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* year 2 Clinical Pathology > renal > Flashcards

renal Flashcards

1
Q

what are the 3 main endocrine functions of the kidneys?

A
  • produce renin (renin-angiotensin system, increases fluid retention)
  • produces erythropoetin (epo)
  • activates vit D into active form
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2
Q

what are the 5 broad causes of vascular damage (which lead to kidney damage)?

A

thrombotic microangiopathy
- thrombi in arterioles/capillaries (secondary to endothelial damage - lots of causes)

vasculitis
- acute/chronic vessel wall inflammation -> narrowing of lumen

hypertension

diabetes

atheroma (eg renal artery stenosis)

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3
Q

what are the broad causes of glomerar damage, leading to kidney damage:

  • immunological? 3
  • non-immunological? 4
A

immunological:

  • circulating immune complexes deposit in glomerulus
  • circulating antigens deposit in glomerulus
  • autoimmune antibodies to basement membrane/glomerular components
nb all of the immunoligcal causes lead to:
- complemetn activation
- neutrophil activation
- reactive oxygen species
- increased clotting factors
which all -> glomerular damage

non-immunological:

  • vessel damage/endothelial injury
  • altered basement membrane
  • abnormal basement membrane or podocytes due to inherited disease
  • abnormal protein deposition (amyloid) impair function
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4
Q

give two examples of conditions which result in circulating immune complexes which deposit in the glomerulus, leading to kidney damage?

A

SLE

IgA/membranous nephropathy

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5
Q

give two examples of autoimmune conditions which consist of antibodies being created against basement membrane/glomerular components, leading to kidney damage.

A

goodpasture’s syndrome
- against BM in lungs + kidneys

post-infective glomerolunephritis

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6
Q

name a non-immunological cause of altered basement membrane

A

diabetes mellitus hyperglycaemia

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7
Q

name one inherited condition which leads to abnormal basement membrane, leading to kidney damage

A

alport disease/syndrome

inherited defect in type 4 collagen

leads to problems with kidneys, ears + eyes

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8
Q

name 3 conditions which can have abnormal protein deposition in the glomerulus, impairing function + leading to kidney damage

A

RA

bronchiectasis

myeloma

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9
Q

what is an amyloid protein?

A

universally used term that refers to abnormal intracellular or extracellular deposition of proteins as fibrils. Amyloid fibrils may be deposited in a variety of organs including brain, liver, heart, kidney, pancreas, nerve and other tissues as a consequence of certain inherited and acquired disorders

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10
Q

name 3 ischaemic causes of tubular damage + 4 toxic causes

A

ischaemic:

  • hypotension (eg shock)
  • blood vessel damage (eg vasculitis, HTN)
  • glomerular damage

toxic:

  • direct toxins
  • hypersensitivity reactions
  • crystal deposits (eg urate)
  • abnormal protein deposition (eg Igs)

ischaemic causes result in reduced perfusion which leads to tubular damage (tubules are very sensitive to ischaemia!)

toxic causes directly result in tubular damage

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11
Q

name 4 types of drug which are nephrotoxic

A
  • NSAIDs
  • ACEi
  • diuretics
  • some antibiotics
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12
Q

name 5 non-drug compounds which are nephrotoxic

A
  • contrast medium
  • ethylene glycol (antifreeze)
  • organic solvents
  • pesticides
  • heavy metals
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13
Q

nephrotic syndome:

  • pathophysiology?
  • 3 main features?
  • 2 other possible features
  • possible complications? 2
A

always due to damage to GLOMERULUS

  • proteinuria
  • oedema
  • hypoalbuminaemia
    (nb proteinuria results in other 2!)

+/- hypertension
+/- hyperlipidaemia

complications:

  • infection
  • thrombosis (as antithrombin lost in urine)
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14
Q

nephrotic syndrome:

  • commonest cause in adults?
  • 2 other common adult causes?
  • 3 rarer causes in adults?
A

membranous nephropathy (commonest)

  • idopathic primary glomerular disorder
  • get thickening of basement membrane
  • affect adults <60
  • M>F

focal segmental glomerulosclerosis (FSGS)

  • various causes (usually idiopathic, but also genetics, heroin use, HIV)
  • M>F

minimal change disease

  • normal histology
  • diagnosis of exclusion
  • M=F

(diabetes, lupus nephritis, amyloid)

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15
Q

what is the most common cause of nephrotic syndrome in children?

A

minimal change disease

  • normal histology
  • diagnosis of exclusion
  • usually excellent prognosis
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16
Q

nephritic syndrome:

  • alternative name?
  • symptoms? 4
A

acute nephritis

  • HAEMATURIA (norm macroscopic)
  • proteinuria (less than in nephrotic)
  • hypertension (slight)
  • low urine output
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17
Q

what are 4 common causes of nephritic syndrome in adults?

A

post-infective glomerulonephritis:

  • weeks after strep throat infection
  • good recovery

IgA nephropathy

  • common primary glomerular disease
  • usu young adults
  • 20-50% renal failure over 20 years

vasculitis
- autoimmune

lupus nephritis (caused by SLE)

  • autoimmune
  • usually young women
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18
Q

what other symptoms would someone with vasculitis have, alongside nephritic syndrome? 5

A
  • unwell
  • fever
  • rash
  • myalgia
  • arthralgia
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19
Q

what are the 4 main causes of nephritic syndrome in children?

A

Henoch-Schönlein purpura

  • a specific IgA nephropathy
  • often follows throat infection
  • most recover completely

haemolytic-uraemic syndrome
- typically children with e. coli gastroenteritis

post infective glomerulonephritis

IgA nephropathy

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20
Q

Henoch-Schönlein purpura:

  • who norm affects?
  • symptoms? 4
A

boys/teenagers

  • arthralgia
  • abdo pain
  • purpuric rash
  • proteinuria/haematuria -> acute kidney injury
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21
Q

haemolytic-uraemic syndrome:

  • symptoms? 3
  • pathophysiology?
A
  • nephritic syndrome/acute nephritis
  • haemolysis
  • thrombocytopenia

norm caused by a toxin produced by e coli
- toxin damages vascular wall -> clots + haemolysis -> thrombocytopenia

get GI symptoms first, renal stuff follows

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22
Q

acute kidney injury (aka acute renal failure)

  • definition?
  • symptoms? 8
A

anuria/oliguria (<400ml/24hr)
+ raised plasma creatinine + urea

  • malaise
  • fatigue
  • nausea
  • vomiting
  • high BP
  • oedema
  • confusion
  • arrythmias
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23
Q

acute kidney injury:

  • most common pre-renal causes? 2
  • most common post-renal causes? 4
  • when is a renal biopsy helpful?
A

pre-renal (norm reduced blood flow -> kidneys):

  • severe dehydration
  • hypotension (bleed, septic shock, LVF)

post-renal (urinary tract obstruction):

  • urinary tract tumours
  • pelvic tumours
  • calculi (kidney stones)
  • prostatic enlargement

only helpful for intra-renal causes of AKI
- imaging better for post-renal stuff

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24
Q

acute kidney injury:

  • most common intra-renal causes in adults? 2
  • most common intra-renal causes in children? 3
A

adults:

  • vasculitis (autoimmune or inflammatory)
  • acute interstitial nephritis (aka tubulointerstitial nephritis)

children:

  • Henoch-Schönlein purpura
  • haemolytic-uraemic syndrome
  • acute interstitial nephritis
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25
Q

acute interstitial nephritis/tubulointerstitial nephritis:

  • usual cause?
  • pathophysiology?
  • prognosis?
A

drugs

tubular damage with inflammation

most recover

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26
Q

acute kidney injuey:

  • complications? 5
  • treatment? 2
A
  • cardiac failure (fluid overload)
  • arrythmias (electrolyte imbalance)
  • GI bleeding (multifactorial)
  • jaundice (hepatic venous congestion)
  • infection (esp lung + urinary tract)
  • depends on underlying cause
  • short term dialysis may be needed

nb with any fluid overload there is a resulting risk of infection

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27
Q

how do the kidneys regulate the acid-base balance in the body?

A
  • excrete acid

- reabsorb bicarbonate (to greater of lesser extents)

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28
Q

what are 4 main groups of effects that chronic renal failure has on the body?

A

reduced excretion of water/electrolytes:

  • > oedema
  • > hypertension

reduced excretion of toxic metabolites:

  • > itchy
  • > confusion
  • > fatigue

reduced production of erythropoetin
-> anaemia

reduced activation of vit d
-> renal bone disease

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29
Q

what is isolated proteinuria?

what are the possible benign causes? 3

what could it also be due to?

A

proteinuria BUT less than nephrotic range
- no allied haematuria, renal failure or oedema

  • postural
  • related to pyrexia
  • related to exercise

renal disease

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30
Q

what does urine sample tend to look like if there is proteinuria?

A

frothy

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31
Q

isolated haematuria:

  • definition?
  • possible causes? 4
  • investigation needed?
A

haematuria +/- proteinuria with NORMAL renal function

  • IgA nephropathy
  • thin basment membrane disease (inherited condition causing abnormally thin glomerular BM - renal function norm normal)
  • alport hereditary nephropathy
  • malignancy

cystoscopy/urological investigations needed to exclude malignancy

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32
Q

acute pyelonephritis:

  • risk factors? 4
  • complication?
A
  • female (ascending infection)
  • instrumentation (ie catheter)
  • diabetes
  • urinary tract structural abnormalities

abscess formation

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33
Q

chronic pyelonephritis:

  • main risk factor?
  • main complication?
A

urinary tract obstruction -> reflux

  • chronic renal failure
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34
Q

renal artery stenosis:

  • most common cause?
  • other cause?
  • pathophysiology?
  • long term effect?
A

most common = renal artery stenosis
- also: arterial dysplasia

ischaemic injury of affected kidney -> activation of renin-angiotensin-aldosterone system (as kidney thinks body is hypovolemic as narrow lumen means low blood flow to kidney) -> HTN -> further damage to kidney = damage spiral

loss of renal tissue -> reduced renal function

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35
Q

how does hypertension cause kidney damage?

A

HTN -> wall thickening + reduction in lumen size

this -> chronic hypoxia
-> loss of renal tubules + reduced renal function

reduced blood flow activates renin-angiotensin-aldosterone system -> exacerbates HTN

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36
Q

what are the two mechanisms of kidney damage seen in diabetes mellitus?

A

hyperglycaemia -> damaged/thickened BM
- therefore glomerulus produces excess extracellular matrix -> nodules in kidneys which reduces function

hyperglycaemia -> small vessel damage -> ischaemia -> tubular damage

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37
Q

If you have an elderly patient with acute renal failure and the cause is not pre-renal or due to drugs, what should you suspect and investigate for?

A

myeloma

38
Q

what is the most common cause of interstitial nephritis?

A

adverse drug reactions

39
Q

causes of urinary tract obstruction:

  • within the lumen?
  • abnormalities of the wall?
  • external compression?
  • functional obstruction?
A

within the lumen:

  • kidney stones (calculi)
  • strictures (post-procedural, post-infective, congenital)
  • neoplasm

abnormalities of the wall:

  • congenital anatomical abnormalities
  • neoplasm (benign or malignant)

external compression:

  • inflammatory conditions (retroperitoneal fibrosis)
  • pregnancy
  • enlarged prostate (BPH, prostitis, neoplasm)
  • tumour outside urinary tract

functional obstruction:

  • neurological conditions
  • severe reflux
40
Q

what are the 3 main sequelae of a urinary tract obstruction?

A

infection
- cystitis, ureteritis, pyelitis, ascending pyelonephritis

stone/calculi formation

kidney damage (acute or chronic)

41
Q

what is a complication of urethral obstruction?

A

bladder hypertrophy

42
Q

what can occur due to chronic ureteric obstruction?

A

hydroureter
- ureter is distended proximal to obstruction

can then -> hydronephrosis
- dilated calyces, pelvis + cortical atrophy

43
Q

what are the clinical features of:

  • acute bilateral obstruction? 3
  • chronic unilateral obstruction? 2
A

acute bilateral obstruction:

  • pain
  • anuria
  • acute kidney injury

chronic unilateral obstruction
- asymptomatic initially
- often get recurrent UTIs
nb takes a loonnng time for symtpoms to present

44
Q

renal calculi/urolithiasis:

  • M or F?
  • peak onset age?
  • most common cause?
  • other causes? 2
A

male predominance

peak onset 20-30 years

hypercalciuria

  • gout (forms a core for Ca2+ crystal formation)
  • hyperoxaluria (hereditary or excess dietary intake)
45
Q

types of causes of hypercalciuria? 4

A
  • hypercalcaemia
  • excessive absorption of intestincal calcium
  • inability to reabsorb tubular calcium
  • idiopathic
46
Q

causes of hypercalcaemia? 3

A
  • bone disease
  • parathyroid hormone excess
  • sarcoidosis
47
Q

struvite renal stones:

  • cause?
  • pathogenesis?
  • typical appearance on imaging?
A

urease producing bacterial infection

  • urease converts urea -> ammonia
  • > rise in urine pH
  • > precipitation of magnesium ammonium phosphate salts -> calculi

large ‘staghorn’ calculi

48
Q

causes of urate renal stones? 3

cause of cystine stones?

A

urate stones

  • hyperuricaemia (caused by gout)
  • hyperuricaemia (caused by patient’s with high cell turnover eg leukaemia)
  • idiopathic
cystine stones (rare!)
- inability of kidneys to reabsorb amino acids
49
Q

what is the gold standard test for renal calculi?

- test if not available?

A

non-contrast CT scan

  • ultrasound in pregnancy or where CT not available
50
Q

commonest type of kidney cancer?

norm age of onset?

main risk factor?
- other risk factors? 5

A

renal cell carcinoma (95%)

  • arises from proximal convoluted tubules
  • norm ‘clear cell’ tumours

65-80 years

SMOKING

  • obesity
  • hypertension
  • oestrogens
  • acquired cystic kidney disease (due to chronic renal failure)
  • asbestos exposure
51
Q

von-hippel lindau syndrome:

  • gene mutated?
  • type of cancers caused?
A

inherited mutated VHL gene -> oncogene

  • kidneys
  • blood vessels
  • pancreas
52
Q

renal cell carcinoma:

  • signs/symptoms? 3
  • % present with systemic symptoms +/or metastases?
A
  • haematuria
  • costovertebral pain (along ribs + back)
  • palpable abdominal mass (if big)

25%

53
Q

name 3 paraneoplastic syndromes associated with renal cell carcinoma (RCC).

what % of people with RCC have a paraneoplastic syndrome?

A

cushing syndrome
- ACTH

hypercalcaemia
- parathyroid hormone related peptide

polycythaemia
- erythropoietin

1%

54
Q

most common type of bladder cancer?

A

urothelial cell carcinoma (aka transitional cell carcinoma)
- 95% of bladder tumours

nb most common in bladder but may arise anywhere from renal pelvis to urethra

55
Q

urothelial cell carcinoma risk factors? 6

A
  • old age
  • male
  • smoking
  • arylamines (dye used in dye factories)
  • Cyclophosphamide (chemo drug)
  • radiotherapy
56
Q

symptoms of urothelial cell carcinoma? 3

A
  • HAEMATURIA (most common)
  • urinary frequency
  • pain on urination (dysuria)
57
Q

urine volumes per 24 hrs in:

  • healthy people?
  • oliguria?
  • anuria?
  • polyuria?
A

healthy people: 750-2000ml

oliguria: <400ml
anuria: <100ml
polyuria: >3000ml (+ is not drinking, norm caused by diabetes insipidus)

58
Q

what things can cause high plasma urea? 4

A
  • high dietary protein
  • lots of tissue protein breakdown (eg post surgery or trauma or GI bleed)
  • renal problems
  • post-renal problems
59
Q

is more urea reabsorbed into the blood when the kidneys are hypoperfused or hyperperfused? why?

what does this mean clinically?

A

MORE urea REabsorbed if kidneys are HYPOperfused

  • as there is more time for urea to diffuse back into the peritubular capillaries

therefore an early clinical sign of hypovolemia is high blood urea

60
Q

what is the relationship between plasma creatinine + renal function

A

not-proportional

GFR can decline hugely and only see a small change in creatinine
- creatinine increases in an exponential fashion

change within individual patient is usually more important than absolute value

61
Q

how do renal physicians predict when a patient with chronic renal failure will need dialysis or transplantation?

A

plot graph of the reciprocal of their plasma creatinine over time and extrapolate it to work out when they will need renall replacement therapy (RRT)

62
Q

When is glomerular filtration rate measured in practise? 2

how is this done?

A
  • kidney donors
  • to work out dose of drug needed for some chemo drugs

radioactive substances are used to work it out

63
Q

what is the formula used to work out creatinine clearance?

when is this used in practise?

A

(urine creatinine conc, mmol/L x urine volume, ml/24hrs) / plasma creatinine conc, umol/L

very very rarely!!
- hard and complicated to measure practically and different units of measurement make maths hard too

64
Q

what changes in blood plasma chemistry are seen during the progression of chronic renal failure?

A

about 50% kidney function:

  • increased creatitine
  • increased urea

then:

  • increased potassium
  • decreased bicarbonate

then:

  • increased phosphate
  • increased uric acid
65
Q

what four factors are used to calculate eGFR?

A
  • plasma creatinine
  • age
  • gender (male = worse)
  • ethnicity (black = worse)
66
Q

what would you expect to happen to:

  • urine volume?
  • urine conc?
  • plasma values: Na/urea/creatinine?
  • urine values: Na/urea?

in:

  • pre-renal kidney failure
  • intra-renal kidney failure
A

pre-renal kidney failure:

  • urine volume: low
  • urine conc: high
  • plasma values of Na/urea/creatinine: all raised
  • urine values of Na: low
  • urine values of urea: high

intra-renal kidney failure:

  • urine volume: low
  • urine conc: low
  • plasma values of Na/urea/creatinine: all raised
  • urine values of Na: high
  • urine values of urea: low-ish

nb kidneys aren’t working so can’t concentrate urine or reabsorb Na

67
Q

what should you always look at in any patient who you suspect kidney damage in?

A

urine volume!!

68
Q

define the stages of kidney failure?

A

stage 1:

  • eGFR >90
  • normal kidney function but urine findings/structural abnormalities indicate kidney disease

stage 2:

  • eGFR 60-90
  • mildly reduced kidney fuinction (+stuff in stage 1)

stage 3:

  • eGFR 30-60
  • moderately reduced kidney func

stage 4:

  • eGFR 15-30
  • severley reduced kidney func
  • planning for RRT

stage 5:

  • eGFR <15 or on dialysis
  • end-stage kidney failure
  • needs transplant/dialysis
69
Q

symptoms of prostatic enlargement?

A

known as: lower urinary tract symptoms (LUTS)

  • urgency
  • hesitancy
  • diminished stream size + force
  • increased frequency
  • incomplete bladder emptying
  • nocturia
70
Q

what is the difference in where BPH (benign prostatic hyperplasia) and where prostate cancer tends to affect the prostate

A

prostate cancer normally affects peripheral zone
- so can be detected using a digital PR

BPH is more likely to affect the central zone, around the urethra, so is more likely to cause urinary symptoms

71
Q

what are the 3 pathological changes that occur during the development of BPH?

what is another name for BPH?

A
  • nodule formation
  • diffuse enlargement of the transition zone + periurethral tissue
  • enlargement of nodules

nodular hyperplasia of the prostate

72
Q

what are the majority of prostate cancers?

what are the main 5, assumed, risk factors for prostate cancer?

A

adenocarcinomas

  • AGE
  • race (african more at risk)
  • family history
  • hormone levels (high testosterone)
  • environmental influences (eg increased consumption of fats)
73
Q

what is the histological scoring system for prostate cancer?

A

gleason scoring system

74
Q

testicular cancer:

  • most common type?
  • age group norm affected?
  • 3 main risk factors?
  • ethnicity more likely to be affected?
  • symptoms? 3
A

germ cell testicular cancer

15-50 years

  • cryptorchidism (+ other probs with testes)
  • family history
  • previous testicular cancer in other testes

caucasian

  • lump in the scrotum
  • dull ache in scrotum
  • feeling of heaviness in the scrotum
75
Q

what is cryptorchidism?

  • how can it predispose to testicular cancer?

what is the treatment for it?

what other complications can it cause? 2

A

one or both testes fail to reach scrotum before birth (or within one year)

testicles need to be cold (are too hot is kept in abdo) -> cancer

orchidoplexy = surgery to move teste into scrotum + permenentley fix it there

  • testicular atrophy
  • infertility
76
Q

hypogonadism:

  • primary causes? 9
  • secondary causes? 4
A

primary causes:

  • undescended testes (cryptorchidism)
  • varicocele
  • cystic fibrosis
  • klinefelter syndrome
  • haemochromatosis
  • mumps
  • orchitis (inflammation of testes)
  • trauma
  • testicular torsion

secondary causes:

  • pituatory failure
  • drugs
  • obesity
  • aging
77
Q

what types of drugs can cause hypogonadism in men? 4

A
  • glucocoticoids (corticosteroids)
  • ketoconazole (antifungal)
  • chemo drugs
  • opiods
78
Q

define + name common symptoms of:

  • cystitis? 3
  • pyelonephritis? 3
  • urethral syndrome?
A 
cystitis:
- inflammation of the bladder
-- dysuria
-- urinary frequency
-- urgency
(also supra-pubic pain/polyuria/nocturia/haematuria)

pyelonephritis:

  • upper urinary tract infection
    • symptoms of lower UTI
    • PLUS abdo/loin pain
    • +/- fever (or other signs of systemic infection)

urethral syndrome:

  • aka abacterial cystitis
    • symptoms of lower UTI without demostrateable infection
79
Q

asymptomatic bacteruria:

  • definition?
  • 4 groups commonly affected?
A 
significant bacteruria (with a single organism
- WITHOUT symptoms of UTI
  • people with catheter
  • diabetics
  • pregnant women
  • elderly women
80
Q

asymptomatic bacteruria:

  • definition?
  • 4 groups commonly affected?
  • what groups should be treated with Abx? 2
A 
significant bacteruria (with a single organism
- WITHOUT symptoms of UTI
  • people with catheter
  • diabetics
  • pregnant women
  • elderly women

use Abx:

  • pregnant women
  • infants
81
Q

name 5 causes of urinary stasis, which can lead to UTIs

A
  • stones
  • strictures
  • prostatic hypertrophy
  • neoplasm
  • pregnancy
82
Q

name a congenital abnormality which leads to increased likelihood of getting UTIs

A

vesico-ureteric reflux (VUR)

83
Q

what is the definition of a complicated UTI, as opposed to an uncomplicated one?

A

complicated:

  • underlying abnormality (structural/functional)
  • presence of foreign body (catheter/renal calculi/biofilm)
  • children <10
  • men <65

uncomplicated UTI = absence of above

84
Q

organisms causing UTIs:

  • most common?
  • common in adult women?
  • associated with kidney stone?
A

most common = E. coli

common in adult women = staph saprohyticus

associated with kidney stone = proteus mirabilis

85
Q

what is pyuria?

what are the causes of STERILE pyuria? 4

A

the presence of pus in the urine (norm due to a bacterial infection)

  • inhibition of bacterial growth (eg already started w antibiotics or specimen contaminated w antiseptic)
  • ‘fastidious’ (hard to grow) bacteria (eg TB, anaerobes)
  • urinary tract inflammation (renal/bladder stones or other renal disease)
  • urethritis (sexually transmitted pathogen - eg gonorrhoea or chlamydia)
86
Q

for a urine sample looking for UTIs, what part of the stream should you ideal use?

A

mid-stream

87
Q

prostatitis:

  • 2 types?
  • normal bacterial cause?
  • normal predisposing factor?
  • symptoms? 3
A

chronic:

  • recurrent UTIs with same organism (norm e coli)
  • asymptomatic in-between

acute bacterial
- post procedure (eg post-prostate surgery/biopsy)

e coli

  • lower urinary tract symptoms
  • fever
  • tender tense prostate on PR palpation
88
Q

what 4 things are tested for in a standard U+E blood test?

A
  • urea
  • creatinine
  • sodium
  • potassium
89
Q

what are the possible complications of chronic kidney disease? 9

why do they occur?

A

Na + water retention -> HYPERTENSION + increased vascular volume -> HEART FAILURE

uraemia -> MALAISE, FATIGUE, SEXUAL DYSFUNCTION + CNS DEPRESSION (reduced GCS)

lack of vit D activation -> hypocalcaemia + hyperphosphatemia -> HYPERPARATHYROIDISM -> breakdown of bone -> OSTEOPOROSIS

lack of erythropoeitin -> NORMOCYTIC ANAEMIA

90
Q

describe the effects of ACE inhibitors on the kidney and when they should be used and when they shouldn’t be used

A

angiotensin II (with ACEi inhibit) constricts the Efferent arteriole -> increased pressure in the glomerulus -> increased filtration

so want to use ACEi in chronic kidney disease to reduce the pressure of the kidneys

however, in AKI, you want to increase the filtration of the kidney so get rid of ACEi increase amount of angiotensin II

  • but remember to put them back on it once the AKI is over!!!

* year 2 Clinical Pathology (11 decks)

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