Urinary Flashcards
What are indications for renal u/s?
- UTI
- palpable mass
- elevated creatinine & or BUN
- severe flank pain
- hematuria
- decrease urine output
- assessment for renal mass seen on CT/IVP
- non visualized kidney
- trauma
- post surgical complications
- biopsy/drainage
- hypertension
- diabetes
Symptoms of a renal infection or disease process:
- flank pain
- hematuria
- polyuria
- oliguria
- fever
- urgency
- weightloss
- general edema
What is urinalysis essential for detecting?
urinary tract disorders in pts. whose renal function is impaired or absent
Hematuria is
RBC in the urine
Pyuria is
Pus in urine
Urine pH is important in managing
diseases such as bacteriauria and renal calculi
pH referes to what?
strength of urine as partly acidic or alkaline solution
The abundance of hydrogen ions in the urine is called:
pH
When is urine acidic?
if it contains an increased concentration of hydrogen ions
The formation of renal calculi partly depends on :
pH of urine
What are associated with alkaline urine?
Renal tubular acidosis and chronic renal failure
What is specific gravity?
measurement of the kidney’s ability to concentrate urine (concentration factor depends on the amount of dissolved waste products)
Specific gravity is esp. low in cases of:
renal failure
glomerulonephritis
pylonephritis
(these cause renal tubular damage, affecting kidney’s ability to concentrate urine)
What can hematuria be associated with?
early renal disease
An abundance of RBC in the urine may suggest:
- renal trauma
- neoplasm
- calculi
- pyelonephritis
- glomerular inflammatory process
- vascular inflammatory process
When may leukocytes present?
with inflammation, infection or tissue necrosis originating from anywhere in the urinary tract
What is hematocrit?
relative ratio of plasma to packed cell volume in blood.
Decreased hematocrit occurs with
acute hemorrhagic processes secondary to disease or blunt trauma
When is hemoglobin present in urine?
When there is extensive damage or destruction of the functioning erythrocytes (injures the kidney and can cause acute renal failure)
Albuminuria is commonly found with
benign and malignant neoplasms, calculi, chronic infections, pyelonephritis
Measurements of creatinine are an index for determining what?
glomerular filtrations rate
T/F: blood serum creatinine levels are said to be more specific and more senstive
T
Creatinine is a byproduct of
muscle energy metabolism
A decreased creatinine clearance indicates
renal dysfunction because creatinine blood levels are constant and only decreased renal function prevents normal excretion of creatine
Creatinine elevated with
- diabetes
- renal function
- acute tubular nephrosis
- pylonephritis
Creatinine decreased with
- debilitation
- starvation
- hyperthyroidism
What is Blood Urea Nitrogen (BUN)?
the concentration of urea nitrogen in blood and is the end product of cellular metabolism (relative to the degree of renal impairment and rate of urea excreted by kidneys)
BUN elevated with:
- renal damage
- renal failure
- dehydration
- chronic or acute renal disease
- urinary obstruction
- GI bleed
- CHF
- shock
BUN decreased with:
- overhydration
- pregnancy
- liver failure
- secondary to smoking
- decrease protein intake
Types of Renal Cystic Disease
- simple renal cyst
- polycystic renal disease
- multicystic dysplastic kidney
- medullary sponge kidney
How often do simple renal cysts occur?
common, 50% of adults over 50 years
Where may simple renal cysts be found?
anywhere in the kidney
When are simple renal cysts clinically significant?
when they distort the adjacent calyces or produce hydronephrosis or pain
Son findings of simple renal cysts:
cystic properties
no septations
cyst may have a cyst or mass within it
Polycystic renal disease may present in two forms:
- autosomal-recessive form
- autosomal-dominant form
What is autosomal-recessive polycystic kidney disease (ARPKD)?
- fairly rare
- dilation of the renal collecting tubules which causes renal failure and in the later forms there is also liver involvement
Four forms of ARPKD?
-perinatal
-neonatal
-infantile
-juvenile
(the earler the symptoms manifest, the less the kidneys are functioning)
Son. findings of perinatal form of ARPKD?
- oligohydramnios
- enlarged echogenic kidneys
Son. findings of later forms of ARPKD?
- enlarged kidneys
- echogenic cortex and medulla
- lack of coritocmedullary differentiation
- may be macroscopic cysts (1-2mm) located in the medulla
- in children there may be also hepatic fibrosis and splenomegaly
What is Autosomal-dominant polycystic kidney disease (ADPKD)?
- common genetic disease in women and men
- bilateral disease characterized by multiple cysts located in the renal cortex and medulla
T/F: ADPKD cysts vary in size and may be asymmetrical?
T
When does ADPKD manifest?
- not until 4th or 5th decade of life
- by age 60, 50% will have end stage renal disease
Symptoms of ADPKD: 7
- pain
- hypertension
- palpable mass
- hematuria
- headache
- UTI
- renal insufficiency
Complications of ADPKD:
- infection
- hemorrhage
- stone formation
- rupture of cysts
- renal obstruction
Associated abnormalities of ADPKD:
- cysts in liver, spleen, pancreas, thyroid, ovary, testes, breast
- cerebral berry aneurysm (Circle of Willis) cerebral arteries
- increased incidence of renal cell carcinoma
- AAA
Statistics of Cerebral Berry Aneurysm
16% have it, 9% die from rupture
Sonographic findings of ADPKD in the fetus:
- moderately enlarged hyperchoic kidneys
- increased corticomedullary differentiation
- further screening necessary
- not compatible with life
Sonographic findings of ADPKD in adults:
- bilateral renal enlargement
- multiple cysts in both cortex and medulla
- advanced cases-normal parenchyma replaced with multiple cysts and kidneys lose shape
- cysts may grow large enough to obliterate renal sinus
- internal debris in cysts
- Walls of cysts may calcify, stones may form within cysts
- complicated cysts may result in spontaneous bleeding
What is multicystic dysplastic kidney?
non hereditary renal dysplasia that usually occurs unilaterally
What is the most common form of cystic disease in neonates?
multicystic dysplastic kidney
T/F: bilateral disease of multicystic dysplastic kidney is incompatible with life?
True
Complications of multicystic dysplastic kidney:
- hypertension
- hematuria
- infection
- flank pain
Son. finding of multicystic dysplastic kidney in neonates and children:
-kidneys appear enlarged
Son findings of multicystic dysplastic kidney in adults:
- kidneys small and calcified
- multiple cysts varying in size with no normal renal parenchyma
What is medullary sponge kidney?
- rare, non-hereditary benign renal disease
- congenital but may not be diagnosed until adulthood
What is medullary sponge kidney associated with?
dilated collecting tubules and cysts that form in the medulla
Son findings of of medullary sponge kidney:
- medulla is very echogenic
- may have associated calcium stones (nephrocalcinosis)
What is medullary nephrocalcinosis?
- calcium that forms in the medullary pyramids
- hyperechoic medullary pyramids with or without shadowing
What is medullary nephrocalcinosis associated with?
- medullary sponge
- hyperparathyroidism
- cushing syndrome
- adrenal gland tumors
- oral pharmocological doses of vitamin E, calcium, steroid use and malignant neoplasms
T/F: sonographic appearance of renal masses is specific
False, nonspecific
What is the first finding suggesting a mass may be present?
abnormal contour
List malignant renal masses:
- renal cell carcinoma
- transitional cell carcinoma
- Wilm’s tumor
- renal lymphoma
What is most common of all renal tumors, (85%)?
renal cell carcinoma
Renal cell carcinoma, AKA:
adenocarcinoma or hypernephroma
Who is renal cell carcinoma likely to affect?
- twice as common in males as females
- 6th decade of life
T/F: If caught early, prognosis for renal cell carcinoma is good?
True
Clinical symptoms of renal cell carcinoma:
- nonspecific
- hematuria
- flank pain
- palpable mass
Staging of renal cancer uses the
Robson system
Sonographic findings of renal cell carcinoma
- most are unilateral
- isoechoic, hypoechoic solid mass
- may be complex due to areas of necrosis
Stage 1 of renal cell carcinoma
confined to the kidney
Stage 2 of renal cell carcinoma
spread to the perinephric fat but within Gerota’s fascia
Stage 3 A of renal cell carcinoma
perinephric involvement with spread to renal vein and or IVC
Stage 3 B of renal cell carcinoma
perinephric with regional lymph node enlargement
Stage 3 C of renal cell carcinoma
perinephric involvement with venous and lymph node involvement
Stage 4 of renal cell carcinoma
invasion of adjacent structures, distal metastasis
Where does transitional cell carcinoma originate from?
the transitional epithelial lining of the urinary tract system
Transitional cell carcinoma is more common in
males, usually after 60 years old
Symptoms of transitional cell carcinoma
- painless hematuria
- blood clots
Son. findings of transitional cell carcinoma:
- most commonly seen in the bladder, but can be anywhere in urinary system
- bladder tumors found in trigone area and the lateral borders of bladder
- bladder tumors are focal non mobile masses within the bladder lumen
- masses in renal pelvis are more easily ID’d than those in the renal sinus
What is squamous cell carcinoma?
- rare, highly invasive tumor
- poor prognosis
Clinical symptoms of squamous cell carcinoma:
hx of chronic irritation and gross hematuria
-palpable kidney secondary to severe hydronephrosis
Son findings of squamous cell carcinoma
- large mass in the renal pelvis
- obstruction from kidney stones
What is renal lymphoma?
- usually a secondary process due to lymphoma
- large renal masses that can be numerous and bilateral
Renal lymphoma is more common in
non-Hodgkin’s lymphoma
Clinical symptoms of renal lymphoma
- uncommon
- hematuria
- fever
- flank pain
- palpable mass
Sonographic findings of renal lymphoma
- variety of appearances, depends on location
- hypoechoic structures with poor acoustic enhancement
- may exhibit numerous thin septa
- renal parenchyma may exhibit a diffuse hypoechoic pattern because of diffuse infiltration
Wilms’ tumor AKA
nephroblastoma
What is the most common solid renal mass of childhood?
Wilms’ tumor/ nephroblastoma
When is Wilm’s tumor common?
rare in newborn, peaks in second year of life
Clinical symptoms of Wilms’ tumor?
- palpable mass
- pain
- anorexia
- nausea
- vomiting
- fever
- gross hematuria
Son findings of Wilms’ tumor
- large flank masses
- well circumscribed
- homogenous
- hypoechoic
- may be complex due to necrosis
- hypertension
Son findngs of angiomyolipoma
- brightly echogenic, may have posterior enhancement
- found in cortex
- tendency to hemorrhage (highly vascular)
What do lipomas consist of?
fat cells
Are lipomas more common in females or males?
females
Clinical symptoms of lipoma
- asymptomatic
- may cause hematuria
Son findings of lipomas
well defined echogenic mass
What do oncocytomas consist of?
large epithelial cells
Oncocytomas are found most often in
older men, occur in the parathyroid glands, thyroid and adrenal glands
Symptoms of oncocytomas:
typically asymptomatic, but tumor may cause pain and hematuria
Son findings of oncocytomas
“spoke-wheel” pattern
Mesoblastic nephroma AKA
fetal renal hematoma, a benign counterpart of Wilms tumor
What is the most common solid neoplasm in the neonate?
mesoblastic nephroma
Is mesoblastic nephroma found more often in men or women?
men
What two abnormalities are associated with mesoblastic nephroma?
large flank mass, hypertension
Issues associated with renal disease
- generalized increase in cortical echoes which are a result of deposits of collagen and fibrous tissues
- interstitial nephritis
- acute tubular necrosis
- amyloidosis
- diabetic nephropathy
- systemic lupus erythematosus
- myeloma
- loss of normal anatomic detail
- chronic pyelonephritis
- tubular ectasia
- acute bacterial nephritis
Endstage renal disease often results in
renal atrophy (seen on u/s by measuring renal length and cortical thickness
What acute diseases can produce renal enlargement and decreased parenchymal echogenicity?
- renal vein thrombosis
- pyelonephritis
- renal transplant rejection
What is acute pyelonephritis?
Upper UTI, resulting from ascending infection through the ureters
Acute pyelonephritis most affects women of what age?
of childbearing age
Symptoms of pyelonephritis include:
- sudden onset of flank pain
- fever
- frequency
- hematuria
- dysuria
When can a clinical diagnosis for acute pyelonephritis be made?
when urinalysis indicates abnormal bacteria, leukocytes, and RBC
Son findings of acute pyelonephritis
- difficult to diagnose son.
- kidneys may be completely normal or slightly enlarged
- dilated blunt calyx
- loss of corticomedullary differentiation
What does chronic pyelonephritis result from?
recurrent or untreated UTI’s (more common in women)
Chronic pyelonephritis may result in
loss of kidney function over time (renal dialysis or transplant may be warranted.)
Clinical symptoms of chronic pyelonephritis include:
- fatigue
- hypertension
- flank pain
- hematuria
Son findings of chronic pyelonephritis:
- dilated blunt calyces
- cortical thinning
- if disease is unilateral , the contralateral kidney may enlarge to compensate
What does renal failure disallow?
normal removal of accumulated metabolites from blood
Pre nenal causes of renal failure:
- loss of profusion due to thrombosis
- shock
- sepsis
- embolization
- heart failure
Intra renal causes of renal failure:
- parenchymal disease
- chronic infections
- renal ischemia
- AIDS
- Exposure to toxins
Post renal causes of renal failure:
- obstructive uropathy
- increase incidence with uncontrolled diabetes
- uncontrolled hypertension
Lab tests that find renal failure:
- Elevated BUN creatinine
- Decrease serum calcium
- low urinary specific gravity
- proteinurea
- RBC and WBC in urine
- anemia
Son findings of renal failure
- decrease renal size
- increase parenchymal echogenicity-fibrosis and scarring
What are renal stones made of?
- calcium
- uric acid
- xanthine
- cystine
Renal stones AKA:
urolithiasis
Majority of renal stones are made with
Calcium
T/F: Renal stones may be found anywhere in the urinary system?
True
What demographics have higher instances of renal stones?
- men
- U.S.
Staghorn calculi:
when stones fill the entire collecting system and become a solid mass
As stones pass thru the ureter they usually become lodged where?
at the renal pelvis and ureterovesicle junction causing excruciating pain
If pain is localized in the flank area, where is the stone likely located?
the kidney or proximal ureter
Clinical symptoms of renal stones
- hematuria
- RBC in urine
- WBC in urine
- bacteria in urine
Treatment for renal stones depends on size and location:
- lithotripsy
- percutaneous nephrolithotomy
- ureteroscopic stone removal
If stones cause obstruction there will be :
hydronephrosis and depending on the location the ureter may be dilated superiour to the level of obstruction
Son findings of renal stones
- very echogenic
- sharp, marginated, clean shadows
What is hydronephrosis?
dilation of the renal pelvis and calyces caused by an obstruction of the urinary tract..if obstruction is at the level of the urethra then bilateral hydronephrosis will occur
Causes of bilateral hydronephrosis:
- stones lodged in urethra
- enlarged prostate
- bladder tumors
- posterior urethral valve syndrome in infants and young boys
Causes of unilateral hydronephrosis
- congenital disorders
- acquired syndromes
- tumors
- inflammatory disorders
- blood clots
- pregnancy
- stones
With hydronephrosis, if obstruction is not corrected, severe deterioration of what may occur?
renal cortex
Hydronephrosis clinical symptoms:
- flank pain
- nausea
- vomiting
- elevated BUN and creatinine
Sonographic findings for hydronephrosis:
-hypoechoic /cystic area within the renal sinus
Grade 1 of hydronephrosis:
small separation of calyceal pattern
Grade 2 of hydronephrosis
bear-claw effect, with fluid extending into the major and minor calyceal system and thinning of the renal parenchyma
Grade 3 of hydronephrosis
massive dilation of the renal pelvis with loss of renal parenchyma
Trauma in the kidneys:
linear absence of echoes in area of traumatized kidney
Renal infarction is usually caused by:
RA obstruction
Results of renal infarction:
- kidney reduced in size
- complete occlusion/multiple infarcts results in small hyperechoic endstage appearing kidney
Renal abscess AKA:
renal carbuncle
Clinical symptoms of abscess:
- fever
- leukocystosis
- flank pain
Perforation of renal abscess in surrounding area
- marked fever
- abdomen board-like rigidity with flank pain
Where does a renal transplant go?
right side of pelvis within retroperitoneum
Indications for renal transplant:
- vascular compromise
- renal failure
- infection
Lymphocele
- predominantly anechoic mass 4-8 weeks post transplant
- can contain septations/debris
- can cause obstruction when large
- can be drained, may reoccur
Urinoma:
post-op complication with in first 2 weeks-ureter anastimosis leak
Hematoma for renal transplant
arise soon after surgery
- new-anechoic
- old-hyperechoic
- contain debris
Son findings of acute rejection of renal transplant:
- enlarged kidney
- decreased cortical echogenicity
- indistinct corticomedullary boundaries
- prominent hypoechoic pyramids
- peri-transplant fluid collections
Severe rejection of renal transplant result in :
- marked hemorrhage in parenchyma
- high-resistive waveforms, decreased, absent, or reversed end diastolic flow, >0.7
- Acute tubular necrosis
- renal artery thrombosis
- RV thrombosis
- Urinary obstruction
- cyclosporing toxicity
