Renal/Urology Flashcards
Features of Nephrotic syndrome?
4 things
Hyperlipidaemia
Oedema
Hypoalbuminaemia
Proteinura
What are features of Nephritic syndrome?
Pharaoh
Proteinuria - sub nephrotic range Haematuria Azotaemia RBC casts Anti-Strep titres Oliguria Hypertension
Protein leakage occurs in ___
Nephrotic syndrome - leads to leaky filter and podocyte dysfunction
Nephritic syndrome has _____ blocking the filter
Antibodies blocking the filter and leading to Inflammation
Three complications of Nephrotic syndrome which lead to the fourth complication?
Infection (cellulitis)
Hypercoaguable state (PE, DVT)
Intravascular volume collapse and shock (third spacing)
Leads to CKD
4 Nephritic syndromes?
IgA nephropathy
Post Strep GN
Anti-GBM
Pauci-immune GN
5 Nephrotic Syndromes:
Minimal change disease FSGS Membranous nephropathy Diabetic nephropathy Amyloid nephropathy
Nephrotic syndrome affecting childhood?
Minimal change - 90% of cases
Management of Minimal change disease?
Mx of complications?
Steroids
Oedema - salt restriction, ,daily weight, Diuretics (with albumin)
Infections - Prophylactic Phenoxymethylpenicillin
Thrombotic risk: Apsirin
Segmental sclerosis on Light Microscopy.
Immunofluorescence: weakly positive for IgM and C3
FSGS
What is benign nephrosclerosis?
Renal changes associated with hypertension causing hyaline arteriosclerosis
Kidneys are atrophic and have a diffuse granular surface
What is primary Vesicoureteric reflux?
Due to anatomical impairment:
a ureter did not grow long enough during the child’s development in the womb, the valve formed by the ureter pressing against the bladder wall does not close properly, so urine refluxes from the bladder to the ureter and eventually to the kidney; typically unilateral
What is secondary VUR?
Blockage in the urinary tract causes an increase in pressure and pushes urine back up into the ureters; typically bilateral
Hypertension in youth, renal impairment can lead to reflux nephropathy (small scarred kidneys) due to chronic _____
Pyelonephritis
VUR with torturous ureter with moderate dilation,blunting of fornices but preserved papillary impressions
Which grade?
Grade 4
Diagnosis of VUR?
- U/S
2.
What are the causes of Primary FSGS?
Minimal change disease progression
Secondary causes of FSGS:
Podoctye injury (inflammation, toxins) or prior nephron loss (reflux nephropathy, Htn, nephrosclerosis)
Mx of FSGS (Primary vs Secondary)
Primary: Prednisolone or consider cyclosporine or tacrolimus
Secondary: Ace-i to lower intraglomerular pressure
Which GN is related to Hepatitis B, paraneoplastic syndrome of melanoma, Gold
Membranous GN
Auto-antibodies to M-type Phospholipase A2 receptor
Membranous GN
Most common nephrotic syndromes in non-DM adults?
Membranous nephropathy
GBM thickening and spikes on silver stain on light microscopy
Membranous GN
Mx of Membranous GN?
Steroids and cyclosporin
Rule of thirds for Membranous GN?
1/3 - experience spontaneous remission
1/3- persistent proteinuria and a reduced but stable renal function
1/3 will lose renal function and result in end stage renal failure
Pathophysiology in Diabetic nephropathy?
Initially hyper perfusion and renal hypertrophy, then thickening of GBM and mesangial volume expansion, then microalbuminuria (WHICH IS REVERSIBLE)
then over proteinuria (Which is irreversible)
Kimmelstiel-Wilson lesion/nodule on light microscopy:
Diabetic nephropathy
Deposition of insoluble inappropriately folded proteins (with altered secondary structures causing it to fold into _____________):
Beta pleaded sheets
- Condition is Amyloidosis
Presentation of Amyloidosis (3):
Presents as proteinuria (amyloid kidneys), restrictive cardiomyopathy, neurological deficits (peripheral neuropathy, carpal tunnel syndrome), pale and waxy appearance and diffuse enlargement of organs (hepatosplenomegaly, macroglossia, etc.), cutaneous ecchymoses (“raccoon eyes”)
Management of Amyloidosis?
melphalan and prednisolone (similar to multiple myeloma), treat CHF
Apple green birefringence on a Congo red stain and polarised light
Amyloidosis
GN Secondary to chronic infections such as hepatitis C, autoimmune processes, and monoclonal gammopathies
Immune complex-mediated: immune complex deposition leading to activation of complement
Membraoproliferative/Mesangiocapillary GN
Light microscopy: glomerular basement membrane reduplication and increased mesangial and inflammatory cells, “tram tracking”
Membranoproliferative GN
Wire loop Glomeruli on Histology:
Lupus Nephritis
MDSOAP BRAIN in Lupus?
Malar Rash
Discoid Rash
Serositis: Pleuritis, pericarditis
Oral or nasopharyngeal ulcers (on palate)
Arthritis: non-erosive and non-deforming (prayer’s signs)
Photosensitivity
Blood work: haemolytic anaemia or leukopaenia
Renal: Lupus nephritis
ANA Positive
Immunolic: anti- dsDNA, anti-smith
Neuropsych issues
Libman-Sacks endocarditis associated with?
SLE
Markers for SLE:
Anti-nuclear antibodies (ANA), anti-dsDNA, anti-Smith (most specific), anti-histone (drug-induced SLE), C3 and C4 (for monitoring)
SLE associated endocarditis, characterised by verrucous valvular vegetations that can be detected on TTE:
Libman-Sacks endocarditis
Typically asymptomatic, however the verrucae can fragment and produce systemic emboli, and infective endocarditis can develop on already damaged valves
GN occurring during and immediately after (1-2 days) viral upper respiratory tract infection
IgA Nephropathy: Caused by an infection triggering IgA production, and subsequent deposition and inflammation in the mesangium
GN associated with Asian, Coeliac disease, coke coloured urine:
IgA nephropathy
Triad for Henoch-Schonlein Purpura:
Palpable purpuric/ptechiae rash over buttocks and lower extremity Arthritis: of large joints with painful oedema Abdominal pain (diarrhea)
Differentiating HSP from ITP and TTP?
HSP has thrombocytosis
Immunofluorescence starry sky:
Post-infective GN
GN typically occurring 2-4 weeks after Group A β-haemolytic M type Streptococcus infections (pharyngitis, scarlet fever, impetigo, etc.)
Post-infective GN
What age group is Post Strep GN most common in?
children aged 4-8yrs
Light microscopy: “hump-like” subepithelial, as well as subendothelial and mesangial electron-dense deposits, neutrophils present, can be crescentic if severe:
Post infective GN
GN occurs due to production of anti-GBM antibodies in response to an unknown stimulus
Anti-GBM membrane disease
Crescentic Glomerulonephritis on Light microscopy:
Anti-GBM GN
Linear ribbon-like IgG pattern on Immunofluorescence:
Anti-GBM disease
Mx of Anti-GBM disease:
Plasmapheresis with either prednisolone or cyclophosphamide
What is pauci-immune GN?
A group of nephritis GN associated with vasculitides:
What markers in Granulomatosis with polyangitis?
c-ANCA, anti-protinase-3
Rhinitis + GN + Eyes affected
Small vessel vasculitis
Granulomatosis with polyangiitis
Glomerulonephritis (Pauci-immune nephritic syndrome) and lung involvement (haemoptysis) with NO presence of granulomas and p-ANCA positive:
Microscopic Polyangiitis
3 stages of Churg-Strauss syndrome:
- Allergic stage: asthma, atopy, rhinitis
- Eosinophilic stage: Eosinophilia (leading to abdominal pain, bleeding)
- Vasculitis stage (Glomerulonephritis - Pauci-immuni nephritis)
p-ANCA positive in _____ and ______
Microscopic Polyangiitis and Churg-Strauss Syndrome
Three types of GN leading to RPGN:
Anti-GBM disease, Immune complex disease, Pauci immune GN
What are the most common causes of scrotal swellings in primary care?
Epididymal Cysts
Where are epididymal cysts located?
Found separate to the body of the testicle and found posterior to the testicle
A _______ describes the accumulation of fluid within the tunica vaginalis.
Hydrocele
Hydroceles may develop secondary to…
Epididymo-orchitis
testicular torsion
testicular tumours
Features of a hydrocele?
Soft, non tender swelling of the hemi-scrotum. Usually anterior and below the testicle.
You can get ‘Above’ the mass. TRANSILLUMINATES with a pen torch.
A ____ is an abnormal enlargement of the testicular veins.
Varocele
4 major symptom categories for BPH?
- Voiding symptoms (obstructive) - hesitancy, dribbling and retaining
- Storage symptoms: urgency, frequency, urgency incontinence and nocturia
- Dribbling
- Complications: UTI, retention, obstructive uropathy
Mx options for BPH?
Wait
Medication: alpha1 antagonist or 5 alpha reductase inhibitors
surgery - TURP!
What medications are used for BPH and what are their side effects?
- Alpha 1 antagonist - Tamsulosin, alfuzosin
First line - decrease smooth muscle tone
Adverse effects - dizziness, postural hypotension, dry mouth, depression - 5 alpha-reductase inhibitors e.g. Finasteride
Block the conversion of testosterone to dihydrotestosterone which is known to induce BPH
They reduce size of prostate and hence may take a while to work.
adverse effects: ED, Reduced libido, ejaculation problems, gynaecomastia
Patient with Sepsis present with AKI. What would her blood gases be like and would she be alkalosed or acidotic?
She would be acidotic and have reduced HCO3- and hence increased anion gap too.
Differentials of a raised anion gap? (TLKR)
Toxins (Salicylates, methanol, ethylene glycol)
Lactic acidosis
Ketones (DKA)
Renal failure (increased urate)
others: Metformin, Isoniazid
Metabolic acidosis with a normal anion gap (due to loss of bicarbonate or accumulation of H++).
4 DDX?
Renal tubular acidosis
Diarrhea
Addison’s disease
Pancreatic fistula
Some causes of hyperkalaemia?
AKI Drugs- Spironlactone, ACE inhibitor, ARBS Metabolic acidosis Addison's disease Rhabdomyolosis Massive blood transfusion
Minimal change disease has an association with Atopy and Hodgkin’s Lymphoma - T or F?
T
In Nephrotic syndrome: Loss of ________, Protein ___& ____ and an associated rise in fibrinogen levels predispose to thrombosis.
Loss of antithrombin III, Protein C and S
Tibial fracture with fasciotomy after an injury.. the patient probably had ____
Compartment syndrome
Post op, worsening of renal function with muddy brown casts is suggestive of ____
Acute tubular necrosis
What is the mode of inheritance of Alport’s syndrome in the majority of cases?
X linked dominant
What is alport’s syndrome?
Congenital defect in the gene which codes for type IV collagen resulting in abnormal glomerular basement membrane.
Presents with a nephritis picture - microscopic haematuria, progressive renal failure and bilateral sensorineural deafness?
What is the most common and important viral infection in solid organ transplant recipients?
CMV
A 60-year-old man presents with visible haematuria for the past three weeks. He has an ache in the left loin but examination is unremarkable other than a LEFT VARIOCELE. He also notes to feeling intermittently hot and sweaty.
Renal cell carcinoma
What endocrine effects do you get in Renal Cell Carcinoma
May secrete eryhtropoetin (Polycythaemic), Parathyroid hormone (Hypercalcaemia), renin, ACTH
Classic triad: haematuria, loin pain, abdominal mass
Renal Cell carcinoma
