open surgery: if very large stone bulk ie complicated large staghorn calculus
• chemolysis: smaller stone fragments dissolved by irrigation through nephrostomy tube
• nephrectomy

Question 31

Treatment ureter stone?

Answer 31

< 5mm will pass spontaneously

> 10mm need surgery