Week 3- Hematuria Flashcards
How many sets of embylogical kidneys form, and what is the order? What germ layer do they come from?
3 sets form:
- pronephros
- mesonephros
- metanephros
All originate from the intermediate mesoderm, from the urogenital ridges.
Describe the sequence of events in kidney formation
- 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
What forms the tubules of the kidney? What forms the collecting system of the kidney?
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.
What is the name for the mesonephric duct later in development?
Th wolffian duct: it diasppears in women.
Where do the gonads develop?
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.
How is the cloaca partitioned?
What do the nonspecific genital features of a foetus end up as in a male and a female?
What are the nonspecific (undifferentiated) genital features in a foetus?
Define nephrolithiasis
The presence of kidney stones in the kidney
What are the diagnostic possibilities for hemturia?
- stones
- infections
- tumours
- GN
- trauma
In order to measure blood in the urine, what do dipsticks actually measure?
hemoglobin
Blood on the dipstick has to be _______ before being considered microhematuria
confirmed by microscopy
What do dysmorphic vs. regular RBCs in the urine tell you?
Dysmorphic: glomerular origin
Morphic: distal-to-glomerular orgina
How much protein is present with tumours/stones/infections/trauma/glomerular nephritis?
Lots of protein with glomerular nephritis
Not very much protein with anything else
What does initial vs. total hematuria suggest?
Initial: bleeding from urethra or prostate (BPH is often intial blood)
Total: bleeding from bladder or above
What does painless vs. symptomatic hematuria suggest?
Painless: BPH or malignancy, GN
Symptomatic: stones, trauma, infection
In the context of hematuria, what does fever suggest? Dysuria/frequency/urgency? Renal colic?
Fever: prostatits, pyelonephritis, UTI
Dysuria/frequency/urgency: inflammatory disease involving the bladder
Renal colic: acute obstruction of the ureter
________ is warranted in every case of hematuria
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
In smokers, what is the risk of RCC and urothelia carcinoma (TCC)?
4x greater for TCC
2x greated fro RCC
What is the classic triad of RCC?
Flank pain
hematuria
palpable mass
(only seen in 10% of patients these days)
What does the paraneoplastic syndrome for RCC include?
anemia
hypertension (renin)
polycythemia (Epo)
hypercalcemia (PTLH)
Stauffer syndrome (elevated liver transaminases)
Cushings
Coagulopathy
weight loss
fever
and so much more….
What are treatment options for primary RCC?
- 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
What are the main types of kidney cancer and bladder cancer?
Kidney
- renal cell carcinoma (90%)
- urothelium carcinoma (TCC)
Bladder
- urothelium carcinoma (95%)
- squamous cell (5%)
What are risk factors for bladder cancer? Kidney cancer?
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
Types of bladder TCC (urothelial carcinoma)?
- papillary (non invasive)
- flat carcinoma in-situ
- invasive
In the DDx for flank pain, what do you NOT want to miss?
abdominal aortic aneurysm rupture
AA dissection
ectopic pregnancy
appendicitis
Common sites of obstruction along the ureter?
- ureteropelvic junction (UPJ)
- crossing of iliac
- ureterovesical junction
What size of stone will probably pass spontaneously?
<0.9 cm (~20%… but percent goes up as the stone gets smaller)
**time frame for passing the stone is days to weeks**
Types of kidney stones
calcium oxalate (most common)
calcium phosphate
urin acid
cysteine
struvite (urease producing bacteria)
others….
How to differentiate GN from malignancy?
GN: more likely with proteinuria, HTN and edema, dysmorphic RBCs and RBC casts
BOth painless and tea-colored urine
How does the field effect apply to bladder cancer?
Very likely to recur because the whole field of tissue (the bladder) has been exposed to the carcinogen.
Risk factors for the five most common kidney stones
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,
Just know
Just know
just know
just know
…cysts are anechoic (fluid filled)
What does this CT-KUB show?
a stone!!!
What are the different kinds of CT scans you would use for hematuria and why?
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?)
When would you use an MRI for hematuria?
- contrast allergy
- pregnancy
Pros: no radiation
Cons: expensive. slow, can’t use with metal implants
What do you do when you have: hematuria with a history of trauma?
CT+ Iv contrast
What do you do when you have: hematuria + pain suggestive of renal colic?
Send for CT-KUB
What do you do when you have: hematuria +flank pain + fever?
U/S first line.
If mass –> CT-renal mass
If obstruction –>CT- IVP
What do you do when you have: painless hematuria?
U/S to rule out stones
If mass –> CT- renal mass
If no mass –> CT-IVP
If renal casts –> nephrologist –> biopsy
What is this? What are the typical features?
Renal calculus. Bright, echogenic spot with acoustic shadow behind it.
Which calculi are radioopaque and radiolucent?
Radioopaque: calcium oxalate, calcium phosphate, struvite
Radiolucent: cysteine, uric acid, others (indinavir, matrix….)
C’est quoi?
a solid mass
DDx of a solid renal mass
Malignant
- renal cell carcinoma
- urothelial carcinoma
- lymphomas
- mets
Benign
- angiomyolipoma
- oncocytoma
Renal infarct
Renal abcess
just know
What is this?
Angiomyolipoma
C’est quoi?
horseshoe kidney
What is multicystic dysplastic kidney?
Happens when the uretic bud doesn’t interact probably with the metanephric mesenchycme…bilateral is incompatible with survival.
What is UPJ obstruction and how does it happen in babies?
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
What is ureter duplication and how does it happen?
When two uretic buds form instead of one. Results in two ureters and two collecting systems. Often one of them gets obstructed
What is ureterocele?
Dilation of the terminal ureter. Most often associated with duplicated ureter
**can cause obstruction
What is the more common fusion abnormality of the kidney?
Horseshoe kidney! “Two metanephric blastema are not separated”
7% of Turner Syndrome patients have this
What is vesicoureteral reflux?
Retrograde movement of urine. Results from an abnormally short uretic bud that cannot be pinched off effectively during voiding.
–> pyelonephritis
What are posterior urethral valves? Who has this?
Affects boys.. it’s a membranous fold in the posterior urethra that can obstruct urine.
Severe PUV can cause in utero renal failure –> oligohydramnios
What is hypospadias?
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
What is cryptorchidism?
Undescended testicle(s). Failure to descend (or only partial descent from abdomen to scrotum (–>testicular cancer, subfertility)
What is CAH, what does it result in for female and males?
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
How does sex develop?
Default is female. Sex hormones are responsible for external genitalia, mullerian inhibiting factor influences internal organs.
What is renal agenesis?
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.
What is the embryologic origin of the nephron, the collecting system, the trigone of the bladder and the rest of the bladder?
Nephron: metanephric mesenchyme (AKA metanephrogenic blastema)(mesoderm)
Collecting system: uretic bud (mesoderm)
Trigone: uretic bud (mesoderm)
Rest of bladder: endoderm
Anatomic locations for hematuria
Kidneys (glomerular or post-glomerular), ureter, bladder, prostate, urethra, menstruation (in women)
What are is an etiologic DDx of hematuria?
“Medical”
- medications/foods
- infection
- coagulopathies
- glomerular nephritis
- congenital anomalies
“Surgical”
- nephrolithiasis
- tumour (benign or malignant)
- trauma
What is the timing you would expect for blood originating from the bladder or prostate?
early
What is the timing you would expect for blood originating from the bladder neck?
late
What is the timing you would expect for blood originating from ureters/kidney?
total
What would alert you that hematuria is from a systemic instead of a GU cause?
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)
What blood/urine tests to order with hematuria?
- 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
What signs/symptoms/findings would you expect for renal colic?
- SEVERE, paroxysmal flank pain, maybe radiating to the groin
- Writhing/inability to sit still
- gross or microscopic hematuria
- nausea +/- vomiting
What signs/symptoms/findings would you expect for bladder cancer?
- Painless total hematuria
- Constitutional symptoms (fatigue, wt loss, fever)
- You’d be able to see it on cystoscopy
What signs/symptoms/findings would you expect for kidney cancer?
- hematuria
- flank pain/ CVA tenderness
- palpable mass
- paraneoplastic syndromes (Stauffer, hypercalcemia, anemia, HTN, polycythemia)
What is the big advantage of CT and MRI over U/S?
Better spatial resolution!!
What does a retrograde IV pyelogram show you?
The upper urinary tract.. the patency of the tract, whether it is blocked etc…
What are stone inhibitors in the urine?
citrate, magnesium, RNA…other things
What is the initial treatment of acute renal colic?
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
Is hydronephrosis with nephrolithiasis an emergency?
No. All stones have some degree of hydronephrosis.
Why isn’t IVP used anymore?
- Time consuming (requires laxative preparation)
- Anatomic detail not as good as CT
- contrast is nephrotoxic
Options for th surgical treatment of large stones?
Extra-corporeal shock wave lithotripsy
Retrograde ureteoscopy (lithotripsy, basket extraction, stent insertion)
Percutaneous antegrade nephrolithectomy
