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Year 2 Semester 3 Urinary System > Session 1 > Flashcards

Session 1 Flashcards

1
Q

Describe the dimensions of the kidney. When would we investigate an abnormality in size?

A

Width 6-7cm
Length 9-14cm
There is sexual dimorphism as the kidneys in men are larger.
Each kidney weight 170-210 g
If more than 2cm difference in size between the two kidneys then that should be investigated. same with if the kidney length is 8cm or less.

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2
Q

What is the basic function of the ureter?

A

Transport urine produced in the kidney to the bladder.

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3
Q

Describe the position of the kidneys

A

Retroperitoneal structures. Upper pole: T11-12 (L) and T12 (R). Generally left kidney is slightly higher as right is pushed down by the liver. Lower pole: L2-3 (L) and L3-4 (R). Hilum of each kidney roughly at L1
Ureter leaves at L1. Ureter crosses into the pelvis usually at level of SI joint. Ureter usually enters bladder at level of ischial spine.

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4
Q

Label the structures of the CT scan.

A

Insert CT scan with labels

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5
Q

How do we palpate the kidney?

A

Difficult normally as kidney is small. Feel for the Renal angle (angle between the 12th rib and erector spinae muscle). Between to feel for right as it sits lower. Often when patients present with kidney inflammation they are tender in the renal angle.

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6
Q

Describe the renal fascial layers

A

pararenal fat (paranephric): External to the posterior layer of the renal fascia (Garota’s fascia), It is extra peritoneal and associated with the lumbar region.

Perirenal fat (perinephric): surrounds the kidney within the renal fascial layers. It is continuous with the fat found in the renal sinus of the kidney.

Insert picture

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7
Q

How are the kidneys held in place

A

Pararenal and perirenal fat and the collagen bundles in the renal fascia. No ligaments.

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8
Q

Describe the ureter position, its different sections and where is most commonly injured. How does it perform its function?

A
  • smooth muscle fibres that propel urine (peristaltic waves) to the urinary bladder
  • ureter is 25–30 cm long diameter ~ 1.5 mm.
  • Retroperitoneal
  • lateral to the tips of the transverse processes of the lumbar vertebrae
  • Ureter beyond the pelviureteric junction (PUJ) divided into
  • proximal (abdominal), middle (pelvic) and distal part (intramural)
  • Ureters are crossed by gonadal (testicular or ovarian) vessels “Water under the bridge”
  • Most common areas of ureteric injury is near the pelvic brim
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9
Q

Describe the intramural segment of the ureter

A
  • Runs obliquely through the bladder wall.
  • Near the bladder the ureter coalesces with bundles of the detrusor muscle in the bladder wall and consists of coarser longitudinally arranged muscle bundles.
  • The length of this intramural part of the ureter in adults is 1.2–2.5 cm
  • There is no sphincter at the VUJ

Urine reflux is prevented because the ureter passes diagonally through the bladder wall musculature

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10
Q

Describe the ureteric wall

A
  • The lumen of the ureter is coated with urothelium

* Urothelium is continuous lining the bladder, ureter and pelvis of the kidney.

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11
Q

What is a duplexed ureter?

A

Two ureters originating from the same kidney. Depending on where it inserts will dictate whether it’s symptomatic or not

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12
Q

Label the bladder

A

Insert bladder diagram

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13
Q

Can you palpate the bladder?

A

When full yes, if not then no

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14
Q

Difference in size of the male and female urethra?

A

Roughly 15cm in males compared to roughly 4cm in females.

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15
Q

How is the internal urinary sphincter innervated in males?

A

With sympathetic innervation to prevent retrograde ejaculation

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16
Q

Label the different segments of the urethra in males

A

Insert diagram on slide 19 of lec 1

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17
Q

Describe the urethral divisions in females

A

Not really divided as its so short

insert diagram

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18
Q

How is female continence achieved

A

External urinary sphincter in urogenital diaphragm, pelvic floor (review this card)

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19
Q

Label the structures within the kidney

A

insert diagram from slide 21 of lec 1

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20
Q

Where is the glomerulus found

A

Only ever found in the cortex of the kidney

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21
Q

What are the stripes seen in renal pyramids

A

Formed by the collecting ducts that run down from the nephrons through the medullary/renal pyramids

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22
Q

What are the renal papillae?

A

The renal papilla is the tip of the renal pyramid where all of the collecting ducts from that pyramid empty out into a minor calyx (in the pelvis of the kidney)

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23
Q

Describe the collecting system of the kidney?

A

Papillae drain into minor calyces which drain into major calyces which drain into the renal pelvis which drains into the ureter. All of these structures are lined with urothelium.

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24
Q

Describe the basic structure of the nephron

A

Blood enters through afferent arteriole into the glomerulus and leaves via the efferent arteriole. ECF filtered from glomerulus into the Bowman’s capsule. Fluid leaves Bowman’s capsule via proximal convoluted tubule into Loop of Henle and then from there into the collecting duct via the distal convoluted tubule. Insert picture

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25
Q

Describe the differences between the cortical and juxtamedullary nephrons

A

Insert table from slide 24 lec 1

Edit EE

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26
Q

What is the blood supply to the kidneys?

A

Left and right renal arteries and blood leaves via the left and right renal veins.

27
Q

How can we identify the superior mesenteric artery?

A

Hooks over the left renal vein?

28
Q

Why are kidneys more susceptible to ischaemic damage?

A

They take roughly 22% of cardiac output and so when blood pressure drops they are often first to sustain damage

29
Q

What structures drain into the left renal vein?

A

Left suprarenal gland (adrenal gland) and left gonadal vein as they don’t have direct access to IVC as aorta is in the way so left renal vein is best option. On the right side there is direct access.

30
Q

Which kidney is best to use for transplants and why?

A

Left kidney as the vessels from it are longer so easier to remove.

31
Q

Describe the position of the right renal artery compared to the IVC

A

It runs posterior to the IVC

32
Q

Describe how blood enters the kidney

A

Enters through renal artery which then splits into 5 segmental arteries (apical, upper, middle, lower and posterior). Each one of those flows into interlobar arteries (between the pyramids), then into the arcuate artery (between the cortex and medulla) then into inter lobular artery and finally into the glomerular arteriole (afferent arteriole)
Insert picture from slide 28 lec 1

33
Q

What is a lobe of the kidney

A

Tissue above the renal pyramid in the cortex.

34
Q

Summarise how blood enters and leaves the kidney

A

Insert picture from slide 29 lec 1

35
Q

What are the possible symptoms of end stage renal disease?

A

Nausea
Vomiting
Fatigue - related to anaemia, other reasons too
Anorexia
Weight loss
Muscle cramps
Pruritus - Itchiness
Lower extremities uncomfortable and swollen (Oedema)
Dry cough - could lead to congestive heart failure, pneumonia and reduced immune system
Shortness of breath - congestive heart failure, anaemia, other reasons
Uraemic - blood in urine
Symptoms relate to toxins in blood, loss of fluid, pH homeostasis, electrolyte homeostasis and loss of kidney endocrine function

36
Q

What are the possible signs of end stage renal disease?

A
  • Tachypnea – and breath may actually smell uraemic – ie like urine
  • Tachycardia
  • Elevated blood pressure – often > 150/100 related to renin angiotensin aldosterone system
  • Dry skin, “uraemic frost” actually rare these days
  • Petechia not uncommon (clotting factors affected)
  • Moist rales posterior lung bases
  • S3 on cardiac exam
  • Abdominal exam usually benign
  • Ext – pitting oedema - congestive heart failure
  • Musculoskeletal pain may occur with pressure
37
Q

What disease encompasses end stage renal disease? Describe it

A

Chronic kidney disease
Can have varying degrees of renal impairment prior to frank kidney failure.
5 stages with stage 5 being end stage renal disease
10% of the population worldwide is affected by chronic kidney disease
More prevalent with age
Can often be asymptomatic so patients can go untreated for many years

38
Q

How does the kidney function as a homeostatic organ?

A
  • Controls volume, osmolarity and acid-base balance of plasma and extracellular fluid (ECF)
  • Controls electrolytes in blood and ECF
  • Recovers (reabsorbs) small molecules filtered by the nephron so we don’t waste metabolically expensive molecules such as amino acids and sugars
  • Excretes nitrogenous waste
  • Excretes other toxic metabolites
  • Maintains RBC production
  • Helps to maintain calcium-phosphorus balance
  • Part of long term blood pressure maintenance
39
Q

How is the kidney related to potassium levels?

A
  • ECF and blood potassium (K) concentration is precisely regulated within a narrow range
  • Typical blood K levels 3.5-5.3 mmol/L
  • In a person with healthy kidneys this K concentration range will be maintained even if large amounts of K are ingested (intravenous may be a different story)
  • This is because many body processes are exquisitely sensitive to K levels – either too low or too high can cause fatal arrythmias - <3 mmol/L or > 8 mmol/L – and in people with underlying cardiac problems even more sensitive
  • Maintenance K balance depends primarily on the kidneys (only 10% lost in faeces) – major sites K excretion are the distal convoluted tubules and collecting ducts
40
Q

How does the kidney function as an endocrine organ

A
  • Kidney produces ~90% of erythropoietin - peptide hormone (10% produced by liver)- made by the interstitial fibroblasts
  • Kidney produces erythropoietin in response to cellular hypoxia
  • Erythropoietin stimulates production of red blood cells in the bone marrow and is essential for RBC production
  • Patients with CKD are consequently often anaemic, people with ESRD are ALWAYS anaemic unless treated with synthetic
  • Kidney proximal tubule cells produce the majority of the mitochondrial cytochrome P450 enzyme, 25hydroxyvitamin D-1 alpha-hydroxylase – this enzyme is required for activation of vitamin D into the physiologically functional form of the vitamin 1,25dihydroxycholecalciferol – calcitriol
  • Patients with severe CKD/ESRD are hence functionally vitamin D deficient
  • Kidney also produces renin
41
Q

Describe vitamin D metabolism

A

Vitamin D3 obtained from skin and diet. transported to liver where it is hydroxylated. The product of that goes to the kidney where 25-hydroxyvitamin D-1 alpha-hydroxylase adds a hydroxy group to carbon 1. this makes 1,25 dihydroxyvitamin D3 (calcitriol), which is the active from of vitamin D. Patients with CKD have trouble making the enzyme 25-hydroxyvitamin D-1 alpha hydroxylase so struggle to make that active form of vitamin D so become vitamin D deficient.

42
Q

A68 y/o woman with ESRD comes to see her GP complaining of muscle aches and pains (myalgias), and pain in her bones especially when she stands or walks. Her GP checks her vitamin D blood levels and finds that she has osteomalacia –severe vitamin D deficiency.
How should her GP treat her?

A

D3 Calcitriol supplements

43
Q

A 48 y/o man with ESRD comes to see his GP complaining of increasing fatigue and dyspnoea; his complete blood count reveals a haemoglobin of 9.1 grams/dL (normal range males: 13 to 17 g/dL).
What is the most likely primary cause of his anaemia?

A

Decreased renal erythropoietin production

44
Q

A healthy 38 y/o woman visits her GP to enquire about some “sports supplements” a friend has recommended to improve her gym workouts; the supplements contain extracts from potassium rich fruits and vegetables and are high in K. The woman is concerned that she might poison herself as an uncle died “from too much potassium stopping his heart”. What advice should she be given?

A

She is a healthy woman and therefore does not have to worry about excess potassium in her diet

45
Q

Why do we ask about smoking when speaking to patients with CKD?

A

Top cause of death for patients with CKD is heart disease and smoking is a major risk factor

46
Q

Why is it important to look at other co morbidities for patients with CKD?

A
  • CKD may go unnoticed – there are subtle symptoms, if any, until quite late
  • CKD often coexists with other conditions (hypertension, diabetes, obesity)
  • Symptoms of CKD may be attributed to other co-morbidities
  • CKD is often diagnosed during investigation of these other conditions
  • It is therefore important to screen for CKD in ‘at risk’ populations
47
Q

Why is important to check the kidneys of patients who have/had Lupus?

A

Lupus can damage the kidneys and lead to CKD/ESRD

Symptoms may be non-specific and/or attributed to other co-morbidities

48
Q

People with ESRD develop vitamin D deficiency and are at increased risk for poor bone health for which reason?

A

Their kidney’s can’t synthesise 25-hydroxyvitamin D-1 alpha-hydroxylase required to activate vit D

49
Q

People with ESRD develop anaemia for which reason?

A

Their kidney’s can’t synthesise erythropoietin required for RBC development

50
Q

People with ESRD are at risk for developing hyperkalaemia for which reason?

A

Their kidneys can’t excrete excess potassium because of loss of functional nephron tissue

51
Q

Why is it important to consider the kidneys when administering drugs?

A

Many drugs are filtered by the kidney so important to consider nephrotoxicity of drug and the time its given over to ensure there’s minimal kidney damage

52
Q

Why would a patient with CKD present with tiredness?

A

have less energy or are having trouble concentrating. A severe decrease in kidney function can lead to a build-up of toxins and impurities in the blood. This can cause people to feel tired, weak and can make it hard to concentrate. Another complication of kidney disease is anaemia, which can cause weakness and fatigue.

53
Q

Why would a patient with CKD present with trouble sleeping?

A

When the kidneys aren’t filtering properly, toxins stay in the blood rather than leaving the body through the urine. This can make it difficult to sleep. There is also a link between obesity and chronic kidney disease, and sleep apnoea is more common in those with chronic kidney disease, compared with the general population.

54
Q

Why would a patient with CKD present with dry and itchy skin?

A

Healthy kidneys do many important jobs. They remove wastes and extra fluid from your body, help make red blood cells, help keep bones strong and work to maintain the right amount of minerals in your blood. Dry and itchy skin can be a sign of the mineral and bone disease that often accompanies advanced kidney disease, when the kidneys are no longer able to keep the right balance of minerals and nutrients in your blood.

55
Q

Why would a patient with CKD need to urinate more often at night (nocturia)

A

When the kidneys filters (glomeruli) are damaged, it can cause an increase in the urge to urinate. Sometimes this can also be a sign of a urinary infection or enlarged prostate (Benign Prostatic Hyperplasia) in men.

56
Q

Why would a patient with CKD present with blood in their urine?

A

Healthy kidneys typically keep the blood cells in the body when filtering wastes from the blood to create urine, but when the kidney’s filters have been damaged, these blood cells can start to “leak” out into the
urine. In addition to signalling kidney disease, blood in the urine can be indicative of malignancy, kidney stones or an infection.

57
Q

Why would a patient with CKD present with foamy urine?

A

indicates protein in the urine. This foam may look like the foam you see when scrambling eggs, as the common protein found in urine, albumin, is the same protein that is found in eggs.

58
Q

Why would a patient with CKD present with persistent puffiness around the eyes?

A

Protein in the urine is an early sign that the kidneys’ filters have been damaged, allowing protein to leak into the urine. This puffiness around your eyes can be due to the fact that your kidneys are leaking a large amount of protein in the urine, rather than keeping it in the body.

59
Q

Why would a patient with CKD present with swollen feet and ankles?

A

Decreased kidney function can lead to sodium retention, causing swelling in your feet and ankles. Swelling in the lower extremities can also be a sign of heart disease, liver disease and chronic leg vein problems

60
Q

Why would a patient with CKD present with poor appetite?

A

This is a very general symptom, but a build-up of toxins resulting from reduced kidney function can be one of the causes.

61
Q

Why would a patient with CKD present with muscle cramps?

A

Electrolyte imbalances can result from impaired kidney function. For example, low calcium levels and poorly controlled phosphorus may contribute to muscle cramping.

62
Q

Describe a full and complete examination of a patient who pay have CKD. Which bits are of greater importance?

A 
General appearance - important
Hands and skin  
BP - important  
Fluid balance - important  
Examination of the pulses including listening for bruits  
Examination of the heart  
Examination of the abdomen  
Urinalysis (assuming they are producing some) - important
63
Q

What ese other than kidney disease can blood in urine signify?

A

Malignancy, kidney stones or an infection

64
Q

Describe the innervation of the of the efferent and afferent arterioles in the kidney?

A

The tone of both arterioles is under the control of a rich sympathetic innervation, as well as a wide variety of chemical mediators.

Year 2 Semester 3 Urinary System (4 decks)

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