Renal & Urology Flashcards
1
Q
Acute pylonephritis presentation
A
Pyrexia
Loin pain + tenderness
Bacteriuria
Rigors, vomiting, oliguria
2
Q
Cystitis (lower UTI) signs/symptoms
A
Frequency, nocturia, urgency, haematuria, smelly urine, suprapubic pain/tenderness, strangury
3
Q
Cystitis predisposing factors
A
Female, pregnancy, menopause, urethral obstruction/malformation, catheter, diabetes (glycosuria)
4
Q
Investigations for UTI
A
MSU dipstick (double +ve nitrites & leucocytes)
Midstream urine MCS
Ask if vaginal discharge (GUM pathology?)
Sepsis 6 if systemically unwell
Further investigations (male, children, treatment-resistant, recurrent, pyelonephritis):
USS - renal scarring/hydronephrosis
CT/IV urography - exclude stones, tumours, diverticula
5
Q
Causes of sterile pyuria
A
Recently treated UTI, appendicitis, TB, chlamydia, bladder cancer
6
Q
Common UTI causative organisms
A
E. Coli - 75% Proteus Staphylococcus Streptococcus Klebsiella Pseudomonas
7
Q
Causes of ureteric obstruction
A
Luminal: calculus, sloughed renal papilla (diabetes/NSAIDs), clot, TCC of renal pelvis/ureter, bladder tumour
Mural: Ureteric stricture (TB, post-calculus, post-surgery), congenital pelviureteric neuromuscular dysfunction, congenital megaureter
Extramural: pelviureteric compression (tumour, diverticulitis, AAA, retroperitoneal fibrosis)
8
Q
Acute ureteric obstruction signs/symptoms
A
10/10 colicky loin-to-groin pain exacerbated when urine volume increases (alcohol/diuretics)
Anuria if complete bilateral obstruction
Polyuria if hydronephrosis causes post-renal AKI
Palpable hydronephrotic kidney
EXCLUDE: acute scrotum, AAA, pregnancy
9
Q
Ureteric obstruction investigations
A
Urine MCS USS to confirm ureteric dilation AXR CT - detailed cause of obstruction Retrograde pyelogram + cystoscopy
10
Q
Aetiology of kidney calculi
A
Form in collecting ducts
Classic sites: pelviureteric junction, pelvic brim, vesicoureteric junction
75% calcium oxalate
Magnesium ammonium phosphate (struvite) - Recurrent urease-positive bacteria (eg. proteus mirabilis) infections predispose individuals to struvite renal stones
Urate based
15% lifetime risk, 20-40y, M:F 3:1
11
Q
Kidney/ureter calculi signs/symptoms
A
Stone in ureter: renal colic, loin-to-groin pain, nausea+vomiting, cannot lie still
Stone in major/minor calyx: dull loin pain
UTI secondary to obstruction
12
Q
Kidney/ureter calculi risk factors
A
Obesity, dehydration, family/personal history, anatomical abnormalities
13
Q
Kidney/ureter calculi investigations
A
Bloods (calcium, phosphate, glucose, bicarbonate, urate)
Urine dip (95% +ve for blood), rule out infection
bHCG
Urine MCS
AXR
Non-contrast CT, can exclude abdominal ddx
14
Q
Bladder calculi presentation
A
UTI symptoms (frequency, pain, haematuria) at the end of micturition, males at tip of penis Perineal pain if trigonitis, anuria/bladder distention
15
Q
Bladder calculi investigations
A
Bloods (calcium, phosphate, glucose, bicarbonate, urate)
Urine dip (95% +ve for blood), rule out infection
bHCG
Urine MCS
16
Q
Renal cell carcinoma aetiology
A
Vascular tumours arising from the proximal tubular epithelium
90% of renal tumours
Risk factor: prolonged haemodialysis
17
Q
Renal cell carcinoma presentation
A
50% incidental
10% classic triad - haematuria, loin pain, abdominal mass + B symptoms (pyrexia, night sweats, weight loss)
Invasion of left renal vein = varicocele
Polycythaemia/hypertension if EPO/renin secretion
18
Q
Renal cell carcinoma investigations
A
Urine cytology USS - solid/cystic mass? CT/MRI CXR - cannonball mets Renal angiography if considering nephrectomy
19
Q
Wilm’s tumour aetiology & presentation
A
20% childhood malignancies
Undifferentiated mesodermal tumour
3.5y, flank pain + abdominal mass
Should not be biopsied
20
Q
Renal cyst aetiology & presentation
A
50% have a renal cyst by 50y
Causes: polycystic kidney disease, medullary cystic disease (childhood disease leads to ESRF), medullary sponge kidney
Asymptomatic or haematuria/pain
21
Q
Transitional cell carcinoma aetiology
A
Transitional cell epithelium lines the calyces, renal pelvis, ureter, bladder, urethra
Bladder tumours 50x more common
Risk factors: smoking, aromatic amines, chronic cystitis, pelvic irradiation
22
Q
Transitional cell carcinoma of the bladder presentation
A
Painless haematuria +/- clots
Reccurrent UTI
Voiding symptoms
Pain from invasion of local structures
23
Q
Transitional cell carcinoma of the bladder investigations
A
Urine MCS/cytology (sterile pyuria?)
Cystoscopy + biopsy
CT/MRI
Lymphangiography to assess spread
24
Q
Causes of bladder outlet obstruction
A
Luminal: bladder tumour
Mural: urethral stricture (post-calculus/infection), congenital, neuropathic bladder
Extramural: BPH, prostatic carcinoma, phimosis, paraphimosis
25
Bladder outlet obstruction signs/symptoms
Suprapubic pain, hesitancy/diminished force of stream, terminal dribbling, overflow incontinence, signs of infection due to stasis of urine
Palpable full bladder
Loin tenderness/palpable hydronephrosis
Enlarged prostate on DRE
26
Bladder outlet obstruction investigations
Bloods: FBC (infection, U&Es)
Urine dip and MCS
USS - hydronephrosis?
CT/MRI
27
Benign prostatic hyperplasia aetiology
Benign nodular/diffuse proliferation of glandular layers of the prostate = enlargement of the inner transitional zone
70% of men >70y
28
Benign prostatic hyperplasia symptoms
```
Filling symptoms (bladder overactivity): frequency, nocturia, urgency, strangury
Voiding symptoms (bladder outlet obstruction): hesitancy, poor stream, terminal dribble, strangury, retention + overflow incontinence
Symptoms due to complications: haematuria, associated UTI
```
29
Benign prostatic hyperplasia investigations
DRE
Frequency/volume chart
Bloods: FBC, U&Es, PSA (<4.0ng/mL = normal)
Urinalysis/MCS
Uroflowmetry (requires >150ml. Flow <12ml/2 suggests obstruction or weak detrusor contraction)
Pre/post-void bladder USS
Transrectal USS +/- biopsy to rule out carcinoma
30
Benign prostatic hyperplasia complications
UTI, overflow incontinence, bladder calculi/diverticulae, bilateral hydronephrosis and renal failure
31
Prostate carcinoma aetiology
80% males >80y but only 4% die from it
Most adenocarcinomas arising from peripheral prostate
Peripheral layer enlargement
Spread can be local (seminal vesicles, bladder, rectum), lymphatic, haematogenous - spinal/pelvic mets
Risk factors: family history, raised testosterone
32
Prostate carcinoma presentation
Asymptomatic: DRE/BPH resection histology
Filling, voiding, complication symptoms
Weight loss/bone pain = mets
Hard + craggy prostate
33
Prostate carcinoma investigations
DRE - T stage
PSA - rise >10ng/mL suggestive of tumour (affected by exercise, intercourse, infection, cystoscopy)
Transrectal USS/biopsy - Gleason grading (2 areas of tissue graded/5 to give score/10. Score<6 = low risk. Score>8=high risk.)
D'amico risk stratification: Gleason + stage + PSA
Bone XR/scan + contrast-enhanced MRI for staging
34
Urethral stricture aetiology
Scar of urethral epithelium, commonly extends into underlying corpus spongiosum
Fibroblastic activity leads to shortening of urethral length + narrowing of lumen
Causes: blunt perineal trauma, catheter insertion, gonococcal/non-gonococcal urethritis
Balanitis xerotica obliterans - white atrophic plaques leading to phimosis
35
Urethral stricture presentation
Obstructive voiding symptoms that gradually worsen: dysuria, hesitancy, urinary retention, splayed stream if meatal stricture
OE: firm areas/periurethral scarring
<50y, no prostate abnormalities
36
Urethral stricture investigation
Uroflowmetry
Urethrogram - stricture length, location, calibre, significance
Urethroscopy
37
Phimosis pathology & presentation
Narrowing of the preputial orifice
Causes: idiopathic, congenital, chronic BXO, traumatic forcible retraction of the foreskin
Child presentation: ballooning of foreskin, poor stream
Adult presentation: pain during intercourse, unability to retract the foreskin
38
Paraphimosis pathology & presentation
Pulling a tight foreskin over the glans, obstructing venous return leading to a swollen painful glans
Can occur following erection/catheter insertion
39
Priapism pathology & presentation
Persistant erection of the corpus cavernosa of the penis
| Causes: idiopathic, trauma, sickle-cell disease, intracavernosal injections for impotence
40
Peyronie's disease pathology & presentation
Upward curvature of the penis when erect (1-3% men)
| Causes: idiopathic, fibrous scarring following trauma
41
Carcinoma of the penis pathology & presentation
Squamous cell carcinomas
Persistent red patch on penis, progressing to infiltrating ulcer. No urethral involvement
Risk factors: 50% cases associated with HPV 16/18, smoking, immunosuppression
42
Varicocele pathology & presentation
Varicosities of the pampiniform plexus (commonly left/adolescence), 10% males, increasing with age
Left testicular vein drains horizontally into the left renal vein (c.f. right drains obliquely into IVC)
Valvular incompetency at junction, left renal tumour
Dragging sensation/ache
'bag of worms' when palpated standing
43
Hydrocele pathology & presentation
Fluctuant fluid that transilluminates - excessive collection of serous fluid in the processus vaginalis
Congenital: associated with hernia sac and patent processus vaginalis - most spontaneously resolve
Primary (idiopathic): 'vaginal hydrocele' - seperate from the peritoneal cavity
Secondary: underlying inflammation in the epididymis/testes or underlying cancer
44
Epididymal cyst pathology & presentation
Cystic degeneration of epididymal structures
Associated with PKD/CF
Cystic (transilluminates) + seperate from testes (upper pole)
Clear/milky (contains sperm)
Can be painful
45
Pathology and types of testicular tumours
Most common solid malignancy in young adults
Risk factors: undescended/ectopic testes (worse if >13y), infertility, hypospadia, family/personal history
Germ cell tumours: seminomas, non-seminomatous germ cell tumours (NSGCTs) (teratomas, yolk sac tumours, choriocarcinomas)
Seminoma - seminiferous tubule cells (30-40y), solid, spermatocyte cells to round cells
Teratoma - totipotent germ cells(20-30y), cystic, variable cell types
Stromal tumours
Lymphoma (older males)
Spread: local - rare. Lymph - para-aortic nodes. Blood - lungs and liver.
46
Testicular tumour presentation
Painless lump, hydrocele, haematospermia
Mets symptoms (breathlessness/abdo swelling) - palpable supraclavicular node
Rarely: painful rapidly enlarging; gynaecomastia due to paraneoplastic hormone production
47
Testicular tumour investigations
Scrotal USS - reveal mass in presence of hydrocele
Tumour markers: NSGCT (AFP, bHCG), semianomas (never AFP, 10% bHCG)
CT CAP - staging
48
Testicular tortion pathology
Usually congenital abnormality (maldescention/bell-clapper testes)
12-18y with history of mild trauma/previous attacks of pain due to partial tortion
Testis twists upon its pedicle obstructing venous return
49
Testicular tortion presentation
Sudden onset severe pain in groin/lower abdomen + vomiting
OE: unilateral hot swollen tender testis, sometimes lying high and transverse within the scrotum
Absent cremasteric reflex
50
Testicular tortion investigation
Doppler USS - show lack of blood supply to testis
| Surgical exploration
51
Testicular appendage tortion pathology + presentation
Tortion of embryological remnant
Less painful than testicular tortion
Small blue nodule visible under the scrotum, no elevation of the testis
Classically occurs at start of puberty
52
Epididymo-orchitis pathology
```
Acute infection (ascending via the vas deferens) followimg gonococcal/non-gonococcal urethritis/E. Coli UTI
Can spread haematogenously (mumps/TB)
```
53
Epididymo-orchitis presentation
```
Painful swelling of the epididymis
Secondary hydrocele
History of discharge (STI)/dysuria (UTI)
OE: DRE may reveal co-existent prostatitis
+ve Phren's sign
```
54
Epididymo-orchitis investigations
First-catch urine MCS and STI screen
| USS
55
Acute bacterial prostatitis presentation
Pyrexia/rigors, perineal pain, difficulty voiding, UTI symptoms, pain on ejaculation/haematospermia
DRE: prostate exquisitely tender and enlarged
May present alongside epididymo-orchitis (infection passes along vas deferens)
56
What ions do the kidneys decrease the plasma concentration of?
creatinine, urea, K+, H+
57
What is the role of the renal corpsucle?
Produce glomerular filtrate
58
What is the role of the proximal convoluted tubule?
reabsorb water, ions and organic nutrients
59
What is the role of the loop of henle?
Descending limb - reabsorption of water
| Ascending limb - reabsorption of Na+/Cl-
60
What is the role of the distal convoluted tubule?
Secretion of ions, acids, drugs, toxins
| Variable reabsorption of water (under control of ADH)
61
What is the role of the collecting duct?
Variable reabsorption of water (under control of ADH)
| Variable solute reabsorption
62
What are the secondary functions of the kidneys?
EPO secretion
Renin secretion
1-alpha-hydroxylation of calcidiol to form calcitriol (vitamin D)
63
What criteria indicate an AKI?
Urine output <0.5ml/kg/h for 6 hours
>50% rise in creatinine over 7 days
>26micromol rise in creatinine over 48h
64
Stage 1 AKI criteria
Serum creatinine: 150-200% increase or 25micromol/l increase in 48h
Urine output: <0.5ml/kg/h for 6h
65
Stage 2 AKI criteria
Serum creatinine: 200-300% increase
| Urine output: <0.5ml/kg/h for 12h
66
Stage 3 AKI criteria
Serum creatinine: >300% increase or >350micromol/l with acute rise of >45micromol/l in 48h
Urine output: <0.3ml/kg/h for 24h or anuria for 12h
67
AKI aetiology & presentation
Risk factors: men, elderly, CKD
Often symptomless with oliguria
Secondary complications: uraemia (vomiting, pruritis, pericarditis, encephalitis), hyperkalaemia (tented T waves), pulmonary oedema (unless pre-renal)
68
Pre-renal AKI aetiology
Inadequate renal perfusion (75%)
Shock: hypovolaemic, cardiogenic, distributive
Renovascular obstruction: embolus, aortic dissection, renal artery stenosis (RAS), thrombosis, ACEIs given in bilateral RAS
Prolonged = acute tubular necrosis --> pourous tubular membranes
Initially, urine osmolarity is high (>500mosmol/kg) + low sodium
If ATN occurs, urine is isotonic with plasma + high sodium
69
Post-renal AKI aetiology
Urinary tract outflow obstruction --> hydronephrosis
Ureter stones, stricture, clots, malignancy
Bladder outlet obstruction (prostatic enlargement, urethral stricture, phimosis/paraphimosis)
70
Renal AKI - acute tubular necrosis
85% of renal AKI
Drugs/toxins damaging tubular cells
Drugs: aminoglycosides (antibiotic '-mycin'), cephalosporins (antibiotic 'cef-'), radiological contrast mediums, NSAIDs
Toxins: heavy metal poisoning, myoglobinuria, haemolytic uraemic syndrome
71
Renal AKI - interstitial nephritis
10% of renal AKI
Drugs bypass basement membrane and cause damage to the interstitium
Causes: antibiotics, diuretics, allopurinol (treats gout), PPIs
72
Myoglobinurea pathology & presentation
```
Follows rhabdomyolysis (trauma, exercise, medications) releasing myoglobins
Dark urine, precipitates within tubules to cause damage
```
73
Haemolytic uraemic syndrome pathology & presentation
Occurs in children following a diarrhoeal illness caused by verotoxin producing E. Coli O157
In adults following an URTI
Thrombocytopenia (purpura), haemolysis, ATN
74
Nephritic screen components
ANCA (ANCA-associated vasculitis) & anti-GBM (Goodpastures) (RPGN)
ANA, dsDNA & complement studies (SLE)
Immunoglobulins, serum electrophoresis (myeloma)
Rheumatoid factor (RA-associated GN)
Hep B/C screen (Mesangiocapillary glomerulonephritis)
ASO (post-strep)
Renal biopsy can be diagnostic if there is uncertainty
75
AKI general first line examinations/investigations
```
Hypotension/hypertension (CKD)
Palpable bladder?
Bloods: FBC (renal anaemia in CKD), U&Es, bicarbonate, phosphate, CRP, clotting (hepatorenal disease may need invasive procedures), creatine kinase (raised in myoglobinurea)
Nephritic screen if cause unclear
ABG
Urine dip and MCS
ECG (risk of hyperkalaemia)
Renal USS (post-renal causes)
Non-contrast CT (if suspect obstucting calculus)
Echo (if suspect uraemic pericarditis)
```
76
Common electrolyte abnormalities in AKI
Rapidly progressing uraemia (anorexia, vomiting, pruritis, encephalopathy, haemorrhagic episodes)
Hyperkalaemia
Hypernatraemia (unless pre-renal)
Metabolic acidosis
Hypocalcaemia/hypophosphataemia (more in CKD)
77
Hyperkalaemia causes & presentation
Pseudohypokalaemia: haemolysis, FBC before U&E, sample taken from drip arm, delay in sample testing
AKI/CKD
Supplements, K sparing diuretics (spironolactone), ACEIs, NSAIDs
Acidosis/DKA
Addison's (primary adrenal insufficiency), tumour-lysis syndrome, burns
On ECG: tented T waves, widened QRS, flattened P/prolonged PR interval
Untreated: VF + tachycardia
78
How is CKD diagnosed?
2 tests (inulin clearance) 3 months apart show reduced eGFR. Staged 1-5
79
CKD stage 1
GFR 90+ but other long-term evidence of kidney disease e.g.
proteinurea/haematuria
Genetic diagnosis
Structural abnormality
80
CKD stage 2
GFR 60-89 + other long-term evidence of kidney disease e.g.
proteinurea/haematuria
Genetic diagnosis
Structural abnormality
81
CKD stage 3
GFR 30-59
82
CKD stage 4
GFR 15-29
83
CKD stage 5
GFR <15
84
Aetiology of CKD
```
DM (20-40%)
Hypertension
Chronic glomerulonephritis
Chronic pyelonephritis
Obstructive uropathy
Renovascular disease
Drugs (long-term NSAIDs)
Polycystic kidney disease
```
85
CKD signs/symptoms
```
Often asymptomatic until advanced
Vague fatigue and anorexia
Polyuria/nocturia
Restless legs syndrome
Sexual dysfunction
Nausea & pruritis (early uraemia), yellow pigmentation, encephalopathy, pericarditis (severe uraemia)
Pedal oedema/pulmonary oedema (can be cause+symptom)
Pallor (anaemia)
Excoriations (pruritis)
Hypertension/fluid overload signs
Pericardial rub (rare)
```
86
CKD investigations
Bloods: FBC, U&Es, LFTs, calcium, phosphate, PTH levels, glucose
Urinalysis & MCS - quantify proteinurea, exclude infection, look for casts
24h urinary protein/creatinine clearance - assess severity/nephrotic syndrome
CXR if pulmonary oedema suspected
Renal USS is obstructive causes suspected
DTPA scan - investigate vascular supply
Renal biopsy if cause unknown
Bone imaging - renal bone disease
87
Renal anaemia pathology
Kidneys normally secrete EPO in response to hypoxia
| Kidney partially loses this function in CKD, leading to anaemia
88
Renal bone disease pathology
Kidneys produce 1-alpha-hydroxylase: calcidiol from liver --> calcitriol (vit D)
Vit D increases intestinal calcium absorption, increases renal reabsorption of calcium, and bone protective factors
Low vit D --> hypocalcaemia + hyperphosphataemia
Low vit D --> osteomalacia --> 2ndary hyperparathyroidism (raised PTH) --> increased calcium reabsorption from bones and renal tubules
Increased osteoclast activity --> cyst formation and marrow fibrosis: osteitis fibrosis cystica
Long term: tertiary hyperparathyroidism + hypercalcaemia leadimg to osteosclerosis of the spine
End result: osteopenia (detected radiologically)
89
CKD secondary hypertension pathology
CKD leads to over-activation of the RAAS leading to hypertension
90
How can diabetes mellitus damage the kidney?
Direct glomerular damage: basement membrane thickening, increased permeability of capillary wall + proteinuria, eventual glomerular hyalinisation ---> CKD
Ischaemia due to arterial disease: atherosclerosis causes reduced eGFR and glomerular ischaemia
Ascending infection
91
Polycystic kidney disease morphology and pathological consequences
AD/AR inheritance. ADPKD 1 in 800 usually bilateral.
Ballottable kidneys, systemic hypertension, CKD, abdominal swelling
Cysts also in liver, lungs, pancreas (asymptomatic)
ARPKD earlier in onset and more malignant course
Liver cysts --> portal hypertension and fibrosis
Associated with berry aneurysms (subarachnoid haemorrhage)
92
Hypertensive renal damage
Thickening of renal artery walls --> inelastic rigid afferent arterioles
Chronic ischaemia, progressive loss of glomeruli (replaced by hyaline tissue)
Exacerbated by renal artery stenosis due to atherosclerosis
93
Chronic interstitial nephritis pathology
Chronic pyelonephritis, irregular areas of scarring, chronic inflammatory infiltrate
Reflux associated chronic interstitial nephritis: incompetent vesicoureteric valves, predisposing inflammation + scarring. Presents in early adulthood
Obstructive chronic interstitial nephritis: anatomic abnormality leads to recurrent infections (prostate, retroperitoneal fibrosis), stones
94
Glomerulonephritis pathology
Common cause of AKI/CKD
Immunological attack by an antibody or T cell attacking an antigen in the glomerulus
Primary (always there) or secondary (acquired/deposited)
Capillary: endothelial cell proliferation (bigger fenestra); capillary wall necrosis; glomerulosclerosis (scarring in the mesangium --> fenestra and capillaries pulled apart)
Basement membrane: thickened (more permeable)
Tubules: deposition of cells in Bowman's space
95
Secondary factors causing deposition of antigens causing glomerulonephritis
```
NSAID HSP
Neoplasm
SLE
Amyloid
Infection
Diabetes
Henoch Schonlein Purpura
```
96
Histological descriptions of glomerular pathology
Global: whole glomerulus is diseased
Segmental: small patches of one glomerulus are damaged
Diffuse: >50% glomeruli
Focal: <50% glomeruli
97
Clinical manifestations of glomerulonephritis
AKI, CKD, asymptomatic haematuria, nephrotic syndrome, nephritic syndrome, rapidly prgressive glomerulonephritis
98
Nephrotic syndrome pathology
TRIAD: proteinurea (3.5g/day), hypoalbuminaemia (<30g/l), oedema (periorbital and peripheral limbs)
Non-proliferative
Renal loss of thromboregulatory proteins (venous thrombosis) and liporegulatory proteins (hyperlipidaemia)
Primary causes: minimal change nephropathy, membranous glomerulonephritis, proliferative glomerulonephitis
Secondary causes: infection, drugs, neoplasm
99
Nephritic syndrome pathology
TETRAD: haematuria + red cell casts, oliguria, proteinuria, hypertension
Proliferative (increased cell numbers) + damage to basement membrane --> casts form from blood and protein
Primary causes: IgA nephropathy, Goodpastures
Secondary causes: SLE, HSP
