Kidneys Flashcards
What does a triad of loin pain, loin mass and haematuria indicate?
Kidney tumour: renal cell carcinoma (triad only occur in 10-15 % ) - mostly non-urological findings
Name 7 causes and risk factors CKD
• Diabetes . Ht • age-related decline. Elderly • glomerulonephritis • medications eg NSAIDs, PPI, lithium • polycystic kidney disease • smoking
Name 8 signs and symptoms ckd
Usually asymptomatic! But can present with • pruritis (itching) • loss appetite • nausea • oedema • muscle cramps • peripheral neuropathy • pallor • ht
Name 4 nb investigations if suspect CKD
• 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
Define kidney failure
Kidney function drops below 15% , losing ability to remove waste and balance fluids, causing overload of toxins in body.
Which bone # can cause renal injury?
12th rib
Define glomerulonephritis
Renal disease characterised by inflammation and damage to glomeruli, allowing protein and blood to leak into the urine
Define nephrotic syndrome
Massive proteinuria (≥3,5g/day) and hypoalbuminaemia (serum albumin ≤ 30 g / L )
Define nephritic syndrome (5)
- Haematuria
- mild to moderate proteinuria < 3.5g/L/day
- hypertension
- Oliguria
- red cell casts in urine
Classification of glomerulonephritis and some examples (6)
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)
Name 4 mechanical congenital causes hydronephrosis
- antenatal hydronephrosis,
- post urethral valves,
- PUJO,
- VUR
Name 10 mechanical acquired causes hydronephrosis
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
Name 6 functional causes hydronephrosis
- neuropathic: neurogenic bladder, diabetic neuropathy, spinal cord disease
- Pharmacologic: anticholinergics, alpha adrenergic agonists
- hormonal: pregnancy (progesterone decreases ureteral tone)
Urgent treatment of hydronephrosis if necessary?
Percutaneous nephrostomy tube or ureteral stent to relieve pressure
Classification and types of renal stones ? (5)
Radio-opaque
• calcium oxalate and calcium phosphate 75-85%
• struvite (infection) 5-10%
. Cystine 1 %
Non -opaque
• Uric and 5-10%
. Indinavir
Etiology and risk factors calcium oxalate/phosphate renal stones? (6)
- 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
Pathogenesis struvite renal stones? (6)
- 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
Name 7 factors and etiology associated with uric acid stone formation
- 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
How is uric acid formed?
Product of purine metabolism
Pathogenesis and etiology cystine stones?
Rare autosomal recessive aminoaciduria (cystine, ornithine, lysine, arginine cola) due to defect in small bowel mucosal and renal tubular absorption
Pathogenesis and etiology indinavir stones?
- Indinavir= protease intribitor used in HIV rx
* soft stones, non-opaque
Name 3 complications renal calculus
- UTI:pyelonephritis, pyonephrosis, perinephric abscesses and fistulae
- obstruction: hydronephrosis, renal failure
- chronic irritation: leukoplakia leading to SCC of renal pelvis
Clinical presentation renal stones? (4)
• 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”
Special investigations for renal stones? (6)
• 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
General treatment measures renal stones? (4)
- High fluid intake
- reduced salt intake (hypercalciuria)
- reduce red meat intake
- don’t restrict calcium intake! May cause hyperoxaluria
- analgesics (NSAIDs), antiemetic
Medical Treatment uric acid stones
- 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
Medical Treatment calcium renal stones (4)
• 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
Treatment struvite renal stones
• Antibiotics 6 weeks
• surgical removal:
- percutaneous nephrolithotomy pcnl
-Open surgery for staghorn calculus
Medical Treatment cystine renal stones
• 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!
Name 5 surgical treatment options for renal stones
- 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
Treatment ureter stone?
< 5mm will pass spontaneously
> 10mm need surgery
