(31) Renal System Disease 1 Flashcards Preview

7. CP - Kidney and Urinary Tract Disease > (31) Renal System Disease 1 > Flashcards

Flashcards in (31) Renal System Disease 1 Deck (159)
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1

What are the functions of the kidney?

- eliminating metabolic waste products
- regulating fluid and electrolyte balance
- influencing acid-base balance
- production of some hormones

2

Which hormones does the kidney produce and what is their function?

Renin = fluid balance

Erythropoietin = stimulates red cell production

3

How many people develop acute renal failure?

Around 26,000 per year in England

4

What is the prognosis for patients with acute renal failure?

Most will recover but around 10,000 will need dialysis. For these patients, mortality is around 50%

5

How many people develop chronic renal failure?

Around 5,500 per year in England

Around 41,000 patients with CRF in England at any one time

6

What proportion of those with chronic renal failure need transplant or dialysis?

- 50% will have a transplant at some point
- 40% haemodialysis
- 10% peritoneal dialysis

7

How many transplants occur?

- 1020 living donor renal transplants
- 1667 deceased donor transplants
- 7000 patients still on the transplant waiting list

(in 2010-2011)

8

In what 6 ways can patients with renal disease present?

- acute renal failure
- nephrotic syndrome
- acute nephritis/nephritic syndrome
- chronic renal failure
- isolated haematuria
- isolated proteinuria

9

Patients with renal disease may present with acute renal failure. What is this?

- rapid rise in creatinine and urea
- generally unwell

(most common presentation)

10

Patients with renal disease may present with nephrotic syndrome. What is nephrotic syndrome?

- oedema + proteinuria + hypoalbuminaemia
- proteinuria >3g per 24 hours (mostly albumin)

Combination of these 3 things define nephrotic syndrome

11

Patients with renal disease may present with acute nephritis/nephritic syndrome. What is this?

Oedema + proteinuria + haematuria + renal failure

(proteinuria normally not as heavy as in nephrotic syndrome)

12

What defines chronic renal failure?

Slowly declining renal function

13

Which 5 different specialties are involved in diagnosing renal disease?

- renal physician
- biochemist
- pathologist
- urologist
- radiologist

14

What role does a renal physician play in diagnosis of renal disease?

- clinical history
- examination

15

What role does a biochemist play in diagnosis of renal disease?

Blood tests:
- urea
- creatine

Urine analysis:
- protein
- electrolytes

16

What role does a pathologist play in diagnosis of renal disease?

Renal biopsy:
- light microscopy (common)
- immunofluorescence (special test)
- electron microscopy (special test)

17

What role does a urologist play in diagnosis of renal disease?

Cytoscopy may be needed:
- obstruction
- some cases of haematuia

18

Why might a urologist be needed if haematuria is found?

Common symptom of bladder cancer

19

What role does a radiologist play in diagnosis of renal disease?

- obstruction
- kidney size
- structural abnormalities

20

What is the glomerulus?

A network of capillaries located at the beginning of a nephron in the kidney. It serves as the first stage in the filtering process of the blood carried out by the nephron in its formation of urine - then passes along tubules

Coiled capillary

21

What is the glomerulus surrounded by?

Bowman's capsule

22

What are the 2 main parts of the kidney?

- cortex (outside part)
- medulla (inside part)

23

What does the renal cortex contain?

Renal tubules and glomeruli

24

What are the 3 layers of the wall of the glomerul?

- podocyte foot processes
- basement membrane
- endothelial cells

(and then the capillary lumen)

25

What allows filtration at there glomerulus?

The podocyte foot processes, basement membrane and endothelial cells (endothelial cells have little pores) - damage to any of these can cause kidney disease

26

What are the different parts (in order) of the renal tubules in the nephron?

- Bowman's capsule
- proximal convoluted tubule (PCT)
- descending limb of Henle
- loop of Henle
- ascending limb of Henle
- distal convoluted tubule (DCT)
- collecting duct (leading to the renal pelvis)

27

What are the different parts (in order) of the blood flow through the nephron?

- branches of the renal artery
- afferent arteriole
- glomerulus (capillary bed)
- efferent arteriole
- vasa recta
- branches of renal vein

28

In which part of the kidney is the loop of Henle?

The renal medulla

29

What is the renal tubule doing?

Concentrating the urine, excreting and reabsorbing substances

30

What else would a disease of the glomerulus affect?

It will cut off the blood supply to the rest of the nephron (tubules)

31

What rare the immunological mechanisms of glomerular damage?

- circulating immune complexes deposit in glomerulus
- circulating antigens deposit in glomerulus
- antibodies to basement membrane or other components of glomerulus

32

What do all of the immunological mechanisms of glomerular damage lead to?

Damage to basement membrane

- complement activation
- neutrophil activation
- reactive oxygen species
- clotting factors

Glomerular damage

33

What are the non-immunological mechanisms of glomerular damage?

- injury to endothelium of vessels
- altered basement membrane due to hyperglycaemia in diabetes
- abnormal basement membrane or podocytes due to inherited disease
- deposition of abnormal proteins in the kidney e.g. amyloid

34

What are the 2 categories of glomerular damage mechanisms?

- immunological
- non-immunological

35

What are the 2 categories of tubular damage mechanisms?

- ischaemic
- toxic

36

What are the ischaemic mechanisms of tubular damage?

- hypotension
- damage to vessels within kidney
- glomerular damage

37

What do the ischaemic mechanisms of tubular damage lead to?

Reduced blood supply to tubules and therefore tubular damage

38

What are the toxic mechanisms of tubular damage?

- direct toxins
- hypersensitivity reactions eg. to drugs
- deposition of crystals in tubules eg. in gout
- deposition of abnormal proteins in tubules e.g. amyloid

39

The degree of damage to renal tubules correlates with what?

Renal function

40

What are the potential mechanisms of vascular damage?

- hypertension
- diabetes
- atheroma eg. renal artery stenosis
- thrombotic microangiopathy
- vasculitis

41

What is thrombotic microangiopathy?

- thrombi in capillaries and small arterioles
- due to endothelium damage
- endothelium damage due to bacterial toxins, drugs, abnormalities in complement or clotting systems etc

42

Give an example of a thrombotic microangiopathy

Haemolytic uraemic syndrome

43

What is vasculitis?

- acute or chronic inflammation of blood vessel walls
- obliteration of lumen by inflammation
- various different types
- adults and children affected

44

Give an example of a type of vasculitis

Wegener's granulomatosis

45

Damage to the vessels can also lead to damage to what?

- damage to the glomerulus
- damage to the tubule

(due to reduced blood flow)

46

Damage to the glomerulus can also lead to damage to what?

Damage to the tubule

47

Why are glomerular diseases so confusing?

- many names refer to microscopic appearances rather than actual disease
- some names are both diseases (when idiopathic) or just appearances (when secondary to a known cause)

48

Give some examples of glomerular diseases where the name is both a disease and also just a description of appearance

- membranous nephropathy (idiopathic disease vs. secondary to known cause)
- FSGS
- mesangiocapillary glomerulonephritis

49

Give some other examples of glomerular diseases (names of actual diseases)

- minimal change disease
- post-infective glomerulonephritis
- anti-GBM disease
- IgA nephropathy
- Henoch-Schonlein purpura
- lupus nephritis (in SLE)

50

Give some other examples of appearances of glomerular diseases (appearance on biopsy)

- proliferative glomerulonephritis
- crescentic glomerulonephritis
- thrombotic microangiopathy

51

What is nephrotic syndrome always due to?

Damage to the glomerulus

52

What does nephrotic syndrome consist of?

- oedema
- proteinuria (>3g in 24h)
- hypoalbuminaemia
- +/- hypertension
- +/- hyperlipidaemia

53

What are the complications associated with nephrotic syndrome?

- infection
- thrombosis

54

What are the common causes of nephrotic syndrome in adults?

- membranous nephropathy
- focal segmental glomerulosclerosis (FSGS)
- minimal change disease
- other causes eg. diabetes, lupus nephritis, amyloid

55

What is the most common cause of nephrotic syndrome in adults?

Membranous nephropathy

56

What is membranous nephropathy?

Thickening of the glomerular basement membrane
- primary glomerular disorder of unknown cause
- idiopathic

57

Who is usually affected by membranous nephropathy?

Usually adults 30-60

M>F

58

How many with membranous nephropathy will progress to end stage renal failure?

20-30%

59

What is focal segmental glomerulosclerosis?

Scar tissue formation in some of the glomeruli

60

What are the causes of focal segmental glomerulosclerosis?

Various possible causes
- most are idiopathic
- genetic
- heroin use
- HIV

61

Which gender is more commonly affected by FSGS?

M>F

62

What is seen in minimal change disease?

Biopsy is normal on light microscopy

(changes only seen on electron microscopy - glomerular damage)

63

Which gender more commonly gets minimal change disease?

M=F

64

What are the common cause of nephrotic syndrome in children?

- minimal change disease
- focal segmental glomerulosclerosis
- other causes are rare

65

What is the most common cause of nephrotic syndrome in children?

Minimal change disease

66

What are the causes of minimal change disease?

Cause is unknown the disease may occur after or be related to:
- allergic reactions
- NSAID use
- tumors
- vaccinations
- viral infection

67

What signs make up acute nephritis?

- oedema
- haematuria
- proteinuria
- acute renal failure

(another presentation of kidney disease)

68

What are the common causes of acute nephritis in adults?

- post-infective glomerulonephritis
- IgA nephropathy
- vasculitis
- lupus
- other forms of primary glomerulonephritis

69

Post-infective glomerulonephritis typically occurs after what?

A few weeks after Streptococcal throat infection

Most recover completely

70

What is the most common primary glomerular disease worldwide?

IgA nephropathy

71

What is the damage in IgA nephropathy caused by?

Abnormal deposits of IgA protein in the glomeruli

72

What is the most common sign of IgA nephropathy?

Haematuria (also swelling of feet)

Typically teenagers and young adults with haematuria

73

How many with IgA nephropathy will progress to renal failure?

20-50% will progress to renal failure over 20 years

74

What are the signs of vasculitis?

- fever
- generally unwell
- may have rash
- myalgia
- arthralgia

75

Who typically gets lupus?

Young women

(autoimmune disease with many manifestations)

76

What are the common causes of acute nephritis in children?

- post-infective glomerulonephritis
- IgA nephropathy
- Henoch-Schonlein purpura
- haemolytic-uraemic syndrome

77

What is Henoch-Schonlein purpura?

- specific type of IgA nephropathy
- M>F

78

What is the typical presentation of Henoch-Schonlein purpura?

Typically young boys/teenagers with
- arthralgia
- abdo pain
- rash
- haematuria
- acute renal failure

Most recover completely

79

What is haemolytic-uraemic syndrome characterised by?

- acute nephritis
- haemolysis
- thrombocytopaenia

80

Who typically gets haemolytic-uraemic syndrome?

Children with E. coli 0157 enteritis

81

What is the diagnosis of acute renal failure based on?

- anuria/oliguria
- raised creatinine
- raised urea

82

What is oliguria?

Production of abnormally small amounts of urine

83

What is the usual prognosis in acute renal failure?

Many patients will recover and have good renal function if they had previously healthy kidneys

Short term dialysis may be needed in some patients

84

What are the 3 categories of causes of acute renal failure?

- pre-renal (most common)
- renal
- post-renal

85

What do pre-renal causes mean?

Reduced blood flow to kidney (MOST COMMON)

86

What do renal causes mean?

Damage to kidney

87

What do post-renal causes mean?

Obstructed urinary tract

88

Give examples of pre-renal causes of acute renal failure

- severe dehydration
- hypotension eg. bleeding, septic shock, left ventricular failure

89

Give some examples of post-renal causes of acute renal failure

- tumours of urinary tract
- tumours in renal pelvis
- bladder stones
- prostatic enlargement

90

In which causes of acute renal failure is a renal biopsy useful?

Useful in renal causes.

Not helpful in pre- or post- renal causes

91

What will all biopsies show in acute renal failure?

ATN - acute tubular necrosis/injury/damage/acute kidney injury (ATI/ATD/AKI)

92

What are the causes of acute renal failure in adults?

- vasculitis
- acute interstitial nephritis/tubulointerstitial nephritis

93

What is acute interstitial nephritis/tubulointerstitial nephritis?

Tubular damage with inflammation, most commonly caused by drug reactions - most recover

94

What are the causes of acute renal failure in children?

- Henoch-Schonlein purpura
- haemolytic uraemic syndrome
- acute interstitial nephritis

95

What are the complications associated with acute renal failure?

- cardiac failure (fluid overload)
- arrhythmias (electrolyte imbalance)
- GI bleeding
- jaundice (hepatic venous congestion)
- infection, especially lung and urinary tract

96

What is the treatment for acute renal failure?

- short term dialysis may be needed
- treat the underlying cause

97

What is chronic renal failure defined by?

Permanently reduced GFR - reduced number of nephrons

98

What is stage 1 chronic renal failure?

kidney damage with normal or increased GFR (>90mL/min/1.73m2)

99

What is stage 2 chronic renal failure?

mild reduction in GFR (60-89mL/min/1.73m2)

100

What is stage 3 chronic renal failure?

moderate reduction in GFR (30-59mL/min/1.73m2)

101

What is stage 4 chronic renal failure?

severe reduction in GFR (15-29mL/min/1.73m2)

102

What is stage 5 chronic renal failure?

kidney failure (GFR

103

At what stage of chronic renal failure is treatment required and more problems start occurring?

Stages 4 and 5

104

What are the common causes of chronic renal failure in adults?

- diabetes
- glomerulonephritis
- reflux nephropathy

105

What is the commonest cause of chronic renal failure in this country?

Diabetes

106

What is reflux nephropathy?

Chronic reflux of urine up the ureter leading to repeated infections and scarring of the kidney

107

What are the common causes of chronic renal failure in children?

- developmental abnormalities/malformations
- reflux nephropathy
- glomerulonephritis

108

What does renal biopsy show in chronic renal failure?

Kidney shows severe scarring with loss of glomeruli and tubules

109

Why is a renal biopsy often unhelpful in established chronic renal failure?

Similar changes are seen in end-stage renal disease due to any cause - so hard to identify the cause

Most biopsies will look the same at this stage

110

What are the effects on the body of chronic renal failure?

- reduced excretion of water and electrolytes cause oedema and hypertension
- reduced excretion of toxic metabolites
- reduced production of erythropoietin leading to anaemia
- renal bone disease

111

What is the likely diagnosis for an elderly patient with acute renal failure?

- acute interstitial nephritis due to drug reactions
- myeloma

112

What is the likely diagnosis for a young male with haematuria and rash?

Henoch-Schonlein purpura

113

What is the likely diagnosis for a teenager/young adult with haematuria?

- post-infective glomerulonephritis
- IgA nephropathy

114

What is the likely diagnosis for an adult with acute renal failure, fever and myalgia?

Vasculitis

115

What is the likely diagnosis for a young woman with haematuria and facial rash?

Lupus

(butterfly rash)

116

What is the likely diagnosis for an adult with nephrotic syndrome?

Membranous nephropathy (most cases idiopathic)

117

What is the likely diagnosis for a child with nephrotic syndrome?

Minimal change disease

118

What tests may be need din isolated haematuria?

Cytoscopy and other urological investigating as bleeding may be from urinary tract tumours

119

What is cytoscopy?

Camera into the bladder

120

What are the likely renal causes of haematuria with normal renal function?

- IgA nephropathy
- thin basement membrane disease
- Alport type hereditary nephropathy

121

What is thin basement membrane disease?

- inherited condition causing abnormally thin basement membranes in the glomeruli
- if no other renal disease is present, kidney function will remain normal

122

What is Alport type hereditary nephropathy?

- inherited abnormalities of collagen type IV causing abnormal basement membrane in the glomerulus
- sometimes have eye and ear problems

123

What are the signs of Alport syndrome?

- renal failure
- +/- deafness
- +/- ocular problems

124

What is the genetic pattern in Alport syndrome?

May be autosomal or X-linked

125

What is isolated proteinuria defined by?

Proteinuria less than the nephrotic range, without haematuria, renal failure or oedema

126

Isolated proteinuria might be benign, due to what?

- postural
- related to pyrexia or exercise

127

Isolated proteinuria might be due to renal disease. What are the common causes in adults?

- FSGS
- diabetes
- lupus

128

Isolated proteinuria might be due to renal disease. What are the common causes in children?

- Henoch-Schonlein purpura
- FSGS

129

What causes renal artery stenosis?

Atheroma (most common)

or arterial dysplasia

130

What does renal artery stenosis lead to?

Ischaemia of the affected kidney - kidney left scarred and shrunken - reduced renal function due to loss of renal tissue

Also hypertension

131

What causes hypertension in renal artery stenosis?

Stenosis leads to activation of RAAS leading to hypertension

132

What is pyelonephritis?

Infection of the kidney

133

How can infection of the kidney (pyelonephritis) occur?

- via haematogenous spread
- via ascending route from bladder

134

What causes acute pyelonephritis?

- more common in women (ascending infection)
- instrumentation of urinary tract
- diabetics
- structural abnormalities or urinary tract

135

What are the complications associated with acute pyelonephritis?

- abscess formation

136

What are the causes of chronic pyelonephritis?

- obstruction or urinary tract
- reflux of urine up ureter
leads to scarring of kidney and can lead to renal failure

137

What are the complications associated with chronic pyelonephritis?

- scarring of kidney
- chronic renal failure

138

How can vasculitis affect the kidneys?

- affect glomerular vessels leading to clotting with obliteration of capillary lumens and destruction of glomerulus
- inflammation of larger arterioles within kidney leading to hypoxia of tubules

139

Vasculitis also often affects other vessels around the body leading to what symptoms?

- rash
- muscle pain
- joint pain

Can also have fever and weight loss due to the inflammation

140

On histology, what does bright pink in the glomerulus indicate?

Bright pink = fibrin - indicated thrombosis within glomerulus

May not be able to see capillary lumens

141

On histology, what do dark dots around an artery indicate?

Inflammatory cells surrounding artery which has fibrin in wall - indicating damage to wall

142

How does hypertension affect the kidneys?

- damages renal vessels leading to thickening of vessel wall and reduction in size of lumen
- produces chronic hypoxia which leads to loss of renal tubules and reduced renal function
- reduced blood flow activates RAAS which exacerbates hypertension

143

How is hypertension shown on renal biopsy?

Can see thickening of the walls of small arteries ad arterioles and a reduction in the size of the lumen

144

What is the commonest cause of end-stage renal failure in Europe and the USA?

Diabetes

145

What about diabetes causes diabetic nephropathy?

Hyperglycaemia

146

How does diabetes cause damage to the kidneys?

- hyperglycaemia damages the basement membrane
- basemement membrane becomes thicker and the glomerulus produces excess extacellular matrix with forms nodules
- diabetes also damages small vessels leading to ischaemia and damage to renal tubules

147

How is diabetic nephropathy seen on renal biopsy/histology?

Can see nodules within the glomerulus

148

How does myeloma cause damage to the kidneys?

- tumour of plasma cells producing immunoglobins
- excess immunoglobins deposit in tubules
- tubules damaged
- inflammation and fibrosis of kidney
- loss of tubules = loss of renal function

149

Is renal impairment due to myeloma reversible?

No, usually irreversible

150

How does a kidney affected by myeloma look on histology?

- immunoglobin deposits in artery walls (smooth, pink, thickened walls)
- tubules destroyed by immunoglobin deposits (bright pink)
- fibrosis (scarring)
- residual tubules

151

What is the function of mesangial cells?

Involved in maintaining structure of glomerulus

remove trapped residues and aggregated protein from the basement membrane thus keeping the filter free of debris

152

What is the main sign of membranous nephropathy on histology?

Thickened glomerular capillary walls

153

What is the main sign of FSGS on histology?

Most of the glomerulus is normal, one area appears solid with loss of capillary lumens

154

What can post-streptococcal glomerulonephritis and IgA nephropathy both show on histology?

Glomeruli which have an increased number of cells and loss of capillary lumens

155

What is seen on histology in acute tubulointerstitial nephritis?

Many lymphocytes and other inflammatory cells (dark dots) present between renal tubules

156

What is a crescent (seen on kidney biopsy)?

Cells proliferating within Bowman's capsule as a response to severe glomerular injury

Crescent surrounds the glomerulus

157

What conditions may crescents be seen in?

Any condition where there is severe glomerular injury
- anti-GBM disease
- severe vasculitis
- severe-infective glomerulonephritis
etc

158

What is seen on histology in acute tubular necrosis/injury?

Loss of nuclei from tubular cells (cell death)

159

What is seen on histology in chronic kidney damage?

Tubular atrophy, shrunken tubules surrounded by interstitial fibrosis