Week 4 - Renal & Urological Problems Flashcards
list the immunological disorders of the kidney (4)
- glomerulonephritis
- goodpasture’s syndrome
- IgA nephropathy
- nephritic & nephrotic syndrome
what is glomerulonephritis
- inflammation of the glomerulus
how can glomerulonephritis be classified?
according to clinical presentation
- nephritic syndrome
- nephrotic syndrome
what is nephritic sybdrome?
- the typical presentation of glomerulonephritis
Note: when just glomerulonephritis is used, it is referring to nephritic syndrome
what causes nephritic or nephrotic syndrome (2)
- disorders of the kidney (pimary)
- systemic diseases that affect the kidney (secondary)
what is the typical cause of nephritic syndrome/glomerulonephritis
- nearly all causes are immune mediated
what are exmaples of immune mediated causes of glomerulonephritis (6)
- post-infectious disease
- sepsis
- endocarditis
- lupus
- rheumatic disease
- idiopathic autoimmune
what are some examples of post-infectious diseases that can cause glomerulonephritis (7)
- streptococci
- penumococci
- hep B
- mononucleosis
- measles
- mumps
- malaria
what are the 4 common manifestations of glomerulonephritis
- hematuria
- proteinuria
- reduced GFR
- hypertension
what are the 3 paths of glomerulonephritis
- acute glomerulonephritis
- rapidly progressive glomerulonephritis
- chronic glomerulonephritis
what is acute glomerulonephritis? what does it result in?
- an abrupt onset of syndrome
- results in acute renal failure, followed by full recovery of renal function
what is rapidly progressive glomerulonephritis? what does it result in?
- an abrupt onset of symptoms
- results in acute renal failure which does not recover
- over weeks to months it progresses to chronic renal failure
what is chronic glomerulonephritis? what does it result in?
- acute glomerulonephritis which progresses slowly (5-20 years) to chronic renal failure
what is APSGN
acute poststreptococcal glomerulonephritis
what causes APSGN
- after someone is infected with streptococcus, the immune attack on the streptococcus antigen results in immune complex deposits in the glomerular capillaries
- the deposits of these immune complexes activates the complement system & causes the inflammatory response
how long does it take for nephritic manifestations to occur in APSGN
- ~7-10 days after the onset of infection
what 2 types of infection with streptococcus occur? which is more common?
- pharyngeal
- cutaneous
- cutaneous is more common
what type of bacteria causes APSGN
- group A streptococcus = streptococcus pyogenes
how long does it take for APSGN to resolve?
- will resolve over a period of weeks
who does APSGN effect? who is it more common in?
- usualy children between ages 3-7
- more common in boys
what can we do to prevent APSGN
- treat the streptococcal infection w antibiotics
how does APSGN effect the structure of the glomerulus (3)? what does this cause?
- the endothelial cells swell & lose their fenestrations
- the podocytes are altered & lose their slits
= RBC and proteins can leak thru - get subendothelial & subepithelial deposits of WBC and immune complexes
= glomerular congestion = difficult to make filtrate
what are the manifestations of APSGN (9)
- hematuria
- proteinuria
- erythrocyte casts
- decreased GFR = oliguria & azotemia
- pain in the flank & lower back
- HTN & edema
- blood analysis results
what causes hematuria & proteinuria in APSGN
- due to damage of the glomerular capillaries = theyr are more permeable
what causes a decreased GFR in APSGN? how does it cause oliguria & azotemia?
- GFR reduces due to the congestion in the capillary with WBC and the immune complexes
- oliguria = decreased GFR = decreased flitrate = decreased urine
- azotemia = can’t filter out the metabolits
how does APSGN cause flank and lower back pain
- due to swelling/distension of the renal capsule which presses on nerves (?)
what type of edema is seen in APSGN
- facial
- preorbital
what causes HTN and edema in APSGN (3)
- due to fluid & salt overload from decreased GFR
- also hyperreninemia
- decreased colloid osmotic P (due to proteinuria)
what does a blood analysis in APSGN show?
- elevation of antibodies to streptococcal antigens
- metabolic acidosis
what 2 types of antibodies will be seen for streptococcal antigens
- antistreptolysin O
2. antistreptokinase ASK
what does a urine analysis in APSGN show?
- proteinuria
- hematuria
- erythrocyte casts
describe the resolution of APSGN; describe it for kids & adults; what can it result in?
- most cases resolve with a diuretic phase after treatment for the infection (esp after kids)
- in adults, not as easily resolved
- some cases may progress to chronic renal failure
what causes nephrotic syndrome
- occurs secondary to a number of disorders
what are some disorders that cause nephrotic syndrome (6)
- infection
- lupus
- exposure to nephrotoxins
- neoplasia
- diabetic nephropathy
- immune-mediate
what is the difference between nephritic and nephrotic syndromw
- both = inflammation of the glomerulus
- nephrotic = no presence of cellular immune cells (WBC)
what are the symptoms of nephrotic syndrome (6)
- marked proteinuria (lots) –> which leads to…
- hypoalbuminemia & hypoproteinuria
- hyperlipidemia
- lipid in the urine
- generalized edema
- no HTN and hypovolemia
how does lipid in the urine present as?
- milky appearance with increased specific gravity
what causes edema in nephrotic syndrome
- loss of proteins = reduced colloid osmotic pressure (which usually pulls fluid in)
where do we see edema in nephrotic syndrome (3)? what does edema cause?
- dependent areas (ex. feet)
- ascites
- effusions (heart or lungs)
- causes weight gain
how does the edema in nephrotic syndrome effect bp?
bp is not usually elevated due to:
- third-spacing (so it is not in vascular space)
- hypovolemia
what are the manifestations of hypovolemia (3)
- syncope
- circulatory shock
- acute kidney azotemia
how does nephrotic syndrome cause hyperlipidemia
- the decreased colloid osmotic pressure stimulate the liver to produce proteins, including lipoproteins
what does hyperlipidemia in nephrotic syndrome result in? (2)
= elevated plasma LDL and VLDL
besides decreased colloid pressure, what does loss of plasma proteins (other than albumin) cause? (5)
- deficient phagocytosis & opsonization
- hypercoagulability
- secondary parathyroidism
- iron deficiency
- abnormal thyroid function
loss of which proteins result in phagocytosis & opsonization
- loss of antibodies and complement proteins
loss of which proteins result in hypercoaguability
- loss of plasma anticoagulants
ex. antithrombin
loss of which protein results in secondary hyperparathyroidism
- loss of vitamin D binding proteins
loss of which protein results in iron deficiency
- loss of transferrin
loss of which protein results in abnormal thyroid function
- loss of thyroid binding protein
some cases of nephrotic syndrome are considered…
- a minimal change disease
what is meant by minimal change disease
- all manifestations are due to proteinuria
- progression to uremia does not occur
is the difference between nephrotic & nephritic syndrome always distinct?
- no, sometime it is difficult or impossible to make
how is nephrotic syndrome treated
- with anti-inflammatory drugs like glucocorticoids to reduce glomerular inflammation
- lasix & spironolactone for fluid & electrolyte control
what are 3 types of infectious & inflammatory disorders of the urinary system
- cystitis
- acute pyelonephritis
- chronic pyelonephritis
what are the 2 categories of UTIs
- upper tract
2. lower tract
what is considered upper tract urinary system?
anything that involves:
- ureter
- kidney
what is considered lower tract urinary system?
anything that involves:
- bladder
- urethra
what is the second most common infection seen by HCP?
- UTIs
what is the most common cause a UTI?
- an ascending infection = microbes enter the urethra as the portal of entry & work their way up
what is the body’s major defense against ascending infection
- the flushing effect of urine flow
why is it that when we take urine samples for UTIs, is it done mid-stream>
-bc at first, there will always be bacteria in urine`
what type of bacteria is the most common cause of UTI? what type of infections does it cause
- escherichia coli
= opportunist infection or nosocomial infection
what type of bacteria is the second most common cause of UTI
- proteus bacteria
what are 6 causes/contributing factors to an UTI?
- ascending infection
- immobility = stasis of urine
- blood-borne organism
- obstruction : ex. prostatic hypertrophy
- vesicoureteral reflux
- incomplete bladder emptying
what is the vesicoureteral reflux?
- congenital defect that causes a defective valve
- this causes backflow of urine into the kidneys
what about e.coli creates its ability to cause UTIs? what typically prevents this?
- its pilli which causes its ability to bind to urinary epithelial cells
- urine flow tends to prevent this
how does glucosuria/diabetes effect E.coli’s ability to cause UTIs?
- the glucose provides an additional energy source
describe the relation between proteus bacteria & urea
- it can use urea as an energy source, liberating free ammonium
who is more susceptible to UTIs? (2)
- young females
2. older men
why are younger females more susceptible to UTIs?
due to anatomical vulnerability:
- short, wide urethra with closer proximity to the anus
why are older males more susceptible to UTIs?
- they suffer from an enlarged prostate
= obstruction & retention of urine = frequent UTIs
what can cause incomplete bladder emptying & obstruction of urine flow (6)
- incontinence
- pregnancy
- scar tissue
- congenital defects of the ureter
- impaired blood supply to the bladder
what are 2 other risk factors for UTIs
- catheterization
- sexual intercourse
describe the relationship between UTIs and renal calculi (kidney stones)
- calculi can obstruct the urine = infection
- while ammonium formed by UTIs makes the urine more alkaline & predisposes calculi formation
what are the 4 main manifestations of cystitis
- pain
- frequency & uregency
- systemic signs of infection
- urinalysis
what type of pain is common in cystitis (2)
- abdominal pain
- dysuria –> pain during micturition
what are the frequency and urgency symptoms of UTI called?
- irritative symptoms
what causes frequency and urgency in UTIs
- inflammation & swelling of the bladder = reduced capacity of the bladder
what are systemic signs of infection seen in UTIs?
- fever
- malaise
- nausea
- leukocytosis
what is leukocytosis
- increased WBC
what is seen during urinalysis for cystitis (3)? what does this cause?
- bacteriuria
- pyuria
- microscopic hematuria
= creates cloudy urine with unusual odour
what is the treatment for UTIs (2)
- antibiotic therapy
- increased fluid intake
both to help eliminate evading organisms
what 2 types of juice are useful for UTIs? why?
- cranberry & blueberry
- contain tannins that interfere w the pili of e.coli & prevent binding to urinary epithelia
what is the cause of pyelonephritis (2)
- an ascending infection from the bladder
- bacteremia
what does pyelonephritis often involve (2)
- the renal pelvis
- medullary tissue
what does pyelonephritis often result in
- inflammation
- possibly necrosis
if pyelonephritis is severe, would happens?
- exudate & pus compress the renal vessels
= ischemia & HTN - or it can compress the ureter = obstructs urine flow
what are the manifestations of pyelonephritis(4)
- pain
- LUTS
- urinalysis abnormalities
- failure to conc the urine
what symptom might you see if pyelonephritis includes bilateral obstruction
- azotemia
what does chronic or repeat infection of pyelonephritis result in?
- chronic kidney failure
what is chronic pyelonephritis
- term used to describe a kidney that has become shrunken & has lost function due to scarrin & fibrosis
what causes chronic pyelonephritis
- usually occurs as the outcome of recurring infections involving the upper urinary tract
what type of pain is experiences during pyelonephritis? what causes it?
- dull & aching lower back/flank pain
- CVA tenderness
due to distension of the renal capsule
describe the urinalysis for pyelonephritis
- pyuria
- bacteruria
- hematuria
- casta (WBC & epithalial)
what are urinary calculi
- kidney stones
what is the most common cause of urinary tract obstruction?
- kidney stones (nephrolithiasis)
what does stone formation require? (2)
- a nucleus to initiate formation ex. cell debris
- an enviro that encourages precipitation ex. pH
what are stones made of?
- various solutes the kidney normally excretes
how many types of stones are there? list them
4
- calcium
- struvite
- uric acid
- cystine
what are 2 types of calcium stones?
- oxalate ( an organic acid found in plants)
- phosphate
what are struvite kidney stones made of
- ammonium
- magnesium
- phosphate
what is the most common type of kidney stone?
- approx 75% contain calcium
what are most calcium stones due to? (3)
- idiopathic hypercalciuria
- hyperparathyroidism
- immobility
uric acid stones account for ___% of stones
- 10
what are the contributing factors to uric acid stones (6) what pH?
- hyperuricosuria
- gout
- chemo
- obesity
- diet high in organ meats, red meat
- acidic urine
struvite stones represent nearly __% of stones
15
what causes struvite stones (2) what pH
- chronic or recurrent UTIs with urea metabolizing bacteria (proteus), where the pH is alkaline
how common are cystine stones?
- very rare
what causes cystine stones?
- inherited disorders of amino acid metabolism
list 4 causes of renal calculi
- precipitation of organic salts in the urinary tract
- dehydration
- high Na and protein diets
- HTN
what is meant by precipitation of salts?
- deposited in a solid form
what two things can cause precipitation of salts in the urinary tract?
- saturation (too much solute, not enough solvent)
- change in solubility (change in pH)
which type of stone prefers acidic enviro? alkaline?
- struvite, calcium phosphate = alkaline
- uric acid, calcium oxylate, cystine = acid
how does dehydration contribute to renal calculi formation
- increases urine concentration (saturation)
- decreases Ca transit time
list the symptoms of kidney stones (7)
- renal colic = lower back & flank pain
- ureteral colic = pain radiating to groin, perineum, scortum
- lower abdominal pain
- oliguria
- hematuria
- with or without fever
- signs of hydronephrosis & hydroureter
what does it mean if kidney stones are obstructing both kidneys
- there is underlying disease
what occurs if a person only has 1 kidney and they have a kdiney stone (2)
- azotemia
- anuria
what 3 things are often required to allow passage of a stone (3)
- fluids
- best rest
- analgesics
what is the specific treatment for oxalate stones (3)
- thiazide diuretics
- alkali therapy
- cholestyramine
what is the specific treatment for struvite stones
- antibiotics (to kill the proteus bacteria)
what is the specific treatment for oxalate, uric acid, and cystine stones?
- alkali
what is the specific treatment for uric acid stones
- allopurinol treatment (inhibits uric acid formation)
- alkali treatment
what is used to chalate calcium?
- cellulose phosphate (calcibind)
what is used to bind oxalate?
- cholestyramine
what dietary changes can be used to treat kidney stones (2)
- low sodium & protein intake
what type of diet change is not very effective for stones? why?
- decreasing calcium intake
- can accelerate oxalate stones
what are 2 types of treatment for kidney stones?
- lithotripsy
- surgery
what are 2 common causes of urinary obstruction
- renal calculi
- prostate disease
what are the 2 most damaging effects of obstruction? why?
- stasis of urine = predisposes to infection
- increased backpressure = can impair renal blood flow & damage renal tissue
obstruction can be either.. (2)
- complete
- or partial
how can increased backpressure damage renal tissue?
- increased pressure in the renal pelvis & calices can obstruct blood flow to the medulla which can cause ischemic damage & necrosis
how long does it take for irreversible nephron damage to occur after complete obstruction?
- within a few days
how long can it take for recovery after obstruction?
- can take weeks
how does prolonged obstruction effect the ureters and renal pelvis??
- causes dilation = hydroureter & hydronephrosis
does pain occur with urinary obstruction? why?
- renal colic occurs due to distension of the bladder, ureter, or renal capsule
when is pain usually more severe with urinary obstructions>?
- in acute obstructions
describe the effect of urinary obstruction on GI
- can cause disruption of visceral innervation
= can impair GI mobility
= abdominal distension & paralytic ileus
why is early treatment & diagnosis of urinary obstruction important?
- failure to restore the urinary flow can result in permanent renal damage
what can be bilateral obstruction result in?
- can result in renal failure
what is BPH
- benign prostate hyperplasia
- nonmalignant growth of the prostate
what is the cause of BPH? what contributes to it?
- cause unknown
- age & hormonal factors play a role
what specifically increases during BPH
- increase cell number
- not cell size (which is hypertrophy)
the normal prostate contains…(2)
- epithelial & smooth muscle cells
describe the role os testosterone in the maintenance of normal prostate size
- acts to produce protein growth factors (FGF, IGF) which help maintain the normal size
describe testosterone & estrogen as the male ages, and how this effects the prostate
- testosterone decreases while serum estrogen rises
- estrogen increases the number of testosterone receptors & increase prostate sensitivity
what type of receptors does prostate smooth muscle contain? what does this cause?
- contains alpha 1 receptors that stimulate them to contract
what 2 things are responsible for the manifestations of BPH
- obstruction to urine outflow
- bladder dysfunction
what are the 2 categories of BPH symptoms?
- irritative
- obstructive
what causes irritative symptoms in BPH
- bladder hypertrophy & dystrophy
what are irritative symptoms in BPH
- frequency
- urgnecy
- nocturia
what causes obstructive symptoms in BPH
- narrowing of the bladder neck & urethra
what is included in obstructive symptoms of BPH? (5)
- difficulty initiating urination
- decreased urinary flow (both force & caliber)
- intermittency
- hesitancy
- dribbling
what are 4 complications of BPH? what causes them?
- UTIs
- hematuria
- post-renal azotemia
- chronic renal failure
from bilateral hydroureter & hydronephrosis
what is used to reveal enlargement of the prostate? how well does this correlate with symptoms
- digital rectal exam
- does not correlate well w symptoms
what 2 other things do digital rectal exams reveal during BPH ?
- bladder distension & hypertrophy
list treatment for BPH (4)
- alpha-1 blockers
- androgen blockade
- prostate stents
- surgery
describe how alpha-1 blockers are effective in tx of BPH
- as noted earlier, alpha 1 receptors are found in the sm. m of the prostate to stimulate contraction
- alpha 1 blockers causes the sm. m to relax, which can make urine flow better & take tension off
describe how androgen blockade is effective in tx of BPH?
- blocks testosterone production
what is a prostate stent?
- a stent used to keep the male urethra open & allow passage of urine during BPH
what is the cause of prostate cancer? what plays a role (2)
- unknown
- enviro & genetic factors play a role
what are risk factors for prostate cancer (6)
- first or second degree-relative woth prostate cancer = 8x the risk
- over age 50 but occurs earlier in men of African descent
- testosterone
- dietary fat & red meat
- obesity & inactivity
- prostatitis
why is it believed that testosterone is a risk factor for prostate cancer?
- men who have been castrated do not develop prostate cancer
is BPH or infectious disease linked to prostate cancer?
- no
what are manifestations of prostate cancer (3)
- most are asymptomtic
- depending on size of tumour, may be changes in urination similar to BPH
- production of a protein called prostate-specific antigen
what is prostate specific antigen (PSA)
- function unknown
- but it is a protein that becomes elevated in the serum during prostate disease (cancer, BPH, prostatitis)
why is screening for prostate cancer so important?
- bc most cases are asymptomatic
list common screening tests for prostate cancer
- serum PSA
- rectal exam
- ultrasound
what can a rectal exam detect during screening on prostate cancer?
- hard nodular tumours
what can an ultrasound detect during screening for prostate cancer?
- can detect small tumours, as small as 5 mm
how is the diagnosis of prostate cancer confirmed?
- prostate biopsy
list 3 treatments for prostate cancer?
- surgery
- radiotherapy
- androgen-deprivation therapy
what are 2 types of hereditary renal disease
- polycystic kidney disease
- medullary cystic disease
what is polycystic kidney disease
- A genetic disorder in which numerous fluid-filled cysts develop in the kidney.
= increased size of kidney
list various metabolic & CT disease processes that have an effect on renal function
- diabetic nephropathy
- gout
- amyloidosis
- systemic lupus erythematosus
- systemic sclerosis (scleroderma)
how does gout effect renal function
- causes excess uric acid
