Renal: Tubular & Interstitial Diseases, Cancer Flashcards
list lab findings in acute tubular necrosis (ATN)
- acute decline in GFR
- serum BUN & creatinine increased
- metabolic acidosis (low HCO3)
- hyperkalemia
- hyperphosphatemia
- anemia (decreased EPO)
describe urinary findings in ATN
- muddy brown granular casts
- epithelial cells casts
- free epithelial cells
- proteinuria (mild)
- microscopic hematuria (mild)
- no pyuria
list physical findings in ATN
- hypotension
- low urine output (oliguria/anuria)
- uremic signs (pericardial friction rub; confusion)
list ischemic causes of ATN
- hypotension
- vasodilatory (septic shock)
- hemorrhagic shock
- hypovolemic shock (vomiting, diarrhea)
list endogenous causes of nephrotoxicity leading to ATN
hemoglobinuria, myoglobinuria
list exogenous causes of nephrotoxicity leading to ATN
aminoglycosides
contrast media; CT/cardiac cath
list the major causes of acute vs. chronic tubulointerstitial nephritis
the pathogenesis of acute drug-induced interstitial nephritis (AIN) is an ____ reaction manifested by interstitial infiltration of ___, ___ and ____
the pathogenesis of acute drug-induced interstitial nephritis (AIN) is an allergic type reaction manifested by interstitial infiltration of eosinophils, lymphocytes and macrophages
the onset of AIN is usually ____ after starting medication which is the first exposure or
____ if second exposure
the onset of AIN is usually 2 weeks after starting medication which is the first exposure or
3-5 days if second exposure
describe what is seen in the urine in AIN
- eosinophils
- sterile pyuria
- WBC casts
- proteinuria (mild)
describe what is seen in blood tests in AIN
- increased BUN & creatinine
- increased eosinophils count
- tubular dysfunction: high K, low HCO3
____ is when bacteria travel retrograde up the ureters to the kidneys, causing pyelonephritis
vesicoureteral reflux is when bacteria travel retrograde up the ureters to the kidneys, causing pyelonephritis
the condition seen in the image is most commonly caused by ____
the condition seen in the image is most commonly caused by E. coli
the condition seen in the image occurs more commonly in which gender? why?
the condition seen in the image occurs more commonly in females due to shorter urethra
describe how the condition in the image can come from the bloodstream
bloodstream: seeding of kidney from sepsis or infective endocarditis
describe the 3 causes of the ascending form of the condition seen in the image
- post-renal obstruction: cervical, prostate or bladder cancer, urethral stricture, kidney stones, vesicoureteral reflux (incompetent valves allow retrograde flow of urine) = hydronephrosis
- neurogenic bladder: autonomic neuropathies, such as diabetes, spinal fractures
- catheter
describe the presentation of the condition seen in the image
- sudden onset of high fever, chills, flank pain, CVA tenderness, dysuria
____ is the most accurate way of diagnosing the condition seen in the image
urine culture is the most accurate way of diagnosing the condition seen in the image
describe what is seen on urine microscopy of the condition seen in the image
- WBCs (neutrophils) & white cell casts
list complications of the condition seen in the image
pyonephrosis, papillary necrosis & perinephric abscess
list the 2 forms of the condition seen in the image
-
chronic obstructive pyelonephritis
- posterior urethral valves
- kidney stones
-
reflux nephropathy (more common):
- vesicoureteral reflux → preferential scarring & calyceal dilatation at poles
describe gross differences in VUR and obstructive forms of the condition seen in the image
-
VUR: preferential scarring & calyceal dilatation at poles
- entire surface of kidney looks abnormal
-
obstructive: diffuse dilatation of calyces & scarring
- abnormality at upper and lower poles of kidney
chronic pyelonephritis leads to “____” of the kidney
explain
chronic pyelonephritis leads to “thyroidization” of the kidney
atrophic tubules contain eosinophilic proteinaceous material reminiscent of thyroid follicles
a complication of the condition seen in the image is that it can progress to ____
a complication of the condition seen in the image is that it can progress to FSGS
describe the pathogenesis of papillary necrosis caused by chronic analgesic abuse
- ingestion of large quantities → papillary damage due to direct toxic effect (acetaminophen)
- ischemic effect of ASA: inhibit PG → abnormal vasoconstriction of intrarenal arteries → chronic tubulointerstitial nephritis
describe what is seen on intravenous pyelogram (IVP) in papillary necrosis
ring defect at the tips of minor calyces
in papillary necrosis caused by pyelonephritis, there is interstitial inflammation that compresses ____
in papillary necrosis caused by pyelonephritis, there is interstitial inflammation that compresses medullary vasculature and leads to ischemia and papillary necrosis
describe the etiology of the condition seen in the image
- BPH
- cervical, prostate or bladder cancer
- kidney stones
- retroperitoneal adenopathy
- papillary necrosis → sloughed off papillae
- strictures
- horseshoe kidney
the condition in the image occurs when there is continued ____ but unable to excrete due to obstruction, which leads to dilatation of ___ and ____
the condition in the image occurs when there is continued glomerular filtration but unable to excrete due to obstruction, which leads to dilatation of renal pelvis and calyces
in the condition in the image, high pressure in pelvis is transmitted through ___ Into the ____ causing _____
in the condition in the image, high pressure in pelvis is transmitted through collecting tubules Into the renal cortex causing renal atrophy
describe the presentation of the condition in the image when it is unilateral vs. bilateral
- unilateral = asymptomatic
- incomplete bilateral = initially polyuria b/c affects ability of tubule to concentrate urine → develop chronic renal failure (waxy casts) and white cell casts → anuria and uremia
list types of renal stones; what is the most common?
describe the pathogenesis of the condition seen in the image
excessive excretion of minerals in urine
the condition in the image becomes symptomatic once it passes into ____
describe symptoms
the condition in the image becomes symptomatic once it passes into the ureters
- renal colic: abrupt onset of flank pain radiating to groin
- superimposed UTI due to urinary stasis
- hydronephrosis due to obstruction of ureter
the overall theme of preventing the condition seen in the image is to decrease ____
what are methods to do this?
the overall theme of preventing the condition seen in the image is to decrease urinary concentration of the causing substance
- increased fluid intake
-
low sodium diet; decrease urinary Ca2+ excretion
- Ca2+ reabsorbed in PCT with Na
-
alkalinization of urine
- increases solubility of uric acid
the condition in the image occurs due to long-standing ____
the condition in the image occurs due to long-standing HTN
the condition in the image occurs when ___ leaks into the ____ causing _____
the condition in the image occurs when plasma proteins leaks into the tunica media causing hyaline arteriosclerosis
in the condition seen in the image, there is ___ and ____thickening
in the condition seen in the image, there is medial and intimal thickening
the presentation of the condition seen in the image is generally ____ with mild ____
the presentation of the condition seen in the image is generally asymptomatic with mild proteinuria
a complication of the condition in the image is that it can progress to ____, with prominent risk factors being ___, ___ and ____
a complication of the condition in the image is that it can progress to chronic renal failure, with prominent risk factors being blacks, high BP and underlying diabetes
diagnosis of the condition seen in the image is by seeing ____ with ___ on urinalysis
diagnosis of the condition seen in the image is by seeing bland urine sediment with mild proteinuria on urinalysis
list extrarenal manifestations of the condition seen in the image
- other manifestations:
- LVH
- retinopathy
- stroke
the condition seen in the image mainly affects the ___ arterioles
the condition seen in the image mainly affects the afferent arterioles
what is the blood pressure seen in the condition in the image?
>180/120 mmHg, or diastolic >130 mmHg
the condition seen in the image occurs in patients with essential ____ or secondary ____, such as: (2 conditions)
the condition seen in the image occurs in patients with essential hypertension or secondary hypertension, such as:
pheochromocytoma
primary hyperaldosteronism
on gross appearance of the condition seen in the image, there is a characteristic ____ appearance due to ____ on the cortical surface
on gross appearance of the condition seen in the image, there is a characteristic flea-bitten appearance due to petechial hemorrhages on the cortical surface
on histology of the condition seen in the image, there is an ____ appearance due to proliferation of _____
on histology of the condition seen in the image, there is an onion-skin appearance due to proliferation of smooth muscle in the tunica media
a complication of the condition seen in the image is ____
a complication of the condition seen in the image is acute renal failure
the presentation of the condition in the image is ____, ____ and ____
the presentation of the condition in the image is hematuria, oliguria and proteinuria
list the extrarenal manifestations of the condition seen in the image
HUS/TTP are disorders characterized by abnormal _____ leading to thrombosis in arterioles and capillaries throughout the body
HUS/TTP are disorders characterized by abnormal platelet aggregation leading to thrombosis in arterioles and capillaries throughout the body
___ are seen in PB smear in HUS/TTP
schistocytes are seen in PB smear in HUS/TTP
in HUS, there is more severe ____ and less pronounced ____ involvement
in HUS, there is more severe renal failure and less pronounced CNS involvement involvement
HUS is classically seen in children 1 week after episode of ____ caused by _____
HUS is classically seen in children 1 week after episode of bloody diarrhea caused by EHEC (O157:H7)
HUS is associated with infections caused by (other than EHEC)…. (3 things)
HUS is associated with infections caused by (other than EHEC)
viral infxns
Shigella
Salmonella
HUS can also be drug induced and caused by…. (5 drugs)
HUS can also be drug induced and caused by:
quinine (tonic water)
Gemcitabine
Cyclosporine
Ticlopidine
OCPs
in TTP, there is more ___ involvement and less severe ____
in TTP, there is more CNS involvement and less severe renal failure
TTP is associated with… (3 conditions)
TTP is associated with:
SLE
HIV
hematological malignancy
renal artery stenosis is most commonly caused by ____
renal artery stenosis is most commonly caused by occlusion due to atheromatous plaque
the kidney with renal artery stenosis is protected from ____, whereas the contralateral kidney would show _____
the kidney with renal artery stenosis is protected from arteriosclerosis, whereas the contralateral kidney would show hypertensive arteriosclerosis
a physical finding of renal artery stenosis is a ____ heard in the flank or epigastric region
a physical finding of renal artery stenosis is a bruit (d/t turbulent blood flow) heard in the flank or epigastric region
on ultrasound in renal artery stenosis, ____ would be seen
on ultrasound in renal artery stenosis, asymmetrical kidney size (small kidney on side of RA stenosis) would be seen
____ is the gold standard of diagnosing renal artery stenosis
renal arteriogram is the gold standard of diagnosing renal artery stenosis
treatment of renal artery stenosis is with ___ and ___
treatment of renal artery stenosis is with angioplasty and stent
list complications of renal artery stenosis
renal failure; hypertensive changes to heart, brain, retina
in renal artery stenosis, the ___ cells can sense hypo-perfusion to the kidney and release ___ leading to hypertension
in renal artery stenosis, the JG cells can sense hypo-perfusion to the kidney and release renin leading to hypertension
the more severe form of the condition seen in the image is caused by a genetic mutation in _____ (aka ___ gene) located on chr. ___
the more severe form of the condition seen in the image is caused by a genetic mutation in PKD1 (aka polycystin gene) located on chr. 16
the less severe form of the condition seen in the image is caused by a genetic mutation in _____ (aka ___ gene) located on chr. ___
the less severe form of the condition seen in the image is caused by a genetic mutation in PKD2 (aka polycystin gene) located on chr. 4
describe the presentation of the less severe form of the condition seen in the image (___ gene located on chr. ___)
PKD2 gene located on chr . 4
- later onset of cysts
- fewer and smaller cysts
- slower progression
- later age of ESRD
describe the possible mechanism for cyst formation in PKD
how can the condition in the image lead to hypertension?
- cysts → compression of renal vessels → renin, aldosterone
how can the condition in the image cause hematuria?
rupture of cysts in collecting duct
why is there flank pain seen in the condition in the image?
stretching of renal capsule
list the extrarenal manifestations of the condition seen in the image
- hepatic cysts
- cerebral aneurysms
- pancreatic cysts
- cardiac valve disease (MVP, AR)
- colonic diverticular disease
- abdominal wall & inguinal hernia
what is one word that helps describe the extrarenal manifestations of the condition seen in the image?
CYSTS/weakening of walls
hepatic cysts
cerebral “cysts” = dilatation of vessel walls = aneurysms (Berry)
pancreatic cysts
weakening of chordae tendinae = MVP
weakening of colonic walls = diverticular disease
weakening of abdominal wall = inguinal hernia
describe a genetic test to diagnose the condition associated with the image
FISH to look for the gene
the most common cause of death in the condition associated with the image is ____
the most common cause of death in the condition associated with the image is heart failure and MI due to HTN
the condition associated with the image can lead to ____ hemorrhage due to ____
the condition associated with the image can lead to subarachnoid hemorrhage due to ruptured Berry aneurysm
the condition seen in the image is caused by a mutation in ___ (aka ___ gene) located on chr. ___
the condition seen in the image is caused by a mutation in PKHD1 (aka fibrocystin gene) located on chr . 6
the cysts in the condition seen in the image originate from ____
the cysts in the condition seen in the image originate from collecting ducts (homogenous)
the ___ sequence is associated with the condition seen in the image; describe this
the Potter sequence is associated with the condition seen in the image;
- oligohydramnios due to renal agenesis
- breech presentation bc can’t flip
- malpositioning of hands and feet
- flat face and low set ears
- pulmonary hypoplasia bc need amniotic fluid to develop
the condition seen in the image is associated with ____ if the patient doesn’t die at birth
the condition seen in the image is associated with hepatic fibrosis/cirrhosis if the patient doesn’t die at birth
describe the condition in the image
medullary (sponge) cystic kidney = benign
list the benign renal tumors
- renal adenoma
- renal oncocytoma
- angiomyolipoma
list the malignant renal tumors
- renal cell carcinoma (90%)
- urothelial carcinoma
- children = Wilm’s tumor
angiomyolipoma is described as being ____ since it contains muscle, fat, and vessels
angiomyolipoma is described as being triphasic since it contains muscle, fat, and vessels
angiomyolipoma is described as being triphasic since it contains ___, ___ and ____
angiomyolipoma is described as being triphasic since it contains muscle, fat and vessels
describe the 2 types of angiomyolipomas
- 50% = tuberous sclerosis (seen in 25 y/o)
- asymptomatic, small
-
sporadic = 45 y/o
- flank pain
- mass
- hematuria
- retroperitoneal hemorrhage
the condition seen in the image is a malignant tumor of ____ cells
the condition seen in the image is a malignant tumor of renal tubular epithelial cells
list the genetic mutations in the different types of renal carcinoma
describe the sporadic type of the condition seen in the image; what is it associated with?
- sporadic = more common; seen in older pts (60+ yrs)
- unilateral and unifcoal
- associated with HTN, obesity, smoking, cadmium batteries, acquired PKD in pts with long-standing dialysis
describe the hereditary type of the condition seen in the image; what 3 conditions are associated with it?
- hereditary = younger adults
- bilateral and multifocal
- associated w/ pheochromocytoma, cerebellar & retinal hemangioblastomas
the condition in the image is associated with a mutation in ____ which is located on chr. ___
the condition in the image is associated with a mutation in VHL (tumor suppressor gene) which is located on chr. 3
list the triad of symptoms of the condition seen in the image; ____ is the most common sign
triad: painless hematuria, flank pain, flank mass
hematuria is the most common sign
list the paraneoplastic syndromes associated with the condition in the image
A PEARL
- A = ACTH → Cushing’s
- P = PTH → hypercalcemia
- E = EPO → polycythemia
- A = AA amyloidosis
- R = renin → HTN
- L = leukomoid reaction → left shift with bandemia
describe the 3 types of the condition seen in the image
- clear cells = most common; has glycogen and lipids
- papillary has psammoma bodies
- chromophobe = well-circumscribed and localized
the treatment for the condition seen in the image is a ____
the condition in the image is associated with a mutation in subtotal nephrectomy
an ___ is contraindicated in the condition seen in the image; why?
an incisional biopsy is contraindicated in the condition seen in the image
it can cause it to spread (RCC spread hematogenously, NOT via lymph)
describe complications of the main treatment of the condition seen in the image
treatment = subtotal nephrectomy = loss of renal mass → FSGS can occur
describe how condition seen in the image can lead to a varicocele
renal vein thrombosis → left testicular vein → varicocele
describe the triad seen in Von Hippel Lindau
- RCC
- pheochromocytoma
- retinal & cerebellar hemangioblastomas
describe the genetic mutation seen in the papillary type of renal cell carcinoma
papillary = mutation in MET which is an oncogene
describe the stages of the condition seen in the image
- stage 1 = confined to kidney
- stage 2 = perirenal fat
- stage 3 = lymph node and IVC
- stage 4 = adjacent organs/metastasis
in the condition seen in the image, there is a mutation in ____ genes located on chr. ___
in the condition seen in the image, there is a mutation in tumor suppressor genes (WT1 and WT2) located on chr. 11
in the condition seen in the image, there is a ___ pattern seen with blastema, stroma and epithelial cells
in the condition seen in the image, there is a triphasic pattern seen with blastema, stroma and epithelial cells
