Urological Disorders Flashcards by Iihan Ali

List the normal functions of the kidney.

Filtration:
Removal of waste substance. Keeping essential substances within the blood e.g. blood cells, large protein including albumin.
Control salt and water balance
Control of acid/base balance
Hormone - erythropoietin (EPO) production: essential for synthesis of Hb.
Vitamin D - 1-alpha hydroxylation of vitamin D.

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List the things kidney dysfunction can lead to.

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

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What are the possible locations for an infection in urological disorders?

What are the potential pathogens?

Bladder - cystitis
Kidney - pyelonephritis

Bacteria - most common
Viral and fungal - immunocompromised patients

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List the components of forming a diagnosis for urological disorders.

History
Physical examination
Urine dipstick
Urine microscopy, culture and sensitivity

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What signs can indicate a patient has a UTI?

Temperature - 38 degrees celsius
BP - 105/70 mmHg
Pulse - 80 bpm
Abdomen - soft, slightly tender over suprapubic area and left loin

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What investigations can be done to determine if a patient has a UTI?

Urine dipstick - 2+ leukocytes, + nitrite, trace of blood

Urine microscopy, culture and sensitivity (blood tests e.g. renal profile: electrolyte, urea and creatinine).

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List the components of the treatment and overall clinical management for UTIs.

Supportive e.g. hydration
AB
Pain control

Consider imaging if other factors or differential diagnosis
Some patients may be very ill and need to be treated as inpatient.

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What does the use of antibiotics for treatment of UTIs depend upon?

Severity of illness

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How can the immune system damage the kidney?

Antibody

Inflammatory cells (neutrophils, monocytes/macrophages, T-cells)

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What is the term for inflammation of the microscopic filtering units of the kidney?

Glomerulonephritis

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What 3 things are a part of the clinical presentation if the urological disorder has an immunological cause?

Nephritic syndrome
Proteinuria
Nephrotic syndrome

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What are the 3 patterns of organ involvement for urological inflammatory conditions?

Kidney only
Kidney and lung
Multiple organs/tissues involved

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What may the diagnostic approach for determining a diagnosis for a urological inflammatory condition involve?

History and physical examination 
Urine test 
Blood test - including immunology tests 
Imaging - start with ultrasound 
Kidney biopsy

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What may a person with nephritic syndrome have?

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

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What may you find upon physical examination of a patient with nephritic syndrome?

Normal temp. + chest and abdomen
Ankle - no peripheral oedema
Pulse 70 bpm
Inflamed tonsil 
BP 140/100

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What investigation results show that a patient has nephritic syndrome?

Urine dipstick: 3+ blood, 2+ protein
Blood tests: raised serum urea and creatinine concentration.
Reduced GFR (autoantibodies not detected)
Urine: raised urine protein:creatinine ratio
Kidney biopsy: IgA Nephropathy

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What is the most common primary glomerulonephritis world-wide?

Nephritic syndrome - IgA Nephropathy

(Deposition of IgA antibody in the kidney; get inflammation and scarring).

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What % ~ of people with glomerulonephritis progress to kidney failure?

30%

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How can you treat nephritic syndrome caused by an IgA nephropathy?

Supportive - treat hypertension and reduce proteinuria. 1st line treatment: angiotensin receptor inhibitor (ARB e.g. irbesartan) or angiotensin converting enzyme inhibitor (ACEI e.g. ramipril).

Immunotherapy - Renal replacement therapy when reaching late stage kidney disease → Kidney transplantation and dialysis.

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Give an example of urological inflammatory conditions with an immunological cause which are organ specific to the kidney and lung.

Goodpasture’s disease - anti-GBM antibody mediated.

Common antigen between lung and kidney: alpha-3 chain of type IV collagen

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Give 2 examples of urological inflammatory conditions with an immunological cause which are systemic diseases (multi-organ).

SLE - autoantibodies (antinuclear factor, anti-dsDNA)

Vasculitis - antineutrophil cytoplasm antibody (ANCA)

Sum up the pathogenesis of diabetic nephropathy.

Inflammation followed by fibrosis → loss of kidney function and failure.

What are the risk factors of diabetic nephropathy?

Hypertension
Poor diabetic control
Smoking

List the clinical features of diabetic nephropathy.

Microalbuminuria
Association with other DM complications of - diabetic retinopathy and neuropathy.
Proteinuria

Outline the treatment and clinical management of diabetic nephropathy.

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

What are the signs and symptoms of nephrotic syndrome?

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

What signs can you find in patient that indicates they have nephrotic syndrome?

Periorbital oedema Temperature normal Ankle - pitting oedema BP - 110/70

What investigation results show that a patient has nephrotic syndrome?

Urine dipstick - no blood, 4+ protein Blood tests - normal serum urea and creatinine concentration, normal eGFR, very low serum albumin concentration (11g/L). Autoantibodies weren't detected. Very high urine protein:creatinine ratio 1000mg/mmol

List a few causes for nephrotic syndrome.

Minimal change glomerulopathy Membranous nephropathy Focal segmental glomerulosclerosis Lupus nephritis (Many more)

What does treatment of nephrotic syndrome involve?

Immunotherapy: - Traditionally use corticosteroid cyclophosphamide. - Recent development - tacrolimus, antibody therapy targeting B cell pathway. Diuretics to reduce the peripheral oedema Prevention of thrombosis using anticoagulation.

What are the key features of minimal change glomerulopathy?

Most common in children (does affect other age groups). Electron microscopy - podocyte effacement - abnormal flattened appearance. Complication → high risk of thrombosis.

List 3 possible location for stones in urological disorders?

Kidney Ureter Bladder

Outline the typical clinical presentation of urological obstructive condition caused by stones.

Pain (abdomen, back-loin) Associated with urine infection Haematuria 90% of kidney stone are radio-opaque.

What sign can be found in patients with a urological disorder caused by stones?

Tenderness of loin and lower abdomen.

What investigation results show that a patient has urological disorder due to stones?

Urine dipstick - haematuria, +/- evidence of urine infection. Blood test - Kidney function (reduced only in some patients). Imaging - plain X-ray, ultrasound or CT scan

Broadly speaking what does treatment of a urological disorder due to stones involve?

Supportive - pain control + hydration

What does specific treatment for an obstructive urological disorder due to stones depend on?

Size and location of stones, availability of local expertise, fitness of patient for general anaesthetics

What 3 treatments can you use for stones?

Shockwave lithotripsy Ureteroscopy Percutaneous nephrolithotomy

What is the purpose of shockwave lithotripsy?

High energy sound waves to break up large kidney stones into smaller ones.

What part of the body do you put a ureterscopy through?

Urethra, bladder and ureter

What is the purpose of percutaneous nephrolithotomy?

Small percutaneous incision. Insertion of nephroscope. Stone is removed (may need to be broken in smaller pieces).

What benign neoplastic condition can occur in the genitourinary system?

Benign prostatic hypertrophy

What malignant neoplastic conditions can occur in the genitourinary system?

Kidney - renal cell carcinoma Ureter and bladder - Transitional cell carcinoma Prostatic cancer Testicular cancer

What is the clinical presentation for neoplastic urological disorders?

Asymptomatic (incidental finding during other investigation)

What investigations can you do to determine if a patient has neoplastic urological disorder (tumour)?

Blood test for marker: prostatic specific antigen (PSA) Urine cytology Kidney function Imaging (ultrasound, CT scan and/or MRI) Staging studies: any evidence of metastasis Histological diagnosis: biopsy or excised tumour

What treatments can you do for a patient has neoplastic urological disorder (tumour)?

To release any obstruction of the urinary tract: nephrostomy, bladder catheter or/and surgery Chemotherapy Radiotherapy Hormonal therapy for hormone sensitive cancer (e.g. prostatic cancer) Surgery

What are the different types of polycystic kidneys?

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

List the conseqeunces of polycystic kidneys.

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

List the treatment options for polycystic kidneys.

Tolvaptan - slow down cysts formation. Treat hypertension, infection Pain control Renal replacement therapy (transplantations, dialysis)

What is tolvaptan?

Vasopressin receptor 2 antagonist

How may we know the patient has a horseshoe kidney?

Imaging of abdomen/pelvis

What are the consequences of horseshoe kidney?

Increased risk of: Obstruction Stone Infection