Pathology Of The Kidney, Ureters And Bladder

Question 1

Kidney Differential Diagnoses

Answer 1

• Trauma
• Swelling/Mass/Tumour - non-neoplastic, benign, malignant (primary/secondary)
• Chronic - chronic inflammatory
• Acute - infection, acute inflammation, immunological
• Stone - genetic, metabolic

Question 2

Causes of Haematuria

Answer 2

Serious causes of haematuria include kidney or bladder cancer; inflammation of the kidney, urethra, bladder, or prostate; polycystic kidney disease; and trauma on urinary tract, among other causes.

Less serious include vigorous exercise and sexual activity.

Question 3

Causes of Acute Renal Failure

Answer 3

• Pre-renal: When the blood flow to the kidney is impaired. The following can cause an impaired blood flow: Severe blood loss, Heart disease, Liver failure, Some medications like aspirin and ibuprofen, Overuse of NSAIDs
• Renal causes: damage to the kidney, A blood clot formation in kidney, Kidney infections, Drugs like chemotherapy and antibiotics, HUS (hemolytic uremic syndrome), Glomerulonephritis – inflammation of the glomeruli which are the kidney filters, Blood vessel inflammation or vasculitis
• Post-renal: urinary obstruction, Diseases that cause blockage of urine include colon cancer, prostate cancer, cervical cancer, and blood clots
• The risk factors include: Age, Diabetes, High blood pressure, Block in the blood vessels in the arm or legs, Kidney disease, Liver diseases

Question 4

Causes of Proteinuria

Answer 4

Dehydration, Inflammation, Low blood pressure, Fever, Intense activity, High stress, Kidney stones, Taking aspirin every day, Very low temperatures. high blood pressure, diabetes, Immune disorders such as lupus, Kidney inflammation (glomerulonephritis), multiple myeloma, Preeclampsia, A buildup of protein in your organs (amyloidosis), Cardiovascular disease, Intravascular hemolysis (a condition in which red blood cells are destroyed), Kidney cancer, Heart failure

Question 5

Kidney functions

Answer 5

fluid and electrolyte balance, resorption of solutes, excretion (of waste e.g. conjugated xenobiotics (substances which are foreign to the body) or urea or excess water), endocrine (renin & bp, erythropoietin & RBCs)

Question 6

Potter Syndrome

Answer 6

Bilateral renal agenesis - often fatal shortly after birth. Caused by a lack of amniotic fluid.

Question 7

Renal Hypoplasia

Answer 7

The kidneys don’t fully develop. Can be unilateral or bilateral. Caused by genetic mutations or drugs taking during pregnancy,

Question 8

Vesicoureteric Reflux

Answer 8

backward flow of urine from the bladder into the kidneys. This causes strong, persistent urge to urinate, pain while passing urine, abdominal pain and fever.

Question 9

Renal Artery Stenosis

Answer 9

narrowing of the arteries that carry blood to the kidneys. This causes high blood pressure, elevated protein levels in urine, decreased kidney function and swelling.

Question 10

Familial Mediteranean Fever

Answer 10

A genetic condition that leads to high fever and inflammation of abdomen, lungs and joints.

Can cause kidney failure.

Question 11

Alport’s Syndrome

Answer 11

Alport syndrome is a genetic condition characterized by kidney disease, hearing loss, and eye abnormalities.

People with Alport syndrome experience progressive loss of kidney function. Almost all affected individuals have blood in their urine (hematuria), which indicates abnormal functioning of the kidneys. Many people with Alport syndrome also develop high levels of protein in their urine (proteinuria). The kidneys become less able to function as this condition progresses, resulting in end-stage renal disease (ESRD).

Question 12

Autosomal Dominant Polycystic Kidney Disease

Answer 12

A genetic disorder in which numerous fluid-filled cysts develop in the kidney. This causes high blood pressure, back pain, headaches, blood in urine, kidney stones and urinary tract infections. Signs and symptoms often develop during adulthood despite cysts being there since birth/childhood.

Question 13

Autosomal Recessive Polycystic Disease

Answer 13

A genetic disorder in which numerous fluid-filled cysts develop in the kidney. This causes high blood pressure, back pain, headaches, blood in urine, kidney stones and urinary tract infections. Much rarer than autosomal dominant and is often lethal in early life.

Question 14

Medullary Sponge Kidney

Answer 14

Medullary sponge kidney is a condition where cysts develop in the urine-collecting ducts and tubules of one or both kidneys. The exact cause of medullary sponge kidney is unknown and there is no cure.

The first sign that a person has medullary sponge kidney is usually a UTI or a kidney stone. UTIs and kidney stones share many of the same signs and symptoms: burning or painful urination, pain in the back, lower abdomen, or groin, cloudy, dark, or bloody urine, foul-smelling urine, fever and chills, vomiting.

Question 15

Medullary Cystic Disease Complex

Answer 15

Medullary cystic disease complex belongs to group of paediatric cystic renal diseases charaterised by progressive tubular atrophy with glomerulosclerosis (chronic tubulointerstitial nephritis) and multiple small medullary cysts.

Question 16

Simple Cyst Kidney

Answer 16

Characterised by small, oval or round thin-walled sacs with watery fluid in the kidney. This causes back pain, abdominal pain and fever.

Question 17

Glomerulonephritis

Answer 17

Inflammation of the kidneys that may involve the glomeruli, tubules or interstitial tissue (functional units of kidney) surrounding them. This causes swelling of the face, hands, feet and legs, blood pressure, blood in urine, and reduced kidney function.

Question 18

Glomerulopathy

Answer 18

Glomerulopathy is generic disease of the renal glomerulus, impairment of which can lead to hematuria or proteinuria due to injury or dysfunction of the endothelium, glomerular filtration barrier or podocyte.

Question 19

Glomerular Disease

Answer 19

• Immunological - MHC/HLA association
• Primary - glomerulonephritis or glomerulopathy
• Secondary - vascular, autoimmune e.g. Systemic Lupus Erythematosus, Amyloidosis, Diabetes, Acquired

Question 20

Goodpasture Syndrome

Answer 20

Goodpasture syndrome is a rare disorder in which your body mistakenly makes antibodies that attack the lungs and kidneys. Lack of energy or tiring easily (fatigue), Nausea, Trouble breathing, Pale skin, Coughing up blood, Burning feeling when urinating, Small amounts of blood in the urine (hematuria), Protein in the urine (proteinuria).

Question 21

Mesangiocapillary (Membranoproliferative) Glomerulonephritis 1&2

Answer 21

Membranoproliferative glomerulonephritis (MPGN) is an uncommon cause of chronic nephritis that occurs primarily in children and young adults. This entity refers to a pattern of glomerular injury based on the following three characteristic histopathologic findings:

• Proliferation of mesangial and endothelial cells and expansion of the mesangial matrix.
• Thickening of the peripheral capillary walls by subendothelial immune deposits and/or intramembranous dense deposits.
• Mesangial interposition into the capillary wall, giving rise to a double-contour or tram-track appearance on light microscopy.

Type I – Subendothelial deposits Type 2 – Dense deposits in the glomerular basement membrane

Question 22

Minimal Lesion Glomerulonephritis

Answer 22

Presents with acute onset of nephrotic syndrome, often following a viral upper respiratory tract infection. Most common in children. Treat with steroids. Marked to proteinuria. Sometimes with Hodgkin’s lymphoma or remission with measles.

Question 23

Focal Segmental Glomerulosclerosis

Answer 23

Focal segmental glomerulosclerosis (FSGS) is a disease in which scar tissue develops on the parts of the kidneys that filter waste out of the blood (glomeruli). FSGS can be caused by a variety of conditions. Marked proteinuria.

Symptoms may include: Foamy urine (from excess protein in the urine), Poor appetite Swelling (called generalized edema, from fluids held in the body), Weight gain.

Causes include: HIV infection, Obesity, Sickle cell disease, Birth defects of the kidneys, Heroin or other drug use, Genetic causes (in rare cases).

Question 24

Nephrotic Syndrome

Answer 24

Results from excreting too much protein in urine due to a kidney disorder. This causes swelling in ankles, feet and around eyes, foamy urine, obesity, and fatigue.

Hypoalbuminaemia, Oedema and Albuminuria, hyperlipidaemia.

Question 25

Proliferative Glomerulonephritis

Answer 25

Diffuse proliferative glomerulonephritis (DPGN) is a common and serious histological form of renal injury seen commonly in those suffering from autoimmune diseases. It advances into rapidly progressive glomerulonephritis with crescents at an accelerated rate and hence if not timely, diagnosed and treated can end up as end-stage-renal disease.

Question 26

Membranous Glomerulonephritis

Answer 26

Membranous glomerulonephritis (MGN) is a slowly progressive disease of the kidney affecting mostly people between ages of 30 and 50 years.

It is the second most common cause of nephrotic syndrome in adults, with focal segmental glomerulosclerosis (FSGS) recently becoming the most common.

Present with nephrotic syndrome.

Question 27

Vascular Causes of Renal Disease

Answer 27

Hypertension, vasculitis, mesangial IgA disease, thrombotic Thrombocytopenic purpura, haemolytic uraemic sydrome.

Question 28

Focal and Segmental Necrotising Glomerulonephritis

Answer 28

Classic renal lesion in Wegener’s granulomatous. Typically associated with scant or no  Immunocomplex deposits. The most common initial features are ear, nose and throat symptoms.

Question 29

Pyelonephritis

Answer 29

A sudden and severe inflammation of kidney due to a bacterial infection (E.Coli most likely). Symptoms include: blood or pass in urine, fever, nausea, vomiting, loss of appetite, pain in the abdomen, fishy smelling urine, cloudy urine, burning feeling when urinating, urgent or frequent urination, fatigue.

Question 30

Tubulointerstitial Disease

Answer 30

Drug hypersensitivity, acute tubular necrosis, shock, ascending infection, systemic lupus erythematous, ischaemia.

Question 31

Urinary Calculi

Answer 31

• 75% calcium -Oxalate and/or phosphate. -Hypercalcaemia-E.G.sarcoid, renal tubular acidosis, hyperPTHism
• Uric acid 20% plus - gout
• Infection -Proteus species - obstruction e.g. vesico-ureteric reflux
• Cystine - 1% - genetic, dehydration

Question 32

Renal Colic Haematuria

Answer 32

Kidney stones causing blood in urine

Question 33

Obstructive Uropathy

Answer 33

Blockage of urinary flow which can occur at any point in the urinary tract. It’s may affect one or both kidneys. Urinary output may be unchanged and serum creatinine can be normal.

Question 34

Hydronephrosis

Answer 34

Refers to dilation of the renal pelvis and can be present with or without obstruction.

Question 35

Post-Renal Renal Failure

Answer 35

• Bladder outflow obstruction - prostate enlargement in man, uterine prolapse in women, calculi, tumours, urethral strictures, neurological damage.
• Hydronephrosis/hydroureter
• caused by obstruction - extrinsic (tumours e.g. cervical cancer), intrinsic (within the wall (intrinsic tumour e.g. transitional cell carcinoma), in the lumen (calculus, blood clot etc).
• must be bilateral to cause renal failure (or unilateral if patient has only one kidney). 

Question 36

Bladder Disease

Answer 36

Caused by inflammation, infection, calculi, neoplasia.

Question 37

Urinary Tract Neoplasms

Answer 37

• Common - bladder (urothelial carcinoma), renal (4 out of five are clear cell carcinoma).
• less common or rare urinary tract tumours - renal carcinomas other than clear cell including transitional cell, renal nephroblastoma (Wilms’ tumour), ureter transitional cell carcinoma, renal/bladder sarcoma.

Question 38

Wilm’s Tumour

Answer 38

Usually in children under three years old. WT1 tumour suppressor gene. histology resembles immature or embryonal blastema. Younger patients have better prognosis. In surgery, radiotherapy, chemotherapy needs to 90% survival.

Question 39

Renal cell Carcinoma

Answer 39

Originates in ducts especially proximal convoluted tubule. Call my list take this clear cell carcinoma. Also papillary, chromophobe. Mostly sporadic. Smoking and obesity are risk factors. Genetics- von Hippel-Lindau Syndrome, autosomal dominant renal clear cell carcinoma, hereditary papillary. More common in men than women. Haematuria most common presentation. Mass, pain, metastasis. Paraneoplastic syndrome e.g. pyrexia, hormones (e.g. EPO).

Question 40

Bladder Cancer

Answer 40

Spectrum of malignancy from superficial, carcinoma in situ to deeply invasive. Tend to recur - 5% pa. Field change. Careful monitoring and follow up. Smoking and industrial (e.g. aniline dyes) are risk factors. Presents with haematuria, dysuria and obstruction.

Question 41

Effects of Acute Renal Failure

Answer 41

Potassium high, creatinine high, may be Liguria, hypertension, (lipids in nephrotic syndrome).

Question 42

Causes of Chronic Renal Failure

Answer 42

• Pre-renal - atherosclerosis
• Renal - glomerulonephritis, diabetes, hypertension, polycystic kidney disease.
• Post-renal - obstruction

Question 43

Effects of Chronic Renal Failure

Answer 43

Potassium high, creatinine high, maybe oliguria, hypertension, anaemia, small kidneys.

Question 44

Renal Osteodystrophy

Answer 44

Biochemical abnormalities and skeletal manifestations in patients suffering from chronic kidney disease.

Question 45

Renal Replacement Therapy

Answer 45

Electrolytes, fluid, excretion, erythropoietin.

Question 46

Haemodialysis

Answer 46

Through the blood circulation.

Question 47

Peritoneal Dialysis

Answer 47

Through the peritoneum. Continuous ambulatory peritoneal dialysis requires a permanent catheter.

Question 48

Nephritic Syndrome

Answer 48

• blood
• pain
• less proteinuria
• oliguria

Question 49

Kidney transplantation

Answer 49

• Donor availability - cadaveric, liver related, liver unrelated.
• Cross matching
• Immunosuppression - risk of infection e.g. BK virus, risk of skin cancer e.g. HPV, risk of lymphoma.

Risks include acute cellular rejection, acute antibody mediated rejection, acute vascular projection, chronic allograft nephropathy (chronic rejection).