SM_243: Hydronephrosis / Nephrolithiasis Flashcards by Nathan Shlobin

Hydronephrosis is ___

Hydronephrosis is a descriptive term referring to the dilation of the renal pelvis and calyces

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Obstructive uropathy is ___

Obstructive uropathy is structural impedance to the flow of urine anywhere along the urinary tract

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Obstructive nephropathy is ____

Obstructive nephropathy is damage to the renal parenchyma resulting from obstruction of urine flow anywhere along the urinary tract

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Describe presentation of acute obstruction

Acute obstruction

Flank pain
Lower abdominal pain
Groin pain
Penile, testicular, clitoral pain
Inner thigh pain
Nausea / vomiting
Fever and chills (infection)

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Describe laboratory tests for obstruction

Obstruction laboratory tests

Serum: azotemia, hyperkalemia
Urine: hematuria, proteinuria, pyuria, urinary casts, crystalluria, elevated urinary sodium, decreased osmolality, decreased urine to plasma creatinine ratio

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Anuria results from ____ obstruction

Anuria results from bilateral obstruction

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Describe acute obstruction

Acute obstruction

Phase I: RBF and ureteral pressure rise (1-1.5 hours)
Phase II: decreased RBF, increased ureteral pressure (1.5-5 hours)
Phase III: decreased RBF, decreased ureteral pressure (> 5 hours)

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Describe gross changes in kidney due to obstruction

Gross changes in kidney due to obstruction

Hydronephrosis variable: extrarenal vs intrarenal collecting system
Compression of papillae: calyceal blunting
Thinning of parenchyma

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Describe histological changes in kidney due to obstruction

Histological changes in kidney due to obstruction

Dilation of tubules and flattening of epithelium
Glomeruli eventually enlarge, Bowman’s capsule thickens, hyalization

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Describe presentation of chronic obstruction

Chronic obstruction

Intermittent flank pain
Weight gain, edema, malaise, anorexia, headaches, fatigue, dysuria
Uremia: m.s. changes, tremors, bleeding
Obstructive symptoms: weak intermittent stream, overflow, incontinence
Irritative symptoms: frequency, urgency nocturia
Polyuria: poor concentrating ability

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Describe diangosis of obstruction

Obstruction diagnosis

Intravenous urogram: delayed nephrogram, delayed pyelogram, hydronephrosis, columning, forniceal rupture
Ultrasonography: dilated collecting system continuity of calcyes and pelvis, anechoic central areas in normally echogenic renal sinus, chronic obstruction with parenchyma thinning
Diuretic renography: Technetium 99m mercaptoacetyltriglycine, > 20 min
Whitaker test: percutaneous renal pelvis pressure transducer, bladder pressure transducer, saline / contrast infued, > 22 cm H20

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___ is gold standard for diagnosing obstruction and occurs when ___ cm H20

Whitaker test is gold standard for diagnosing obstruction and occurs when > 22 cm H20

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Describe postobstructive diuresis

Postobstructive diuresis

Polyuria after release of bilateral obstruction
Physiologic release of urea, sodium, water
Pathologic impaired concentrating ability and sodium resorption

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Describe symptoms of infection in obstruction

Infection in obstruction

Fever, chills, rigors
Tachycardia
Hypotension = sepsis
Leukocytosis, pyuria, bacteriuria

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Bactermia in obstruction involves ____, ____, and ____

Bactermia in obstruction involves pyelolymphatic urine backflow, pyelovenous urine backflow, and forniceal rupture (extravasation)

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Treatment for obstruction and infection includes ____, ____, and ____

Treatment for obstruction and infection includes antibiotics, IV fluids, and drainage via percutaneous nephrostomy or ureteral stenting

Urolithiasis formation involves ____, ____, and ____

Urolithiasis formation involves supersaturation, crystallization, and aggregation

Describe physical chemistry of urolithiasis

Urolithiasis physical chemistry

Solubility product (Ksp): point at which saturation is reached and crystallization occurs
Formation product: urine metastable with respect to CaOx, inhibitors / matrix / nucleation /; etc
Inhibitors: Mg, citrate, etc
Complexors: citrate, Mg
Promoters: glycosaminoglycans, Tamm-Horsfall protein

Describe types of kidney stones

Kidney stones

Calcium oxalate (most common)
Uric acid
Struvite (infection stones)
Calcium phosphate
Cystine

Initial evaluation of nephrolithiasis includes ____, ____, and ____

Initial evaluation of nephrolithiasis includes urinalysis, urine culture, and serum studies

Hypercalciuria is ___

Hypercalciuria is increased urinary excretion of Ca

Present in 50-70% of kidney stone patients

Describe treatment for hypercalciuria

Hypercalciuria treatment

Idiopathic hypercalciuria (HCTZ, chlorthalidone, moduretic): fluids, low salt diet, thiazide diuretics
Secondary hypercalciuria: parathyroidectomy, correct underlying disease

Describe treatment for hyperoxaluria

Hyperoxaluria treatment

Low oxalate diet
Increased Ca intake
Calcium citrate
Pyridoxine
Magnesium oxide

Describe causes of hyperuricosuria

Hyperuricosuria causes

Gout
Increased purine intake

Increased turnover of nucleic acids: hematologic malginancies, hemolytic anemia, rhabdomyolysis, psoriasis

Increased uric acid synthesis: alcohol consumption

Inborn errors of metabolism

Uricosuric agents

Hyperuricosuria treatment involves \_\_\_\_, \_\_\_\_, and \_\_\_\_

Hyperuricosuria treatment involves low purine diet, alkaline urine, and allopurinol (if gout)

Describe struvite stones

Struvite stones * Urease producing bacteria use urease to supply their demand for nitrogen * Urea represents principal excretory nitrogenous product in urine * Bacteria split urea with urease to NH3 * NH3 used to form glutamate and glutamine

\_\_\_\_, \_\_\_\_, \_\_\_\_, and ____ are urease-producing bacteria

Proteus, Klebsiella, Pseudomonas, and Staphylococcus are urease-producing bacteria

Struvite stone treatment involves ___ and \_\_\_

Struvite stone treatment involves stone free and antibiotics

Cystinuria is caused by ____ and leads to\_\_\_\_

Cystinuria is caused by inborn error of transport of dibasic amino acids and results in supersaturation and stone formation * Dibasic amino acids: cystine, ornathine, lysine, arginine

Describe treatment of cystinuria

Cystinuria treatment * Potassium citrate: alkalinize to 6.5 - 7 * Low salt diet * Thiola: mixed disulfide * 3L of urine: dilution

Three points in the ureter that a stone will most likely not pass are \_\_\_, \_\_\_, and \_\_\_

Three points in the ureter that a stone will most likely not pass are ureteral pelvic junction, iliac vessels, and ureteral vesical junction

Patient may die from post-obstructive diuresis if not recognized or managed correctly due to \_\_\_

Patient may die from post-obstructive diuresis if not recognized or managed correctly due to hyponatremia

Septic patient with hydronephrosis and obstructing stone in proximal ureter should be managed with ____ or \_\_\_\_

Septic patient with hydronephrosis and obstructing stone in proximal ureter should be managed with ureteral stent or percutaneous nephrostomy tube

It is important to relieve obstruction because obstruction causes ___ and \_\_\_

It is important to relieve obstruction because obstruction causes AKI and CKD

Hypercalciuria is \_\_\_, \_\_\_, or \_\_\_

Hypercalciuria is absorptive (from GI tract), renal leak, or primary hyperparathyroidism