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Flashcards in Renal Deck (117):
1

Where does horseshoe kidney get stuck?

IMA

2

Where is horseshoe kidney adjoined?

Lower Poles

3

Potter Syndrome

1. lung hypoplasia
2. flat face with low set ears
3. Limb defects

All due to oligohydraminos from bilateral renal agenesis

4

How to DDx Dysplastic Kidney disease from PKD

Dysplastic Kidney Disease is NOT inherited and can be uni or bilateral

PKD is always bilateral

5

Autosomal Recessive PKD presentation

BILATERAL enlarged kidneys w/ cysts in medulla/Cx

Presents in infants with renal failure and HTN
May have Potter Syndrome

6

ARPKD associated with

Congenital hepatic fibrosis and hepatic cysts

7

Autosomal dominant PKD presentation

young adult with HTN (high renin), hematuria, worsening renal failure

8

ADPKD associations

Berry anneurysms, hepatic cysts, MVP

Think cysts in vessels, heart, and liver

9

ADPKD genetic mutations

APKD1 & APKD2 gens

10

Medullary Cystic Kidney Disease

Cysts in medullary collecting ducts

parenchymal fibrosis leads to SHRUNKEN kidney and worsening renal failure

11

Acute renal failure hallmarks

Azotemia (increased BUN and Creatinine) often with oliguria

12

Prerenal Azotemia

Decreased blood flow to kidney
leads to decreased GFR, azotemia, and oliguria

13

Prerenal azotemia labs

BUN:Creatinine > 15 (normal 15)
FENa < 1%
Urine Osmolarity > 500 mOsm/kg

Kidney is still functioning so some BUN is reabsorbed

14

Postrenal Azotemia

Urinary Tract obstruction increases back pressure decreasing GFR
Also forces BUN back into blood
azotemia and oliguria

15

Early Postrenal azotemia Labs

BUN:Creatinine > 15
FENa < 1%
Urine Osmo > 500

looks just like prerenal azotemai

16

Late postrenal azotemia labs

BUN:creatinine < 15
FENa > 2%
Urine Osmo < 500

17

Acute Tubular Necrosis

Injury/necrosis of tubular epithelial cells
Plug tubules decreasing GFR

Brown Casks in urine

18

Acute Tubular Necrosis Labs

BUN:Creatinine < 15
FENa > 2%
Urine Osmo <500

19

Etiology of Acute tubular necrosis

Ischemia, Nephrotoxic (Rx, heavy metals, urate, etc.)

20

Clinical features of Acute tubular necrosis

oliguria with brown casts
elevated BUN and Creatinine
Hyperkalemia
Metabolic Acidosis (increased anion gap)

21

Tx acute tubular necrosis

dialysis, remove toxin
2-3 week recovery

tubular cells are stable cells so they take time to reenter cell cycle

22

Acute Interstitial Nephritis

Rx induced hypersensitivity involving interstitium and tubules
NSAIDs, penicillin, diuretics

23

Acute Interstitial Nephritis Sx

Fever, oliguria, rash days to weeks after start of Rx
Eosinophils in urine

24

Acute Interstitial nephritis Tx

Stop Rx

25

Renal Papillary Necrosis

Necrosis of renal papillaries
Gross hematuia and flank pain

26

Renal Papillary Necrosis Causes

DM, analgesic abuse, Sickle cell, acute pyelonephritis

27

Minimal Change Disease associated with

hodgkins lymphoma

28

#1 Nephrotic Syndrome in kids

Minimal Change Disease

29

Histo of Minimal Change disease

Effacement of foot processes which leads to selective proteinuria (only albumin)

Glomerulus pretty much looks normal

30

Tx or Minimal Change Disease

Steroids
Due to pathogenesis: Cytokines mediate damage

31

Nephrotic Syndromes associated with HBV and HCV

Focal Segmental Glomerulonephritis
Type I membranoproliferative glomerulonephritis

32

Nephrotic syndromes with foot process effacement

Minimal change disease
Focal Segmental glomerulosclerosis

33

Focal segmental glomerulosclerosis findings

Some glomeruli (focal)
involving only part of glomerulus (segmental)
sclerosis
effacement of foot processes

34

Spike and Dome appearance
Grainy Immunofluorescence

Membranous Nephropathy
Complex deposition is subepithelial
No response to steroids

35

Nephrotic Syndromes with negative immunofluorescence

Focal segmental glomerulosclerosis
Minimal change disease

36

Who gets Focal Segmental Glomerulosclerosis? Associations?

Hispanics and Af. Am.

Sickle Cell, Heroin, HIV

37

Most common nephrotic syndrome in Caucasian adults

Membranous Nephropathy

38

Membranous Nephropathy associations

Whites
HBV/HCV
SLE
Rx (NSAIDs, Penicillamine)

39

Subendothelial complex deposition
Tram track appearance
HBV/HCV associated

Membranoproliferative disease type I

40

Intramembranous complex deposition
Associated with C3 nephrotic factor
unregulated complement

Membranoproliferative Type II

C3 nephrotic factor stablizes C3 convertase --> complement does not get shut off

41

Membranoproliferative histo

Thick glomerular basement membrane due to complex deposition

poor response to steroids

Think of thickening (proliferation) of the basement membrane (membranous)

42

DM Nephrotic findings

HYALINE ARTERIOLOSCLEROSIS
High serum glucose leads to nonenzymatic glycosylation of vascular basement membrane

43

Tx of DM nephrotic Sx

ACE

Hyaline deposits in efferent arteriole. ACE prevents Angiotensin II vasocontriction of efferent arteriole decreasing Sx

44

Kimmelstiel Wilson Nodules

Diabetes Mellitis

sclerosis of mesangium

45

Apple Green apple birefringenc after Congo Red stain
Deposits in mesangium

Systemic Amyloidosis

Kidney is most common organ involved

46

Why are nephritic syndromes hypercellular?

Immune complexes deposit activating complement.
C5a attracts neutrophils mediating damage to kidney

47

Poststreptococcal Glomerulonephritis Sx

Nephritic Syndrome
Coke-colored urine (blood)
oliguria
HTN
periorbital edema

Lumpy bumpy IF--type III hypersensitivity

48

Poststreptococcal Glomerulonephritis buzz word

Subepithelial hump on EM

49

Nephrogenic Strep organisms

Must have M protein--mediates damage
Group A ß-hemolytic Strep
other bugs can do it too

50

Poststrep GN Tx

Supportive--disease is self limiting in kids

In adults could progress to Rapidly progressive glomerularnephritis--very bad

51

Nephritic Syndrome that progresses to renal failure in weeks to months

Rapidly progressive glomerularnephritis

52

Rapidly Progressive glomerulonephritis buzz

Crescents in Bowman space
composed of Macrophages and Fibrin

53

Immune Complex in messangium
recent mucosal infection
RBC casts in urine
Child

IgA Nephropathy (Berger Disease)

54

X-Linked
Defect in Type IV collagen
Thinning of glomerular basement membrane

Alport Syndrome

55

Alport Syndrome Sx

Sensory hearing loss
Isolated hematuria
Ocular disturbances

56

Rapidly Progressive GN with Linear IF

Goodpasture syndrome

Ab against collagen of alveolar and glomerular basement membrane
Hematuria, hemoptysis
young adult male

57

Rapidly Progressive GN with Granular IF

PSGN
Diffuse Proliferative GN

58

Rapidly Progressive GN with negative IF

Wegener granulomatosis
microscopic polyangiitis
Churg-Strauss Syndrome

59

DDx Churg-Strauss from microscopic polyangiitis

CS has
1. Granulomatous inflammation
2. Eosinophilia
3. Asthma

Not found in Microscopic polyangiitis

60

Most common renal disease in SLE

Diffuse Poliferative glomerulonephritis (nephritic)

Membranous Nephropathy (#1 nephrotic) is not as common as DPGN

61

Labs to DDx Wegener from Churg-Strauss

Weg–c-ANCA
CS–p-ANCA

62

UTI bugs

E. coli
S. saprophyticus
Klebsiella
Proteus
enterococcus faecalis

63

Dysuria, urinary frequency, urgency, suprapubic pain, NO systemic signs

Cystitis (bladder infxn)

64

most common type of spread for UTI development

Ascending spread
females more common due to short urethra

65

UTI Dx gold standard

Culture > 100,000 colony forming units

66

Dipstick findings for cystitis

Positve leukocute esterase and nitrites

67

Sterile Pyuria

suggests urethritis
1. Chlamydia
2. Neisseria gonorrhoeae

68

Pyelonephritis cast

WBC Cast

69

Pyelonephritis Sx

Cystitis Sx +
Fever, FLANK pain, WBC casts, Leukocytosis

70

Pyelonephritis bugs

E. coli
Klebsiella
E. faecalis

71

Chronic Pyelonephritis findings

Interstitial fibrosis and atrophy of tubulesdue to multiple infxns.

Cortical scarring with blunted calyces (scarring of upper and lower pole (reflux)

Eosinophilic proteinaceous material resembling thyroid

waxy casts in urine

72

Etiology of chronic pyelonephritis

Vesicoureteral reflux (kids)
obstruction (BPH, cervical CA)

73

Thyroidization of the kidney

Chronic pyelonephritis

74

Most common type of kidney stone

Ca oxalate or Ca phosphate

75

Tx Ca stones

hydrochlorothiazide

76

Causes of Ca stones

Idiopathic hypercalciuria
hypercalcemia
Crohn's Disease

77

Ammonium Magnesium Phosphate stone etiology

infection with urease + bugs --> alkalinizes the urine
1. Proteus
2. Klebsiella

78

Stone that cannot be seen on x-ray (radiolucent)

Uric Acid Stones

Dx with US

79

Risk factors for Uric Acid stones (7)

Hot arid climates
low urine Volume
acidic pH
Gout
hyperuricemia
leukemia
myeloproliferative diseases

80

Staghorn Stone in Kids

Cysteine Stone
associated with cysteinuria

81

Tx of Cysteine Stone

Hydration
Alkalinize urine

82

Tx Uric acid stones

Allopurinol
K+ HCO3- (alk. urine)

83

Tx Ammonium Magnesium Phosphate Stones

Surgery
Clear infxn

84

Most common causes of End Stage Kidney Failure

DM
HTN
Glomerular Disease

85

Uremia

Increased nitrogen waste in blood

Sx: nausea, anorexia, pericarditis, plt. dysfxn, encephalopathy w/ asterixis, deposition of urea chrystals in skin

86

Sx of Chronic Renal Failure

Uremia
HTN--due to high renin (Na and water retension)
hyperkalemia with metabolic acidosis
anemia due to decreased erythropoeitin
hypocalcemia
renal osteodystrophy

87

Sight of erythropoietin production

renal peritubular interstitial cells

88

Mechanism of hypocalcemia with renal failure

decreased 1-alpha-hydroxylation of Vit. D by proximal tubule cells

hyperphosphatemia

89

Renal osteodystrophy

2º to Hyperparathyroidism, osteomalacia, and osteoporosis

90

Tx of Renal failure

dialysis or kidney transplant

91

Increased risk at end stage kidney failure

Renal Cell CA

Cysts develop in shrunken kidney during dialysis

92

Hamartoma comprised of blood vessels, smooth mm., adipose tissue

Angiomyolipoma

93

Angiomyolipoma frequency is increased with

tuberous sclerosis

94

Mutation with RCC

Loss of VHL tumor suppressor gene

leads to increased IGF-1 (promotes growth) and HIF transcription factor (inc. VEGF and PDGF)

95

RCC classic triad

1. Hematuria
2. Palpable Mass
3. Flank Pain

96

RCC presentations

Fever, weight loss, or paraneoplastic syndrome (EPO, renin, PTHrP, ACTH

Left Sided varicocele due to hematogenous spread into Left renal vein

97

Gross and Micro findings of RCC

Gross–yellow mass
Micro–clear cytosol (most common type is clear cell)

98

Sporadic RCC

Unilateral
Single mass in upper pole
Smoking is main risk factor

99

Hereditary RCC

Von Hippel-Lindau (Autosomal Dominant)
inactivation of VHL gene

Hemangioblastoma in cerebellum and RCC

100

Wilm's Tumor is comprised of

Blastema–embryologic kidney mesenchyme

primitive glomeruli, tubules, and stromal cells (blastema forms all of it)

101

Wilm's tumor presentation

Large, unilateral mass with hematuria and HTN (renin)

102

WAGR Syndrome

Wilm's tumor
Aniridia
Genital Abnormalities
Retardation–mental/motor

103

Wilm's Tumor Gene mutation

WT1

104

Beckwith-Wiedermann Syndrome

Wilm's Tumor
Neonatal hypoglycemia
muscular hemihypertrophy (muscular asymmetry)
Organomegally (tongue)

105

#1 tumor of lower urinary tract and location

Urothelial CA

most commonly in bladder

106

Urothelial CA presentation

Painless hematuria

107

Major risk factors for urothelial CA

***Smoking*** (polycyclic aromatic hydrocarbons)
naphtylamine
azo dyes (hair dresser)
Long term cyclophosphamide or phenacetin

108

Flat urothelial CA

develops high grade then invades

early p53 mutation

109

Papillary urothelial CA

Develops low grade --> high --> then invades

No p53 mutation

110

Squamous Cell CA of the bladder risk factors

Schistosoma hematobium (Egytian Male)
long standing nephrolithiasis

Chronic irritation to bladder

111

Squamous cell CA of the lower Genitourinary tract most common site

malignant proliferation of squamous cell

bladder most common

112

Adenocarcinoma of the lower urinary tract associated with (3)

1. Urachal Remnant (dome of bladder)
2. Cystitis glandularis
3. Extrophy of the bladder

113

Malignant proliferation of glands involving the bladder

adenocarcinoma

finger-like projections

114

Nephrotic Syndrome Characteristics

Gross Hematuria
Proteinuria > 3.5 grams/day
Hyperlipidemia
Fatty Casts
Thromboembolism (loss of protein C/S in urine)
Increased Risk of Infection (Ig protein loss in urine)

115

Nephritic Syndrome Characteristics

Hematuria
RBC casts
Proteinuria < 3.5 g/day
Oliguria
HTN
Azotemia

Inflammatory process involving glomeruli

116

1º Amyloidosis is associated with

Multiple Myeloma

117

2º Amyloidosis is associated with

TB
RA