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FERGU > Week 3- Hematuria > Flashcards

Week 3- Hematuria Flashcards

1
Q

How many sets of embylogical kidneys form, and what is the order? What germ layer do they come from?

A

3 sets form:

  1. pronephros
  2. mesonephros
  3. metanephros

All originate from the intermediate mesoderm, from the urogenital ridges.

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2
Q

Describe the sequence of events in kidney formation

A
  • The pronephros grows down, becomes mesonephros
  • mesonephros does the job of the kdney for the 1st trimester. pronephros disappears
  • mesonephros continues to grow down and grows into the cloaca
  • the uretic bud grows out of the metanephric duct
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3
Q

What forms the tubules of the kidney? What forms the collecting system of the kidney?

A

The metanephric mesenchyme. The uretic bud forms everything else.

The uretic bud induces the the metanephric mesenchyme to form a cyst that elongates a forms a glomerulus at one end and attaches to the collecting duct at the other end.

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4
Q

What is the name for the mesonephric duct later in development?

A

Th wolffian duct: it diasppears in women.

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5
Q

Where do the gonads develop?

A

They develop at the top of the mesonephric duct. In males the wolffian ducts stay around, in females the muellerian ducts show up and become the ovaries, uterus and 2/3 of vagina.

In males the spermatacord grows and descends into the scrotum via the inguinal canal.

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6
Q

How is the cloaca partitioned?

A
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7
Q

What do the nonspecific genital features of a foetus end up as in a male and a female?

A
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8
Q

What are the nonspecific (undifferentiated) genital features in a foetus?

A
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9
Q

Define nephrolithiasis

A

The presence of kidney stones in the kidney

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10
Q

What are the diagnostic possibilities for hemturia?

A
  • stones
  • infections
  • tumours
  • GN
  • trauma
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11
Q

In order to measure blood in the urine, what do dipsticks actually measure?

A

hemoglobin

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12
Q

Blood on the dipstick has to be _______ before being considered microhematuria

A

confirmed by microscopy

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13
Q

What do dysmorphic vs. regular RBCs in the urine tell you?

A

Dysmorphic: glomerular origin

Morphic: distal-to-glomerular orgina

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14
Q

How much protein is present with tumours/stones/infections/trauma/glomerular nephritis?

A

Lots of protein with glomerular nephritis

Not very much protein with anything else

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15
Q

What does initial vs. total hematuria suggest?

A

Initial: bleeding from urethra or prostate (BPH is often intial blood)

Total: bleeding from bladder or above

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16
Q

What does painless vs. symptomatic hematuria suggest?

A

Painless: BPH or malignancy, GN

Symptomatic: stones, trauma, infection

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17
Q

In the context of hematuria, what does fever suggest? Dysuria/frequency/urgency? Renal colic?

A

Fever: prostatits, pyelonephritis, UTI

Dysuria/frequency/urgency: inflammatory disease involving the bladder

Renal colic: acute obstruction of the ureter

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18
Q

________ is warranted in every case of hematuria

A

imaging!!!! (except in young women with a known cause, like bacterial cystitis)

-cystoscopy for the bladder and CT-KUB or CT-IVP or U/S for the kidneys and ureter

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19
Q

In smokers, what is the risk of RCC and urothelia carcinoma (TCC)?

A

4x greater for TCC

2x greated fro RCC

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20
Q

What is the classic triad of RCC?

A

Flank pain

hematuria

palpable mass

(only seen in 10% of patients these days)

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21
Q

What does the paraneoplastic syndrome for RCC include?

A

anemia

hypertension (renin)

polycythemia (Epo)

hypercalcemia (PTLH)

Stauffer syndrome (elevated liver transaminases)

Cushings

Coagulopathy

weight loss

fever

and so much more….

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22
Q

What are treatment options for primary RCC?

A
  • surgery (radical or partial nephrectomy)
  • if not surgical candidate, radio frequency ablation or cryotherapy with molecular therapy (VEGF inhibitors, mTOR inhibitors)
  • no radiation (except brain/bone mets), no convetional chemo or immunotherapy
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23
Q

What are the main types of kidney cancer and bladder cancer?

A

Kidney

  • renal cell carcinoma (90%)
  • urothelium carcinoma (TCC)

Bladder

  • urothelium carcinoma (95%)
  • squamous cell (5%)
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24
Q

What are risk factors for bladder cancer? Kidney cancer?

A

Kidney

  • smoking
  • obesity
  • heavy metals, asbestos
  • renal failure
  • genetic (von hippel lindau syndrome, tuberous sclerosis)

Bladder

  • somking
  • azo dyes
  • long-term cyclophosphamide
  • anagesic abuse nephropathy
  • prior radiation
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25
Q

Types of bladder TCC (urothelial carcinoma)?

A
  • papillary (non invasive)
  • flat carcinoma in-situ
  • invasive
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26
Q

In the DDx for flank pain, what do you NOT want to miss?

A

abdominal aortic aneurysm rupture

AA dissection

ectopic pregnancy

appendicitis

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27
Q

Common sites of obstruction along the ureter?

A
  • ureteropelvic junction (UPJ)
  • crossing of iliac
  • ureterovesical junction
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28
Q

What size of stone will probably pass spontaneously?

A

<0.9 cm (~20%… but percent goes up as the stone gets smaller)

**time frame for passing the stone is days to weeks**

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29
Q

Types of kidney stones

A

calcium oxalate (most common)

calcium phosphate

urin acid

cysteine

struvite (urease producing bacteria)

others….

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30
Q

How to differentiate GN from malignancy?

A

GN: more likely with proteinuria, HTN and edema, dysmorphic RBCs and RBC casts

BOth painless and tea-colored urine

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31
Q

How does the field effect apply to bladder cancer?

A

Very likely to recur because the whole field of tissue (the bladder) has been exposed to the carcinogen.

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32
Q

Risk factors for the five most common kidney stones

A

calcium oxalate (most common)

  • dietary oxalate, hypercalciuria

calcium phosphate

  • hyperparathyroidism
  • RTA

urin acid

  • gout

cysteine

  • autosomal recessive condition

struvite

  • infection with urease producing bacteria (e.g. proteus, klebsiella, pseudomonas, staph,
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33
Q
A

Just know

34
Q
A

Just know

35
Q
A

just know

36
Q
A

just know

…cysts are anechoic (fluid filled)

37
Q

What does this CT-KUB show?

A

a stone!!!

38
Q

What are the different kinds of CT scans you would use for hematuria and why?

A

CT-KUB: no contrast, used for suspected stone

CT-IVP: has contrast, used for stones and masses (?)

CT- renal mass: has contrast, used to differentitate renal masses (e.g. enhancing?)

39
Q

When would you use an MRI for hematuria?

A
  • contrast allergy
  • pregnancy

Pros: no radiation

Cons: expensive. slow, can’t use with metal implants

40
Q

What do you do when you have: hematuria with a history of trauma?

A

CT+ Iv contrast

41
Q

What do you do when you have: hematuria + pain suggestive of renal colic?

A

Send for CT-KUB

42
Q

What do you do when you have: hematuria +flank pain + fever?

A

U/S first line.

If mass –> CT-renal mass

If obstruction –>CT- IVP

43
Q

What do you do when you have: painless hematuria?

A

U/S to rule out stones

If mass –> CT- renal mass

If no mass –> CT-IVP

If renal casts –> nephrologist –> biopsy

44
Q

What is this? What are the typical features?

A

Renal calculus. Bright, echogenic spot with acoustic shadow behind it.

45
Q

Which calculi are radioopaque and radiolucent?

A

Radioopaque: calcium oxalate, calcium phosphate, struvite

Radiolucent: cysteine, uric acid, others (indinavir, matrix….)

46
Q

C’est quoi?

A

a solid mass

47
Q

DDx of a solid renal mass

A

Malignant

  • renal cell carcinoma
  • urothelial carcinoma
  • lymphomas
  • mets

Benign

  • angiomyolipoma
  • oncocytoma

Renal infarct

Renal abcess

48
Q
A

just know

49
Q

What is this?

A

Angiomyolipoma

50
Q

C’est quoi?

A

horseshoe kidney

51
Q

What is multicystic dysplastic kidney?

A

Happens when the uretic bud doesn’t interact probably with the metanephric mesenchycme…bilateral is incompatible with survival.

52
Q

What is UPJ obstruction and how does it happen in babies?

A

The ureter is constricted at the ureteropelvic junction eitehr by abnormal smooth muscle developent, or an aberrant crossing vessel

…causes hydronephrosis, loss of renal function

53
Q

What is ureter duplication and how does it happen?

A

When two uretic buds form instead of one. Results in two ureters and two collecting systems. Often one of them gets obstructed

54
Q

What is ureterocele?

A

Dilation of the terminal ureter. Most often associated with duplicated ureter

**can cause obstruction

55
Q

What is the more common fusion abnormality of the kidney?

A

Horseshoe kidney! “Two metanephric blastema are not separated”

7% of Turner Syndrome patients have this

56
Q

What is vesicoureteral reflux?

A

Retrograde movement of urine. Results from an abnormally short uretic bud that cannot be pinched off effectively during voiding.

–> pyelonephritis

57
Q

What are posterior urethral valves? Who has this?

A

Affects boys.. it’s a membranous fold in the posterior urethra that can obstruct urine.

Severe PUV can cause in utero renal failure –> oligohydramnios

58
Q

What is hypospadias?

A

abnormal development of the genital tubercle. The urethral meatus is in the ventral side of the penis somewhere between the penis and the proximal part of the glans. Also will have incomplete foreskin

59
Q

What is cryptorchidism?

A

Undescended testicle(s). Failure to descend (or only partial descent from abdomen to scrotum (–>testicular cancer, subfertility)

60
Q

What is CAH, what does it result in for female and males?

A

Congenital adrenal hyperplasia: ends up in the overprodcution of androgens because one of the other cholesterol containing pathways is ineffective, so precursor is shunted to the androgen pathway. Rarely it results in underproduction

Females: virilization of the external genitalia (no effect on internal genitalia)

Males: if under-production, under-virilization

61
Q

How does sex develop?

A

Default is female. Sex hormones are responsible for external genitalia, mullerian inhibiting factor influences internal organs.

62
Q

What is renal agenesis?

A

When a kidney fails to develop. Some genes associated, most probably multifactorial. One possibility is the left kidney bud migrated to the right side and fusing with the right kidney.

63
Q

What is the embryologic origin of the nephron, the collecting system, the trigone of the bladder and the rest of the bladder?

A

Nephron: metanephric mesenchyme (AKA metanephrogenic blastema)(mesoderm)

Collecting system: uretic bud (mesoderm)

Trigone: uretic bud (mesoderm)

Rest of bladder: endoderm

64
Q

Anatomic locations for hematuria

A

Kidneys (glomerular or post-glomerular), ureter, bladder, prostate, urethra, menstruation (in women)

65
Q

What are is an etiologic DDx of hematuria?

A

“Medical”

  • medications/foods
  • infection
  • coagulopathies
  • glomerular nephritis
  • congenital anomalies

“Surgical”

  • nephrolithiasis
  • tumour (benign or malignant)
  • trauma
66
Q

What is the timing you would expect for blood originating from the bladder or prostate?

A

early

67
Q

What is the timing you would expect for blood originating from the bladder neck?

A

late

68
Q

What is the timing you would expect for blood originating from ureters/kidney?

A

total

69
Q

What would alert you that hematuria is from a systemic instead of a GU cause?

A

Myoglobin/hemoglobin could be from crush injuries

Fever

Sepsis

History of infection

Bleeding elsewhere (nosebleeds, rectal, INR, PTT etc..)

Pain (renal colic? flank pain?)

Constitutional symptoms (weight loss, night sweats)

Medication (ASA, statins..)

Malignancy risk factors (smoking, occupational, FHx, radiation, cyclophosphamide Tx)

Proteinuria (present –>glomerular nephritis)

70
Q

What blood/urine tests to order with hematuria?

A
  • CBC/Diff (infection?)
  • Hb (loss of blood)
  • Urinanalysis (proteins..)
  • Microscopic analysis of urine (RBCs, WBCs, casts, crystals)
  • urine culture (infection)
  • urine cytology (malignancy)
  • PTT, INR, platelets (coagulopathy)
  • creatinine (renal function
71
Q

What signs/symptoms/findings would you expect for renal colic?

A
  • SEVERE, paroxysmal flank pain, maybe radiating to the groin
  • Writhing/inability to sit still
  • gross or microscopic hematuria
  • nausea +/- vomiting
72
Q

What signs/symptoms/findings would you expect for bladder cancer?

A
  • Painless total hematuria
  • Constitutional symptoms (fatigue, wt loss, fever)
  • You’d be able to see it on cystoscopy
73
Q

What signs/symptoms/findings would you expect for kidney cancer?

A
  • hematuria
  • flank pain/ CVA tenderness
  • palpable mass
  • paraneoplastic syndromes (Stauffer, hypercalcemia, anemia, HTN, polycythemia)
74
Q

What is the big advantage of CT and MRI over U/S?

A

Better spatial resolution!!

75
Q

What does a retrograde IV pyelogram show you?

A

The upper urinary tract.. the patency of the tract, whether it is blocked etc…

76
Q

What are stone inhibitors in the urine?

A

citrate, magnesium, RNA…other things

77
Q

What is the initial treatment of acute renal colic?

A

Pain/Nausea management

  • narcotics
  • NSAIDS (inhibit prostaglandin)
  • anti-emetics

Hydration

Anti-spasmotics (alpha blockers)

Antibiotics

  • if infection is suspected, BUT hematuria +pyuria alone do not suggest infection–> wait for the urine culture to come back
78
Q

Is hydronephrosis with nephrolithiasis an emergency?

A

No. All stones have some degree of hydronephrosis.

79
Q

Why isn’t IVP used anymore?

A
  • Time consuming (requires laxative preparation)
  • Anatomic detail not as good as CT
  • contrast is nephrotoxic
80
Q

Options for th surgical treatment of large stones?

A

Extra-corporeal shock wave lithotripsy

Retrograde ureteoscopy (lithotripsy, basket extraction, stent insertion)

Percutaneous antegrade nephrolithectomy

FERGU (7 decks)

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