Renal and Urogenital Pathology Flashcards
Types of Renal Pathology (3)
Glomerular, tubular and vascular
What is Radiology used to diagnose in renal pathology (4)
Obstructions
Malignancies
Size
Other abnormalities
Types of Renal Biopsy investigations (3)
electronmicroscope
immunofluorescence
light microscope
Pathogenesis of most renal pathologies
Damage to basal membrane OR epithelial cells OR podocyte cells = disturbances in filtration
Types of Renal Vascular damage (3)
Thrombotic microangiopathy (thrombi and endothelial damage)
Vasculitis (inflame)
Renal stenosis - diabetes, hypertension and antheroma
Glomerular damage
vascular and basal membrane damage
Immunological Glomerular damage causes (3)
Circulating immune complexes = SLE or IgA
Circulating antigens deposit in glomerulus
Antibodies against the Basal membrane (autoimmune)
Immunological response in Glomerulus stimulates? that causes damge (4)
complement activation
Neutrophil activation
Reactive O2 species
Clotting factors
Non-immunological Glomerular damage? (3) + examples
Enodthelial injury eg. Vasculitis
Altered Basal Membrane eg. hyperglyceamia or inherited disease
Abnormal protein deposition eg. Amyloid
3 types of tubular damage? + examples
Ischemic - eg. hypotension
Drug induced eg. Antibiotic, NSAIDs or ACEi
Toxic eg. crystal deposits (gout)
Nephritic VS Nephrotic syndrome - cause
Nephritic = acute nephritis or inflammation Nephrotic = Due to glomerulus damage
Nephritic Vs Nephrotic - signs and symptoms
Nephritic = Haematuria +++ (macroscopic)
Also: proteinuria, hypertension and low urine volume
Nephrotic = Proteinuria +++ (frothy urine)
Also: Hypoalbuminaemia –> oedema, hypertension
Diseases that cause Nephrotic syndrome (3)
Membranous nephropathy - thicken Basal membrane
Focal Segmental glomerulosclerosis (FSGS) - hereditary, Heroine and HIV
Minimal Change - in children due to steroids
Disease that cause Nephritis (Nephritic syndrome) = 4
Prior infection - strep OR Ecoli (haemolytic-ureamic syndrome in kids),
IgA Nephropathy - autoimmune in young adults
Vasculitis - fever, purpuric rash, myalgia (Henoch-schonein purura in children)
Lupus - autoimmune
Acute (7) VS Chronic renal Failure (5) - presentation
Acute = rapid onset, anuria, raised creatinine and urea, malaise, fatigue, N&V and arrhythmias
Chronic = same as above + oedema, hypertension, anemia and bone disease
Acute (pre, renal and post = 7) Vs Chronic renal failure (3) - Causes
Acute:
Pre = ischemia
Renal = infection and malignancy = tubular damage
Post (obstructive) = UTI, enlarge prostate, pelvic tumour, stones
Chronic: diabetes, glomerulanephritis, reflux nephropathy
Acute Renal Failure complications (4)
Fluid/ Cardiac overload = pulmonary oedema
GI bleeds
Jaundice (hepatovenous congestion)
Infections = lung and urinary
Nephritis Vs Pyelonephritis
Nephritis = (Infection and toxins) BUT mainly autoimmune
Pyelonephritis = ascending UTIs reaching the renal Pelvis (more common in women)
Vasculitis - effect on kidneys + other symptoms
Inflammation in glomeruli vessels = thrombosis and obliteration of lumen
Rash, weight loss, fever, myaglia
Renal Artery stenosis - Cause + effect on kidneys. Presentation + why?
Atheroma and arterial dysplasia = ischemic injury and loss of function
Hypertension = due to hypoperfusion of the kidneys stimulating the angiotensin system
Diabetes - affect on kidneys? –> end stage renal failure (most common cause)
Hyperglycemia = Thickening of BM and glomerular damage
Small vessel damage = ischemia and tubular damage
Hypertension = affect on kidneys?
Damage vessel walls = thickening and occlusion = ischemia
Hypoperfusion to kidneys = angiotensin and worsens hypertension
Malignancy = type of tumour + affect on kidneys?
Plasma cell
Ig G deposits = inflammation and fibrosis = irreversible decline in function
Obstructive uropathy two types
Intrinsic = in the urethral lumen - stones, inflammation and infection, malignancy, clots
Extrinsic = outside the ureter (compression) - strictures, tumours, pregnancy
Bladder causes of obstructive uropathy
vesicoureteral reflux (valvular issues) = back flow of urine and infections
Tumours
Stones
Neurological = stasis and infection
Complications of Obstructive uropathy (5) - depend on SITE, DURATION and DEGREE
Bladder muscle hypertrophy
Hyroureter - dilation of ureter (proximal)
hydonephrosis - CHRONIC = dilated pelvis, calyces, cortical atrophy
Acute renal failure - reduced glomerular filtration
Chronic Renal failure - following hydonephrosis = loss of function
Causes of Urological Calculi or stones (urlithasis) (4)
Excess substances that precipitate eg. calcium
Change in urine constitutes eg. pH
Poor urine output eg. supersaturation
Decreased citrate levels
Calcium stones in 70% of patient - composition and causes
Calcium oxalate and Calcium Phosphate
Hypercalcaemia - bone disease, PTH excess and sarcoidosis
Excessive intestinal absorption + inability to reabsorb in tubules
Struvite stones in 15% of patients - composition and cause
Magnesium ammonium phosphate
Urease producing bacteria = ammonia = rise in pH = precipitation and ‘stag horn’ caliculi on CT
Urate stones 5% of patients - composition and cause
uric acid
Hyperuricaemia in patients with gout and leukaemia
Gold Standard diagnosis of Renal stones (>95% of cases)
Non-contrast CT (or USS in pregnancy)
Renal Cell Carcinoma risk factors - age, gender etc. (8)
age 60-80 Male (3:2) tobacco obesity hypertension oestrogens cystic kidney disease asbestos
Renal Cell carcinoma - two types - histological presentation
Clear cell (most common) = well defined, yellow tumour, small bland nuceali - invade fat and renal vein
Papillary renal cell carcinoma = cystic/ mulitply. Foamy cuboidal cells with fibrovascular cores, macrophages and calcium
Presentation of RCC (renal cell carcinoma)
Haematuria, bollatile/ palpable kidneys, costovertibral pain
Usually late presentation due Mets (25% of cases)
Paraneoplasic syndrome = Cushings, hypercalcaemia, polyclythaemia (erythropoietin)
5 year survival for RCC - average, organ contained, invasive and distant mets
45% average
70% - confined
50% - invasive
8% - mets = poor response to chemo
Urothelial cell carcinoma - % of bladder cancers?
95%
Can present in the rest of system BUT most common in the bladder
Risk factors of UCC (urothelial cell carcinoma) (5)
older age M>F Smoking cyclophosphamide (chemo) Radiation
Presentation of UCC
Haematuria
Urinary frequency
pain on urination
Urinary tract obstruction
UCC types (progression)
Papilloma-papillary carcinoma
Invasive papillary carcinoma
Flat non invasive Papillary carcinoma (CIN) - cells shed in the urine so analysis is necessary
Flat invasive papillary carcinoma
5 year survival for UCC Non invasive (Tis) Muscular invasion (T2)
95% - non invasive
60% - muscular invasion
Solute concentration depends on:
Solute amount and solvent volume
Function of the kidneys
Excrete - urea and uric acid
Regulate - acid balance and water
Endocrine - renin and erythropoietin
3 reasons for kidney function tests
Detect damage
Measure functional damage
Distinguish between impairment and function
eGFR - what does it measure + involved? When is it used?
Estimated Glomerular filtration rate
Clearance of DTPA
Sex, age, creatinine levels and average surface ares (1.73m2)
Only used in dialysis and kidney failure patients
Plasma Creatinine - normal range? Unhealthy level? What it signifies?
50-140umol/L
1000 umol/L in chronic renal disease
Increases and eGFR decrease BUT is not a proportional to renal damage
Creatinine Clearance equation
urine creatinine mmol/L x urine volume (ml)/plasma creatinine (umol/L)
Normal creatinine clearance? Reasons for different levels?
100-130 ml/min
Unreliable
BUT increased due to secretion in tubules and decreases due to reaction to drugs
Plasma Urea normal range? measures?
5-8 mmol/L
unspecific measure of health
Reasons for changes in plasma urea? In health?
Intake of protein in GI tract and tissue proteins
Affected by kidney re-absorption, excretion and distribution
Kidney re-absorption is 40% BUT higher with slower tubular flow rate (hypoprofusion)
Increased Plasma Urea during?
GI bleeds - trauma
Reduced in Renal blood flow and extracellular fluid volume (hypoprofusion) in acute and chronic renal failure
Plasma Na normal references range
135-145 mmol/L
Urine Volume normal range? Different levels?
750-2000 ml/25 hours
Oliguria <400 ml
Anuria <100 ml
Polyuria >3000 ml
Urine measures (5)
Urea
Sodium
Protein
Glucose and Blood
ADH level in the blood?
Due to renin release stimulating ADH –> aldosterone
High due to hypoprofusion of the kidneys
Which zone of the prostate due carcinomas usually reside?
Peripheral zone - easy to diagnose on digital rectal exam (DRE)
Which zone of the prostate is BPH usually reside in?
central and transitional zone - not easy to diagnose
BPH - benign prostatic hyperplasia? symptoms (5)? Risk?
Obstruction of the ureter = Weak Stream (size and length), Increased urgency and frequency Incomplete bladder emptying Nocturia Hesitancy
Increased age
Most common cancer of the prostate
Adenoma carcinoma
Risk factors for prostate cancer (6)
Age 40 - 50 African race Family history Diet Hormones Exposure to chemicals?
Staging and grading of prostate Cancer
Stage = TMN Grade = Gleason system
Treatments (4)
Surgery
Radio
Chemo
Hormone therapy = anti-androgens –> regression of disease and can extend life by 15 years
PSA - what used for? what issues?
Prostate specific antigen
Blood marker for prostate cancer - increased levels = increased chance
BUT lots of false negatives and positives so NOT used in the UK
Testicular cancer Risks (5)
Family history European/ white descent Cryptorchidism Hormone imbalance Gonadal dysgenesis
Cryptorchidism - what this results in?
Failure for testes to descend >1 year after birth
ECTOPIC testes = ab, inguinal or high scrotal. Bilateral or unilateral (more common on the right)
Hormone imbalances and increased temp of ectopic testes
Hypogondalsim - what it causes?
reduced androgens = testicular atrophy
Primary hypogonadism due to? (7)
undescended testes Klinerfelter syndrome mumps trauma CF testicular torsion varicocele
Secondary hypogonadism due to ? (3)
Pituitary failure
Drugs - steroids, opiods, chemo
Obesity - adipose turn androgens in to oestrogens
Types of Testicular tumour (3)
Yolk sac
Seminoma (germ cell)
Paratesticular structures (eg. tunica vaginalis)
Mesenchymal tumours
Yolk sac tumours - most common in? Presentation?
Children or mixed germ cell tumours in adults
alpha fetoprotein elevated in blood and testes replaced with a gelatinous mass
Seminoma - age? presentation? blood markers?
35-45 years old
testicular enlargement with or with out pain - RARE = inferitliy and gynecomastia
PLAP and hCG
Inflammatory conditions of the testes (5 - long confusing words = just need to be able to recognize them)
Epididymoorchitis Granulomatous orchitis Sarcoidosis Malakoplakia sperm granulomas
Normal Flora of the Urogenital tract
Kindeys and ureter
Bladder
urethra
STERILE = kindeys, ureter and bladder (usually)
Urethra = perineal flora
1) skin = staph
2) lower GI = aerobic (enterobacteriaceae and gram negative coliforms) and Gram positive cocci
UTIs Complicated Vs uncomplicated
Complicated = due to underlying abnormality (structure or function) eg. insertion of foreign body (catheter) OR results in urinary stasis
Uncomplicated = not due to any of the above
Cystitis Vs pyelonephritis
Cystitis = inflammation of the bladder = LUTI
Pyelonephritis = inflammation of the ureter, renal pelvis and kidneys = UUTI
Symptoms of Cystitis
dysuria, urgency increase, frequency, nocturia, suprapubic pain, polyuria, haematuria
Symptoms of pyelonephrits
same as LUTI + loin and unilateral flank pain, fever, N&P, CRP and WBC elevated
Urethral syndrome - what is it? symptoms? ages?
Abacterial cystitis or frequent dysuria
Same symptoms as UTI no infection
Age 30 - 50
Signification Bacteriuria - (KASS criteria level)
Bacteria grown in urine culture above the KASS criteria count of 10^5 cfu/ml
Asymptomatic Bacteriuria
Significant levels of (one species) bacteria cultured but no symptoms
Sterile Pyuria
puss cells in urine BUT no bacteria cultured
Causes of UTIS - sex ratio (5)
Females 10:1 Urinary stasis - pregnancy, BHP, stones, strictures and neoplasm Instrumental Sexual intercourse fistulae congenital
Bacterial causes of UTIs (3)
Ecoli
staphylococcus saprophyticus
Enterococcus
Causes of Sterile Pyruia (4)
Inhibition of bacterial growth by AntiBs
Fastidious - hard to grow organism
UT inflammation - eg. by stones
Urethritis eg. by STIs gonorrhea or chlamydia
Catheter UTI = two locations of bacteria? and why?
Bacteriuria - due to biofilm of colonization (distinguish from actual infection)
Bacteraemia - on removal = discharge from site. AntiB prophylaxis used
Dipstick test for UTI - type of sample? result?
Clean catch midstream sample (can aspirate bladders of children) = no normal flora cultured
NITRITE, blood, protein, WBC = cystitis
BLOOD = pyelonephritis suspected
Urinary TB test
Acid fast bacilli - in 3 early morning urine samples
Microbial treatment of LUTI (4) - length of treatment?
nitrofurantoin
pivemcillinan
Trimethroprin
fosfomycin
Females = 3 days Males = 7 days
Microbial treatment for Pyelonephritis (UUTI) (5) - same as LUTI and empiric? length?
Pivemicllinan, trimethroprin, fosfomycin
Empiric = cefuroxime, ciprofloxacin
7 - 14 days
Treatment for symptomatic bacteriuria
Only in pregnant, infant or elderly with catheter
Non - microbial treatment of UTIs (4)
remove device
anti- inflammatory
Fluids
drainage of abscesses
