urological disorders

Question 1

what are normal functions of the kidney

Answer 1

• filtration (removal of waste and keeping essentials in blood)
• control salt and water balance
• control of acid/base balance
• hormone (EPO production)
• vitamin D - 1 alpha hydroxylation of vitamin D

Question 2

what are features of kidney dysfunction

Answer 2

• filtration failure (accumulation of waste substance, haematuria, proteinuria, low serum protein inc albumin in blood)
• hypertension, water retention (sometimes dehydration because unable to make concentrated urine)
• metabolic acidosis
• anaemia
• vitamin D deficiency (and secondary hyperparathyroidism)

Question 3

what are some inflammatory urological disorders

Answer 3

• infection including cystitis
• non infective causes : metabolic - including diabetic nephropathy, immunological - nephritic syndrome, nephrotic syndrome

Question 4

what are some obstructive urological disorders

Answer 4

• stones

- benign prostatic hypertrophy

Question 5

what are some developmental/genetic urological disorders

Answer 5

polycystic kidneys

horseshoe kidney

Question 6

what are 4 ways to detect kidney disease

Answer 6

1) raised conc of waste substances
2) presence of blood in urine
3) low blood pressure/high
4) abnormal hormone profile

Question 7

explain what having a raised conc of waste substances shows

Answer 7

raised conc of waste substances in the blood
reduction in GFR > accumulation of waste in blood
CLINICAL test = measure serum concentrations of urea and creatinine

Question 8

explain what the presence of blood in the urine shows

Answer 8

may be due to damaged glomeruli (leaking from cells into the urine) or bleeding due to structural problems - tumours, polycystic kidneys
CLINICAL tests = urine dipstick or microscopy of urine

Question 9

why is blood pressure low in patients who may have a urological disorder

Answer 9

normally blood pressure is often high due to salt and water retention in patients
some have low due to dehydration or have low in vascular volume because they are unable to make concentrated urine or losing too much sodium in urine or dehydration due to vomiting
may be more obvious in standing position (postural hypotension)

Question 10

explain what having an abnormal hormone profile means

Answer 10

reduction of synthesis in erythropoietin (result in anaemia - detected in reduced conc of Hb in FBC) 
secondary hyperparathyroidism (increased PTH as a secondary response to vit D deficiency - high conc of PTH can be measured in peripheral blood in presence of low or normal serum calcium, high or normal serum phosphate, routine vit D - blood test does not detect 1,25 vit D conc)

Question 11

what are some possible locations for an infection

Answer 11

bladder - cystitis
kidney - pyelonephritis
the bladder kidney and ureter are connected

Question 12

what are some other contributing factors to infection/inflammatory conditions

Answer 12

obstruction
stones
prostatic hypertrophy

Question 13

what are some potential pathogens

Answer 13

bacteria = most common
virus = immunocompromised patients
fungal = immunocompromised patients

Question 14

how do we make the diagnosis for a UTI

Answer 14

urinary tract infection
history
physical examination
urine dipstick
urine microscopy, culture and sensitivity

Question 15

what are some investigations that need to take place in case of a UTI

Answer 15

urine dipstick
2+ leukocytes
\+ nitrate
trace of blood
urine microscopy
culture and sensitivity 
(blood tests eg renal profile : electrolyte, urea and creatinine)

Question 16

what are treatments for UTI

Answer 16

antibiotics (depend on severity, most common bacteria in local area, modified when sensitivity from culture is available)
some need to be treated as inpatient (severe)
pain control
supportive treatments - hydration
consider imaging

Question 17

how can the immune system damage the kidney

Answer 17

antibody
inflammatory cells (neutrophils, monocytes/macrophages, T cells) - recruitment and further inflammation

Question 18

what are some clinical presentations of immunologically caused inflammatory conditions of the kidney

Answer 18

nephritic syndrome
proteinuria
nephrotic syndrome
glomerulonephritis (inflammation of the microscopic filtering units of the kidney)

Question 19

what is the pattern for organ involvement of kidney inflammatory conditions

Answer 19

kidney only
kidney and lung
multiple organs/tissues involved

Question 20

what is the diagnostic approach for suspected kidney disease

Answer 20

history and physical examination
urine test
blood test - including immunology tests
imaging - start with ultrasound
kidney biopsy

Question 21

what are some features of nephritic syndrome

Answer 21

haematuria - blood in urine
variable amount of proteinuria
may have hypertension, reduced urine output, increased urea and creatinine

Question 22

how do we make the diagnosis for nephritic syndrome

Answer 22

history and physical examination
urine dipstick and microscopy
urine protein : creatinine ratio
blood test - including immunology tests, kidney function
kidney biopsy

Question 23

what is nephritic syndrome : IgA nephropathy

Answer 23

most common primary glomerulonephritis world wide
esp in far east
deposition of IgA antibody in the kidney (detected by immunohistochemistry)
inflammation and scarring

Question 24

what is the disease for the inflammatory condition affecting both the kidney and lungs (organ specific) and what links the lung and kidney

Answer 24

anti-glomerular basement membrane (GBM) antibody mediated : Goodpasture’s disease
shared common antigen between the lung and kidney : a3chain of type 4 collagen

Question 25

what is the systemic disease for when multiple organ/tissue are involved

Answer 25

systemic lupus erythematosus (SLE) - autoantibodies : antinuclear factor, anti-dsDNA
vasculitis : antineutrophil cytoplasm antibody (ANCA)

Question 26

what is the pathogenesis for diabetic nephropathy

Answer 26

inflammation and fibrosis

Question 27

what are the risk factors for diabetic nephropathy

Answer 27

hypertension
poor diabetic control
smoking

Question 28

what are some clinical features of diabetic nephropathy

Answer 28

microalbuminuria - measure albumin : creatinine to measure albumin
proteinuria
association with other complications of diabetes mellitus : diabetic retinopathy/neuropathy

Question 29

what is the treatment and clinical management for diabetic nephropathy

Answer 29

optimised diabetic control
optimised treatment of hypertension
reduce proteinuria using ARB or ACEI
stop smoking
new treatments - SGLT2 inhibitor
transplantation (inc combined pancreas and kidney transplantation)
dialysis

Question 30

what are the features for nephrotic syndrome

Answer 30

peripheral oedema (face/ankle = most common)
severe proteinuria
low serum albumin
variable amount of microscopic haematuria
associated with hyperlipidaemia

Question 31

how do you make the diagnosis

Answer 31

history
physical examination
urine dipstick 
urine microscopy
urine protein : creatinine ratio
blood tests : kidney function, immunology test
kidney biopsy

Question 32

what are some causes for nephrotic syndrome

Answer 32

minimal change glomerulopathy
membranous nephropathy
focal segmental glomerulosclerosis
lupus nephritis
others

Question 33

treatment for nephrotic syndrome

Answer 33

immunotherapy (corticosteroid, cyclophosphamide, recently = tacrolimus, antibody therapy targeting B cell pathway)
diuretics - to reduce the peripheral oedema
prevention of thrombosis - anticoagulation (deep vein thrombosis and pulmonary embolism)

Question 34

what are some key features of minimal change glomerulopathy

Answer 34

most common in children, also affects other age groups
normal light microscopy
electron microscopy : podocyte effacement - abnormal flattened appearance
complication - high risk of thrombosis

Question 35

what are some possible locations for obstructive stone conditions

Answer 35

kidney
ureter
bladder

Question 36

what is the clinical presentation for someone with stones

Answer 36

pain (abdomen, back loin)
blood in urine
associated with urine infection
about 90% of kidney stones are radio opaque

Question 37

what is the treatment for patients with stones

Answer 37

supportive
pain control
hydration
specific treatment - depending on size and location of stones
availability of local expertise and fitness of patient for general anaesthetics

Question 38

what is shockwave lithotripsy

Answer 38

high energy ultrasound waves to break up large kidney stones into smaller ones

Question 39

what is ureteroscopy

Answer 39

through the urethra, bladder and ureter = scope

Question 40

what is percutaneous nephrolithotomy

Answer 40

small percutaneous incision - insertion of nephroscope, stone is removed (may need to be broken into smaller pieces)

Question 41

what are the types of polycystic kidney disease and what are their inhertiances

Answer 41

neonatal - autosomal recessive
adult onset - autosomal dominant
some patients without family history

Question 42

what are the consequences of polycystic kidneys

Answer 42

loss of kidney function
pain
bleeding into renal cysts
infection of renal cysts
asymptomatic in some patients

Question 43

what are some treatments for polycystic kidneys

Answer 43

new med - tolvaptan (a vasopressin receptor 2 antagonist) to slow down cyst formation
treat hypertension and infection
pain control
renal replacement therapy - transplantation, dialysis

Question 44

what is the developmental/genetic condition horseshoe kidney

Answer 44

kidneys are not separated and are slightly lower

imaging of abdomen/pelvis

Question 45

what are the consequences for horseshoe kidneys

Answer 45

increased risk of
obstruction
stone
infection