Pathology Flashcards
what is AKI?
this is acute kidney injury- a sudden onset 24h reduced glomerular filtration rate, reduced urine output and increased nitrogenous waste products in the blood (urea and creatine)
what are the 3 broad causes of AKI?
pre-renal
intra-renal
post-renal
name 2 causes of pre-renal AKI
renal artery stenosis
hypotension
name 3 causes of intra-renal AKI
autoimmune disease in the glomerulus- SLE inflammation- acute glomerulonephritis infection drugs vascular change
name 3 causes of post-renal AKI
benign prostatic hyperplasia
kidney caliculi
bladder cancer obstructing the ureters
name systemic symptoms of AKI
rash red eyes arthralgia haemoptysis haematuria
what investigations do you do for AKI?
USS of kidneys!!!!! FBC- coagulation abnormalities, autoantibodies (ANCA, ANA) urine dipstick- haematuria BENCE JONES proteins glucose levels- Diabetes insipidus? LFT- cirrhosis U&E check medications- rule out NSAID, ACE-I causes ECG for any caridac abnormalities JVP and BP
name 3 nephrotoxic drugs
ACE-I, lisinopril
NSAIDS, ibruprofen
Gentomyocin
what are Bence Jones protiens?
monoclonal globulin proteins found in the urine in acute kidney injury because the kidney is no longer filtering the blood properly
apart from in AKI where else would you se Bence Jones proteins in the urine?
Myeloma
name 4 factors in AKI which would indicate the need for dialysis
- unresponsive to treatment
- requiring a transplant
- persistent hyperkalaemia
- refractory pulmonary oedema
define CKD
a progressive decline in GFR for over 3 months with or without evidence of kidney damage
GFR
name 8 risk factors for developing AKI
- age over 75
- CKD
- DM
- CF
- peripheral vascular disease
- sepsis
- drugs (esp newly started)
- chronic liver disease
for each of the 5 stages of CKD state the range of GFR values per ml/min/1.73m2
stage 1= GFR>90, with other evidence of KD
stage 2= GFT 60-89, with other evidence of KD
stage 3a= 45-59, ± evidence of KD
stage 3b 30-44, ± evidence of KD
stage 4= 15-29, severe reduction in GFR ± evidence of KD
stage 5=
why is declining GFR a problem?
good renal function is essential for the patient to recover and survive
declining GFR is an independent risk factor for CVD- this is the chief cause of death from renal failure
name 4 conditions in which there is early screening for CKD
diabetes mellitus
hypertension
CVD
multisystem disorders which involve the kidneys such as SLE
what endocrine hormone may be elevated in CKD?
parathyroid hormone
name 5 complications of CKD
- cardiovascular disease
- DEATH
- hypertension
- gout- due to urate retension
- osteoporosis- due to reduced excretion of phosphate- increasing PTH levels- increasing osteoclast activity
anaemia- reduced EPO- reduced production of RBC’s
electrolyte and fluid balance problems
what are the 2 types of urinary stones and which one is more common?
calcium phosphate
calcium oxalate- more common
give 4 presentations of urinary colic
- loin pain
- renal colic- extremely painful, cannot sit still squirming pain
- nausea
- vomitting
other signs and symptoms include: urgency, frequency, dysuria, strangury, pain radiating to the labia or tip of the penus
name 5 predisposing factors to urinary colic
- high protein diet
- poor fluid intake
- family history
- drugs- epinephride increases the crystallation in urine; found in common cold and flu remidies
- infection
name 5 preventative measures for renal colic
- over-hydration
- normal dairy intake
- reduce BMI
4 active lifestyle - low salt diet
name 4 complications of urinary colic
- pyonephrosis
- hydronephrosis
- systemic sepsis
- chronic renal damage
what investgations should you do for suscpeted Urinary Colic?
MSU- mid stream urine sample and cultures
FBC: levels of calcium, urate, elevated ESR, CRP
non contrast computerised tomography kidneys, ureter and bladder; NCCTKUB- does not affect the kidney function; enables easy view of kidneys and where the obstruction is
KUBXR
USS- not as sensitive
what is the treatment for a sever urinary caliculi causing acute kidney injury?
urgent removal of the caliculi using percutaneous nephrolithotripsy (shock wave therapy to break up the caliculi) or uteroscopic removal.
what is the treatment for mild urinary caliculi?
watch and wait
alpha blockers to vasodilate urethra
cystine binders- captopril to reduce cystine in urine
overhydration to help pass the stone
name 2 complications of AKI
hyperkalaemia and pulmonary odedema
name 10 clinical features of renal failure
Skin: pallor, yellow skin pigmentation, brown nails, purpura, pruitus, scratch marks, bruising
Heart: hypertension, cardiomegaly, pericarditis, arrhythmias
Lungs: pleural effusion, pulmonary or peripheral oedema
MSK/Neuro: retinopathy, peripheral neuropathy, encephalopathy, seizures, coma
give 3 differential diagnosis for urinary caliculi
- testicular torsion
- ectopic pregnancy
- appendicitis
name 3 causes of glomerulonephritis
- SLE
- IgA nephropathy
- Good pastures syndrome: Anti GBM disease
what antibody is present in Goodpastures syndrome and what does this affect?
IgA- it is an antibody to the glomerular basement membrane and alveoli membrane in the lungs. It destroys type 4 collagen
what is the commonest cause of nephrotic syndrome in children?
minimal change disease
name 3 primary causes of nephrotic syndrome
Membraneous nephropathy
minimal change disease
focal segmental glomerulosclerosis
name 2 primary causes of nephritic syndrome
IgA nephropathy, rapidly progressing glomerulonephritis,
name 3 secondary causes of nephritic syndrome
SLE
anti-GBM
post streptococcal glomerulonephritis
name 3 secondary causes of nephrotic syndrome
DM
SLE
Hepatitis
sarcoidosis, amyloidosis
name 2 complications of nephrotic syndrome
infections, eg cellulitis, peritonitis- loss of serum IgG through glomeruli, PE, renal vein thrombosis
Hyperlipidaemia
which is the most common glomerular disease?
IgA nephropathy (Burger’s disease)
which glomerular disease is associated with hodgkins lymphoma
minimal change glomerulonephritis
which glomerular disease is most common in children?
minimal change glomerulonephritis
which glomerulonephritis is the most aggressive
rapidly proliferating glomerulonephritis
which glomerulonephritis can be caused by sick cell disease?
focal segmental glomerulosclerosis
which glomerular disease if nor treated will be most likely to progress to end stage renal failure?
focal segmental glomerulosclerosis
name 5 causes of haematuria
- Renal cell carcinoma
- transitional cell carcinoma
- acute cystis
- benign prostatic enlargement
- urethritis
how does haemaglobin if present in the urine produce a positive test on dipstick?
it has a peroxidase activity- can catalyse the reaction on the chromogen indication in the dipstick test to produce a trace.
describe what you would expect to see on a renal biopsy fora patient with IgA nephropathy and a patient with rapidly proliferating nephropathy
for IgA nephropathy- deposition of IgA and c3 in the mesangial cells under immunofluourescence, and mesangial cell proliferation.
For rapidly proliferating nephropathy- crescents affecting most glomeruli and epithelial proliferation
what would you expect to see in a child with minimal change disease on renal biospy?
no change on light microscopy
on electronmicroscopy there would be effacement of the podocyte foot processes.
give 3 reasons why the testis might swell
- tumour
- torsion
- infection
name 3 other structures in the scrotum which may swell apart from the testis and give a reason why each would swell
- cord- varicocele
- epididymis- infection
- tunica vaginalis- trauma causing bleeding
how would an epididymal cyst present
extratesticular, fluctuant, cystic swelling which tansilluminates and are readily palpable separate from the body of the testes.
how would you differentiate a epidiymal cyst from a spermatocele?
there is no way to differentiate clinically but spermatocele have sperm present and a milky fluid asparate
which type of swelling is sometimes described as feeling like a bag of worms?
varicocele- they increase with an increase in abdominal pressure and will not transilluminate
if the fluid from a hydrocele is aspirated and looks straw coloured, what components do you suscpect make it this colour?
protein
fibrin
polymorphs
which non malignant scrotal disease appears as a smooth pear like swelling>
hydrocele
why is a varicocele more common in the left testicle than the right?
The venous drainage from the left testicle goes into the left renal vein before it drains into the IVC. The drainage is not direct- more chance of obstruction/valve maldevelopment to occur on the left side. Whereas the right side drains directly into the IVC.
name 2 causes of a haematocele
trauma and a tumour causing haemorrhage of the tunica vaginalis
what is the function of sertoli cells?
they promote sperm development by secreting testicular fluid
which non malignant scrotal disease is associated with palma fibromatosis?
peyronies disease
which cells in the testes produce testosterone and where are they found?
leydig cells- found in clusters between seminiferous tubules
what are the components of semen?
fructose- energy for the sperm
sperm
prostaglandins- to stimulate female peristaltic contractions
clotting enzymes to convert fibrinogen into fibrin causing semen to clot
fibrinogen
which zone of the prostate enlarges in benign prostatic hyperplasia?
the prei-urethral transition zone
which hormone causes proliferation of the glands and stroma causing benign prostatic enlargement?
testosterone produced by leydig cells is activated becoming dihydrotestosterone- increased smooth muscle tone.
how do you differentiate between a hydrocele and a epididymal cyst provided that they both transiluminate?
an epididymal cyst is palpable separate from the testis whereas a hydrocele is not.
why might a benign prostatic enlargement present with oligouria?
the enlargement of the prostate may obstruct and distort the urethra preventing urination.
name 4 symptoms of benign prostatic enlargement
- urgency
- nocturia
- hesitation
- reduced forcefullness of stream flow
- post void dribbling
- incomplete emptying
which zone of the prostate is more susceptible to prostatic cancer and which is more susceptible to BPH?
Cancer= peripheral zone BPH= peri-urethral transitional zone
what investigations would you do for BPH?
DRE- should feel a smooth palpable mass and the midline groove
Cytoscopy- to check for median lobe involvment
USS- to asses obstructions adn size of enlargement
biopsy- to check its enlarged
FBC: show any inflammatory markers
how might you treat BPH?
alpha blockers to prevent further smooth muscle hyperplasia= Tamulosin
5 alpha reductase inhibitors- finesteride
what is the action of finesteride and how does it help BPH?
finesteride inhibits the breakdown of testosterone to dihydrotestosterone; which causes hyperplasia of the prostate in BPH
how would you treat a patient with BPH whose showing upper urinary tract dilation?
Transurethral prostatic resection.
name the 3 types of cancer you can get in the bladder
- transitional cell carcinoma
- adenocarcinoma
- squamous cell carcinoma- only arises from metaplastic squamous epithelium in the bladder
which parasite causes chronic inflmmation of the urinary tract and is associated with causing squamous cell carcinoma of the bladder?
schistosomiasis
what is the most common tumour of the urinary tract?
transitional cell carcinoma of the bladder
which GI tract carcinoma is associated with having an increased risk of urothelial carcinomas?
non hereditary polycystic colorectal carcinoma
name 4 risk factors for urothelial tumours
- NHPCC
- smoking
- chronic inflammatoin- schistosomiasis infection, recurrent UTI’s
- drugs: cyclophosphamide exposure
what is the most common presentation of urothelial tumours?
painless haematuria
there may also be increased frequency; suggesting a UTI but there is absence of any significant bacteria
what investigations should you do if you suspect urothelial tumour?
dipstick urine- showing haematuria, and rule out UTI
flexible cytoscopy- can take biopsies
USS- rule out obstructions/anatomical abnormalities
FBC: to rule out infection
explain the t staging of baldder cancer
Ta= bladder tumour confined to epithelium T1= invading the lamina propria T2= invading the muscle T3= invading the extravesicle fat T4= invading local organs
what are the treatment options for TCC of the bladder invading into the detrusor muscle?
BCG therapy
local resection of Cystectomy- complete removal of the bladder and replacement with a pouch from the de-epithelialated ileum, diverting the urinary flow into a catheter.
radiation and neoadjacent chemotherapy to downstage the tumour
what type of carcinoma is prostate cancer histologically?
adenocarcinoma
how do prostate carcinomas usually present
symptoms of UTI: increased frequency, hesitation, urinary retension and post void dribbling.
What staging system is used to classify prostate cancer?
Gleeson scoring system
briefly explain the gleeson scoring system
scores the prostate cancer between 2-10 according to how aggressive it is. The higher the number the more aggressive
Carcinomas above 10 are very aggressive
Carcinomas between 2-6 are low grade
name 3 ways of treating prostate cancer
- radical prostectomy- (transurethral)
- high intensity ultrasound photodynamic therapy
- watchful waiting
- GnRH analogues
5 alpha reductase inhibitors- finasteride
what is the function the prostate gland
- produces semen
it surrounds the urethra and relies on androgens for its growth and development
name the 3 layers which make up urothelium histologically
- umbrella cells
- intermediate cells
- basal cells
what are the symptoms which dont commonly present in prostate cancer but are more suggestive of it?
weight loss
back pain
anaemia
name 3 side effect which may occur after a transurethral resect prostectomy?
- infection
- retrograde ejaculation
- Bleed
- Impotence
- DVT
what investigations would you do for suspected prostate cancer
DRE- hard craggy non mobile mass, obliterated median grove
Xray- for bone metastases
Biopsy and CT- to stage and grade the tumour (biopsy guided by USS)
FBC: prostate specific antigen levels are elevated
apart form in prostate adenocarcinoma where else might PSA be elevates?
prostate specific antigen is elevated in BPH and UTI’s as well as prostatic cancer
give 2 associations with the development of prostate carcionma
elevated testosterone levels
family history
as a result of prostate cancer treatment, erectile function may be lost. What treatment might you use?
phosphodiesterase type 5 inhibitors: Viagra
give a GnRH analogue that might be used to treat metastatic disease
goserelin
What is the difference between a complicated and uncomplicated UTI?
an uncomplicated UTI occurs in a normal urinary tract, a complicated UTI occurs in an abnormal UTI
name 3 organisms responsible for UTI’s
E.coli
coaulase negative staph
Klepsiella spp
name the 3 arteries supplying the penis
- bulbous artery- corpus spongiosum and glands
- cavenosal artery- corpus cavernosa
- dorsal artery- skin, fascia and glands
what is the venous drainage of the penis
pudenal and deep dorsal veins
what nerve roots provide the parasympathetic innervation of the penis
S2,3,4
Which nerve roots provide the sympathetic innervation of the penis (sensory innervation to the skin and glans penis)
T11-12
which nerve is responsible for penile ejaculation and which part of the autonomic NS does it arise?
pudenal nerve, sympathetic NS
name 3 factors controlling erectile function
- central control- hypothalamus, oxytocin pro-erectile pathways
- endocrine control- testosterone is required for sexual stimulation
- peripheral control- smooth muscle cell relaxation and arterial vasodlation mediated via parasympathetic NS
briefly describe the process of an erection
tactile stimuli- stimulation of parasympathetic NS, release of Ach at NMJ- release of NO from endothelial cells (due to upregulation of cAMP)- vasodilation of cavernosal artery and smooth muscle cell relaxation- increased blood flow into the penis- erection
define erectile dysfunction
the inability to obtain or sustain an erection to complete/obtain satisfaction for sexual performance
name 5 risk factors for erectile dysfunction
- transurethral radical prostectomy
- obesity
- smoking
- older age group
- renal failure
name 4 indications for a psychological cause of erectile dysfunction
- younger age group
- good nocturnal and early morning erection
- sudden onset
- stimulational ED
give 5 causes of erectile dysfunction
- multiple sclerosis
- cauda equina syndrome
- depression
- age related problems
- vascular disease
how do you diagnose erectile dysfunction?
erectile dysfunction questionnaire- assesses patients sexual satisfaction, sexual desire and erectile function out of 30.
what investigations would you do if a patient presents with erectile dysfunction?
plasma and urinanalysis of glucose- rule out DM
serum testosterone levels
Nocturnal tumescence and rigidity tests (see how flaccid/rigid the penis is at night)
name 4 different treatment options for erectile dysfunctio
- phosphodiesterase 5 inhibitors: Viagra
- testosterone replacement therapy if testosterone deficient
- sublingual amorphine- dopamine agnosit enhancing sexual desire/response
- transurethral alpostadil (pellet inserted into the urethra- stimulates vasodilation of cavenosal artery)
name 2 surgical procedures which are available for erectile dysfunction
- malleable prosthesis
2. inflatable prosthesis
what is the difference between BPE and BPH
BPE= what you feel on DRE BPH= histological diagnosis showing peri-urethral transition zone hyperplasia
which gene mutation is responsible for ADPKD? and which chromosome is it found?
gene mutation in PKD1 codes for polycystine.
found on chromosome 16
name 3 complications of ADPKD
berry aneurysm rupture
lung cysts/liver cysts
hypertension
why does PKD present with back pain?
because the kidneys are enlarging putting pressure on the back
what investigations would you do for PKD?
MRI- assess the size of the kidneys
USS- determine the no and size of the cysts
genetic testing; for the presence of PKD1 gene mutation or PKHD1 mutation (seen in ARPKD)
what is the treatment options for PKD?
treatment is not curative (unless transplant)
reduce BP- lisinopril (ACE-I)
treat infections
dialysis
genetic counselling to prepare for transplant
pain relief via laproscopic removal of cysts
what is the gene mutation seen on chromosome 6 in ARPKD?
PKHD1- polycystic kidney and hepatic disease gene 1, gene encodes for polyductin. Mainly presents in infancy
which type of PKD more commonly presents in infancy?
autosomal recessive PKD
if a patient presented with palpable kidneys, hepatomegaly, portal hypertension and haematuria what would you suspect to be the diagnosis?
autosomal recessive polycystic kidneys and hepatic disease
what is nephronophthisis?
congenital renal medullary cysts
name the 3 different types of renal replacement therapy
- haemodialysis
- peritoneal dialysis
- kidney transplant
name 3 types of renal tumours
- renal cell carcinoma
- transitional cell carcinoma
- Wilm’s tumour (nephroblastoma)
name 5 risk factors for developing RCC
- smoking
- family history; Von Hippel Landau syndrome
- obesity
- HTN
- PKD
name 4 symptoms RCC can present with
- loin pain
- unexplained haematuria
- palpable mass
- hypercalcaemia
- fatigue
which vessel might a RCC invade?
renal vein
where do transitional cell carcionmas typically arise if in the kidneys?
in the renal pelvis
name 3 complications of RCC
- polycythenia - due to increased EPO production
- hypertension- due to increased renin production
- anaemia- due to reduced EPO production
where does lymph from the kidneys drain?
into the para-aortic nodes
how does a renal cell carcinoma look microscopically?
clear nodule full of fat and lymphocytes
why might a RCC present with varicocele?
if the RCC has invaded the Left renal vein- causes increased pressure in the testes causing dilation of the tunica vaginalis with fluid
what investigations would you do for a RCC?
FBC: inflammatory markers
Abdo CT- stage tumour
USS and biopsy- determine stage of tumour and detect any local invasions
what treatment options are there for RCC?
primary treatment: surgical excision- partial nephrostomy if less than 7cm, full nephrostomy if >7cm
Cryotherapy- freeze the tumour with helium
radiofrequency ablation
name 2 types of germ cell tumour
seminoma (20-30’s)
teratoma (
how do testicular tumours present?
scrotal mass- primary
abdominal discomfort or back ache (para-aortic metastases)
dyspnoea or haemoptysis- lung metastases
give 3 risk factors for developing a testicular tumour
- family history
- testicular maldescent
- infantile hernia
how does a semioma present histologically?
uniform histology
primitive spermatogonia
syncytiotrophoblast cells
name 2 tumour markers for teratoma?
alpha feto-protein
beta human coriogonadotrophin
describe the components of dialysis fluid
low potassium
low urea
low phosphate
to ensure these are remove from the blood into the dialysis fluid
high glucose and bicarbonate to correct acidosis and provide energy
equivalent Na and Cl ion concentrations to keep their concentration constant in the blood.
name 3 waste products of the blood
- urea
- potassium
- phosphate
name 3 modes of access to the blood for haemodialysis and naem which is the preferential method
- cannulation of a large vein (usually the vena cava in emergencies)
- arterio-venous fistula (preferential method)
- synthetic graft- when anatomical variation does not allow for the formation of an AV fistula
name 5 complications of dialysis
- infection risk
- nausea and vomitting due to systemic upset
- blocked dialysis catheter
- amyloidosis due to a build up of beta-2 microglobulin
- cramps due to capillary bypass
anaphylactic reaction to ethylene oxide used to sterilise dialysis machines
what is peritoneal dialysis
up to 3L of dialysis fluid is pumped into the peritoneal cavity via a silicon tube, using the peritoneum as a filtration barrier (as it has a large blood supply) to remove the waste products from the blood.
name the 2 types of peritoneal dialysis
- continuous ambulatory dialysis
2. automated peritoneal dialysis
what is the minimum time automated peritoneal dialysis needs to be undertaken for?
8 hours
name 4 complications of peritoneal dialysis
- hernias because of intrabdomial pressure
- constipation due to pressure on GI tract
- sepsis- if the catheter becomes infected
- pleural effusion if the dialysis fluid leaks through the diaphragm into the lungs
what is the difference between haemofiltration and haemodialysis?
haemofiltration is a direct filtration of the blood removing its waste products and replacing it with fluid, no dialysis fluid it used. Haemodialysis used dialysis fluid, and is less expensive
name 5 factors which makes a patient eligible for a kidney transplant
- need to have an increased predicted life expectancy after the transplant
- no age related co-morbidity
- no active cancers outside the kidneys
- in endstage kidney disease but still fit enough to undertake the operation
- a suitable kidney donor match
name the 2 drugs which immediately following a kidney transplant a patient will be given to prevent graft rejection
methyprednisolone
basiliximab
name 3 maintenance drugs used long term in renal transplantation
- prednisolone
- azothioprine
- ciclosporin calcineurin inhibitor
name 4 risks and 4 benefits of Renal transplantation
Benefits: 1. improve quality of life 2. increase life expectancy 3. stop dialysis 4. relax fluid intake (also reveses renal bone disease) Risks: 1. graft rejection 2. life long side effects of immunosuppressants- osteoporosis/ infection 3. increased infection risk 4. surgery risks; DVT
what is cold and warm ischaemia
cold ischaemia= when the kidney organ is kept on ice for over 30 hours causing a lack of oxygen supply and death of the organ
warm ischaemia= when the kidney is not kept cool enough during transport/ is not immediately put on ice; results in irreversible damage to the organ
what are the 3 types of graft rejection
acute
hyperacute
chronic
briefly explain the differences between each type of graft rejection
Hyperacute: minutes- hours after graft is implemented; pre-formed anti-donor antibodies; type 2 hypersensitivity reaction.
Acute: days- weeks after implementation, T cell mediated type 4 hypersensitivity reaction
Chronic: months- years after implementation, unclear mechanism
how do you prevent each type of graft rejection?
acute: anti-rejection therapy and HLA matching prior to transplant
hyperacute: mix host serum and donor cells to check for ABO group matching
Chronic: immunosuppressants and good HLA matching
name 5 causes of urinary obstruction at the level of the kidneys
- renal caliculi
- TCC
- RCC
- ADPKD
- TB infection
others include- renal artery aneurysm causing clotting int he real pelvis, wilms tumour, gonococcal infection
name 5 causes of urinary obstruction at the level of the ureters
- pregnancy
- caliculi
- hydroureter (dilation of the ureter with possible narrowing further down)
- BPH
- infection- fibrosis of the ureter- thinner lumen
other include: GI abnormalities, ureter tumour
name 5 causes of urinary obstruction at the level of the bladder and urethra
- BPH
- pregnancy
- Caliculi
- TCC of the bladder
- philmosis- congenital abnormality where you cannot retract the foreskin
others include: urethral stricture, prostatitis, prostate adenocarcinoma, paraurethral abscess
where are the 3 most common sites of a UTO?
vesico-uteric junction
where the ureters cross the pelvic brim
pelvic-uteric junction
name 5 complications of UTO’s
- hydronephrosis (obstruction is distal to the renal pelvis preventing urine outflow and causing a backlog of urine to accumulate and dilate the renal calyxes and pelvis)
- tumour development due to fibrosis
- megaureter- dilation of the ureter to enable urine to pass around the obstruction
- increased risk of UTI
- bladder dysfunction/hypertrophy
soon after bilateral ureteric obstruction what hormone might use see elevated in the blood and why?
atrial natriuretic peptide- because it stimulates vasodilation of the afferent arteriole (vasoconstriction of the efferent arteriole) increasing blood pressure in the nephrons to try and shift the obstruction
if ureteric obstruction is not relieved within a week what would you expect to see histologically in the kidneys?
parenchymal thickening due to oedema (fluid build up)
widening of bowmans space
BM thickening in the tubules
give 4 effects of ureteric obstruction on the tubular function
- reduced urinary acidification
- disregulation of aquaporin channels- impaired ability to concentrate urine
- functional changes
- reduced Na transport due to reduced concentration regulation in the interstitial fluid.
what investigations would you do for a urinary tract obstruction?
- FBC- inflammatory markers
- U&E- check renal function
- USS- detect hydronephrosis, and location of obstruction
- retrograde urogram (kidney Xray) to detect abnormalities/where obstruction is
how do you treat a lower urinary tract (below the level of the bladder)
urethral/suprapubic catheter
treat underlying cause- remove caliculi/tumour
monitor weight and manage fluid &electrolyte balance
name 3 complications of chronic urinary tract obstruction
renal atrophy
hypertension
recurrent infections
how do you treat an upper urinary tract obstruction?
if severe nephrostomy under GA
abx for infection
monitor post obstruction diuresis- may go into hypovolaemic shock if relief of large volumes of fluid.
name 3 reasons to treat caliculi?
- may cause infection
- bladder stones increase the risk of squamous cell carcinoma
- large stones may occlude calyxes and cause hydronephrosis- irreversible renal damage
what is cystitis?
inflammation of the bladder; predisposition to pyeonephrosis
a patient with prolonged antibiotic use presents with increased frequency, dysuria and cloudy urine. You suspect cystitis. Name the organism which may be the cause
candida (because of the prolonged antibiotic use)
how does cystitis commonly present
dysuria (pain when voiding) suprapubic pain frequency strangury haematuria and cloudy urine
what is the most common cause of a UTI?
E.coli
how do you treat cystitis in a pregnant women?
nitrofurantoin, because its less teratogenic
what is the common antibiotic used to treat cystitis?
trimethoprim
how might prostatitis feel on DRE?
boggy tender protastatic glands due to neutrophil cell infiltrate
how might prostatitis present?
flue like symptoms, lower backache, UTI’s , swollen or tender prostate, pain on defecation, enlarged bladder.
what is chronic bacterial prostatitis?
this is the presence of bacteria in the prostate causing infection for more than 3 months. pelvic pain and voiding frequency increases
which condition might you suspect with white cells but not bacterial growth on standard urine culture?
renal TB
what sort of inflammation does schistosomiasis cause?>
granulomatous cystitis
what are the most common causes of urethritis?
gonococcal infection
chlamydia
what is the 1st line treatment for prostatitis?
IV antibiotix- gentamicin
trans-urethral USS guided abscess drainage if >1cm
how does urethritis present?
dysuria, purulent discharge of urine
what is the treatment for Neisseria gonorrhoea?
ceftriaxone (IM) and azithiomycin
what is the treatement for chlamydia trachomatis?
tetracycline
how might epididymo-orchitis present?
enlarged warm testis, unilateral scrotal pain, ± fever and malaise
what investigations should you do if you suspect epididymo-orchitis?
MSU- analysis and culture
USS to rule out abscess
what treatement and advice would you give for epididymo-orchitis provided the infection was due to E.coli?
- wear supportive underwear to reduce pain
- NSAIDS if required
- quinolone abx
if epididymo-orchitis was casued by TB, what would you except to see in the biopsy and in MSU?
biopsy: caseating necrotic granulomatous inflammation
MSU: sterile pyruia with acid-alcohol fast baccili
what is pyelonephritis?
infection of the renal parenchyma and soft tissues of the renal pelvis- puss in the kidneys§
why is E.coli the most common cause of pyelonephritis?
because of its P.pilli on its cell surface enabling retrograde ascent up the ureter
what is emphysematous cystitis?
gas in the bladder wall due to gas fermenting organism (normally e.coli)
boys present with pyelonephritis in infancy, but females after the age of 35; explain why.
boys in infancy may have anatomical abnormalities
females over the age of 35 are more likely to experience urethral trauma due to pregnancy.
name 3 complications of pyelonephritis
- renal papillary necrosis
- pyonephritis (complete obstruction of the urinary tract near the renal pelvis)
- perinephric abscess- infection spreads out of the renal capsule into peri-renal tissues…..ADRENAL GLANDS!!!
Buzz word: Sterile pyuria, think…..
Renal TB
treatment for pyelonephritis
IV antibiotics
catheter
analgesia (not NSAIDS)
which type of continous bladder drainage has the lowest risk of infection?
intermittent self catheterisation
which type of continuous bladder drainage has the highest risk of infection, but no risk of hydronephrosis?
urethral catheterisation
which type of continuous bladder drainage is most suitable for tetraplegic patients?
suprapubic catheter
give 4 complications involved with continuous bladder drainage
- increased risk of infection
- risk of trauma
- risk of urethral erosion in urethral catheterisation
- incorrect positioning may pull on genitalia- damage
what is the function of the parasympathetic nerves from roots S2,3,4, in the micturation reflex?
innervate the detrusor muscle- contraction - voiding
what is the function of the hypogastric nerve/sympathetic root T12-L2 in the micturition reflex
cause contraction of the internal sphincter in the male- preventing micturition
cause relaxation of the detrusor muscle- enabling urine to collect in the bladder; preventing voiding
what is the function of the pudenal nerve (sacral output) in the micturition reflex?>
pudenal nerve innervates the external sphincter- contraction inhibits voiding- it is conciously contolled; hence you dont wee unless there is a suitable place!
define urinary incontinence
the inability to control the passing of urine- resulting in retention or unintentional urine release
name 5 risk factors for incontinence
- pregnancy
- obesity
- diuretics
- caffine
- alcohol
hysterectomy and bowel dysfunction are others
what are the 3 broad causes of urinary incontinence?
- neuropathic- neurogenic detrusor overactivity
- obstructive
- urinary tract injury- infection/pressure
define stress incontinence
leakage of urine due to an incompetent sphincter, typical when intra-abdominal pressure increases- cough, laugh, exercise
define urge incontinence
overactive bladder/detrusor muscle overactivity.
there is an urge to urinate followed shortly by urination; no central control
overflow incontinence
high residual volume of the bladder resulting in constant post void dribble
what is functional incontinence>?
patient is aware that they need to void, but for some physical or cognitive dysfunction they cannot get to the bathroom
name 5 methods of managing incontinence
- reduce intake of diuretics; drugs and caffeine, alcohol
- physiotherapy; pelvic flood exercises
- psychological therapy for functional incontinence as a result of cognitive dysfunction
- botox- to paralyse sphincter and detrusor muscle
- mirabegon; B3 agonist- inhibits detrusor contraction
what is a cystoplasty?
this is where the size of the bladder is increased by surgicaly implementing part of the de-epithelialised ileum into the bladder to make it larger. This should reduce bladder pressure and reflux into the kidneys
what is the difference between a paraplegic and a tetraplegic patient?
paraplegic patient is paralysed from the waist down- ie they still have cognitive control over their arms wherease a tetraplegic patient is usually paralysed from C5 downwards- there is no hand cognition control
state 3 differences between a spastic and flaccid bladder
- spastic bladder has no consicous control, whereas a flaccid bladder there is conscious control
- spastic bladder= unco-ordinated contractions and relaxations may result in dyssynergia. In a faccid bladder the lesion is below T12-L1 therefore no impulses reach the brain- bladder does not contract when full- overfills-reflux
- spastic bladder- lesion is above T12, flaccid bladder lesion is below T12
how might a MS patient present with bladder dysfunction?
frequency, nocturia, cognitive impairment, incontinence, poor bladder emptying
how would you treat an MS patient with bladder dysfunction
depends on their post-void residual volume
>100ml post void residual volume- intermittent self catheterisation and antimuscarinics
how would you treat a tetraplegic patient with urinary incontinence?
suprapubic catheter convene drainage (condom catheter)
give 4 causes of an areflexive (flaccid) bladder
spina bifida
sacral fracture
transverse myelitis
ischaemia injuries
name a side effect of the alpha blocker doxazacin
dizziness
name 4 symptoms of Alports disease
hearing loss
haematuria
proteinuria
retinal abnormalities
name 3 symptoms of medullary sponge kidney
tubular dilatation
renal stones
congenital abnormalities
name 2 symptoms of tuberous sclerosis
renal cysts
seizures
mental retardation
which nerve drives detrusor contraction and urethral contraction
detrusor= parasympathetic- S2,3,4
urethral contraction= sympathetic- T12-L2
what are the 3 parts of the male urethra
protastatic
membranous
penile
name 5 symptoms of bladder outflow obstruction due to prostatic hyperplasia
incomplete emptying post void dribble poor stream flow hesitency nocturia
what does specific gravity on a urine dipstick measure
reflects concentration of solutes in the urine
which cytokine is associated with glomerulosclerosis
TGF- beta
what is the most common cause of idiopathic haematuria (particularly in Asians)
IgA nephropathy normally following a streptococcal throat infection/ post strenuous exercise
why might nephrotic syndrome predispose to thrombosis
loss of antithrombin 3, protein C and protien S through the glomerulus
associated rise in fibrinogen levels
name 2 lymph nodes where bladder cancer might metastasise to?
inguinal nodes
iliac nodes
what is uraemia and how does it commonly present?
uraemia is urea in the blood, presents with lethargy, chest pain, confusion, hiccoughs and decreased body temperature
why is creatine used as an estimate of GFR?
freely filtered
not reabsorbed
not metabolised in the body
however it is secreted slightly- hence GFR is an overestimate
why is using creatine concentration in the urine not a reliable way to measure GFR? what is the better method?
creatine does undergo some secretion therefore GFR estimate is slightly overestimated. Inulin is a better method of measuring GFR.
name the protein which is found int the glomerular basement membrane that is damaged in kidney disease?
Nephrin- it helps interlock podocyte foot processes thogether
name 2 hormones which the kidneys produce and which cells they are produced from
- EPO from friboblastoid cells type 1
2. renin- from juxtaglomerular cells
name 2 hormones activated in the kidneys
- angiotensin 2
2. vitamin D (1,25dihydroxyvitamin D)
name 3 substances you would expect to see elevated in the blood in the presence of a teratoma
- beta human coriogonadotrophin hormone
- alpha fetoprotien (tumour marker)
- lactic dehydrogenase
define anion gap
the difference between measured cations and measured anions found in either the plasma, serum and urine.
which growth factor causes remodelling of the glomerulus?
vascular endothelial growth factor
give 3 absolute contraindications of a renal transplantation
- active infection
- cancer (if >5yrs ago consider cured)
- severe co-morbidity
give 3 reasons why a live donor organ is better than a donor after cardiac death?
- live donor organs are planned- therefore better matching of organ- less chance of rejection
- there is less chance of delayed graft function due to long warm ischaemia time
what 2 investigations need to be done before transplantation on the donor?
need to be assessed by an independent assessor from the human tissue authority. Check for ABO group matching, and whether the donor is able to cope physiologically with one functioning kidney
