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Kidneys Flashcards

1
Q

Fetal lobulation vs scarring

A

Lobulation: Renal surface indentation overlie the space between the pyramids.

Scarring: Renal surface indentation overlie the medullary pyramids.

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2
Q

Dromedary hump affects which side?

A

Left side.

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3
Q

Re Renal agenesis:

Unilateral vs bilateral:

A

Unilateral: Female: Gynae anomaly eg unicornuate uterus
Male: Agenesis of epididymus/ VD/ SV cyst

Bilateral: Potter sequence

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4
Q

Define Potter sequence:

A

Insult (eg ACE I’s) –> Renal agenesis–> Pulmonary hypoplasia

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5
Q

Define Mayer Rokitansky Kuster Hauser

A

Mullerian duct anomalies including the absence or atresia of the uterus.

Associated with unilateral renal agenesis.

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6
Q

What sign is used to differentiate surgical absent vs congenital absence of adrenals.

A

Pancake adrenal sign or lying down adrenal.

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7
Q

What are the complications of horseshoe kidney?

A
  • Injury
  • UPJ obstruction
  • Recurrent infection
  • Recurrent stones
  • Wilm’s tumour- 8x more common
  • TCC from all those UTI’s
  • Renal carcinoid
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8
Q

What syndrome are associated with horseshoe kidney:

A

Turner syndrome and renal carcinoid.

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9
Q

What type of bone metastases in RCC?

A

ALWAYS Lytic bone mets

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10
Q

RF for RCC:

A

Smoking
Syndromes like VHL
Chronic dialysis > 3 years
Family history

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11
Q

What sort of liver mets RCC produce?

A

Hypervascular mets

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12
Q

What makes a lesion highly suspicious for RCC?

A
  1. Contrast enhancement >15 HU

2. Calcification in a fatty mass lesion. - CLEAR CELL type, can produce fatty liver metastases.

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13
Q

What are the 4 subtypes of RCC?

A
  1. Clear cell
  2. Papillary
  3. Medullary
  4. Chromophobe
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14
Q

Which subtype of RCC is associated with Sickle cell trait?

A

Medullary

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15
Q

Which subtype of RCC is associated with Birt Hogg Dube?

A

Chromophobe

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16
Q

Which subtype of RCC is associated with VHL:

A

Clear cell

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17
Q

What is the DDx for T2 dark renal mass/cystic lesions?

A
  1. Papillary RCC
  2. Haemorrhagic cysts- likely T1 bright
  3. Lipid poor AML. Think of tuberous sclerosis
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18
Q

Describe RCC Staging:

A
  1. Limited to kidney and < 7cm
  2. Limited to kidney and > 7cm
  3. Still inside Gerota’s fascia
    3A: RV invasion
    3B: IVC below diaphragm
    3C: IVC above diaphragm
  4. Outside Gerota’s fascia, ipsilateral adrenal.
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19
Q

What is papillary RCC is associated with ?

A

Hereditary papillary renal carcinoma

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20
Q

Re Renal lymphoma

  • Appearance? Unilateral or bilateral?
A

Most commonly bilateral, enlarged kidneys with small low attenuation cortically based solid nodules or masses.

A solitary mass is seen in 25%.

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21
Q

Out of all the renal masses what is the most likely to preserve the normal reniform shape?

A

Lymphoma

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22
Q

What is the most common visceral organ involved in leukaemia?

A

Kidneys

Typically the kidneys are smooth and enlarged. Hypodense lesions are cortically based only.

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23
Q

Re Oncocytoma:

  • DDx
  • On USS and PET
A
  • Solid mass with central scar- no malignant features such as vessel invasion.
  • DDx RCC, till proven otherwise
  • USS: spoke wheel vascular pattern
  • PET: hotter than surrounding renal cortex.
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24
Q

Name a syndrome associated with bilateral oncocytomas:

A

BHD- Birt Hogg Dube

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25
Q

RCC vs oncocytoma on PET

A

RCC is typically COLDER than surrounding renal parenchyma on PET.

Oncocytoma is typically HOTTER than surrounding renal parenchyma on PET.

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26
Q

What are the multilocular cystic nephroma- MLCN?

BUZZWORD

Age group

A

These are non communicating fluid filled locules surrounded by thick fibrous capsule. Characterised by absence of solid component or necrosis.

BUZZWORD: Protrudes into the renal pelvis.

Bi modal: 4 year old boys and 40 year old women.

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27
Q

List the Bosniak cyst classification:

A
  1. Simple cysts < 15 HU with no enhancement.
  2. Hyperdense < 3cm. Thin calcification, thin septation.
    2F. Hyperdense > 3cm. Minimally thickened calcifications (5% chance of cancer).
  3. Thick septations, mural nodules (50% chance of cancer)
  4. Any enhancement > 15HU. 100% chance of cancer
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28
Q

Hyperdense cyst

A

If the mass is > 70HU and homogenous - it is benign.

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29
Q

ADPKD

  • Age group
  • Association:
A

Autosomal Dominant in ADults

  • Hypedense cysts with calcified walls due to prior haemorrhage.
  • Cysts in liver 70%
  • Berry aneurysm
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30
Q

ARPKD

  • Presentation?
  • Liver findings?
A

HTN and renal failure.

  • Instead of cysts in the liver, they have abnormal bile ducts and fibrosis. CONGENITAL HEPATIC FIBROSIS is always present in ARPKD.
  • The ratio of liver and kidney disease is inversely related.
  • USS: Kidneys are smoothly enlarged and diffusely echogenic with loss of corticomedullary differentiation. .
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31
Q

Uraemic cystic kidney disease

A

40% of patients with end stage renal disease develop cysts. This rises with duration of dialysis

The cysts will regress after transplant.

One cause of small kidneys.

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32
Q

Multiple filling defect on a RUG.

A

Condyloma acuminata

Instrumentation including retrograde urography is contraindicated because of risk of seeding

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33
Q

What type of cancer is urethral cancer

A

Squamous cell cancer except prostatic urethra has TCC

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34
Q

Urethral diverticulum cancer

A

Adenocarcinoma

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35
Q

Saddle bag configuration on sag MRI, repeated infection

A

Female urethral diverticulum

Risk of adenocarcinoma

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36
Q

Re VHL

  • AD/AR/X linked?
  • what type of RCC?
A
  • Autosomal Dominant- AD

- Causes renal cysts and RCC (Clear cell).

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37
Q

VHL is a multi system disease. Which organs does it affect?

A

Multi system disease:

a) Pancreas:
- Cysts,
- Serous microcystic adenomas,
- Nuroendocrine tumour

b) Adrenal: Phaeochromocytoma
c) CNS: Haemangioblastoma

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38
Q

Re Tuberous sclerosis

  • AD/AR/X linked?
  • Which organs are affected?
A
  • AD, hamartoma

a) Lungs: LAM and chylothorax
b) Renal: Bilateral AML and RCC
c) Heart: Rhabdomyosarcoma
d) Brain:
- Giant cell astrocytoma
- Cortical and subcortical tubers
- Subependymal nodules

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39
Q

Re Lithium nephropathy:

What does it cause?

A

Diabetes insipidus and renal insufficiency

Normal to small sized kidneys with numerous tiny cysts

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40
Q

Multicystic Dysplastic Kidney - MCDK

  • Age group
  • Features?
A

Paediatric, formed in utereo

  1. Non functioning renal tissue- No excretory function in NM
  2. Contralateral renal tract abnormality in 50%-
    Vesico ureteric reflux most common anomaly followed by PUJ obstruction.
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41
Q

What does lipid poor AML most likely represent?

A

Tuberous sclerosis

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42
Q

What happens in chronic pyelonephritis:

A

Scarring, cortical thinning and atrophy, with hypertrophy of normal tissue.

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43
Q

What is the appearance of the acute pyelonephritis:

A

Striated nephrogram with perinephric stranding.

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44
Q

Most common organism responsible for pyelonephritis:

A

E Coli

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45
Q

What is emphysematous pyelitis:

  • RF?
A

This is localised to collecting systems. Gas in the ureters and dilated calyces.

RF: Female, Diabetes, Urinary obstruction

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46
Q

What do you understand by the term Pyonephrosis:

A

This is infection or obstruction of collecting system. Fluid level is seen in the collecting system on USS.

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47
Q

What are the causes of pyonephrosis?

A
  • Stones
  • Tumour
  • Sloughed papilla secondary to pyelonephritis
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48
Q

Re XGP

  • Process?
  • BUZZWORD
A
  • Most common cause is STAGHORN calculi, and repeated infection (proteus) which leads to chronic destructive granulomatous process.
  • Psoas and perirenal abscess
  • BUZZWORD: BEAR PAW sign on CT
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49
Q

Re Papillary necrosis:

  • Define
  • Causes
A

This is ischaemic necrosis of the renal papilla most commonly involving the medullary pyramids.

  • Most common cause:
    - Diabetes
    - Pyelonephritis
    - Sickle cell- 50% develop this.
    - TB
    - Analgesia
    - Cirrhosis
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50
Q

Papillary necrosis:

Sign?
Appearance

A
  1. Lobster claw sign: the necrotic cavity in the papilla with linear streaks of contrast inside the calyx has been called a lobster claw sign.
  2. Filling defects in the calyx,
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51
Q

The most common extrapulmonary site of TB infection is….

A

Urinary tract: Papillary necrosis and parenchymal destruction. Extensive calcification: Putty kidney: Autonephrectomy

52
Q

Name a sign of renal TB

A

Kerr Kink : Scarring leading to sharp kink at PUJ

Putty kidney: Auto nephrectomy

53
Q

This type of renal calculi cannot be seen on plain film:

A

Uric acid

54
Q

This type of renal calculi cannot be seen on CT:

A

Indinavir- seen in HIV patients.

55
Q

Which group of patients are more susceptible to get cystine stones?

A

Associated with congenital disorder of metabolism

56
Q

What are the most common causes of medullary nephrocalcinosis? (3)

A

Hyper PTH
Medullary sponge kidneys.
Renal tubular acidosis- type 1

57
Q

When I say unilateral medullary nephrocalcinosis, you say…

A

Medullary sponge kidney

58
Q

What are the associations of medullary sponge kidneys? (3)

A

Ehlers Danlos Syndrome
Carolis disease
Beckwith- weidman

59
Q

What is a Page kidney? Give an example:

A

This is a sequella of long standing compression of the kidney by some kind of subcapsular collection/haematoma/seroma.

Ex: post lithotripsy haematoma, F?U scan would show a shrunk up kidney

60
Q

Delayed vs persistent nephrogram:

A

Delayed would be in keeping with stone, and page kidney

Persistent nephrogram: ATN, shock, RVT and injury

61
Q

What are the two signs of renal infarct?

A
  1. Cortical rim signs

2. Flip flop enhancement

62
Q

What are the causes of RVT?

A
  1. Dehydration
  2. Indwelling umbilical venous catheter- most common in neonates
  3. Nephrotic syndrome- most common in adults.
63
Q

How would patients with RVT present ?

A

can mimic renal stone, flank pain, enlarged kidney and delayed nephrogram.

On doppler: reversed arterial diastolic flow and absent venous flow.

64
Q

RVT on Doppler: (2)

A
  1. Reversed arterial diastolic flow and

2. Absent venous flow.

65
Q

Where is the injury?

a) wedge shaped perfusion
b) Diffuse non perfusion
c) Persistant nephrogram

A

a) wedge shaped perfusion: segmental artery injury
b) Diffuse non perfusion : Devascularised kidney
c) Persistant nephrogram: RVT/Injury

66
Q

What do you know about PTLD post transplant?

A

Uncommon complication of transplant associated with B cell proliferation.
Most common after one year of transplant. Usually multi organ affected.
Treatment: stop immunosuppression.

67
Q

Significant exposure to cyclophosphamide, is associated with increased risk of……… Cancer

A

Urothelial cancer

68
Q

What are the 3 zones of adrenals? What do they release?

A
  1. Zona Glomerulos: Aldosterone
  2. Zona Fasiculata: Cortisol
  3. Zona Reticularis: Androgen
69
Q

What does adrenal medulla produce?

A

Catecholamines

70
Q

What are the two causes of adrenal hypertrophy?

A
  1. 21 Hydroxylase deficiency

2. Cushing syndrome

71
Q

What would patients with 21 Hydroxylase deficiency present with?

A 
Congenital adrenal hypertrophy:
Genital ambiguity (girls) or salt losing pathology (boys).

Imaging: Adrenal limb width > 4mm and loss of central hyper echoic stripe.

72
Q

What are the causes of Cushing syndrome?

A

a) Pituitary adenoma - 75%
b) Adrenal adenoma- 20%
c) Ectopic production from small cell lung cancer- bilateral gland hypertrophy

73
Q

What causes bilateral adrenal hypertrophy?

A

Ectopic production from small cell lung cancer- bilateral gland hypertrophy

74
Q

What are the causes of adrenal haemorrhage?

A
  • Stress: Breech birth, fatal distress, congenital syphilis

- Trauma

75
Q

What is Waterhouse Friderichsen syndrome?

A

Haemorrhage of the adrenal in the setting of fulminant meningitis ( from Neisseria Meningitidis)

76
Q

Name the lesion:

This (adrenal) mass lesion is usually large at presentation (>3cm), usually heterogeneous on CT.

MRI: T2 BRIGHT

A

Pheochromocytoma

77
Q

What NM studies are used to diagnose pheochromocytoma?

A

MIBG and octreotide

MIBG better since octreotide also uptakes in the kidney

78
Q

What do you understand by the “ rule of 10” in pheochromocytoma:

A 
10% are extra adrenal- usually at IMA
10% bilateral
10% in children
10% hereditary
10% NOT active- no HTN
79
Q

Which syndromes are associated with pheochromocytoma

A

VHL
MEN IIa/IIb

Less likely: NF 1, Sturge Weber, TS

80
Q

Define Carney triad:

A
  1. Extra adrenal pheochromocytoma
  2. GIST
  3. Pulmonary chondroma (hamartoma).

PS do not confuse this with carney complex ( cardiac myxoma and skin pigmentation)

81
Q

What are the myelolipima associated with?

A

Cushings
Congenital adrenal hyperplasia
Conns

82
Q

Appearances of myelolipoma

A

Benign tumours containing bulky fat
1/4 have calcification.
If > 4cm can bleed- retroperitoneal bleed.

NON FUNCTIONAL masses.

83
Q

Which tumours metastasise ti adrenals?

A 
Lung 40%
Breast 20%
Colon
Stomach
Lymphoma
Melanoma
RCC
Prostate
Pancreas 
Thyroid
84
Q

What do you know about adrenal cortical carcinoma?

A 
Usually large  (4-10cm), maybe functional (Cushing)
Can calcify in 20% of cases. 
Can have central necrosis.

Bad news! Direct invasion

85
Q

How would you diagnose adrenal adenomas?

A
  1. Non contrast < 10 HU
  2. MRI: Drop out on in and out of phase T1
  3. Contrast: two options:

a) Absolute:

[Enhanced CT - Delayed CT]
—————————————– x 100, > 60% = adenoma
[ Enhanced CT- Plain CT]

b) Relative :

[ Enhanced CT - Delayed CT]
—————————————— x 100, > 40% = adenoma
Enhanced CT

86
Q

Which two conditions can present with functional adenomas?

A
  • Cushings- ++++ cortisol

- Conn syndrome- ++++ aldosterone

87
Q

What is a Conn’s syndrome?

A

Too much aldosterone-
most commonly caused by :

  • Benign adenoma (70%)
  • Cortical carcinoma- rare, can accompanied by hypercortisolism
88
Q

What does adrenal calcification imply?

A

Previous trauma
Infection - TB
Certain tumours: cortical carcinoma, neuroblastoma.
Melanoma mets

89
Q

What is a Wolman disease?

A

AUNT MINNIE:
Bilateral enlarged calcified adrenals. Hepatosplenomegaly
It is a fat metabolism error (fat deposition everywhere including lymph nodes) - fatal within 6 months.

90
Q

Name the condition:

Bilateral enlarged calcified adrenals
It is a fat metabolism error - fatal within 6 months.

A

Wolman disease

91
Q

MEN I

A

3 P’s

  1. Pituitary Adenoma
  2. Parathyroid hyperplasia (90%)
  3. Pancreatic tumour ( Gastrinoma)
92
Q

Name the condition:

  1. Pituitary Adenoma
  2. Parathyroid hyperplasia (90%)
  3. Pancreatic tumour ( Gastrinoma)
A

MEN I

93
Q

MEN IIa

A

1M, 2Ps

  1. Medullary thyroid cancer - 100%
  2. Pheochromocytoma- 33%
  3. Parathyroid hyperplasia
94
Q

MEN IIb

A

2Ms, 1P

  1. Medullary thyroid cancer - 80%
  2. Marfanoid habitus/ mucosal neuroma
  3. Pheochromocytoma - 50%
95
Q

What are the causes of MEGA ureter?

A

Most cases have dilation of the lower 1/3. Almost always unilateral. Favouring the LEFT side.

  1. Distal adynamic segment
  2. Reflux at UVJ
  3. Idiopathic
96
Q

Name the anomaly:

Reverse J or fish hook appearance of ureters are seen in on IVU

A

Retrocaval ureter- circumcaval

97
Q

What is the Weigert Meyer Rule regarding renal duplicated system?

A

The upper pole inserts inferior and medial

98
Q

In duplicated system:

The upper and lower pole are more prone to what?

A

Upper pole: Obstruction and uretrocele

Lower pole: Reflux

99
Q

Name the condition:

Cobra head sign on IVU

A

Uretrocele - this is cystic dilation of intravesicular ureter secondary to obstruction at the ureteral orifice.

Associated with duplicated system especially the upper pole.

100
Q

What is the treatment for congenital PUJ obstruction?

A

Pyeloplasty

101
Q

What is PUJ obstruction associated with?

A
  • It is associated with crossing vessels: early branching lower pole compresses the uretercausing PUJO
  • Associated with MCDK on the other side
102
Q

How to tell the difference between a prominent extra renal pelvis and congenital PUJO

A

Whitaker test: Urodynamic study + integrate pyelogram

It measure the pressure differential between the renal pelvis and the bladder

103
Q

Ddx ureteral wall calcifications (2)

A
  1. TB

2. Schistosomiasis

104
Q

What is urethritis cystica:

A

Numerous tiny sub epithelial fluid filled cysts within the wall of the ureter- result of chronic inflammation - from stones, chronic +/- infection).
Seen in diabetic with recurrent UTI. Might be increased risk of cancer.

105
Q

Where does ureteral pseudodiverticulosis affect most?

A

It favours the upper and middle third.

Associated with malignancy

106
Q

What is Leukoplakia

A

This is squamous metaplasia secondary to chronic irritation - stone or infection. There will be mural filling defects.
It is considered pre malignant.( the cancer is squamous cell).

107
Q

What cancer type is associated with leukoplakia?

A

Squamous cell

108
Q

Malakoplakia?

What is it?
BUZZWORD: Michaelis Gutman bodies

A

This is an inflammatory condition in the setting of chronic UTI’s . Seen in immunocompromised patients

Plaque like or nodular intramural lesion causing obstruction.

NOT pre-malignant

109
Q

What are the causes of RPF?

A
  • Idiopathic: Ormond disease
  • Radiation
  • Medication - Methyldopa, ergotamine, methysergide
  • Inflammatory : pancreatitis, pyelonephritis, inflam aneurysm
  • Malignancy: Lymphoma, desmoplastic reaction
110
Q

What is RPF associated with

A

IgG4 disorders: Auto immune pancreatitis, reidels thyroids, inflammatory pseudotumour.

Medial deviation of ureters.

111
Q

RPF on NM:

A

Fibrosis will be GALLIUM avid and PET HOT in early stages and COLD in its later stages.

Metabolically active RPF : increased FDG and Gallium uptake regardless of benign or malignant underlying cause

112
Q

Name the condition:

Imaging BUZZWORD: Goblet or Champagne glass sign in CT IVU:

A

TCC

113
Q

Rank the TCC locations:

A

Bladder –> Renal pelvis —> Ureters (75% in distal 1/3)

114
Q

Major predisposing factor for renal Squamous cell

A

Schistosomiasis

115
Q

Name the haematogenous metastases to ureters (4)

A

Very rare- GI, prostate, renal and breast

116
Q

Ddx for lateral deviation of the ureters (3)

A

Retroperitoneal adenopathy
Aortic aneurysm
Psoas hypertrophy- proximal ureter

117
Q

Ddx for medial (waisting) deviation of the ureters (4)

A

RPF
Retrocaval ureter- right side
Pelvic lipomatosis
Psoas hypertrophy- distal ureter

118
Q

Prune belly (Eagle Barrett) (3)

A

Malformation triad which occurs in males (big wide belly))

  1. Deficiency of abdominal musculature
  2. Hydroureteronephrosis
  3. Cryptorchidism
119
Q

What is the diagnosis?

IVU: right ureter is deviated medially in the lumbar region?

A

Retrocaval ureter

120
Q

MRS findings in the setting of prostate cancer:

* The role of MRS in the transitional zone is unclear*

A

Choline is elevate-to reflect the increased cell membrane turnover

Creatinine, also detected on MRS, is unchanged

Polyamine and citrate - reduced

The [Creatine + Choline] / Citrate to Ddx cancer from normal prostate.

121
Q

What are the signs of shock on CT?

A 
Adrenal enhancement
Collapsed IVC
Small hypotenuse spleen
Small aorta and mesenteric arteries
Intense pancreatic enhancement
Dilatation of fluid filled intestine with thickening of fold and increased enhancement of the wall
122
Q

Any new or enlarging or heterogeneous mass in setting of nephroblastomatosis is indicative of …

A

Wilm’s tumour

123
Q

Pear shaped bladder (2)

A
  1. Pelvic lipomatosis

2. Haematoma

124
Q

Sign of Extraperitoneal bladder rupture

A

Molar tooth sign

125
Q

Lon irregular stricture in the distal bulbous urethra

A

Gonococcal

GU (4 decks)

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