Renal and Urological Pathology Flashcards
presentation of acute renal failure
unwell - malaise, fatigue, nausea, vomiting, arrhythmias
anuria/ oliguria
rapid rise in creatinine and urea
pre-renal causes of acute renal failure
reduced blood flow to kidney - severe dehydration, hypotension
renal causes of acute renal failure
damage to kidney
post-renal causes of acute renal failure
urinary tract obstruction - urinary tract tumours, pelvic tumours, calculi, prostatic enlargement
complications of acute renal failure
cardiac failure - fluid overload arrhythmias - electrolyte imbalance GI bleeding Jaundice - hepatic vein congestion Infection - esp. lung and urinary tract
what is chronic kidney disease
permanently reduced GFR = reduced number of functional nephrons
causes of chronic kidney disease
adults - diabetes, glomerulonephritis, reflux nephropathy
chlidren - developmental abnormalities, glomerulonephritis, reflux nephropathy
presentation of chronic kidney disease
reduced urine output: excretion of water electrolytes > oedema and hypertension
reduced excretion of toxic metabolites
reduced epo production = anaemia and renal bone disease
renal manifestation of hypertension
damages renal vessels > wall thickening and reduced lumen size > reduced perfusion > ischaemia and activation of RAAS = ^HTN
renal manifestation of diabetes
damage due to hyperglycaemia
BM thickens
glomerulus produces excess extracellular matrix
small vessel damage causs ischaemia and tubular damage
renal manifestation of myeloma
excess Igs deposit in tubules which cause inflammation and fibrosis
renal tubule loss = irreversible decline in renal function
renal manifestation of vasculitis
inflammation in glomerular vessels can cause clotting and obliteration of capillary lumena and glomerulus destruction
inflammation of larger renal arterioles can cause tubule hypoxia
often part of systemic disease
renal manifestation of renal artery stenosis
due to atheroma or arterial dysplasia - ischaemic injury
activation of RAAS = HTN
loss of renal tissue = reduced function
nephrotic syndrome causes
damage to glomerulus adults: membranous nephropathy (idiopathic primary glomerular disorder) Focal segmental glomerulosclerosis minimal change disease diabetes, lupus nephritis, amyloid
children:
minimal change disease
focal segmental glomerulosclerosis
nephrotic syndrome presentation
oedema proteinuria >3g in 24hs hypoalbuminaemia \+/- hypertension \+/- hyperlipidaemia
acute nepritis presentation
oedema haematuria proteinuria HTN acute renal failure
causes of acute nephritis
adults: post infective glomerulonephritis - after strep throat infection IgA nephropathy vasculitis SLE
children:
post-infective glomerulonephritis and IgA nephropathy
Henoch-Schonlein purpura
haemolytic uraemic syndrome
haematuria causes
IgA nephropathy
thin basement membrane disease
alport hereditary nephropathy - type IV collagen cause abnormal BM sometimes with eye and ear problems
what is pyelonephritis
infection via haematogenous spread
what is autosomal dominant polycystic kidney disease
bilateral cystic change > loss of functional renal parenchyma > chronic renal failure
clinical features of AD polycystic KD
HTN, polyuria, end stage renal disease between 40-60
pathenogenesis of AD polycystic KD
mutation of PKD1
what is autosomal dominant polycystic kidney disease
cystic disease of kidneys and liver in childhood
pathenogenesis of autosomal recessive polycystic KD
mutation of PKDH1
most common kidney cancer
clear cell carcinoma
male or female renal Ca
males
risk factors for renal carcinoma
tobacco, obesity, HTN, oestrogens, acquired cystic kidney disease, asbestos
what is the most common several cancer syndrome observed in RCC
von hippel-lindau
what happens in V H-L sydrome
VHL gene required for breakdown of hypoxia inducible factor-1 oncogene
causes cell growth and survival
presentation of RCC
haematuria, palpable abdominal mass, costovertebral pain
incidental
late presentation - systemic or mets
what are paraneoplastic syndromes
clinical syndromes that result from substances produced by tumours
paraneoplastic syndromes associated with RCC
Cushing’s - ^ACTH
hypercalcaemia - PTH related peptide
polycythaemia - ^epo
morphology of clear cell renal carcinoma
well defined yellow tumours
haemorrhagic areas
may extend to perinephric fat
tendency to invade renal vein
morphology of papillary renal cell carcinoma
more cystic
more likely to be multiple
overall 5 year survival or RCC
45%
organ confined >70%
distant mets = poor prognosis - chemo resitstant
most common bladder tumour
urothelial cell carcinoma
risk factors for urothelial cell carcinoma
age gender - male smoking arylamines cyclophosphamide radiotherapy
presentation of urothelial cell carcinomas
haematuria
urinary frequency
pain
urinary tract obstruction
histological patterns in TCC
papilloma-papillary carcinoma
invasive papillary carcinoma
flat noninvasive carcinoma
flat invasive carcinoma
causes of UT obstruction at pelvis
caliculi
tumours
uretopelvic stricture
causes of UT obstruction at intrinsic ureter
calculi tumours clots sloughed papilla inflammation
causes of UT obstruction at extrinsic ureter
pregnancy
tumours
retroperitoneal fibrosis
causes of UT obstruction at bladder
calculi
tumour
functional - neurogenic
causes of UT obstruction at urethra
posterior urethral valves
stricture, tumours
causes of UT obstruction at prostate
hyperplasia
carcinoma
prostatitis
sequelae of obstruction of UT
infection - cystitis, uretitis, pyelitis, ascending pyelonephritis
acute/chronic kidney damage
complications from UT obstruction
hydronephrosis - result of chronic obstruction
acute complete obstruction = reduction in glomerular filtration rate > acute renal failure
clinical features of UT obstruction
acute bilateral obstruction - pain, acute renal failure, anuria
chronic unilateral obstruction - asymptomatic, cortical atrophy and reduced renal function
pathenogenesis of renal calculi
excess of substances which may precipitate out e.g. Ca
change in urine constituents causing precipitation of substances
poor urine output
decreased citrate levels
classification of renal calculi
calcium stones - most common
struvite stones - magnesium ammonium phosphate
urate stones - uric acid
cystine stones
why do calcium stones form
hypercalciuria due to hypercalcaemia excessive Ca absorption from gut inability to reabsorb tubular Ca idiopathic RF: gout, hyperoxaluria
why do struvite stones form
urease producing bacterial infection
urease = urea > ammonia
rise in urine pH
precipitation of magnesium ammonium phosphate salts > staghorn calculus
gold standard test for renal calculi
non-contrast CT scan
sequelae of renal calculi
obstruction
haematuria
infection
squamous metaplasia +/- squamous cell carcinoma
benign prostatic hyperplasia definition
enlargement of the prostate
overgrowth of the epithelium and fibromuscular tissue of the transition zone and periurethral area
BPH pathogenesis
arises from centrally situated glands
- nodule formation
- diffuse enlargement of the transition zone and periurethral tissue
- enlargement of nodules
aetiology of BPH
impaired cell death
BPH lower uterine symptoms
urgency hesitancy diminished stream, size and force increased frequency incomplete bladder emptying nocturia
cancer of the prostate
adenocarcinoma
grading for prostatic cancer
gleason grade
risk factors of prostatic cancer
age race family history hormones levels environmental influences androgens inherited polymorphisms
when do the majority of germ cell tumours occur
young males
incidence accelerating rapidly following puberty and peaking close to 30 years of age
pre-existing medical conditions that are associated with the development of testicular germ cell tumours
prior TGCT in contralateral testicle cryptorchidism impaired spermatogenesis inguinal hernia hydrocele disorders of sex development prior testicular biopsy atopy testicular atrophy
age range of seminoma
most commonly 35-45 years old
uncommon in men >50
rare in children
clinical presentation of seminoma
testicular enlargement with or without pain
mets in 10%
some have no symptoms
markers of seminona
elevated serum PLAP (40%) and hCG (10%)
macro seminoma
well demarcated
cream coloured
homogeneous
corsely lobulated
teratoma age range
first and second decades of life
teratoma presentation
gradual testicular swelling with or without pain
almost always benign before puberty
markers of teratoma
pure teratoma = no markers
macro teratoma
well-demarcated, solid or multicystic
what is cryptorchidism
one or both testicles fail to descend and reach scrotum before birth
most of the time has reached scrotum by 1 year
which side is cryptorchidism most frequent on
right
complications of cryptochidism
testicular atrophy
infertility
carcinoma - TGCT
skin flora
predominantly coag-neg staphylococci
lower GI tract flora
aerobic bacteria - enterobacteriaceae
gram positive coccus - enterococcus
what is cystitis
lower UTI
symptoms of cystitis
dysuria urinary frequency urgency supra-pubic pain/ tenderness polyuria, nocturia, haematuria
what is pyelonephritis
Upper UTI - kidney and/or renal pelvis
symptoms of pyelonephritis
symptoms of lower UTI
loin/abdominal pain/ tenderness
fever
symptoms of systemic infection
what is asymptomatic bacteruria
significant bacteruria without symptoms of UTI
predisposing factors to UTI
female urinary stasis instrumentation sexual intercourse fistulae congenital abnormalities
what is a complicated UTI
underlying abnormality
presence of a foreign body
most common UTI causing organism
E.coli
causes of sterile pyuria
inhibition of bacterial growth
hard to grow organisms
urinary tract inflammation
urethritis (sexually transmitted pathogens)
what is a catheter UTI
indwelling catheterisation results in bacteriuria
biofilm formation > colonisation
which other devices can also cause UTI
urostomies
nephrostomies
what can be seen on a urine dipstick
blood
protein
nitrite
white blood cells - leucocyte esterase
non-antimicrobial management of UTIs
fluid intake anti-inflammatories device removal drainage if obstruction/ abscess recurrent UTIs - significant recurrent UTIs >3 episodes in 12 months cranberry juice
requirements for antibiotics in UTI
present in urine minimally toxic effective against likely organisms easily administered cheap
examples of antibiotics given in UTI
Nitrofurantoin
Pivmecillinam
Trimethoprim
Fosfomycin
treatment of cystitis
females - 3 days antibiotics
males - 7 days
pyelonephritis treatment
empiric therapy - cefuroxime, ciprofloxacin
piperacillin-tazobactam
7-14 days depending on antibiotic used
who should be treated with asymptomatic bacteruria
pregnant women
infant - prevent pyelonephritis
prior to urological procedures
elderly
perinephric abscess
renal stones and/or diabetics
obstruction of infected kidney
gram neg bacilli
intrarenal abscess
haematogenous spread: unilateral, single, renal cortex
s. aureus
can be associated with classic acute pyelonephritis
what is prostatitis
inflammation of the prostate
symptoms of prostatitis
Lower UT symptoms
fever
tender prostate
uropathogens - e. coli
laboratory tests of renal function
glomarular filtration rate eGFR creatinine clearance plasma creatinine plasma urea urine volume urine urea urine sodium urine protein urine glucose haematuria
definition of oliguria
<400mL/24hrs
anuria
<100mL/24hrs
polyuria
> 3000mL/24hrs
normal urine output
750-2000mL/24hrs
plasma urea reference range
3-8mmol/L
factors influencing plasma urea concentration
GIT protein > liver amino acids
Tissue protein > liver amino acids
> plasma urea
distribution volume > plasma urea
Kidney reabsorption/ excretion
kidney filtration
how is urea excreted
filtered at glomerulus
40% reabsorbed in health
if more is absorbed then tubular flow is slow
tubular flow is slow when there is hypoperfusion
causes of increased plasma urea
GI bleed trauma renal hypoperfusion acute renal impairment chronic renal disease post renal obstruction - calculus, tumour
normal range for plasma creatinine
50-140 umol/L
increase in conc as..
GFR increases
plasma creatinine in chronic renal disease
may increase to 1000umol/L
creatinine clearance in health
30-40% higher than GFR
creatinine clearance in chronic renal disease
tubular secretion increased
eGFR in stage 1 CKD
90+
eGFR stage 2 CKD
60-89
eGFR stage 3A CKD
45-59
eGFR stage 3B CKD
30-44
eGFR stage 4
15-29
eGFR stage 5
<15
pre-renal oliguria findings
GFR reduced
ADH increased - conc urine/low vol
renal hypoperfusion = renin
increase Na reabsorption - urine Na low
Pre-renal failure causes
dehydration
haemorrhage
renal artery damage
hypotension
renal oliguria findings
GFR reduced
weak urine/ low volume
renal renin secretion may be raised > HTN, nephrons unable to absorb sodium
renal oliguria findings
intrinsic damage
- tubular necrosis
- chronic infection
- immunological damage - SLE
- toxic damage - drugs, heavy metals, poisons
features of renal renal failure
anaemia
haematuria
proteinuria
urine casts
calcium/ phoshate
bone disease
