Pathology Flashcards
What is diabetic nephropathy?
Microvascular complication of diabetes
1. Glomerular + tubular Hypertrophy- Inc GFR
2. Glomerular Hyperfiltration (mesangial Hyperexpansion)
3. Microalbuminuria
4. Clinical Nephropathy (Dec GFR, proteinuria)
= end stage renal failure
Why can diabetic nephropathy be difficult to pick up via GFR?
GFR actually increases in early stages of diabetic nephropathy due to hypertrophy of glomerular + tubular cells (+mesangial cells at a later stage)
+ GRF dysfunction is hard to detect as an issue till drops to below 60%
What is the cardiac link with chronic kidney disease?
LVH/ Renal vascular disease
Investigate- Abdominal Aortic Angiogram (look for stenosis)
Atheromebolic Disease- Eosinophilia + peripheral skin lesion (purpuric rash) common in Its on warfrin
What is vasculitis?
Inflammed reaction in wall of any blood vessel- can be in single/ multiple organs and defined by size of vessel involved
Aortic/Large- Takaysu, Giant Cell
Medium- Polyartritis nodosa, kawasaki disease
Small- granulomatous polyarteritis (wegners), microscopic polyarteritis (pulmonary), eosioniphilic polyarteritis
What is granulomatous polyarteritis (wegners)?
Small vessel inflammatory vasculitis of the respiratory tract
Upper- epistaxis, sinusitis, deafness, nasal deformity
Lower- cough, dyspnoea, haemoptysis, pulmonary haemorrhage
+ pericarditis, scleritis, myalgia
Vasculitis rash
How do you diagnose and treat vasculitis?
Urine- blood, protein, urea/ creatinine
Bloods- Inc CRP, Inc AlkPh (Biliary,liver)
Hyperglobulaemias, +ve ANCA(PANCA microscopio, CANCAwegners)
Renal Biopsy
Treats- steroids + immunosuppressants
What is the link between renal disease and infective endocarditis?
Bacterial/ Fungal Infection of Cardiac Valves (step viridians, staph aureus, enterococci, HIV-IVdrugs) the immune complexes stick in kidneys - glomerulonephritis + small cell vasculitis
Do echo, CXR (cardiomegaly) and 3 sets of blood for infection
Give vancomycin + gentamicin + rifampicin (general) till know cause
Strep- penicillin/ vancomycin (if allergic)
Staph- flucoxacilin/ flucoxaciliin + rifampicin + gentamicin (if prosthetic)
Treat Endocarditis will treat renal disease
What stops urine coming up from the bladder back into the kidney?
Pressure of urine in bladder and muscle of bladder and ureters stops urine flowing back up
Where are the 3 constrictions of the ureter? Why are these clinically important?
Pelvic-Ureteric Junction
Crossing of ureter with common iliac artery
Vesico-ureteric junction- into bladder
What angle do ureters enter the bladder at?
Acute angle
Where is the urinary tract sterile from?
Kidney- internal urethral orifice (upper urthera)
How do you take a urinary specimen? What must you be careful of?
Void- stop midstream- disguard-take more= Mid Stream Specimen of Urine (MSSU) stop contamination via bacteria from terminal urethera (gut +skin)
How do you diagnose a urinary tract infection?
MSSU bacterial count of >104 + symptoms (fever, tachycardia, suprapubic pain/tenderness, inc frequency and urgency, dysuria)
What can a UTI lead to if infection spreads?
Uretheritis- Urethra
Bladder- Cystitis
Ureterritis- ureters
Acute Pylonephritis- Kidney (if recurrent/ prolonged- chronic pyelonephritis)
What predisposed someone to a UTI?
- Urine Stasis- obstruction (vesicoureteric-congential, benign prostatic hyperplasia, uterine prolapse, tumours/ calculi)
- Pushing bacteria up urethra- sex (uncomplicated UTI- short urethra, pregnancy), elderly, poor voiding (MS, stroke)
- General- catheterisation, ureteric stent, diabetes, abnormal tract, oestrogen deficiency, bowel-bladder fistula, immunosuppression/steroids
What are the signs and symptoms of a UTI?
Flank pain Dysuria (painful micturition) Smelly. cloudy Urine Suprapubic Pain (affecting bladder) Kids- failure to thrive, fever, nausea, vomit, not eating (reflux nephropathy- cystogram)
How do you investigate and treat a UTI?
Investigate- MSSU + microscopy (>104), urinalysis (blood, leukocytes, protein)
US (kids + men)
Treat- Fluids, Antibiotics (amoxycillin) if severe use IV and advice on predisposing factors (eg./ void before and after sex)
What are the complications of UTI?
Actue- sepsis
Chronic- chronic pylenephritis= hypertension + Chronic renal failure
Bladder- squamous cell carcinoma, retension
What is nephrolithiasis? What is the most common type?
Kidney stones- calcium most common component- calcium oxalate most common stone- best seen on x-ray
Triple Phosphate- Infective via chronic infection, cant see these/ gallstones on X-ray
A Pt presents with-
Renal Pain- fixed in loin
Haematuria
Repeated UTI
Loin Tenderness (pain radiates to genitals)
Pyrexia
What is the most likely diagnosis? How would you investigate this?
Nephrolithiasis (kidney stones)
Constant pain with mild fluctuations (not colic unless in hollow organ)
Investigate via
Bloods- FBC, creatinine, calcium, phosphate
MSSU + microscopy
CT KUB best
KUB xray- calcium stones
(US can miss stones so complimentary use)
How do you treat nephrolithiasis?
Kidney Stone- Surgical
- Extracorporeal shock wave lithotripsy (<2cm sized stones, cant give if pregnant/ anticoagulants)
- Percutaneous Nephrolithotomy, open surgery (rare- simple/ partial/ total nephrectomy least reassurance rate)
- Open ureterolithotomy- flexible uretero-renal scope + stent
- Endoscopic- is severe
A Pt presents with Supra pubic/ groin/ penile pain Sudden interrupted stream persistent Uti What is your most likely clinical diagnosis and how do you treat this?
Bladder stones
Treat via transurethral cystolitholapaxy- camera, US waves to crush
What is AKI? How is it staged?
Rapid loss of glomerular filtration and tubular function over hours- days (lose fluid balance, electrolyte homeostasis, acidosis,
AKI 1- urine output <0.5mL over 6-12hrs
AKI 2- urine output <0.5 over >12hrs
AKI 3- urine output <0.3mL >24hrs/ anuria for 12hrs
What are the main causes of acute kidney injury?
- Pre-Renal- Blood flow to kidney eg./ haemorrhage, dehydration, vomiting, diarrhoea, diuretics, laxatives, hypotension, congestive cardiac failure, liver failure, arterial occlusion, NSAIDS, Ace Inhibitors, OCP, Intrinsic (damage to renal parenchyma), acute tubular necrosis (drugs, radio contrast), acute glomerulonephritis (autoimmune, drugs, infection), acute intersitiual nephritis, vasculitis, Inc BP.
- Post-Renal- urine obstruction, intraluminal , intramural (stricture, malignancy, prostatic disease), extramural (retroperitoneal fibrosis, malignancy)
How does hypotension/ hypovolemia tie into AKI?
Results in acute tubular necrosis kidney is susceptible to hypo perfusion due to heterogeneity of blood supply
How are myelomas involved in renal disease?
Monoclonal proliferation of plasma cells
presents as anemia, back pain, chord compression, hypercalcaemia- diagnose via bone marrow aspiration, urinary bence jones protein, serum paraprotein
How would you investigate a suspected case of AKI?
Urine- dipstix for blood + protein, PCR (albumin- creatinine ratio)
Renal USS
Renal Biopsy
How do you prevent an onset of AKI from risk groups?
Risk Groups- previous, elderly, heart failure, liver disease, DM, vascular disease
S-sepsis 6 treatment
T-Toxins-gentamycin, NSAIDS, IV contrast
O- Optimise Bp and volume (fluids + remove diuretic meds)
P- Prevent harm- u+e, medication and fluid balance
How do you treat sepsis?
Sepsis 6
- Blood Cultures
- Urine + U+E monitoring
- Fluids
- Antibiotics
- Lactate Levels
- 02 stats
What are the 5Rs for IV prescribing?
Resus Routine Maintenance Replacement Redistribution Reassesment
What are the stages of chronic kidney disease?
1- GFR >90 some damage 2- GFR 60-89 3- GFR A(45-59), B (30-44) 4- 15-29 5- <15 (dialysis)
Why is creatine not a good marker of kidney function?
Creatinine will be in normal range until 60% of total kidney function is lost
Also affected by muscle mass (more muscle mass= higher serum creatinine)
What would you find in urine is GBM is damaged?
WBC< RBC, high molecular weight proteins (globulin, albumin) eg./ good pastures disease
What is CKD?
Presence of kidney damage (abnormal blood, urine, xray findings) OR GFR <60ml/min
caused by Diabetes, glomerulonephritis (IgA, vasculitis), hypertension, renovascular disease (eg./ renal artery stenosis, atherosclerosis) and all causes of acute over 3months
A Pt presents with- Jaundice Hypertension Polyuria, oliguria, nocturne Peripheral oedema Vomit, anorexia, ureic odour congnitive dysfunction. What is your most likely diagnosis? How do you confirm this and how would you go about treating it?
Chronic Kidney Disease
Bloods- anemia, glucose, LFTs, bicarb, creatine kinase
Urine dipstick- blood and proteins
Us kidney
Biopsy (if large/ unclear diagnosis)
Treat-
Cause- obstruction/ drugs/ Ca/ glucose control
BP control- ACE Inhibitors, Angiotensin Receptor Blockers,
statins (CV risk of atheroma) + anticoagulants
anemia (b12, folate, iron)
acidosis- sodium bicarb
loop diuretics (oedema)
What do you have to be careful of when treating a Pt with acidosis?
If they are hypertensive as sodium bicarbonate increases blood volume
this can occur in chronic kidney injury due to acidosis (result of kidney failure) and hypertension (causing kidney failure)