Urinary System Diseases and Pathology Flashcards
(180 cards)
1
Q
what is the definition of chronic kidney disease?
A
kidney damage (on imaging, urine or blood) +
eGFR < 60 +
lasting over 3 months
2
Q
what is the most common test to measure kidney glomerular filtration rate?
A
creatinine clearance
3
Q
what is an important drawback of eGFR measurements?
A
it’s an estimation based on how much creatinine you think the person should excrete normally
4
Q
what are three important criteria for determining kidney disease?
A
- kidney’s excretory function
- kidney’s reabsorptive function
- kidney’s anatomy
5
Q
how many stages of CKD are there?
A
5
6
Q
what is an arbitrary measure for working out the stages of CKD?
A
increase GFR in increments of 15 from CKD5 up to normal level
7
Q
what are the common equations used to measure eGFR?
A
MDRD4
CKD-EPI
8
Q
what are some of the risk factors for developing CKD?
A
- diabetes
- glomerulonephritis
- systemic diseases (SLE, vasculitis)
- genetic diseases (polycystic kidneys)
- renovascular disease
9
Q
what investigations should be carried out to work out the cause of CKD?
A
- blood tests
- urine tests
- imaging (ultrasound)
- renal biopsy
10
Q
what are the stages of CKD management?
A
- find the underlying disease
- slow down renal decline
- address GFR-relaled complication
- prepare for renal replacement therapy
11
Q
how is renal decline mostly slowed down in CKD?
A
maintaining BP
reducing proteinuria
treating underlying disease
12
Q
what are some of the possible complications of CKD related to reduced eGFR?
A
anaemia acidosis bone disease CV disease dialysis electrolyte imbalance oedema hypertension
13
Q
how many types of haematuria are there, and what are they?
A
2: frank (visible) haematuria and microscopic haematuria
14
Q
when is haematuria defined as microscopic?
A
when there are >2RBC per mm3
15
Q
what are some of the symptoms renal disease presents with?
A
pain pyrexia haematuria/proteinuria oliguria/polyuria/nocturia palpable mass renal failure
16
Q
what is the definition of oliguria?
A
urine output <0.5ml/kg/hour
17
Q
what is the definition of polyuria?
A
urine output >3L/day
18
Q
how can chronic renal failure present?
A
anaemia tiredness oedema hypertension pain itch CVS problems neuropathy nausea/vomiting dyspnoea coma
19
Q
how can ureteric diseases present?
A
pain haematuria pyrexia palpable mass (if hydronephrosis) renal failure
20
Q
what are three common symptoms often seen in urinary system diseases?
A
pain
pyrexia
haematuria
21
Q
where is the micturition centre found?
A
in the pons
22
Q
where is the voluntary inhibition of micturition controlled?
A
in the cortical centre
23
Q
what is an important risk factor for acute urinary retention?
A
benign prostatic obstruction
24
Q
what is the management of acute urinary retention?
A
immediate catheterisation
25
is acute or chronic urinary retention painful?
acute is painful, chronic is painless
26
what is a common cause for chronic urinary retention?
detrusor muscle underactivity
27
what makes up the triple filter layer in the glomerulus?
- capillary endothelium
- basal membrane
- podocytes
28
what is the mesangium?
it's a collection of cells that support the structure of the glomerulus
29
what are some common presentations of glomerulonephritis?
- haematuria
- proteinuria (heavy or slowly rising)
- hypertension
- renal failure
30
what are the two main classes of glomerulonephritis?
proliferative vs non-proliferative
31
what is the difference between nephritic and nephrotic glomerulonephritis?
nephritic - haematuria, cellular casts, dysmorphic RBC
| nephrotis - proteinuria,oedema, hypoalbuminaemia
32
what is the main feature of nephrotic syndrome, and how does it arise?
heavy proteinuria causes loss of oncotic pressure in blood, fluid build up in ECF causing oedema
33
what are the three main causes of haematuria?
- UTI
- calculus
- tumour
- (glomerulonephritis)
34
if a patient gets a MSSU dipstick test and urine culture, then gets an ultrasound and finally a biopsy, what are these investigations individually looking for?
MSSU dipstick + urine culture - look for UTI
ultrasound - look for stones or tumours
biopsy - look for glomerulonephritis
35
which classification of glomerulonephritis is more likely to present with hypertension, haematuria and rising creatinine?
nephritic GN
36
what is rising creatinine a sign of?
renal failure
37
what characterises nephrotic syndrome?
oedema
hypoalbuminaemia
proteinuria
hyperlipidaemia
38
what characterises nephritic state?
haematuria
cellular casts, dysmorphic RBCs
hypertension
renal insufficiency
39
what is the aetiology of glomerulonephritis?
```
idiopathic
infection
autoimmune
tumour
drugs
```
40
where does proteinuria normally arise from?
- glomerulus
| - tubules
41
where does haematuria normally arise from?
anywhere in urinary tract (kidneys, ureters, bladder, urethra)
42
is nephritic or nephrotic glomerulonephritis more likely to present with hypertension?
nephritic glomerulonephritis
43
what is the commonest cause of nephrotic syndrome?
diabetes
44
what do diffuse, focal, global and segmental mean in terms of glomerulonephritis morphology?
diffuse - >50% of glomeruli affected
focal - <50% of glomeruli affected
global - whole glomerulus affected
segmental - only part of glomerulus affected
45
is nephritic or nephrotic glomerulonephritis more likely to present with both haematuria and proteinuria?
nephritic glomerulonephritis
46
how do you distinguish between IgA GN and post-strep GN if a patient presents with GN a day after their infection?
the time between infection and GN: post-strep occurs a few weeks after the infection
47
which bacteria are most likely to cause post-infective GN?
Group A strep - strep pyogenes
48
what antibodies are found in patients with granulomatosis with polyangiitis?
ANCA (anti-neutrophil cytoplasmic antibodies)
49
what areas of the body are commonly affected in patients with granulomatosis with polyangiitis? what are the resulting symptoms?
nose
lungs
kidneys
50
what is seen on microscopy in the glomeruli of patients with membranous GN?
IgG and complement 3 infiltration in glomerular basement membrane (GBM)
51
what is seen on microscopy in the glomeruli of patients with IgA GN? what is the distribution pattern of the disease?
IgA deposits in mesangium
52
what is the main rule of thumb regarding pathophysiology of nephrotic and nephritic GN?
nephritic - inflammatory process in mesangium causing haematuria, filtration system stays intact unless there's scarring
nephrotic - damage to filter (podocytes or GBM) causing proteinuria
53
what's the treatment of post-infective GN?
focus on immediate symptom relief:
hypertension - control BP
oedema - diuretics
infection - antibiotics
54
what are the two commonest forms of adult nephritic and nephrotic GN worldwide?
nephritic - IgA GN
| nephrotic - membranous GN
55
what is the prognosis of IgA GN?
- spontaneous resolution
| - progression to CKD and crescentic GN
56
which diseases are most likely to cause crescentic GN?
- ANCA-associated diseases (granulomatosis with polyangiitis, microscopic polyangiitis)
- anti-GBM glomerulonephritis
57
what's the treatment for crescentic glomerulonephritis?
- high dose steroids
- immunosuppression (cyclophosphamide, rituximab)
- plasmaphoresis
- complement inhibitors
58
at which age ranges is anti-GBM most likely to present?
30s and 60/70s
59
which kidney disease do children most often present with?
minimal change disease
60
what is the treatment for minimal stage disease?
- first incidence: corticosteroids (prednisolone 1mg/kg) until remission, then taper down over 6months
+ anti-thrombotics
if nephrotic syndrome, salt/fluid restriction and diuretics
- first relapse: steroids
- further relapses: immunosuppression
61
what is the most likely complication of minimal stage disease?
side effects from long-term steroid use
62
what is an important test to carry out in young women who present with proteinuria?
pregnancy test
63
which type of nephrotic GN does not respond to steroids?
focal and segmental glomerulosclerosis
64
what is the treatment for focal and segmental glomerulosclerosis?
- general measures for nephrotic syndrome
| - steroids, and if no response, immunosuppression
65
what can membranous GN be caused by?
- idiopathic
- tumours
- autoimmune conditions (SLE, RA)
- drugs (eg NSAIDS)
66
what is the treatment for membranous GN?
- general measures
| - steroids/immunosuppression in alternation
67
what is the prognosis of membranous GN?
1/3 goes into spontaneous remission
| 1/4 goes onto developing CKD in a few years
68
what do non-proliferative glomerulonephritides normally present with?
nephrotic syndrome
69
what do proliferative glomerulonephritides normally present with?
nephritic state
70
what are some of the complications that arise from kidney transplantation surgery?
- bleeding/haematoma
- thrombosis
- lymphocele
- urine leakage
- infection
71
what is the principle of immunosuppression after kidney transplantation?
drugs need to target two signalling points in the immune response to be effective
72
what is the treatment protocol for immunosuppression after renal transplantation?
induction - basiliximab
| maintenance - tacrolimus + mycophenolate +/- steroids
73
what are the possible types of kidney donors?
- deceased (brain or cardiac death)
| - living (related, unrelated, paired, pooled, altruistic)
74
what are the extended criteria for cardiac death donors?
>60yo
| 50-59 but with HTN, CVS death or high creatinine
75
why is a living donor kidney preferable to a deceased donor kidney?
because the survival rate with the living donor kidney is longer
76
why should the waiting time for kidney transplantation be kept to a mininum?
because delay can cause comorbidities which may reduce the eligibility of the receiving patient
77
what is the benefit of receiving a kidney transplantation instead of staying on dialysis?
mortality is reduced
78
is kidney donation safe?
yes, provided the correct donor is selected
79
what are some of the complications which may arise after renal transplantation?
- rejection
- CVS complications
- infection
- malignancy
80
what is the most common form of malignancy developed after a renal transplantation?
skin cancer
81
why is malignancy a risk factor in patients who have received a renal transplantation?
because immunosuppressants inhibits the cancer cell surveillance of the immune system
82
how can T-cell mediated renal transplant rejection present itself?
tubulitis
arteritis
endothelialitis
83
what are some of the types of renal transplant rejection encountered?
```
hyper-acute rejection
acute rejection (T-cell mediated or antibody mediated)
```
84
how can antibody-mediated renal transplant rejection present itself?
- microvascular infiltration
- donor specific antibodies
- positive C4d
85
what is the chance of developing post-transplant diabetes mellitus by 1 year after renal transplantation?
1/3
86
why is CMV an important virus to consider in renal transplantation patients?
- it is the most common infection after transplantation
- it can affect many different systems
- it compromises the survival of the graft
87
what characterises BK virus in patients with renal transplantation?
- polyoma virus
| - SV40
88
where is the BK virus normally found in healthy individuals?
urinary epithelium
89
what are the risk factors for developing a BK virus nephropathy?
- aggressive immunosuppression
- damage to donor kidney
- demographic (age, male sex, white)
90
what are the possible clinical signs of BK-virus infection after renal transplantation?
- ureteric stenosis
- interstitial nephritis
- end-stage renal failure
91
what are the possible outcomes to a renal graft after a BK virus infection?
dysfunction or loss of graft
92
how is a BK-associated nephropathy treated?
- reduction of immunosuppressants
| - anti-viral therapy
93
what are the most common cancers to get after a renal transplant?
- renal cancer
- skin cancer
- non-hodgkin lymphoma
94
why is it more likely to develop certain cancers after renal transplantation?
because immunosuppression reduces the immune surveillance of cancer cells
95
what is the size of the normal prostate?
15-25cc
96
which area of the prostate is more likely to develop malignant tumours?
peripheral zone
97
which area of the prostate is most affected in BPH?
transition zone
98
what are the two broad categories of LUTS?
```
voiding symptoms (obstructive)
storage symptoms (irritative)
```
99
what symptoms fall under voiding symptoms in LUTS?
hesitancy
poor urine flow
terminal dribbling
incomplete emptying
100
what symptoms fall under storage symptoms in LUTS?
urgency
frequency
incontinence
nocturia
101
what investigations should be done if a patient presents with LUTS?
```
digital rectal examination
MSSU and bloods
uroflowmetry
post-voiding bladder USS/renal tract USS
flexible cystoscopy (if haematuria)
urodynamic studies
prostate biopsy (if PSA or DRE abnormal)
```
102
what is the main medical treatment for BPO?
alpha blockers
103
what is the main surgical treatment for BPO if medical therapy is not sufficient?
TURP
104
what are possible side effects of treating BPO with alpha blockers?
hypotension
| retrograde ejaculation
105
what are some of the complications associated with TURP?
bleeding
incontinence
retrograde ejaculation
infection
106
what are some of the complications associated with BPO and BOO?
```
LUTS worsening
UTIs
acute/chronic urinary retention
stones
renal failure
```
107
what is the treatment for uncomplicated and complicated BOO?
uncomplicated - alpha blockers/5ARI, TURP if necessary
| complicated - TURP or long-term catheterisation
108
what is the main aetiological factor for chronic urinary retention?
detrusor underactivity
109
what are the possible complications after inserting a catheter for acute/chronic urinary retention?
post-decompression haematuria
infection
osmotic diuresis
electrolyte abnormalities
110
what are the sites of possible upper urinary tract obstruction?
pelvico-ureteric junction (PUJ)
ureter
vesico-ureteric junction (VUJ)
111
what are the sites of possible lower urinary tract obstruction?
bladder neck
prostate
urethra
foreskin
112
what is the difference between pyonephrosis and pylonephritis?
pyonephrosis - infected kidney due to obstruction and urine collection
pylonephritis - inflamed kidney with no obstruction
113
what is the difference between pyonephrosis and hydronephrosis?
pyonephrosis - infection due to build-up of urine
| hydronephrosis - build-up of urine with no infection
114
between hydronephrosis, pylonephritis and pyonephrosis, which is the biggest emergency?
pyonephrosis
115
is acute or chronic urinary retention most likely to present with renal failure, and why?
chronic is more likely, especially when high-pressure chronic retention, as it impairs the counter-current system
116
how can chronic urinary retention present based on pressure?
high pressure: painless but incontinent, bilateral hydronephrosis and raised creatinine
low pressure: painless, normal kidney function, normal creatinine
117
what are two consequences of reduced GFR in the context of clinical pharmacology?
- half-life of drugs excreted by kidneys increased
| - protein binding reduced, causing an increase in free active drug
118
what is the most common type of bladder cancer?
transitional cell carcinoma
119
what type of bladder cancer is caused by schistosomiasis?
squamous cell carcinoma
120
where can transitional cell carcinoma occur?
anywhere in the urinary system
121
how is transitional cell carcinoma staged?
G1, G2, G3
| then TNM stage
122
what are the main two T staging classifications of TCC, and their incidence?
- superficial (75%)
| - muscle-invasive (25%)
123
if a patient presents with haematuria with possible risk of bladder cancer, what investigations are done?
- bloods: U&E
- BP
- urine culture/cytology
- cystourethroscopy
- USS + CT urogram
124
what is the treatment for bladder TCC?
surgical resection
125
once bladder cancer is diagnosed through imaging, how is it staged?
- TURBT (biopsy) and EUA (examination under anesthetic)
- CT for TNM (size, metastases)
- bone scan if symptomatic
- CTU
126
what characterises bladder carcinoma in situ?
non-muscle invasive but is a precursor of muscle-invasive bladder cancer --> very aggressive
127
what type of cancer is normally found in the upper urinary tract?
transitional cell carcinoma
128
what are the possible symptoms and signs of UTUC?
haematuria
flank pain
unilateral hydronephrosis/ureteric obstruction
palpable mass
129
what investigations should be done for UTUC?
bloods: FBC, U&E, creatinine,
imaging: IVU or CT-IVU
staging: CT scan, biopsy
130
what is the treatment for UTUC?
nephroureterectomy
| endoscopic laser ablation if unsuitable for surgery
131
what are the possible cell types giving rise to renal cell carcinoma?
clear cell
papillary
chromophobic
132
what are the benign types of renal cancer?
oncocytoma
| angiomyolipoma
133
what are the risk factors for bladder cancer?
```
hereditary
smoking
aromatic amines
infection (eg schistosomiasis)
chronic/recurrent UTIs
```
134
what are the risk factors for renal cell carcinoma?
```
antihypertensive drugs
hereditary
smoking
obesity
end-stage renal failure
```
135
how can renal cancer present itself?
asymptomatic
triad of: loin pain, mass and haematuria
metastatic/paraneoplastic symptoms
136
what are the investigations done for renal cancer?
bloods: FBC,U&E, creatinine
urinalysis: haematuria + cytology
imaging: USS, CT scan (triple phase); MAG3 + DMSA to assess renal function prior to treatment
137
what are the treatment options for different stages of bladder cancer?
low risk - tumour resection + 1 course intravesical chemo
high risk/CIS - tumour resection + BCG vaccine
muscle-invasive - neo-adjuvant chemo to reduce size, then cystectomy/long term chemo/radiotherapy
138
which urinary tract cancer is unresponsive to chemo or radiotherapy?
renal cell carcinoma
139
what is the treatment for renal cell carcinoma?
radical nephrectomy
| TKIs or immunotherapy if unsuitable for surgery
140
what is the most important imaging technique used to diagnose and stage renal cell carcinoma?
triple phase CT scan
141
what imaging techniques are sometimes used during diagnosis of renal cell carcinoma, to assess function of each kidney?
nuclear imaging: DMSA and MAG3 scans
142
in which zone of the prostate is malignant cancer normally found?
in peripheral zone
143
how does prostate cancer normally present?
asymptomatic, found incidentally
144
if locally invasive, where does prostate cancer normally invade?
rectum
bladder/urethra
pubic bone
145
what are the three main diagnostic tests for prostate cancer?
ad-hoc PSA testing
DRE
TRUS biopsy
146
why is PSA not a useful screening tool?
because there are other causes for raised PSA
147
what are the risk factors for PSA?
family history of prostate/breast cancer
age
geography (western countries)
race (afro-caribbean)
148
what are some of the other causes for a raised PSA?
```
BPH
UTI
prostatitis
physiological causes
recent interventions
```
149
how is the Gleason sum score calculated in prostate cancer?
score of largest area of differentiation + score of second largest area of differentiation
150
what are the four stages of prostate cancer?
1 - non-invasive
2 - locally invasive
3 - metastatic
4 - hormone refractory
151
what is the surgical treatment for prostate cancer?
prostatectomy
152
what are the medical treatment options for prostate cancer?
LHRH analogues
| LHRH antagonists
153
what should you bear in mind when giving LHRH analogues to a prostate cancer patient?
tumour flare on initial treatment - give anti-androgen treatment
takes months to work
154
what imaging tests are used to stage prostate cancer?
bone scan
| CT/MRI
155
where is the main lymphatic spread of prostate cancer?
iliac lymph nodes
156
what are the surgical treatment options for prostate cancer?
- prostatectomy
| - bilateral orchidectomy (hormone therapy = surgical castration)
157
what are the medical treatment options for prostate cancer, alongside surgery?
brachytherapy, EBRT, hormone replacement
158
what are the medical hormone replacement options for prostate cancer?
LHRH analogues
anti-androgens
LHRH antagonists
oestrogen
159
how do testicular tumours commonly present?
```
painless lump
painful swelling (after trauma)
metastatic symptoms
```
160
what tumour markers are screened for when diagnosing testicular cancer, and what are they indicative of?
alpha-fetoprotein --> seminoma
beta-human chorionic gonadotrophin --> teratoma
lactate dehydrogenase --> generic tumour burden
161
what is the common lymphatic drainage of testicular cancers?
para-aortic lymph nodes
162
what investigations are carried out for testicular cancers?
bloods (tumour markers)
urinalysis
USS, CXR, CT scan
163
what is the surgical treatment for testicular cancer?
radical orchidectomy, lymph node dissection
164
what are medical treatment options for testicular cancer?
chemotherapy/radiotherapy
165
where is the incision made for testicular cancer, and why?
inguinal incision, to make sure fascia and lymph nodes are all removed
166
what are common types of UTIs?
```
pyelonephritis (acute/chronic)
renal abscess
cystitis
urethritis
prostatitis
epidydimo-orchitis
```
167
what are some of the general risk factors for UTIs?
```
malnutrition
diabetes
immunosuppression
steroids
pregnancy
urinary retention
```
168
what are some of the specific urinary tract related UTIs?
```
females (short urethra)
sexual intercourse
poor micturition habits
congenital abnormalities
stasis of urine
foreign bodies (catheters, stones)
menopause (low oestrogen)
bladder-bowel fistula
```
169
what is the most common causative organism for UTI?
E. coli
170
what are some of the possible causative organisms of UTI?
E coli
klebsiella
proteus
enteococcus
171
what is the most common mode of UTI transmission?
transurethral route
172
what are the investigations done for a UTI?
MSSU:
- blood, protein, leucocytes, nitrites
- microscopy, culture and sensitivity
173
what does a MC&S show in UTIs?
microscopy/Gram stain shows if organism is gram positive or negative
culture shows what kind of organism it is
sensitivity shows what antibiotics the organism is sensitive to
174
what volume of a particular organism normally signifies an infection?
10^4 or higher
175
if UTIs are recurrent, or occur in children or men, what should be considered as a possible cause?
structural abnormalities or urinary tract
176
what additional investigations, other than MSSU analysis, should be done for UTIs in men and children?
CT scan, IVU or isotope studies
177
what are the main principles of management for UTIs?
identify and treat causative agent
| address predisposing factors
178
how are UTIs treated?
- fluids
| - antibiotics
179
why are fluids an important part of UTI treatment?
because fluids cause higher urine flow, which helps flush out bacteria
180
which antibiotics are often considered for UTI treatment?
amoxycillin
cephalosporin
trimethoprim
