Pathology Flashcards
Elevation of CREATINE differentials?
Renal failure
Chronic nephritis
Renal obstruction
Diabetes
Elevation of BUN differentials?
Renal failure Parenchymal disease Renal obstruction Dehydration Diabetes
Elevated with infection or inflammation?
Total WBC count
Decreased with hemorrhage?
Hematocrit
Indications for renal imaging…
Abn lab values - BUN &/or CREAT Abn urinalysis Pain Difficulty with urination Repeat UTI
Most common renal mass is a __________.
Simple renal cyst
Simple renal cysts occurring in __________% of adults over __________ yrs old.
50%
50 yrs old
Simple renal cysts are not significant unless they __________ or __________ or __________.
Distort the calyces
Produce pain
Hydronephrosis
Simple renal cysts are __________.
Asymptomatic
Simple renal cysts sonographically?
Well defined Well circumscribed Anechoic Smooth walls Through transmission - enchacement No color within Spherical
Types of renal cysts?
Peripelvic
Parapelvic
Exophytic
Milk of calcium
Describe peripelvic cysts…
Develop from lymphatic system
Small, multiple, bilateral
Originate in the renal sinus/pelvis
Does not communicate with collecting system
Describe parapelvic cysts…
Renal hilum
Originates from parenchyma & protrudes into renal sinus
Does not communicate with renal collecting system
Close proximity to renal pelvis & major calyces
Not related to dilatation of calyces or ureters
Parapelvic cysts may mimic __________.
Hydronephrosis
Parapelvic cysts sonographically?
Well defined mass - solitary & large
May have irregular border
**May obstruct the kidney
Which cyst can obstruct the kidney? Peripelvic or parapelvic?
Parapelvic obstructs NOT peripelvic
Describe a cortical cyst…
Small cortical cysts may be difficult to differentiate from pyramids
Describe an exophytic cyst…
Projected out away from the kidney
Describe a milk of calcium cyst…
Fluid level within a cyst
Very rare
What diseases & syndromes present with cystic areas of the kidney?
Von Hipple-Lindau Tuberous Sclerosis Acquired cystic disease of dialysis IPKD APKD Multicystic Dysplastic Kidney Medullary Cystic Disease
Cysts with Von Hipple-Lindau…
Autosomal-dominant genetic
Tumors of the central nervous system & orbits
ABD cysts
Cysts with Tuberous Sclerosis…
Autosomal genetic - multiple system Multiple renal cysts Multiple angiomyolipomas Mental retardation Seizures/epilepsy Cutaneous/skin lesions
Acquired cystic disease of dialysis…
Increased incidence of cysts, adenoma, renal carcinoma
Bleeding can cause flank pain
What is IPKD?
Infantile Polycystic Kidney Disease
Also called Autosomal Resessive Polycyctic Kidney Disease or Potter Type I
What is APKD?
Adult Polycystic Kidney Disease
Also called Autosomal Dominant Polycystic Kidney Disease or Potter Type II
Congenital Cystic Disease…
Autosomal Resessive Polycystic Kidney Disease Rare Chromosome 6 Dilation of renal collecting tubules Renal failure
Perinatal ARPKD?
Leads to renal failure and demise
Oligohydramnios
Enlarged echogenic kidneys
Neonatal/Infant ARPKD?
More common in females
Bilateral enlarged echogenic kidneys with cysts (3B’s-BIG, BRIGHT, BILATERAL)
Infants often die with complications of renal failure & hepatic disease
Juvenile ARPKD?
Lack of corticomedullary differentiation
Small cysts in the medulla
Hepatic fibrosis & splenomegaly
Describe ADPKD…
Common Men & women Most common is chromosome 16 Bilateral Multiple cysts (in other organs also) Dialysis Associated with liver cysts
Clinical findings of ADPKD?
Flank pain Hypertension Mass Hematuria Headache UTI Renal insufficiency
Fetus ADPKD sonographically?
Moderately enlarged hyperechoic kidneys
Adult ADPKD sonographically?
Bilateral renal enlargement Loss of shape Multiple cysts Normal renal parenchyma can be displaced with cysts Can become infected or hemorrhagic May lead to renal failure
Describe Multicystic Dysplastic Kidney…
Non-hereditary
Renal dysplasia
Unilateral
__________A the most common palpable mass & cystic disease in neonates.
Multicystic Dysplastic Kidney
Multicystic Dysplastic kidney may lead to __________, __________, __________, and __________.
Infection
Hypertension
Hematuria
Flank pain
Multicystic Dysplastic Kidney sonographically…
Enlarged kidneys Multiple cysts Ureteral atresia Ureteropelvic obstruction If bilateral, not compatible with life Non functioning kidney Compensatory hypertrophy of the other kidney
Describe nephronophthisis…
Autosomal resessive/dominant forms
Salt wasting nephropathy
Bilateral
Describe medullary cystic disease…
Tubular atrophy Glomerular sclerosis Multiple small cysts Loss of cortico-medullary junction Renal failure
Types of renal calcifications…
Urolithiasis
Neohrolithiasis
Nephrocalcinosis
Describe urolithiasis…
Combo of chemicals in urine Kidney stones anywhere in the urinary tract Common Causes obstruction Severe back pain
Describe nephrolithiasis…
Kidney stones within the kidney
Men
Renal calculi appear as reflective echogenic foci
Staghorn calculus-large stones in the central portion
Urolithiasis-Nephrolithiasis sonographically?
Renal stones are echogenic with shadowing
Color Doppler - TWINKLING artifact
Treatment of urolithiasis-nephrolithiasis…
*renal acidosis
Extracorporeal shockwave lithotripsy
Percutanceous nephrolithotomy
Ureteroscopic stone removal
__________ Is an accumulation of calcium within renal parenchyma (medullary & cortical).
Nephrocalcinosis
Nephrocalcinosis sonographically?
Diffuse foci calcium
Bilateral
Very echogenic pyramids
Loss of cortico-medullary junction
__________ Is calculi within the cortex.
Cortical nephrocalcinosis
Describe medullary sponge kidney…
Rare birth defect
Benign
Calcium stones
Dysplastic dilatation of tubules
Types of malignant renal tumors…
Renal cell carcinoma Transitional cell carcinoma Squamous cell carcinoma Lymphoma Metastases Wilm's tumor
__________ Is the most common renal tumor.
Renal cell carcinoma
Renal cell carcinoma is __________ as common in females as in males.
Twice
*6th to 7th decade of life
Clinical findings of renal cell carcinoma…
Hematuria
Flank pain
Palpable mass
Unexplained weight loss
Renal cell carcinoma deals with __________ system.
Staging-Robson
Progression of Staging-Robson system…
- Confined to kidney
- Spread to perinephric fat but within Gerota fascia
- Perinephric involvement with spread to renal vein &/or IVC
- Perinephric involvement with regional lymph node enlargement
- Perinephric involvement with venous & lymph
- Invasion of adjacent structures
What is renal cell carcinoma also called?
Hypernephroma
Renal cell carcinoma sonographically…
Echogenic mass
Complex
Calcification
Highly vascular - “basket sign”
__________ Is most common tumor of the collecting system.
Transitional cell carcinoma
Describe transitional cell carcinoma…
Often multiple Higher in males Hypoechoic mass in the renal pelvis Invasive Pain secondary to obstruction Hematuria
Describe renal lymphoma…
Secondary to non-hodgkins or hodgkins Bilateral invasion Multiple nodules Enlarged kidneys No definite mass
Metastases…
Common primaries - melanoma, lymphoma
CA of: lung, breast, colon, cervix, pancreas
Wilm’s tumor…
Also called nephroblatoma Associated with Beckwith-Wiedemann Sporadic aniridia (no color in the eyes) Omphalocele Palpable mass Nausea & vomiting Gross hematuria
__________ Is the most common solid renal mass of childhood.
Wilm’s tumor
Wilm’s tumor may invade the venous extending into the __________ and __________.
IVC and rt atrium
*mets to lung
Wilm’s tumor venous obstruction may lead to __________, __________, or __________.
Leg edema
Varicocele
Budd-Chiari
Name the 6 benign solid tumors…
Angiomyolipoma Adenoma Lipoma Oncocytoma Nephroma Fibroma
All tumors are treated as __________ until proven otherwise.
Malignant
Describe angiomyolipoma (AML)…
MOST COMMON benign renal tumor - muscle and fat
Renal hamartoma
May be hemorrhagic
Focal, solid, echogenic mass in the cortex
**KNOW THIS!!!
Describe an adenoma…
Benign renal tumor Tubular epithelial Incidental finding Well defined mass in renal cortex Calcifications Cannot differentiate from RCC
Describe a lipoma…
Fat cells Females Asymptomatic Hematuria Well defined echogenic mass Connective tissue tumor
Describe an oncocytoma…
Benign and well defined Large epithelial cells Males over 65 Also in parathyroid, thyroid, adrenals Asymptomatic Hematuria and pain "SPOKE WHEEL" pattern with a central scar (stellate scar)
With renal disease, you examine the __________.
Renal parenchyma
Name 6 inflammatory renal diseases…
Acute pyelonephritis Acute tubular necrosis Pyonephrosis Glomerulonephritis Fungal-candidiasis Abscesses
Inflammatory cystic disease can be inflammatory or __________.
Necrotic
Describe inflammatory or necrotic cystic disease…
Pain Hematuria, proteinuria, pyuria WBC in urine, WBC elevated Internal echoes Thicken walls
Renal infection progression? Describe it sonographically.
Pyelonephritis to bacterial nephritis to abscess
Shaggy borders
Loss of ability to distinguish cortex from medulla
Describe acute pyelonephritis…
Inflammation involving pyelocaliceal lining
Infection can begin in bladder and spread
May appear normal on US
Describe emphysematous pyelonephritis…
Life threatening infection Air in parenchyma - "comet tail" artifact Bacteria - escherichia coli Diabetic Enlarged inflamed kidneys
Describe chronic pyelonephritis…
May lead to renal failure
Decreased renal size
Cortical thinning
Describe xanthogranulomatous pyelonephritis…
Uncommon Chronic obstruction and infection Large non functioning kidney Staghorn calculus Females
Clinical findings of acute tubular necrosis…
Flank pain Vomiting Hematuria Infection Leukocytosis Decreased blood flow Enlarged kidney
Describe acute tubular necrosis…
Acute renal failure
May be reversed
Bilateral enlarged kidneys with hyperechoic pyramids
Describe pyonephrosis…
Pus within the obstructed collecting system
Requires drainage
Describe acute glomerulonephritis…
Necrosis in the glomeruli
Enlarged, poorly functioning, bilateral
Increased cortical echoes
Symptoms - nephrotic syndrome, HYPERTENSION, anemia, edema
Clinical findings of acute focal bacterial nephritis…
Fever
Pain
Pyuria
Increased BUN, albumin, total plasma proteins
Describe acute interstitial nephritis…
Infections such as scarlet fever and diphtheria
Enlarged kidneys
Increased echogenicity
Symptoms - uremia, proteinuria, hematuria, rash, fever
Describe lupus nephritis…
Systematic lupus erythematosis CONNECTIVE TISSUE disorder Females Increased cortical echogenicity Renal atrophy
Symptoms - hematuria, proteinuria, hypertension, renal vein thrombosis, renal insufficiency
Describe fungal candidiasis…
Focal abscesses - fungal balls on US
Clinical findings of renal abscesses…
Acute onset
Fever, chills
Increased WBC
Pyuria
Renal abscesses sonographically…
Complex pattern due to debris
Gas may produce a dirty shadow
What is schistosomiasis?
Parasitic infection
Other countries in Africa
What is renal failure?
Kidneys inability to filter
Renal failure will have increased __________ and __________.
BUN and CREATINE
Pre renal failure causes?
Nephroschlerosis Infarction Renal artery stenosis CHF Thrombosis of the renal vein
What causes renal failure?
Acute tubular necrosis - MOST COMMON
Describe acute renal failure…
Functions of the kidneys decreases Common condition Abrupt transient - comes and goes Oliguria Decreased profusion Acute azotemia - BUN & CREAT increase
Describe chronic renal failure…
Functions of the kidneys decreased
Obstructive nephropathies
Parenchyma disease
Nephrons destroyed
What is glomerulonephritis?
Chronic failure of the nephrons
What is renal vascular disease?
Chronic failure of the renal vascular system
What is chronic pyelonephritis?
Chronic failure of the interstitial
Chronic renal disease sonographically…
Diffusely echogenic kidney
Decreased size
Describe renal medical disease type I & II…
Type I - increased echogenicity, decrease in corticomedullary junction, as progressing to chronic: kidney size decreases
Type II - distortion of normal anatomy, focal lesions
Clinical findings of hydronephrosis…
Non specific complaints to severe pain
Acute urinary retention
Increased BUN & CREAT - azotemia
What is hydronephrosis?
Separation of renal sinus by fluid filled areas
Differentiate from extra renal pelvis
With hydronephrosis, scan the is if the __________ are __________.
Ureters are obstructed
Hydronephrosis can be caused by __________.
Overhydration
With hydronephrosis, __________ scanning is important.
Post void
Describe intrinsic hydronephrosis…
Stricture - narrowing
Renal calculi
Bleeding
Pyelonephrosis
Describe extrinsic hydronephrosis…
Pregnancy Pelvic mass Bladder neck obstruction Trauma Prostate hypertrophy Urethritis
Describe congenital hydronephrosis…
Ureteropelvic obstruction
Posterior urethral valve
Retro caval ureter
Describe hydronephrosis grade I, II, III…
Grade I - small separation of the calyceal pattern (splaying)
Grade II - bear claw effect with fluid extending into the calyceal system
Grade III - massive dilation with loss of renal parenchyma
Describe obstructive hydronephrosis…
RI of renal vessels may increase
No ureteral jet on the affected side
Bilateral indicates obstruction in the lower urinary system - enlarged prostate, bladder tumor, urethral valve syndrome
Describe nonobstructive hydronephrosis…
Reflux, infection, distended bladder, pregnancy
Check for jets
False positive hydronephrosis differentials…
**Extra renal pelvis Parapelvic cysts Reflux Multi cystic Renal artery aneurysm Overextended bladder
False negative hydronephrosis differentials…
Staghorn calculus
Polycystic disease
Severe dehydration
Describe renal artery stenosis…
Presents with HYPERTENSION Arteriosclerosis Fibromuscular hyperplasia Direct and indirect Doppler - "banana peel" **check AO also
__________ Is an increase in velocity in the main renal artery.
Renal artery stenosis
Renal artery stenosis is __________ cm/sec.
Important
> 150-190
Renal artery stenosis may happen in __________ one renal artery.
More than
For renal artery stenosis, RI of __________ is the upper limit of normal.
Important
.070
Describe NORMAL renal artery intrarenal Doppler…
Rapid systolic upstroke and early diastolic peak
Describe ABNORMAL renal artery intrarenal Doppler…
Absence of systolic peak Prolonged upstroke Decreased peak systolic (> .19) Dampening of the waveform **Tardus-parvus --> decreased acceleration and peak
What is the RAR formula?
Important
RAR = renal artery peak systolic velocity
—————————————-
aortic peak systolic velocity
Abnormal RAR is __________.
Important
> 3.5
For renal Doppler __________ is the gold standard.
Renal arteriography
Describe renal vein thrombosis…
Enlarged kidneys
Dilation of the renal vein proximal to the obstruction
Decreased flow
Describe renal infarction…
Tissue necrosis - wedged shaped
Results from thrombus, tumor, or obstruction
Irregular masses
Lumpy bumpy renal contour
Renal transplant complications…
Rejection Acute tubular necrosis Hemorrhage Infarction Recurrent glomerulonephritis Rupture Renal emphysema
Renal transplant consists of surgery of __________ and surgery to __________.
Surgery of donor kidney
Surgery to place the kidney in the iliopelvic region
Renal transplant has a __________ hr baseline check-up
48
Renal transplant: serial check-ups every __________ months
3-6
What is Dopplered after a renal transplant?
Main renal artery Segmental or intralobar Arcuate Renal vein Iliac artery
After a renal transplant, there should be a __________ structure, __________ pyramids, and __________ appears as parallel lines posterior to the kidney.
Smooth structure
Sonolucent pyramids
Psoas muscle
Describe renal transplant rejection…
Hyperacute within hrs
Acute within days to months
Chronic within months
Immunologic
Renal transplant rejection sonographically…
Enlargement and decreases echo of the pyramids Hyperechoic cortex Localized anechoic areas Distortion of the renal outline Patchy sonolucent areas
Renal transplant rejection has little differentiation between __________ and __________ with small __________ margins.
Parenchyma and sinus
Irregular margins
Post transplant failure could lead to what diseases?
Acute tubular necrosis Cyclosporine toxicity Malignancy Extraperitoneal fluid Hematoma Perinephric abscess LYMPHOCELE - common complication Obstructive nephropathy Graft rupture Arteriovenous malformations
Describe transplant Doppler…
Low filter Small scale RI > .90 indicates acute rejection RI < .70 unlikely to indicate rejection No flow indicates occlusion
What is a hematoma?
ABD collection of blood
Drop in hematocrit
Well defined sonolucent area
Describe a renal hematoma…
Decrease in hematocrit
Hematuria
Describe bladder diverticulum…
Herniation of the bladder wall
Congenital or acquired
Neck connecting adjacent fluid filled structure
What is the MOST common cause of urethral obstruction in boys/male infants? Describe it.
Posterior urethra valves syndrome (PUV) - flap of tissue covers the opening in the area of the urethra
What is a ureterocele?
Urethra obstruction
Cystic dilation of the distal ureter
What is cystitis?
Bladder inflammation
Thickening of the bladder wall
Describe bladder tumors…
Transitional cell carcinoma Gross hematuria Focal bladder wall thickness Color Doppler for increased vascularity Evaluate kidneys
Describe ureteral jets…
Phenomenon describing urine entering the bladder
Absence is a sign of obstruction
“Candle sign” - low continuous jet indicating partial obstruction
