Week 3 Flashcards
What are some of the key features that distinguish glomerulonephritis from pyelonephritis?
Glomerulonephritis
- Non-infective
- Presents as glomerular tufts with secondary tubulointerstitial changes
- Usually diffuse, may be focal
- Immunological mechanisms are often implicated but there doesn’t seem to be any one single cause
Pyelonephritis
-
Bacterial infection of the renal pelvis, calyces, tubules and interstitium. E. coli is the most common causative organism
- also Pseudomonas and Strep. faecalis
- Can be acute or chronic
- Patchy distribution
- More common in females
Why are females more predisposed to developing UTIs?
They have shorter, wider urethras
What are some of the risk factors for developing pyelonephritis?
Age and sex
Pregnancy
Urinary tract obstructions e.g. calculi, strictures, neoplasms, congenital abnormalities etc.
Compromised uretero-vesical valves and vescio-ureteric reflux
Diabetes
How might someone with chronic pyelonephritis present?
What would be the appearance on renal imaging?
Often no previous history of UTI, and symptoms are vague
Hypertension and/or uraemia
Large volume of dilute urine
On renal imaging, coarse cortical scarring and distortion of the calyces is seen
If a patient presented with vague symptoms such as weight loss, fever, loin pain and dysuria, and on imaging caseating granulomatous inflammation was seen in the kidneys, what might the diagnosis be?
Tuberculous Pyelonephritis
Caseous foci are identical to those seen in the lung of tuberculosis patients - slow growth with progressive renal destruction which can spread to ureters, bladder and other viscera
What bacterial species can cause cystitis?
E. coli
Klebsiella
Proteus
Psuedomonas
What tropical infection can predispose to numerous urothelial malignancies?
Schistosomiasis
Urinary tract obstruction can eventually lead to what in the kidney?
Hydronephrosis
Patient presents with haematuria! What questions do you ask them?
How long?
Is it painful? (a.k.a. dysuria)
Changes in urinary frequency?
Any symptoms of infection?
Other consitutional symptoms?
Where in the strain of urine? Beginning, end, or throughout?
Does it occur every time you go the bathroom?
What are the clots like? e.g. shape, colour
Lifestyle factors/Occupation - smoking, drinking, exposure to various chemicals e.g. dyes, diesel fumes etc.
What are “storage symptoms” related to? Give some examples of these symptoms
Related to bladder function
Frequency of urination
Urgency
Incontinence
Nocturia
Sense of incomplete empyting
Pain with filling of the bladder
What are “voiding symptoms” related to? Give some examples of these symptoms
Related to urinary flow e.g. due to obstruction
Hesitancy
Poor flow
Post-urination dribbling
Intermittent stream
Spraying/deviation of stream
Patient presents with a lump in the groin! What questions do you ask?
Quick or gradual appearance?
Changing size?
Bilateral?
Painful? Signs of skin change e.g. redness etc.
Recent trauma or infection?
Soft or hard lump - NB: testicular cancer lumps are described as being stone-like
Constitutional symptoms?
STIs? Discharge?
Does it go away at any point e.g. when lying down?
What is the “classic triad” of renal tumours?
Why is it not actually that great diagnostically?
Classic triad
- Pain
- Lump in loin
- Frank haematuria
Not great because it’s only seen in ~20% patients with renal tumours - most present asymptomatically
What are the three concepts of dialysis?
What toxins are removed, and what is infused?
- Diffusion
- Convection
- Adsorption
Potassium, urea and sodium are all removed, and bicarbonate is infused
Simple cysts in kidneys are very common/very uncommon
Do they usually cause functional disturbance?
Simple cysts in kidneys are very common, can be multiple and large and usually cause no functional disturbance
How is infantile polycystic kidney disease inherited?
What gene is involved?
How does it present in the kidneys?
Inherited in an autosomal recessive manner (ARPKD)
Mutation is in the PKDH2 gene on chromosome 6
Causes bilateral renal enlargement, elongated cysts and dilatation of the medullary collecting ducts
What other congenital condition is Infantile Polycystic Kidney Disease/ARPKD associated with?
Also associated with congenital hepatic fibrosis
The Liver is the most common site for cysts to develop in alongside the kidney
What are the two potential gene defects that can result in development of autosomal dominant polycystic kidney disease (ADPKD)? Which of these defects is more common?
How do patients with ADPKD present?
PKD gene 1 present on Chromosome 16 (accounts for 90% of ADPKD)
PKD gene 2 present on Chromosome 4 (accounts for the remaining 10%)
Patients present usually in middle adult life with abdominal mass, haematuria, hypertension and chronic renal failure
Where else might cysts present in a patient with ADPKD? What pathologies may develop?
Cysts can develop in the liver, pancreas and lung, usually with no functional effect
Cysts can also develop in the brain, known as Berry aneurysms of the Circle of Willis, and this can result in the development of subarachnoid haemorrhages
Name some types of benign renal tumour
Fibroma - common, medullary origin, seen as white nodules
Adenoma - seen as yellowish nodules and more cortical
Angiomyolipoma - mix of fat, muscle and blood vessels.
Juxtaglomerular cell tumour (JGCT)
If you suspected a patient had a benign renal tumour and were trying to differentiate between a fibroma and an adenoma, how would you tell these two apart?
Fibroma - white nodules and medullary origin
Adenoma - yellowish nodules and cortical origin
What other disease are angiomyolipomas associated with?
Tubular sclerosis
JGCTs produce what?
How does this present clinically?
JGCTs produce renin
This results in the development of secondary hypertension
What are the 3 mechanisms by which renin is released?
- Baroreceptor mechanism - decreased pressure in the afferent arteriole in the kidneys prompts renin release
- Sympathetic nerve mechanism - beta1-adrenergic nerves stimulate renin release (think fight or flight and increased blood pressure etc.)
- Macula densa mechanism - sense drops in NaCl in distal convoluted tubule and promote renin release
Very generally, describe the Renin-Angiotensin-Aldosterone System
Renin produced by juxtaglomerular cells in kidney
Angiotensinogen produced by liver, converted to angiotensin I by renin.
Angiotensin I is converted to Angiotensin II by Angiotensin Converting Enzyme produced by the lungs
Angiotensin II acts on the adrenal glands to cause the release of Aldosterone, which promotes the retention of Na+ and thus increases blood pressure
What vertebral level are the kidneys?
Right kidney - T12-L2
Left kidney - T11-L1
Name some types of malignant renal tumour
Nephroblastoma (Wilm’s Tumour)
Urothelial carcinomas - present in the renal pelvis and calyces
Renal cell carcinoma - a.k.a. clear cell ca, hypernephroma, Grawitz tumour. Arises from renal tubular epithelium
What malignant renal tumour is the most common intra-abdominal tumour in children?
Nephroblastoma (Wilm’s Tumour)
What is the most common primary renal tumour in adults?
Who gets it?
How does it present?
Renal Cell Carcinoma a.k.a. Grawitz tumour, Clear Cell ca. etc.
Most common in people age 55-60. M:F 2:1
Presents with abdominal pain, haematuria, flank pain, general features of malignant disease
What are some paraneoplastic features of renal cell carcinoma?
Polycythaemia (increased number of RBCs in the blood due to erythropoetic stimulating substance)
Hypercalcaemia
Where might a renal cell tumour extend to?
Extension via the renal vein into the IVC and eventually end up in right atrium - confers a worse prognosis
What is the most common form of bladder cancer? What is its most common presenting feature?
What are some of the risk factors?
Most common form of bladder cancer is Transitional Cell Carcinoma (TCC) - 90% of bladder cancers.
Most common presenting symptom is haematuria
Risk factors
- Aniline dyes
- Working in the rubber industry
- Benzidine
- Cyclophosphamide
- Schistosomiasis
- Smoking
Where do most TCCs occur?
How does this present?
75% of TCCs occur in the trigone
This can cause ureteric obstruction
What is the most common malignant bladder cancer in children?
Embryonal Rhabdomyosarcoma
What is more likely to present with haematuria - prostate cancer or benign prostate hyperplasia?
BPH more commonly presents with haematuria (20%), while prostate cancer is less common (0.7%)
Can sport cause haematuria?
Yes! Both contact and non-contact sports can cause haematuria
Non-contact a.k.a. Jogger’s haematuria
Disappears on its own after 7-10 days
Where is the likely source of the bleed if a patient presents with haematuria…
- at initial urination
- at terminal urination
Initial - bladder
Terminal - prostate
Development of what type of cancer is associated with schistosomiasis and Aristolochia (a plant)?
TCC
What is the “Israel Triad” of symptoms associated with renal cancer?
Pain
Haematuria
Renal mass (lump in loin)
Working interiorly to exteriorly, what are the 3 layers of fibres in the detrusor muscle?
Inner longitudinal muscle fibres
Circular muscle fibres
Outer longitudinal muscle fibres
What are ‘phimosis’ and ‘paraphymosis’?
Phymosis - inability to retract the foreskin back past the glans of the penis
Paraphymosis - inability to return the foreskin back after having retracted it over the glans of the penis
What are voiding symptoms related to? Are they more common in males or females?
Give some examples
Related to flow and stem from a blockage. Obstruction is more common in males
- Poor flow
- Intermittent stream
- Spraying/deviation of stream
- Hesitancy
- Post-micturation dribbling
What are storage symptoms related to? Are they more common in males or females?
Give some examples
Storage symptoms are related to the bladder (e.g. overactivity) and are more common in females
- Frequency
- Urgency
- Nocturia
- Urge incontinence
- Sense of incomplete emptying
- Pain with filling of the bladder
What are the two types of haematuria?
Microscopic (non-visible)
Macroscopic/Visible (gross/frank etc.)
What questions do you need to ask specifically about the bleeding in a patient presenting with frank haematuria?
Presence of clots?
Mild, moderate or severe?
Shape of clots?
Is it painful or painless?
At what point in the stream does the blood appear? (nb - terminal bleeding is specific to prostate)
How is microscopic haematuria diagnosed?
Dipstick shows 3-5 RBCs per HPF (high-power field)
How can benign prostatic hyperplasia be treated?
Alpha blockers (relax the muscles of the prostate and bladder neck)
Finasteride (blocks the conversion of testosterone to dihydrotestosterone and reduces prostate size)
TURP (transurethral resection of the prostate)
What are the various zones of the prostate?
Transitional Zone - gives rise to BPH, and only ~20% of prostate cancers arise from here
Central Zone - only 1-5% of prostate cancers arise from here
Peripheral Zone - makes up the majority of prostatic glandular tissue and is the origin for up to 70% of prostatic cancers
In general, benign changes in the prostate occur in the ____ zone and malignant changes occur in the ____ zone
Bengin - central/transitional zone
Malignant - peripheral zone
What age group is prostatic cancer most commonly seen in?
Peak is 70-74, with 85% of cases occuring in patients over 65
Rare in under 50s
How are the majority of prostate cancers picked up clinically?
How might prostate cancer present clinically?
Most are asymptomatic and found by PSA tests and abnormal DRE findings
May present with lower urinary tract symptoms, haematuria/haematospermia, bone pain, anorexia/weight loss etc.
Where is PSA produced and what is its function?
How to serum levels of PSA change in prostate cancer?
Is PSA a good marker for prostate cancer?
Produced by secretory epithelial cells in the prostate gland and functions to liquefy sperm
In a healthy individual, PSA levels will be high in semen and low in the blood, however PSA in the blood will increase with prostate cancer
PSA isn’t great for diagnosing prostate cancer - it has good sensitivity (90%) but isn’t very specific (40%)
In what other conditions might a raised serum PSA be seen in?
What is required when considering PSA measurement in an asymptomatic individual
BPH
Prostatitis/UTIs
Urinary retention
Catheterisation
In an asymptomatic individual, PSA counselling is essential due to the low specificity of the test
How is diagnosis of prostate cancer confirmed in a patient with raised PSA and abnormal findings on DRE?
With a TRUS (Trans-rectal ultrasound-guided) biopsy
10 biopsies are taken, 5 from each lobe of the prostate
What type of cancer are the majority of prostate cancers?
Multifocal adenocarcinomas (>95%)
How are prostate cancers graded?
Using Gleason’s Scoring (1-5)
Two most abundant cell types are added together to give a score between 2 and 10
Very good predictor of prognosis
What benign renal pathology can be identified by the appearance of a central scar on CT
Oncocytoma
If a young patient presented with multiple bilateral renal cell carcinomas or other renal cancers e.g. phaeochromocytoma, what autosomal dominant condition might you suspect?
What genetic defect would be seen in this condition?
You might suspect Vonn Hippel Lindau
This is caused by a defect in the VHL gene due to a deletion in 3p25
VHL is a tumour suppressor gene, and this defect results in VEGF, PDGF and angiogenesis
