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ESA 3- Urinary System > Pathology Of The Urinary System > Flashcards

Pathology Of The Urinary System Flashcards

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1
Q

What does the site of glomerular injury determine?

A

A patients clinical presentation

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2
Q

What are the types of glomerular injury?

A

Primary

Secondary

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3
Q

What is a primary glomerular injury?

A

Just affecting the glomerulus

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4
Q

What is a secondary glomerular injury?

A

Systemic injury that has in turn damaged the glomerulus

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5
Q

What are the sites of glomerular injury?

A

Subepithelial
Within glomerular basement membrane
Subendothelial
Mesangial/paramesangial

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6
Q

Where is considered to be sub-epithelial when considering glomerular injury?

A

Anything that affects podocytes/podocyte side of glomerular basement membrane

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7
Q

Where is considered to be subendothelial when considering glomerular injury?

A

Inside the basement membrane

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8
Q

Where is mesangial/paramesagnial tissue found?

A

Supporting the capillary loop

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9
Q

What are the potential pathologies of the glomerulus?

A

Fluid can block

Fluid can leak

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10
Q

What can cause the glomerular filter to block?

A

Renal failure

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11
Q

What are the main symptoms of renal failure causing filter blockage?

A

Hypertensive

Haematuria

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12
Q

What conditions are caused by the leaking of the glomerular filter?

A

Proteinuria

Haemoturia

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13
Q

What protein is found in the urine in proteinuria resulting from the leakage of the glomerular filter?

A

Albumin

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14
Q

Do proteinuria and haemoturia occur separately or together as a result of glomerular filter leakage?

A

Can be either, depending on damage

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15
Q

What is proteinuria?

A

The presence of excess serum proteins in urine

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16
Q

What is the diagnostic criteria of proteinuria?

A

<3.5g filtered every 24 hours

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17
Q

What is presence of proteins in urine due to?

A

Podocyte damage

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18
Q

How does podocyte damage lead to proteinuria?

A

The widening of the fenestration slits causing protein to be leaked when it would normally not be filtered.

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19
Q

What can proteinuria be said to be?

A

A ‘less severe’ nephrotic syndrome

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20
Q

What is nephrotic syndrome?

A

When over 3.5g of proteins is filtered in 24 hours

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21
Q

What is the result of nephrotic syndrome?

A

Generalised oedema

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22
Q

Why does nephrotic syndrome cause generalised oedema?

A

As a lot of protein is being filtered, oncotic pressure is reduced

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23
Q

What is the most likely site of injury in nephrotic syndrome?

A

Podocyte/subepithelial injury

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24
Q

What are the common primary causes of proteinuria/nephrotic syndrome?

A

Minimal change glomerulonephritis
Focal segmental glomerulosclerosis
Membranous glomerulonephritis

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25
What are the common secondary causes of proteinuria/nephrotic syndrome?
Diabetes mellitus | Amyloidosis
26
Why can diabetes mellitus lead to proteinuria/nephrotic syndrome?
Microvascular complications affect kidneys
27
When does minimal change glomerulonephritis present?
In childhood/adolesence
28
What happens to the incidence of minimal change glomerulonephritis (MCG) with age?
It reduces with increasing age
29
What does MCG cause?
Heavy proteinuria or nephrotic syndrome
30
What is the treatment for MCG?
Usually responds well to steriods
31
What is the problem with MCG treatment?
May reoccur once weaned off treatment
32
Does MCG progress to renal failure?
Not usually- normally purely protein loss from kidney
33
Why is MCG named as such?
Because when looking at the glomeruli under a light microscope, they appear to be completely normal
34
How can the changes in MCG be seen?
Under an electron microscope
35
What can be seen under a electron microscope with MCG?
Damage to podocytes is evident- widening fenestration slits, which allow protein to lead through
36
What is the pathogenesis of MCG?
Unknown
37
Why is FSGS considered to be focal?
It involves less than 50% of glomeruli on light microscopy
38
Why is FSGS considered to be segmental?
It involves part of the glomerular tuft
39
What is the fibrosis aspect of FSGS?
Scarring
40
When does FSGS present?
In adulthood
41
When does FSGS present?
Adulthood
42
How does the FSGS response to steroids differ from that of MCG?
It is less responsive to steroids
43
Why is protein present in the urine with FSGS?
Podocytes undergo damage and subsequent scarring, so protein is lost in urine
44
What is responsible for podocyte damage in FSGS?
A circulating factor
45
What evidence is there for FSGS being caused by a circulating factor?
In transplanted kidneys, the same damage occurs
46
Can minimal change FSGS progress to renal failure?
Yes
47
What is the pathogenesis of FSGS?
Unknown
48
What is the most common cause of nephrotic syndrome in adults?
Membranous glomerulonephritis (MG)
49
What does MG result from?
Immune complex deposits in the sub-epithelial space
50
What is the basis of MG?
Probably an autoimmune basis, however also evidence that it may be secondary
51
What is the autoimmune basis of MG likely to be?
Autoantibody to podocytes
52
What is the evidence that MG may be a secondary disease?
It is associated with other conditions
53
What other conditions that MG is associated with?
Particular malignancies, e.g. Lymphoma
54
What rule does MG follow?
The rule of thirds
55
What is the rule of thirds with MG?
1/3 just get better 1/3 'grumble along' with proteinuria but are fine 1/3 progress to renal failure
56
What is shown on the micrograph of MG?
Capillary loop far too thick | Basement membrane looks specky
57
What is nephritic syndrome?
Renal failure due to blocking of the filter
58
What is the most common glomerular nephropathy'?
IgA nephropathy
59
When can IgA nephopathy occur?
At any age
60
What is IgA nephropathy characterised by?
Deposition of IgA antibody in the glomerulus
61
How does IgA nephropathy classically present?
With visible/invisible haematuria
62
What has IgA nephropathy been shown to have a relationship with?
Mucosal infections
63
Why does IgA nephropathy have a relationship with mucosal infections?
IgA protects mucosal surfaces
64
In what respects is IgA nephropathy variable?
In its histological features and course
65
How does the course of IgA nephropathy vary?
Some, but not all, patients have proteinuria, and a significant proportion of patients, but not all, progress to renal failure
66
Why does variation in the course of IgA nephropathy occur?
Unknown
67
What histological features may occur in IgA nephropathy?
Mesangial proliferation | Scarring
68
What is the treatment for IgA nephropathy?
No effective treatment
69
What are the hereditary nephropathies?
Thin GBM nephropathy | Alport syndrome
70
What is the problem with distinguishing between the hereditary nephropathies?
The two are not completely distinct, with a grey area between them
71
What are the features of thin GBM nephropathy?
``` Nephropathy Benign familial nephropathy Isolated haemoturia Thin GBM Benign course ```
72
What are the features of Alport syndrome?
``` X linked Abnormal collagen IV Associated with deafness Abnormal appearing GBM Progresses to renal failure ```
73
What renal symptoms can diabetes mellitus lead to?
Progressive proteinuria Progressive renal failure Mesangial scleorosis
74
What kind of damage to the kidney occurs in diabetes mellitus?
Microvascular (damages glomerulus directly)
75
What does mesangial sclerosis in diabetes mellitus lead to?
Nodules
76
What happens to the basement membrane of the glomerulus in diabetes mellitus?
It thickens to 4-5x normal
77
How common is Goodpasture syndrome?
Relatively uncommon
78
Why is Goodpasture syndrome clinically important?
It is very rapidly progressing Glomerular Nephritis
79
What is Goodpasture syndrome bought about by?
An autoantibody to collagen IV in basement membranes
80
Where does Goodpasture syndrome affect?
Only the kidney
81
Why does Goodpasture syndrome only affect the kidney?
Unknown
82
How is Goodpasture syndrome treated?
Immunosuppresion | Plasmophoresis
83
What is the limitation of the treatment of Goodpasture syndrome?
It can only be treated if caught early
84
What is Goodpastures syndrome characterised by?
IgG deposition, but no extracellular matrix deposit
85
What is vasculitis?
Inflammation of the blood vessels
86
Why does vasculitis affect the kidney?
Because its highly vascularised
87
What happens in vasculitis?
Blood vessels are attacked directly in the glomerulus by anti-neutrophil cytoplasmic antibody (ANCA)
88
Is vasculitis treatable?
Yes, if caught early
89
What are the mechanisms responsible for the different expression of immune complex mediated disease?
Subepithelial deposits | Mesangial deposits
90
Give an example of an immune complex mediated disease that leads to subepithelial deposits
Membranous glomerulonephritis
91
What happens in the subepithelial deposits mechanism of immune complex mediated disease?
Antigen abnormally recognised on podocytes, circulating IgG binds to it, forming immune complexes in the glomerulus
92
Are circulating immune complexes causing damage in subepithelial deposits?
No
93
Give an example of an immune complex mediated disease that leads to mesangial deposits
IgA nephropathy
94
What happens in the mesangial deposits mechanism of immune complex mediated disease?
Immune complexes can be deposited in the mesangium, as there is no podocytes or basement membrane to act as a barrier
95
What is the most common cancer in men in the UK?
Prostate cancer
96
Is prostate cancer the most common cause of death from cancer in men?
No, it is the second most common
97
What happens to most men who are diagnosed with prostate cancer?
They are more likely to die with it than of it
98
What are the risk factors of prostate cancer?
Age Family History Race
99
What is the relationship between prostate cancer and age?
There is a correlation with increasing age
100
Who is prostate cancer uncommon in?
Men younger than 50
101
What is the relationship between family history and prostate cancer?
4x increased risk
102
What is considered to be a family history of prostate cancer when considering risk?
If one 1st degree relative is diagnosed with prostate cancer before age 60
103
Why is family history only considered when a family member is diagnosed before age 60?
Any diagnosis after 60 was probably age related
104
How does the incidence of prostate cancer differ between the races?
Incidence in asian < caucasian < afro-caribbean
105
What is the usual clinical presentation of prostate cancer?
Vast majority asymptomatic Urinary symptoms Bone pain
106
What urinary symptoms are usually seen in prostate cancer?
Benign enlargement of the prostate Bladder over activity +/- CaP
107
When is bone pain seen in prostate cancer?
Advanced metastatic prostate cancer
108
What is an unusual clinical presentation of prostate cancer?
Haematuria
109
When is haematuria seen in prostate cancer?
In advanced prostate cancer
110
What is the first stage in diagnosis of prostate cancer?
A digital rectal examination (DRE) and serum PSA (prostate specific antigen) is used to assess wether or not a biopsy of the prostate is necessary
111
What happens if a biopsy of the prostate is necessary?
It is carried out via a TRUS (transrectal ultrasound) guided biopsy of prostate
112
How are lower urinary tract symptoms (LUTS) caused by prostate cancer treated?
Transurethral resection of prostate
113
What factors influence treatment decisions in prostate cancer?
``` Age Digital rectal exam PSA level Biopsies MRI scan and bone scan ```
114
What can be determined from the digital rectal exam with prostate cancer?
The stage
115
What are the potential stages of prostate cancer?
Localised (T1/2) Locally advanced (T3) Advanced (T4)
116
What is used to judge biopsies in prostate cancer?
Gleason Grade
117
What is being looked for on a MRI scan and bone scan with prostate cancer?
Nodal/visceral metastases
118
How are established prostate cancers treated?
Surveillance Radical prostatectomy Radiotherapy
119
When is surveillance appropriate in treatment of established prostate cancers?
If the cancer is low risk
120
How can it be determined that a cancer is low risk?
The Gleason score is quite low
121
Why may surveillance be more appropriate than treatment in established prostate cancers?
Treatment may do more harm than good
122
How is an radical prostatectomy conducted?
Open Laparoscopic Robotic
123
What form of radiotherapy is conducted to treat established prostate cancers?
External beam or low dose brachytherapy (implanted beads)
124
How are developmental prostate cancers treated?
High intensity focused ultrasound (HIFU) Primary cryotherapy Brachytherapy
125
What happens in primary cryotherapy?
Freeze the prostate
126
What kind of brachytherapy is given in developmental prostate cancer?
High dose
127
How is metastatic prostate cancer treated?
Hormones | Pallitation
128
What are the hormone based treatments for metastatic prostate cancer?
Surgical castration | Medical castration
129
How is medical castration performed?
LHRH agnoists
130
What are the palliation based treatments for metastatic prostate cancer?
Single-dose radiotherapy Bisphosphonates Chemotherapy
131
How is locally advanced prostate cancer treated?
Surveillance Hormones Hormones and radiotherapy
132
How is haematuria classified?
Visible | Non-visible
133
What is the change of malignancy on investigation if haemoturia is visible?
20%
134
What malignancies might cause haemoturia?
Kidney | Ureter
135
Is non-visible haemoturia symptomatic?
Can be symptomatic or asymptomatic
136
How is non-visible haematuria detected?
Via microscopy or urine dipstick
137
How is haematuria detected using urine dipstick?
Perioxidation of haem
138
What are the urological differential diagnoses of haemoturia?
``` Cancer Stones Infection Inflammation Benign prostatic hyperplasia (large) Nephrological (glomerular) ```
139
What cancers can can haematuria?
Renal cell carcinoma Upper tract transition cell carcinoma Bladder cancer Advanced prostate cancer
140
What needs to be asked about when taking a history for haematuria?
``` Smoking Occupation Painful or painless Other lower urinary tract symptoms Family history ```
141
What should be looked for on examination with haematuria?
``` BP Abdominal mass Variocele Leg swelling Assess prostate by DRE ```
142
What is a varicocele?
Collection of veins in the scrotum
143
What should be looked for on prostate assessment?
Size | Texture
144
What investigations should be done with haematuria?
Urine culture and cytology (abnormal cells) FBC Ultrasound Flexible cystoscopy
145
How common is bladder cancer, compared to other cancers, in the UK?
7th most common cancer
146
What is happening to the incidence of bladder cancer?
Decreasing
147
What is the male to female ratio of bladder cancer?
2.5:1
148
What % of bladder cancers are transitional cell carcinomas (TCC)?
90%
149
What are the risk factors for bladder cancer?
Smoking Occupational exposure Schistosomiasis
150
By how much does smoking increase the risk of bladder cancer?
4x increased risk
151
What is the latent period for occupational exposure with bladder cancer?
20 years
152
What occupational exposures can lead to bladder cancers?
Rubber or plastics manufacture (Arylamines) Handling of carbon, crude oil, combustion (polyaromatic hydrocarbons) Painters Mechanics Printers Hairdressers
153
Give an example of where schistosomiasis is common
Eygpt
154
What are the stages of bladder cancer?
Superficial (Ta/T1) Tis (in situ) Muscle invasive
155
What % of bladder cancers are superficial?
75%
156
What % of bladder cancers are Tis?
5%
157
What % of bladder cancers are muscle invasive?
20%
158
What is the treatment for high risk non-muscle invasive TCC?
Check cytoscopies | Intravesical chemotherapy/immunotherapy
159
What is the treatment for low risk non-muscle invasive TCC?
Check cytoscopies
160
What are the categories of treatment for muscle invasive TCC?
Potentially curative | Not curative
161
What are the potentially curative treatments for muscle invasive TCC?
Radical cystectomy or radiotherapy, with or without chemotherapy
162
What are the not curative treatments for muscle invasive TCC?
Palliative chemotherapy/radiotherapy
163
What is a radical cystectomy/
The removal of the urinary bladder
164
How can urine be passed following a radical cystectomy?
A piece of ileum may be used to make a conduit from the ureters to the abdomen, where urine can be collected in a bag May attempt to reconstruct the bladder from a piece of small intestine
165
How common is renal cell carcinoma, compared to other cancers, in the UK?
8th most common cancer in UK
166
What % of all upper urinary tract tumours are renal cell carcinomas?
95%
167
What is happening to the incidence and mortality of renal cell carcinomas?
It is increasing
168
What is the male to female ratio of renal cell carcinoma?
3:2
169
What % of renal cell carcinoma (RCC) have metastases on presentation?
30%
170
What are the risk factors for RCC?
Smoking Obesity Dialysis
171
By how much does smoking increase the risk of RCC?
Doubles it
172
Where can metastases of RCC spread?
To lymph nodes, up the renal vein and vena cava, and into the right atrium and sub-capsular fat (perinephric spread)
173
What is the treatment for established RCC?
Surveillance Radical nephrectomy Partial nephrectomy
174
What is a radical nephrectomy?
Removal of kidney, adrenal, surrounding fat, upper ureter
175
What is the treatment for developmental renal cell carcinoma?
Ablation
176
What is ablation?
Removal of tumour from surface of kidney via erosive process
177
What are the palliative treatments for RCC?
Molecular therapies targeting angiogenesis | Immunotherapy
178
What % of malignancies of upper urinary tract are upper tract transitional cell carcinoma (TCC)?
5%
179
What can TCC be due to?
The spread of cancer from the bladder up the ureter
180
What % of TCC are due to the spread of cancer from the bladder up the ureter?
5%
181
What % of cancers of the upper urinary tract spread to the bladder?
40%
182
What are the investigations for TCC?
Ultrasound CT urogram Retrograde pyelogram Ureteroscopy
183
What is being looked for on ultrasound with TCC?
Hydronephrosis
184
What is hydronephrosis?
Swelling of kidney due to backup of urine
185
What is being looked for on a CT urogram with TCC?
Filling defect | Ureteric structure
186
What happens in a retrograde pyelogram?
Inject contrast into the ureter
187
What is taken with a ureteroscopy with TCC?
Biopsy | Washing for cytology
188
What is the treatment for TCC?
Nephro-uretectomy
189
What is a nephro-urecterectomy?
Removal of the kidney, fat, ureter, and cuff of bladder

ESA 3- Urinary System (13 decks)

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