Urological disorders

Question 1

What is the role of the kidney in a healthy individual?

Answer 1

Filtration:
-removal of waste substance
-keeping essential substances within blood e.g. large proteins including albumin
Control of salts and water balance
Control of acid/base balance
Hormone: erythropoietin production for Hb synthesis
Vitamin D: 1-alpha-hydroxylation of vit D

Question 2

What happens to the kidney in kidney dysfunction?

Answer 2

Filtration failure:
-Unwell with accumulation of waste substance
-Haematuria (blood in urine) and proteinuria, low serum proteins inc. albumin in blood
Hypotension and water retention (sometimes dehydration because unable to make concentrated urine)
Metabolic acidosis
Anaemia
Vitamin D deficiency and secondary hyperparathyroidism

Question 3

What are the causes of inflammatory urinary disorders?

Answer 3

Infection including cystitis
Non-infectious causes:
-metabolic including diabetic nephropathy
-immunological : Nephritic syndrome and nephrotic syndrome

Question 4

What are the examples of obstructive urinary disorders?

Answer 4

Stones and benign prostatic hypertrophy

Question 5

What are the examples of neoplastic urinary disorders?

Answer 5

Kidney, bladder, prostatic, testicular cancer

Question 6

What are the examples of developmental/genetic urinary disorders?

Answer 6

Polycystic kidneys

Horseshoe kidney

Question 7

What are possible locations for a urinary infection?

Answer 7

Bladder: cystitis
Kidney: pyelonephritis

Question 8

What are potential pathogens of a urinary infection?

Answer 8

Bacteria: most common
Virus: immunocompromised patients
Fungal: immunocompromised patients

Question 9

How is diagnosis made for a UTI?

Answer 9

History
Physical examination
Urine dipstick
Urine microscopy, culture and sensitivity

Question 10

How is a UTI treated?

Answer 10

Antibiotics:
-depends on severity of illness
-given for the most common bacteria in the area
-modified when sensitivity from urine culture is available
Pain control
Impatient treatment if they’re very ill
Supportitive e.g. hydration

Question 11

How can the immune system damage the kidney?

Answer 11

Potential mechanisms:

• antibody
• inflammatory cells (neutrophils, monocytes/macrophages, T cells)

Question 12

How does an immunological inflammatory condition present?

Answer 12

Nephritic syndrome
Proteinuria
Nephrotic syndrome

Question 13

What is glomerulonephritis?

Answer 13

Inflammation of the microscopic filtering units of the kidney

Question 14

How would you diagnose an immunological urinary problem?

Answer 14

History
Physical inflammation
Urine test
Blood Test: inc immunology tests
Imaging: start with US
Kidney biopsy

Question 15

How does nephritic syndrome present?

Answer 15

Haematuria
Variable amount of proteinuria
May have hypertension, reduced urine output, increased urea and creatinine

Question 16

How would you diagnose nephritic syndrome?

Answer 16

History
Physical examination
Urine dipstick
Urine microscopy
Urine protein: creatinine ratio
Blood tests: kidney function, immunological test
Kidney biopsy

Question 17

What is a very common type of nephritic syndrome?

Answer 17

IgA nephropathy
Deposition of IgA in the kidney
Inflammation and scarring
about 30% progress to kidney failure

Question 18

What are supportive treatments for IgA neuropathy?

Answer 18

treat hypertension and reduce proteinuria
First line treatment is angiotensin receptor inhibitor (ARB) e.g. irbesartan or
angiotensin converting enzyme inhibitor (ACEI) e.g. ramipril
Reduce sodium intake

Question 19

What are immunotherapy treatments for IgA neuropathy?

Answer 19

Renal replacement therapy: when reaching late stage kidney disease
kidney transplantation
dialysis

Question 20

What is an example of an organ specific inflammatory urinary disease?

Answer 20

Organs involved: Kidney and lung
Anti- glomerular basement membrane (GBM) antibody mediated: Goodpasture’s disease
Shared common antigen between lung and kidney is the alpha-3-chain of type IV collagen

Question 21

What is an example of a systemic inflammatory urinary disease?

Answer 21

Systemic Lupus erythematosus: autoantibodies include antinuclear factor, anti-dsDNA

Vasculitis: antineutrophil cytoplasm antibody

Question 22

What is the pathogenesis of diabetic neuropathy?

Answer 22

Inflammation and fibrosis

Question 23

What are risk factors of diabetic nephropathy?

Answer 23

Hypertension
Poor diabetic control
Smoking

Question 24

What are clinical features of diabetic nephropathy?

Answer 24

Microalbuminuria
Proteinuria
Associated with other complications of diabetes mellitus:
- diabetic retinopathy
-diabetic neuropathy

Question 25

What are treatments of diabetic nephropathy?

Answer 25

``` Optimised diabetic control Optimised treatment of hypertension Reduced proteinuria using ARB or ACEI Stop smoking New clinical trials: SGLT2 inhibitor Transplantation (inc. combined pancreas and kidney transplantation) Dialysis ```

Question 26

What are clinical presentations of nephrotic syndrome?

Answer 26

``` Peripheral oedema Severe proteinuria Low serum albumin Variable amounts of microscopic haematuria Associated with hyperlipidaemia ```

Question 27

How do we diagnose nephrotic syndrome?

Answer 27

``` History Physical inflammation Urine dipstick Urine microscopy Urine protein: creatinine ratio Blood Test: kidney function and immunological Kidney biopsy ```

Question 28

What are causes of nephrotic syndrome?

Answer 28

Minimal change glomerulopathy Membranous nephropathy Focal segmental glomerulosclerosis Lupus nephritis

Question 29

What are treatments of nephrotic syndrome?

Answer 29

Immunotherapy: - traditionally corticosteroids and cyclophosphamide - recent development: tacrolimus and antibody therapy targeting B cell pathway Diuretics: to reduce peripheral oedema Prevention of thrombosis: anticoagulation

Question 30

What are possible locations of stones?

Answer 30

Kidney Ureter Bladder

Question 31

What are clinical presentations of stones?

Answer 31

Pain (abdomen and back) Blood in urine Associated with UTI About 90% of kidney stones are radio-opaque

Question 32

What are supportive treatments of stones?

Answer 32

Pain control | Hydration

Question 33

What are specific treatments for stones?

Answer 33

Shockwave lithotripsy: high energy sounds waves used to break down large kidney stones Ureteroscopy: through urethra, bladder and ureter Percutaneous nephrolithotomy: small percutaneous incision. Insertion of nephroscope. Stone is removed (may need to be broken to smaller pieces)

Question 34

What is an example of a benign neoplasm?

Answer 34

Benign prostatic hypertrophy

Question 35

What are examples of malignant neoplasms?

Answer 35

Kidney: Renal cell carcinoma Ureter and bladder: transitional cell carcinoma Prostatic cancer Testicular cancer

Question 36

What are clinical presentations of a neoplasm tumour?

Answer 36

Asymptomatic (incidental finding during other investigations) Haematuria Pain

Question 37

What investigations are used to diagnose neoplasms?

Answer 37

Imaging (US, CT, MRI) Urine cytology Blood test for marker: prostatic specific antigen (PSA)- can have false positives Kidney function Histological diagnosis: biopsy or excised tumour Staging studies: any evidence of metastasis

Question 38

What are treatments of a neoplasm?

Answer 38

To release obstruction: nephrostomy, bladder catheter and/or surgery Chemotherapy Radiology Hormonal therapy for hormone sensitive cancers e.g. prostatic cancer Surgery

Question 39

What are different types of polycystic kidneys?

Answer 39

Neonatal: autosomal recessive Adult onset: autosomal dominant Some patients without family history

Question 40

What are consequences of polycystic kidneys?

Answer 40

``` Loss of kidney function Pain Bleeding into renal cysts Infection of renal cysts Asymptomatic in some patients ```

Question 41

What are treatments for polycystic kidney disease?

Answer 41

New medication: Tolvaptan (vasopressin receptor 2 antagonist) to slow down cyst formation Treat hypertension, infection Pain control Renal replacement therapy (transplantation, dialysis)

Question 42

How can we find out if a patient has a horseshoe kidney?

Answer 42

Imaging of abdomen/ pelvis

Question 43

What are consequences of a horseshoe kidney?

Answer 43

increased risk of: obstruction stones infection