module 12 intra-renal disorders

Question 1

categories of intra-renal disorders

Answer 1

congenital
neoplastic
infectious
obstructive
glomerular

Question 2

intra-renal disorders occur

Answer 2

primarily within the kidney and have the potential to result in renal insufficiency or failure

Question 3

common s/s of intra renal disorders

Answer 3

pain: nephralgia
- felt at costovertebral angle (CVA)
- d/t distention/inflammation of renal capsule
Damage to kidney without pain is common d/t dec pain receptors in kidney
Abnormal urinalysis
- foundation for Dx
- dark, strong-smelling urine: dec. renal function
- cloudy pungent urine: infectious process

Question 4

agenesis

Answer 4

congenital abnormality

• kidneys do not develop in fetus
• bilateral; not compatible with life
• unilateral: compensatory hypertrophy of functional kidney

Question 5

hypoplasia

Answer 5

congenital abnormality
some fetal kidney development, but kidney is smaller than normal
- can lead to pediatric ESRF
single kidney can maintain normal renal function

Question 6

cystic kidney disease (polycystic)

Answer 6

congenital abnormality 
genetically transmitted renal disorder resulting in fluid-filled cysts
- can expand and disrupt blood flow
- localized or both kidneys
- can lead to renal failure, requiring dialysis or transplant
2 types
- autosomal recessive form
- autosomal dominant 
more common in men
inc. in prevalence with aging

Question 7

polycystic diseases and genes

Answer 7

both types, genes code for proteins associated with primary cilium on surface of tubule cells

• cilium senses urine flow and linked to regulatory responses, including Ca channels
• mutation -> growth dysregualtion and abnormal remodeling

Question 8

cystic kidney disease autosomal dominant

Answer 8

chromosome 16, PKD1: 85%
chromosome 4, PKD2: 15%
- reduction of intracellular Ca and excessive concentrations of intracellular cAMP
-> normal functioning tissue reduced
-> many round cysts of varying size
-> other organs can develop cysts: liver
Dec. GFR and ability to concentrate urine
manifests in 40-59 y/o
cysts multiply and expand -> kidney hypertrophy -> dec. GFR., compacts and distorts vascular system -> ischemia -> RAAS activation

Question 9

cystic kidney disease s/s

Answer 9

early: dec. ability to concentrate urine 
HTN
pain
proteinuria 
hematuria 
concomitant cystic liver involvement 
Dx: genetic hx, ultrasound 
Tx: supportive, control BP and managing associated pathologies

Question 10

renal cell carcinoma

Answer 10

neoplasm
VHL gene
metastatic disease (clear cell)
originate in renal cortex from cells of proximal convoluted tubule
May have familial pattern, risk inc. with 1st degree relative
staging system I-IV
metastases resistance to radiation, immunotherapy, and chemo.

Question 11

risk factors for renal cell carcinoma

Answer 11

smoking
obesity
HTN
first degree relative

Question 12

s/s of renal cell carcinoma

Answer 12

asymptomatic till advanced
CVA tenderness
hematuria
palpable mass

Question 13

papillary carcinoma

Answer 13

MET gene

Question 14

Stage I neoplasm

Answer 14

tumor within capsule

Question 15

Stage II neoplasm

Answer 15

tumor invades perirenal fat

Question 16

Stage III neoplasm

Answer 16

tumor extends into renal vein or regional lymphatics

Question 17

Stage IV neoplasm

Answer 17

matastases to common areas

• lungs
• heart
• liver
• other kidney
• bone

Question 18

nephroblastoma (wilm’s tumor)

Answer 18

5th most common pediatric malignancy
- 65% < 5 y/o
- usually unilateral
- develop from embryonic pluipotent kidney precusor cells (nephrogenic rests)
- genes: WT1, chromosome 11; WT2
Large encapsulated tumors with rapid growth
-> hemorrage, cystic changes, necrosis
-> renal pelvis compression, infiltration into blood

Question 19

nephroblastoma (wilms tumor) s/s

Answer 19

palpable mass
abd. pain
HTN
hematuria
tumor thrombus in inferior vena cave -> dec. venous return and lower extremity edema

Question 20

normal protective mechanisms against infection

Answer 20

Acidic pH: hostile environment for bacteria
Presence of urea: hostile environment
Men: bacteriostatic prostatic secretions
Women: glands in distal urethra secrete mucous
Micturition: wash out pathogens: reflex to expel urine
Unidirectional urine flow: prevents reflux
Epithelial cells: physical barrier

Question 21

pyelonephritis

Answer 21

infection of kidney 
-  renal tubules, pelvis, calculi
most common cause
- ascending infection from the lower urinary tract 
-- vesicoureteral reflux
-- intrarenal reflux 
other cause: hematogenous infection

Question 22

pyelonephritis causative agents

Answer 22

E. coli
enterobacter
enterococcus
proteus mirabilis
klebsiella
staph 
strep

Question 23

risk factors for UTI

Answer 23

inc. age
vesicoureteral reflux
congenital anatomoic anomalies
female
pregnancy
diaphragms with spermicidal agents for contraception
neurogenic bladder
instrumentation of urinary tract 
urinary obstuction
glucocorticoids, radiation, chemo
immunodeficiency 
DM 
obesity
sickle cell trait

Question 24

acute pyelonephritis

Answer 24

infection of renal pelvis/parenchyma usually from ascending UTI
Unlikely to occur without obstruction or ureteral reflux
Dx: presence of WBC casts indicative of upper UTI
Tx: abx

Question 25

acute pyelonephritis s/s

Answer 25

sudden onset
fever
chills
CVA tenderness
s/s of lower UTI
- dysuria, urgency, frequency
N/V
anorexia

Question 26

chronic pyelonephritis

Answer 26

usually associated with chronic reflux or obstructive process leading to persistent urine stasis
-> scarring and loss of functional nephrons
characterized by small atrophied kidneys with diffuse scarring and blunting of calices

Question 27

chronic pyelonephritis s/s

Answer 27

abd./flank pain
fever
malaise
anorexia

Question 28

chronic pyelonephritis risk factors

Answer 28

bacteriuria associated with obstructive disorders

• calculi
• neurogenic bladder
• vesicoureteral reflux

Question 29

obstruction

Answer 29

condition that interfere with urine flow
congenital or acquired
changes result from
- location and degree of obstruction (partial or complete, unilateral or bilateral)
- duration and timing (acute onset or chronic)
-> urine stasis -> infection and structural damage
-> dilation of tract proximally

Question 30

common causes of obstruction

Answer 30

stones
tumors
prostatic hypertrophy
strictures of the ureters or urethra

Question 31

complication of obstruction

Answer 31

infection
sepsis
AKI
CKD

Question 32

Complete obstruction leads to

Answer 32

hydronephrosis: build up of fluid in kidney
dec. GFR
ischemic kidney damage r/t inc. intraluminal pressure
acute tubular necrosis
CKD

Question 33

complete obstruction pathogenesis

Answer 33

complete obstruction -> dilation of ureter (hydroureter)
renal pelvis and tubules enlarge with inc. presser, and papillae flatted
hydronephrosis -> dec. GFR and dec. renal perfusion -> ischemia

Question 34

obstruction s/s

Answer 34

wt. gain
nausea
anorexia
malaise
HA
inc. abdominal girth
ankle edema

Question 35

renal calculi (nephrolithiasis)

Answer 35

crystal aggregates composed of organic and inorganic materials located within the urinary tract
- tend to form d/t solute supersaturation (required), low urine volume, and abnormal pH
uncommon before 20, peak 20-30 y/o
dehydration -> inc. crystalization

Question 36

Most renal calculi composed of

Answer 36

calcium crystals

other:
- uric acid
- struvite
- cystine
- stone assoc. with medication

Question 37

renal calculi s/s

Answer 37

stationary stones asymptomatic 
migration causes
- intense renal colic pain, abrupt onset and may radiate
- N/V
- diaphoresis 
- hematuria 
- tachycardia
- tachypnea
If stone is in ureter
- dysuria
- urgency
- frequency

Question 38

renal calculi tx

Answer 38

fluids: > 2L per day
lithotripsy
endoscopy ureteral stenting 
ureteroscopy
pain meds
-Stones tend to reoccur, prevention by inc. fluid intake and dietary changes