renal infections and tumours: Flashcards
Urinary tract infection (UTI):
Inflammation of
urinary tract - Usually caused by bacteria from gut flora
Classified according to location Cystitis– bladder inflammation Pyelonephritis – inflammation of upper urinary tract Urethritis – inflammation of the urethra
Urinary tract:
Normally – most bacteria washed out of
the urethra during micturition
• Bladder contraction prevents reflux of urine to the ureters and
kidneys.
Bacteriocidal Environment • Low pH • High osmolarity of urea • Secretions from uroepithelium • Presence of a protein called Tamm-Horsfall protein (uromodulin)
urinary tract infection
- predisposing factors:
- Age / host defense – Pregnancy – Calculi – Medical procedures (e.g catheter) – Diabetes – Chemotherapy – Tumors – Antibiotics
Urinary tract infection:
Presents as a clinical constellation of symptoms
• Pyelonephritis is common in younger
women
•Unilateral symptoms are suggestive of
pyelonephritis rather than ureteric extension of cystitis which is more likely to be bilateral
• Often occurs in otherwise well
women
UTI’s: CYSTITIS
Cystitis is inflammation of bladder
• Infection with coliform
bacteria
– E. coli 80%
– Klebsiella, Proteus, Staph (10%), Pseudomonas
• (Can also be caused by fungal infection ,parasitic invasion –Schistosomiasis–Africa, South America)
• Women (30%) > Men (1%); Why?
•≈10% of women will have a UTI per year
• ≈60% of women will have a UTI in a
lifetime
ACUTE CYSTITIS – CLINICAL FEATURE:
- signs of bladder irritability and cloudy urine:
signs of bladder irritability: • Urgency • Frequency • Dysuria (painful urination) • Lower abdominal pain
cloudy urine: • Pyuria (pus in urine) • Hematuria • Bacteriuria (70%) • Chills, fever, nausea, vomiting
- 10% asymptomatic
ACUTE CYSTITIS – CLINICAL FEATURE:
serious symptoms:
more serious symptoms:
- Cloudy urine
- Hematuria
- Foul smelling urine
- Flank pain
ACUTE CYSTITIS – CLINICAL FEATURE
- asymptomatic and older patients:
Asymptomatic
• Healthy people may have evidence of bacteria in the urine but have no infection
•‘Asymptomatic bacteriuria’ – no treatment required exceptin pregnant women.
Older patients
•May not experience these
symptoms
• Often experience non–localised abdominal discomfort
•ALSO AT RISK OF CONFUSION, COGNITIVE IMPAIRMENTAND RAPID PROGRESSION TO SEPSIS
•Older adults with UTI and another concurrent illness are at greater risk of
mortality
UTI - management:
- History, presenting signs, urinalysis,
urine culture, full blood count
•Identifying presence of bacteriuria & Px
of appropriate AB
• Managing any underlying risk factors
e.g. obstruction
• Very common for recurrence (25% within a week)
• Follow up urine cultures are recommended to avoid repeat attacks
• BUN, creatinine, electrolyte values obtained to rule out change in renal function
UTI - management:
Older patients (esp. from nursing homes) are often resistant to some antimicrobials • Interventions also include – Antibiotics – Adequate fluid intake – Urinary alkaliniser • Intravenous rehydration may be needed in severe cases • Hot packs to relieve discomfort
UTI’s: Acute Pyelonephritis
Bacterial infection of the upper urinary tract – renal pelvis
• Usually caused by E. coli (80%) after an underlying, predisposing condition
• Usually occurs because of spread from ureter (cystitis) but may occur from blood borne infection
• Will affect renal pelvis, calyces & medulla
– it is rare for glomerular involvement
• If infection is extensive, can permanently damage tubules
• Can result in permanent renal
damage
UTI’s: Acute Pyelonephritis
- patho:
- clinical manifestations:
Pathology
• Enlargement, scalered areas of
abscess, increased neutrophils in the
tubules
- Clinical Manifestations
Generally produces fever, chills, flank p
proteinuria, pyuria (PMN’s
in the urine) white cell casts hematuria, generalized malaise
Different symptoms from cystitis by clinical manifestation alone is difficult
UTI’s: Acute Pyelonephritis:
Prehospital management
Prehospital management
• pain relief
• transport
• Consider fluids (consult for ALS)
– Septic & hypotensive
– Long transport
Definitive
– Antibiotic therapy
UTI’s - Treatment:
Prehospital
– Symptomatically
– Analgesia
Definitive treatment – Blood and urine tests required – Analgesics (anaesthetics, opiates) – Fluid replacement – Anti- emetics
UTI’s: CHRONIC PYELONEPHRITIS
• By definition, any chronic renal inflammation
• By name-honoured misnomer, severe scarring from one or more kidney
infections
• Pyelonephritis always produces some renal scarring around the calyces and renal pelvis and among the tubules
• Once scarring occurs, one
is more likely to get a bacterial infection (blood borne)
UTI’s: CHRONIC PYELONEPHRITIS
- Causes
- Specific cause may be unknown (idiopathic)
- Vesicoureteral reflux
- Renal stones
- Recurrent acute pyelonephritis may be associated with chronic pyelonephritis
- Drug toxicity from analgesics such as NSAIDS
- Ischemia, irradiation, immune-‐complex
UTI’s: CHRONIC PYELONEPHRITIS
- Pathophysiology
Chronic obstruction of the urinary tract prevents elimination of bacteria ⇒ Progressive inflammation ⇒ Altered renal pelvis and calyces ⇒ Destruction of tubules ⇒ Atrophy, dilation ,diffuse scarring ⇒ Impaired urine concentrating ability ⇒ Chronic kidney failure
UTI’s: CHRONIC PYELONEPHRITIS:
- Clinical Manifestations
• Early symptoms can be minimal –Hypertension, flank pain, dysuria, frequency • As tubular function is lost –Hyperkalemia, metabolic acidosis – Risk of dehydration
Types of tumors:
- Benign cortical adenoma of kidney–uncommon
- Carcinoma of kidney, mainly clear cell(adenocarcinoma)
- Wilms tumour – nephroblastoma in children
- Bladder – transitional cell carcinoma & squamous cell carcinoma
It is very rare for a cancer from another part of the body to spread to the kidney.
Renal Adenoma:
• Uncommon • Solid, encapsulated, usually located near cortex • Can become malignant • => usually surgically removed
Renal Cell Carcinoma (RCC) 1
Malignancy of renal tubular or ductal cells
• ~85% of all renal cancers – (5–10% are of renal pelvis)
• Survival rate 96% at stage 1; 23% at stage V
Classified according to cell type and extent of metastasis • Clear cell (glycogen & lipids) 70 % • Papillary type 15 %
Renal cell carcinoma 2 – risk
- Male: female = 2:1
- Age 50–60 years
- Cigarette, pipe and cigar smoking(tobacco)
- Analgesic use
- Sporadic (95%) – loss of VHL gene
- Genetic (5%):
Renal cell carcinoma (RCC)
Arising in the lower pole.
• Usually slow growing and can reach a considerable size before detection because there is a lot of room
to enlarge in the retroperitoneum,
and there is another kidney to provide renal function
• Presenting symptoms usually include flank pain and heamaturia
Clinical manifestations of RCC:
• Largely a ‘silent’ disorder in early stages
• In its earliest stages, kidney cancer causes no pain.
• Therefore, symptoms of the disease usually appear when the tumor
is large and begins to affect nearby organs.
Clinical manifestations of RCC
• Classic triad in only 10% of cases –
haematuria, flank pain and flank mass
• Haematuria occurs in about 70
–90% of cases, most reliable sign, but can be intermilent/ microscopic
• Mimics other conditions due to advanced systemic disease
• Fever, malaise, weakness and weight loss
• Polycythaemia (Excess E
Clinical manifestations of RCC 2
Clinical manifestations of RCC 2 • hypercalcaemia • hypertension, • hepatic dysfunction, feminisation or masculinisation, • Cushing's syndrome
Wilms Tumor – Nephroblastom
• Usually a solitary mass, occurs anywhere in kidney
• Usually sharply demarcated – variably
encapsulated
• Grow large and distort the kidney structure
Symptoms
• large abdominal mass,hypertension
• Some children may have abdominal pain and vomiting
• Haematuria may be present
Treatment • good prognosis if diagnosed early • Surgery • Chemo • Sometimes radiation therapy
Bladder tumours:
Neoplasia
• Spectrum: benign papilloma, carcinoma --in--situ, invasive, metastatic • Bladder tumors = 2% of all malignant tumours • 95% of bladder cancers are transitional cell carcinoma (TCC) --urothelium •Also squamous cell carcinom
