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Urological Disorders Flashcards

1
Q

What are the 3 categories the urological disorders can be classified into?

A

Inflammation
Obstructive
Developmental/ Genetic

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2
Q

What are the functions of a normal kidney?

A
  1. Filtration
    - Removal of waste substance
    - Keeping the essential substance within the blood: e.g.
    blood cells, large protein including albumin
  2. Control salt and water balance
  3. Control of acid/base balance
  4. Hormone: erythropoietin (EPO) production:
    essential for synthesis of Haemoglobin (Hb)
    - an renin
  5. Vitamin D: 1-α-hydroxylation of vitamin D
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3
Q

What happens to kidney function with kidney dysfunction?

A
  1. Filtration failure
    - Unwell with accumulation of waste substance
    - Haematuria and proteinuria, low serum protein,
    including albumin, in blood
  2. Hypertension, water retention (sometimes
    dehydration because unable to make concentrated
    urine)
  3. Metabolic acidosis
  4. Anaemia
  5. Vitamin D deficiency and secondary
    hyperparathyroidism
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4
Q

What are inflammatory urinary disorders?

A

Infection, including cystitis (UTI)

Non-infective causes:
1. Metabolic, including diabetic nephropathy
2. Immunological
- Nephritic syndrome
- Nephrotic syndrome

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5
Q

What are obstructive urinary disorders?

A

Stones
Benign prostatic hypertrophy

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6
Q

What are developmental/ genetic urinary disorders?

A

Polycystic kidneys, horseshoe kidney

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7
Q

Where can urinary disorders occur?

A

Stones can occur in the ureter or in the bladder

Renal disease in the kidneys

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8
Q

Is raised concentration of waste substance in the blood a consequence of kidney disease?

A

True: Reduction in glomerular filtration rate will result in accumulation of waste substances in the blood. The most common clinical test is to measure serum concentrations of urea and creatinine.

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9
Q

Is presence in blood cells a consequence of kidney disease?

A

True: Presence of blood cells in the urine may be due to damage glomeruli (leaking from cells into the urine) or bleeding due to structural problems, such as tumours or polycystic kidneys. The blood cells may be detected by urine dipstick or microscopy of urine.

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10
Q

Is the blood pressure always high with kidney disease?

A

False: Although the blood pressure is often high due to salt and water retention in patients with kidney diseases.

In some patients, the blood pressure low in some patients who have
-dehydration
or
- low in vascular volume

because unable to make concentrated urine, or losing too much sodium in urine or dehydration due to vomiting. Blood pressure changes can be measured by blood pressure machine in the sitting or supine position. Some patients’ low blood pressure may be more obvious in the standing position (postural hypotension).

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11
Q

Is abnormal hormone profile a consequence of kidney disease?

A

True: Reduction of synthesis in erythropoietin or secondary hyperparathyroidism.

The patients may have low erythropoietin production result in anaemia. This may be detected in reduced concentration of haemoglobin in full blood count with the relevant medical history of late stage chronic kidney disease, despite sufficient vitamin B12, folate and iron store. Because of cost, the direct measurement of erythropoietin is only done in some atypical clinical situations.

OR increased parathyroid hormone (PTH) as a secondary response to vitamin D deficiency (secondary hyperparathyroidism). High concentration of PTH can be measured in peripheral blood in the presence of low or normal serum calcium, high or normal serum phosphate. Routine vitamin D blood test does not detect 1,25 vitamin D concentration.

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12
Q

What are the possible locations for an infection?

A

Bladder: cystitis

Kidney: pyelonephritis

Consider other contributing factors e.g. obstruction, stones, prostatic hypertrophy

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13
Q

What are potential pathogens?

A

Bacteria: most common

Virus: immunocompromised patients

Fungal: immunocompromised patients

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14
Q

How does a bladder infection occur (cystitis)?

A

Harmful pathogen enter bladder causing inflammation

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15
Q

How do we make the diagnosis of a UTI?

A

History
Physical examination
Urine dipstick (link to dipstick practical)
Urine microscopy, culture and sensitivity

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16
Q

What is the treatment and overall clinical management of a UTI?

A

Antibiotics:
❖ depending on the severity of illness
❖ the most common bacteria in the local area
❖ modified when the sensitivity from urine culture is available

Some patients may be very ill and need to be treated as inpatient.
Pain control
Supportive e.g. hydration
Consider imaging if other factors or differential diagnosis.

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17
Q

What would you expect to see on a urine culture?

A

E.coli

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18
Q

How can the immune system damage the kidney?

A

Potential Mechanisms:
Antibody
Inflammatory cells (neutrophils, monocytes/macrophages, T cells)

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19
Q

What are clinical presentations of inflammatory condition with immunological causes of kidney damage?

A

Nephritic syndrome
Proteinuria
Nephrotic syndrome

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20
Q

What is the difference between nephritic and nephrotic syndrome?

A

The nephrItic syndrome is a clinical syndrome that presents as hematuria, elevated blood pressure, decreased urine output, and oedema. The major underlying pathology is inflammation of the glomerulus that results in nephritic syndrome.

Nephrotic syndrome has symptoms include. too much protein in your urine, called proteinuria. low levels of a protein called albumin in your blood, called hypoalbuminemia. swelling in parts of your body, called edema.

Nephritic= blood

Nephrotic= protein

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21
Q

What Is glomerulonephritis?

A

Inflammation of the microscopic filtering units of the kidney

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22
Q

How can you check for inflammatory cells in the kidney?

A

Immunostaining of inflammatory cells (brown staining) in a kidney biopsy

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23
Q

What are the potential patterns of organ involvement in imlammatroy conditions with an immunological cause?

A

Kidney only
Kidney and lung
Multiple organs/tissues involved

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24
Q

What is a diagnostic approach of inflammatory conditions?

A

History and physical examination

Urine test

Blood test: including immunology tests

Imaging: start with ultrasound

Kidney biopsy

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25
What is nephritic syndrome?
Haematuria Variable amount of proteinuria May have hypertension, reduced urine output, increased urea and creatinine
26
How do we make a diagnosis for nephritic syndrome?
History Physical examination Urine dipstick (link to dipstick practical) Urine microscopy Urine protein : creatinine ratio Blood tests: - kidney function - immunology test Kidney biopsy
27
What are possible symptoms for nephritic syndrome?
Sore throat Red in urine High blood pressure in dipstick there is high blood and protein Urine has a raised urine protein: creatinine ratio Kidney biopsy has IgA nephropathy
28
What is IgA nephropathy?
The most common primary glomerulonephritis world-wide. Very high prevalence in Far East. Deposition of IgA antibody in the kidney (detected by immunohistochemistry). Inflammation and scarring. About 30% progress to kidney failure.
29
What is the treatment for IgA nephropathy?
Supportive: - Treat hypertension and reduce proteinuria First line treatment: angiotensin receptor inhibitor (ARB) (e.g. irbesartan) or angiotensin converting enzyme inhibitor (ACEI) (e.g. ramipril) - Reduce sodium intake Immunotherapy: (Many different choices, ongoing clinical trials) - Renal replacement therapy: when reaching late stage kidney disease ❖ Kidney transplantation ❖ Dialysis
30
What is an organ specific: kidney and lung disease?
Anti-glomerular basement membrane (GBM) antibody mediated: Good pasture’s disease. - Shared common antigen between lung and kidney: α3chain of type IV collagen.
31
What are examples of systemic diseases: multiple organ/ tissue involved?
Systemic lupus erythematosus (SLE): autoantibodies: antinuclear factor, anti-dsDNA. Vasculitis: antineutrophil cytoplasm antibody (ANCA).
32
What is diabetic nephropathy?
The most common cause of chronic kidney disease and kidney failure in the Western World. Pathogenesis: inflammation and fibrosis
33
What are the risk factors for diabetic nephropathy?
Hypertension Poor diabetic control Smoking
34
What are the clinical features of diabetic nephropathy?
- Microalbuminuria - Proteinuria Association with other complications of diabetes mellitus - Diabetic retinopathy - Diabetic neuropathy
35
What is the treatment and management control for diabetic nephropathy?
Optimised diabetic control Optimised treatment of hypertension Reduce proteinuria using ARB or ACEI Stop smoking New treatments: SGLT2 inhibitor Transplantation (including combined pancreas and kidney transplantation) Dialysis
36
What happens to the glomerulus with diabetic nephropathy?
Thickened glomerular basement membrane Deposition of extracellular matrix in the glomerulus
37
What is nephrotic syndrome?
Peripheral oedema Severe proteinuria Low serum albumin Variable amount of microscopic haematuria Associated with hyperlipidaemia
38
How do we make the diagnosis for nephrotic syndrome?
History Physical examination Urine dipstick (link to dipstick practical) Urine microscopy Urine protein : creatinine ratio Blood tests: kidney function, immunology test Kidney biopsy
39
What are symptoms for nephrotic syndrome?
Frothy urine Periorbital oedema ankle: pitting oedema Urine dipstick: high protein, no blood BLood test: very low serum albumin concentration Very high urine protein: creatinine ratio (minimal change glomerulopathy in kidney biopsy)
40
What are the causes for nephrotic syndrome?
lots of reasons e.g., Minimal change glomerulopathy Membranous nephropathy Focal segmental glomerulosclerosis Lupus nephritis
41
What are the key features of minimal change glomerulopathy?
Most common in children, also affect other age groups Normal light microscopy Electron microscopy: podocyte effacement-abnormal flatten appearance (figure below) Complication: high risk of thrombosis
42
What are the treatment for nephropathy?
Immunotherapy - Traditionally: corticosteroid, cyclophosphamide - Recent development: tacrolimus, antibody therapy targeting B cell pathway Diuretics: to reduce the peripheral oedema Prevention of thrombosis: anticoagulation
43
Is this a good approach to investigate and treat patients with possible inflammatory condition of the kidney? "Just rush along and start some medication asap"
False: It is not a good approach to rush along and start medication without appropriate medical history, physical examination and investigation. The best approach will be to take a careful medical history and physical examination, which will guide the choice of appropriate investigation to establish the diagnosis of the possible inflammatory conditions of the kidney. Then, it will be important to discuss with the patient the prognosis and the treatment option.
44
Is this a good approach to investigate and treat patients with possible inflammatory condition of the kidney? "give antibiotics and immunosuppression to everyone"
False: the choice of antibiotics or immunosuppressive medications should only be used with the relevant clinical diagnosis. Medication history, including any previous allergy to medication, is very important. In patients with bacterial infection of the urinary tract, it will be very helpful to collect bacterial culture samples before the first dose of antibiotics, if possible. It is also important that antibiotics needs to be given as soon as possible in potentially life-threatening infection.
45
Is this a good approach to investigate and treat patients with possible inflammatory condition of the kidney? "Carry out comprehensive immunological investigation for all the patients"
False: this is one the hardest clinical practice questions. The history and physical examination is the best guidance to choose the appropriate immunological tests.
46
Is this a good approach to investigate and treat patients with possible inflammatory condition of the kidney? "Urine dipstick"
True: urine dipstick test will provide screening results within 1 minute. This quick results will be very helpful for choice for further laboratory investigation or give some indication for initial treatment (for example, patients with clinical history of urine infection, and urine dipstick for nitrite and leukocytes).
47
What is an obstructive disorder example?
Stones
48
Where are the possible locations for stones?
Kidney Ureter and Bladder
49
What are the clinical presentation of stones?
Pain (abdomen, back-loin). Blood in urine. Associated with urine infection. About 90% of kidney stone are radio-opaque.
50
What is noticed with stones during a physical examination?
Tenderness of loin and lower abdomen.
51
What are the investigation for stones?
Urine inspection and dipstick: Blood in urine, +/- evidence of urine infection. Blood test: Kidney function (reduced only in some patients). Imaging: Plain X ray, ultrasound or CT scan.
52
What is the supportive treatment for stones?
Pain control and hydration
53
What does the specific treatment for stones depend on?
Size and location of stones Availability of local expertise Fitness of the patient for general anaesthetics
54
What are the specific treatments for stones?
Shockwave lithotripsy Ureteroscopy Percutaneous nephrolithotomy
55
What is shockwave lithotripsy?
High energy ultrasound waves to break up large kidney stones into smaller one
56
What is ureteroscopy?
Through urethra, bladder and ureter. minimally invasive
57
What is percutaneous nephrolithotomy?
Small percutaneous incision. Insertion of nephroscope. Stone is removed (may need to broken in smaller pieces).
58
What are the different types of polycystic kidneys?
Neonatal: autosomal recessive Adult onset: autosomal dominant Some patients without family history
59
What are the consequences of polycystic kidneys?
Loss of kidney function Pain Bleeding into the renal cysts Infection of renal cysts Asymptomatic in some patients
60
What is the treatment of polycystic kidney disease?
New medication: Tolvaptan (a vasopressin receptor 2 antagonist) to slow down the cysts formation. Treat hypertension, infection. Pain control. Renal replacement therapy (transplantation, dialysis).
61
How do we know if a patient has a horseshoe kidney?
Imaging of abdomen/ pelvis
62
What are the consequences of horseshoe kidney?
Obstruction Stone Infection
63
What are the variety of clinical presentation of immunological kidney diseases?
Kidney only, e.g. IgA nephropathy Kidney and lungs, e.g. anti-GBM disease Systemic multiorgan/tissue e.g. SLE, vasculitis
64
Can patients always go home the same day after treatments for stones in the urological systems?
False: Although some patients may be treated and discharge home on the same day, there are some patients who will have severe infection and dehydration. These patients may need to be treated as inpatients with intravenous antibiotics and rehydration. If there is significant obstruction for urine outflow, the patient will also need procedure to unblock the obstruction. For example, bladder catheter for bladder outflow obstruction or nephrostomy for kidney urine outflow obstruction.
65
Is past medical history not important for diagnosis and treatment of stones?
False: The past history, such as previous history of urological stone, urinary tract infection, previous surgery and medication history, including allergy to medications, are all important in making the diagnosis and carrying out the appropriate treatment.
66
Do urine cultures have to be sent for bacterial culture when considering stones?
True: Bacterial culture from urine samples is very important, because the patient may have bacterial infection of the urinary tract at the same time.
67
Are plain abdominal X ray not useful for stones?
False: About 90% of urological stones are radiopaque. A plain abdomen X ray cover the kidney, ureter and bladder region is therefore very useful. This type of X ray investigation is available in all Accident and Emergency Department and Walk-in Medical Centres.
68
What does damage to the glomerulus do?
Glomerular damage compromises the filtration function
69
What does reduced kidney functionality do?
Could cause tiredness (due to loss of detoxifying kidney function and reduced erythropoietin (EPO) production causing anaemia) and swollen ankles (due to water retention in the periphery as a result of loss of proteins and reduced kidney function).
70
What are the pros and cons for X-rays for checking the urinary tract?
Quick, easy and readily available in most hospital departments, but patient is exposed to radiation
71
What are the pros and cons of ultrasounds to check the urinary tract?
Can detect the dilation of the urinary system due to the obstruction which can be useful in spotting loss of function. Small stones cannot be detected.
72
What are the pros and cons of CT scans to check the urinary tract?
Highly sensitive in detecting small stones but involves radiation exposure.
73
What are the possible causes of stones?
Prostate enlargement Any nervous system disease damaging the bladder nerves Gout Hydration Diet
74
Why does prostate enlargement cause stones?
This is a common condition in men of older age - can obstruct urine excretion, causing stones to form in the bladder from the minerals in the urine.
75
Why does any nervous system disease damaging the bladder nerves cause stones?
This will cause partial urine excretion, causing stones to develop in the bladder. E.g., neurological disease generally affecting 60+ age adults.
76
Why does gout cause stones?
Increased blood uric acid levels → increased risk of kidney stone development.
77
Why does hydration/ dehydration cause stones?
Being dehydrated concentrates the urine, increasing the chances of stones
78
Why does your diet cause stones?
A diet rich in Sodium or animal protein or poor in Calcium can lead to stone formation as it can cause an increase in Calcium, uric acid and oxalate levels (different stone types) respectively in urine.
79
What are stone forming chemicals?
calcium, oxalate, urate, cystine, xanthine, and phosphate

BRS UROLOGY & RENAL (10 decks)

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