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FERGU > Week 3- Hematuria > Flashcards

Week 3- Hematuria Flashcards

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1
Q

How many sets of embylogical kidneys form, and what is the order? What germ layer do they come from?

A

3 sets form:

  1. pronephros
  2. mesonephros
  3. metanephros

All originate from the intermediate mesoderm, from the urogenital ridges.

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2
Q

Describe the sequence of events in kidney formation

A
  • The pronephros grows down, becomes mesonephros
  • mesonephros does the job of the kdney for the 1st trimester. pronephros disappears
  • mesonephros continues to grow down and grows into the cloaca
  • the uretic bud grows out of the metanephric duct
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3
Q

What forms the tubules of the kidney? What forms the collecting system of the kidney?

A

The metanephric mesenchyme. The uretic bud forms everything else.

The uretic bud induces the the metanephric mesenchyme to form a cyst that elongates a forms a glomerulus at one end and attaches to the collecting duct at the other end.

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4
Q

What is the name for the mesonephric duct later in development?

A

Th wolffian duct: it diasppears in women.

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5
Q

Where do the gonads develop?

A

They develop at the top of the mesonephric duct. In males the wolffian ducts stay around, in females the muellerian ducts show up and become the ovaries, uterus and 2/3 of vagina.

In males the spermatacord grows and descends into the scrotum via the inguinal canal.

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6
Q

How is the cloaca partitioned?

A
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7
Q

What do the nonspecific genital features of a foetus end up as in a male and a female?

A
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8
Q

What are the nonspecific (undifferentiated) genital features in a foetus?

A
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9
Q

Define nephrolithiasis

A

The presence of kidney stones in the kidney

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10
Q

What are the diagnostic possibilities for hemturia?

A
  • stones
  • infections
  • tumours
  • GN
  • trauma
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11
Q

In order to measure blood in the urine, what do dipsticks actually measure?

A

hemoglobin

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12
Q

Blood on the dipstick has to be _______ before being considered microhematuria

A

confirmed by microscopy

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13
Q

What do dysmorphic vs. regular RBCs in the urine tell you?

A

Dysmorphic: glomerular origin

Morphic: distal-to-glomerular orgina

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14
Q

How much protein is present with tumours/stones/infections/trauma/glomerular nephritis?

A

Lots of protein with glomerular nephritis

Not very much protein with anything else

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15
Q

What does initial vs. total hematuria suggest?

A

Initial: bleeding from urethra or prostate (BPH is often intial blood)

Total: bleeding from bladder or above

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16
Q

What does painless vs. symptomatic hematuria suggest?

A

Painless: BPH or malignancy, GN

Symptomatic: stones, trauma, infection

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17
Q

In the context of hematuria, what does fever suggest? Dysuria/frequency/urgency? Renal colic?

A

Fever: prostatits, pyelonephritis, UTI

Dysuria/frequency/urgency: inflammatory disease involving the bladder

Renal colic: acute obstruction of the ureter

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18
Q

________ is warranted in every case of hematuria

A

imaging!!!! (except in young women with a known cause, like bacterial cystitis)

-cystoscopy for the bladder and CT-KUB or CT-IVP or U/S for the kidneys and ureter

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19
Q

In smokers, what is the risk of RCC and urothelia carcinoma (TCC)?

A

4x greater for TCC

2x greated fro RCC

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20
Q

What is the classic triad of RCC?

A

Flank pain

hematuria

palpable mass

(only seen in 10% of patients these days)

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21
Q

What does the paraneoplastic syndrome for RCC include?

A

anemia

hypertension (renin)

polycythemia (Epo)

hypercalcemia (PTLH)

Stauffer syndrome (elevated liver transaminases)

Cushings

Coagulopathy

weight loss

fever

and so much more….

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22
Q

What are treatment options for primary RCC?

A
  • surgery (radical or partial nephrectomy)
  • if not surgical candidate, radio frequency ablation or cryotherapy with molecular therapy (VEGF inhibitors, mTOR inhibitors)
  • no radiation (except brain/bone mets), no convetional chemo or immunotherapy
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23
Q

What are the main types of kidney cancer and bladder cancer?

A

Kidney

  • renal cell carcinoma (90%)
  • urothelium carcinoma (TCC)

Bladder

  • urothelium carcinoma (95%)
  • squamous cell (5%)
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24
Q

What are risk factors for bladder cancer? Kidney cancer?

A

Kidney

  • smoking
  • obesity
  • heavy metals, asbestos
  • renal failure
  • genetic (von hippel lindau syndrome, tuberous sclerosis)

Bladder

  • somking
  • azo dyes
  • long-term cyclophosphamide
  • anagesic abuse nephropathy
  • prior radiation
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25
Types of bladder TCC (urothelial carcinoma)?
- papillary (non invasive) - flat carcinoma in-situ - invasive
26
In the DDx for flank pain, what do you NOT want to miss?
abdominal aortic aneurysm rupture AA dissection ectopic pregnancy appendicitis
27
Common sites of obstruction along the ureter?
* ureteropelvic junction (UPJ) * crossing of iliac * ureterovesical junction
28
What size of stone will probably pass spontaneously?
\<0.9 cm (~20%... but percent goes up as the stone gets smaller) \*\*time frame for passing the stone is days to weeks\*\*
29
Types of kidney stones
calcium oxalate (most common) calcium phosphate urin acid cysteine struvite (urease producing bacteria) others....
30
How to differentiate GN from malignancy?
GN: more likely with proteinuria, HTN and edema, dysmorphic RBCs and RBC casts BOth painless and tea-colored urine
31
How does the field effect apply to bladder cancer?
Very likely to recur because the whole field of tissue (the bladder) has been exposed to the carcinogen.
32
Risk factors for the five most common kidney stones
calcium oxalate (most common) * dietary oxalate, hypercalciuria calcium phosphate * hyperparathyroidism * RTA urin acid * gout cysteine * autosomal recessive condition struvite * infection with urease producing bacteria (e.g. proteus, klebsiella, pseudomonas, staph,
33
Just know
34
Just know
35
just know
36
just know ...cysts are anechoic (fluid filled)
37
What does this CT-KUB show?
a stone!!!
38
What are the different kinds of CT scans you would use for hematuria and why?
CT-KUB: no contrast, used for suspected stone CT-IVP: has contrast, used for stones and masses (?) CT- renal mass: has contrast, used to differentitate renal masses (e.g. enhancing?)
39
When would you use an MRI for hematuria?
- contrast allergy - pregnancy Pros: no radiation Cons: expensive. slow, can't use with metal implants
40
What do you do when you have: hematuria with a history of trauma?
CT+ Iv contrast
41
What do you do when you have: hematuria + pain suggestive of renal colic?
Send for CT-KUB
42
What do you do when you have: hematuria +flank pain + fever?
U/S first line. If mass --\> CT-renal mass If obstruction --\>CT- IVP
43
What do you do when you have: painless hematuria?
U/S to rule out stones If mass --\> CT- renal mass If no mass --\> CT-IVP If renal casts --\> nephrologist --\> biopsy
44
What is this? What are the typical features?
Renal calculus. Bright, echogenic spot with acoustic shadow behind it.
45
Which calculi are radioopaque and radiolucent?
Radioopaque: calcium oxalate, calcium phosphate, struvite Radiolucent: cysteine, uric acid, others (indinavir, matrix....)
46
C'est quoi?
a solid mass
47
DDx of a solid renal mass
Malignant * renal cell carcinoma * urothelial carcinoma * lymphomas * mets Benign * angiomyolipoma * oncocytoma Renal infarct Renal abcess
48
just know
49
What is this?
Angiomyolipoma
50
C'est quoi?
horseshoe kidney
51
What is multicystic dysplastic kidney?
Happens when the uretic bud doesn't interact probably with the metanephric mesenchycme...bilateral is incompatible with survival.
52
What is UPJ obstruction and how does it happen in babies?
The ureter is constricted at the ureteropelvic junction eitehr by abnormal smooth muscle developent, or an aberrant crossing vessel ...causes hydronephrosis, loss of renal function
53
What is ureter duplication and how does it happen?
When two uretic buds form instead of one. Results in two ureters and two collecting systems. Often one of them gets obstructed
54
What is ureterocele?
Dilation of the terminal ureter. Most often associated with duplicated ureter \*\*can cause obstruction
55
What is the more common fusion abnormality of the kidney?
Horseshoe kidney! "Two metanephric blastema are not separated" 7% of Turner Syndrome patients have this
56
What is vesicoureteral reflux?
Retrograde movement of urine. Results from an abnormally short uretic bud that cannot be pinched off effectively during voiding. --\> pyelonephritis
57
What are posterior urethral valves? Who has this?
Affects boys.. it's a membranous fold in the posterior urethra that can obstruct urine. Severe PUV can cause in utero renal failure --\> oligohydramnios
58
What is hypospadias?
abnormal development of the genital tubercle. The urethral meatus is in the ventral side of the penis somewhere between the penis and the proximal part of the glans. Also will have incomplete foreskin
59
What is cryptorchidism?
Undescended testicle(s). Failure to descend (or only partial descent from abdomen to scrotum (--\>testicular cancer, subfertility)
60
What is CAH, what does it result in for female and males?
Congenital adrenal hyperplasia: ends up in the overprodcution of androgens because one of the other cholesterol containing pathways is ineffective, so precursor is shunted to the androgen pathway. Rarely it results in underproduction Females: virilization of the external genitalia (no effect on internal genitalia) Males: if under-production, under-virilization
61
How does sex develop?
Default is female. Sex hormones are responsible for external genitalia, mullerian inhibiting factor influences internal organs.
62
What is renal agenesis?
When a kidney fails to develop. Some genes associated, most probably multifactorial. One possibility is the left kidney bud migrated to the right side and fusing with the right kidney.
63
What is the embryologic origin of the nephron, the collecting system, the trigone of the bladder and the rest of the bladder?
Nephron: metanephric mesenchyme (AKA metanephrogenic blastema)(mesoderm) Collecting system: uretic bud (mesoderm) Trigone: uretic bud (mesoderm) Rest of bladder: endoderm
64
Anatomic locations for hematuria
Kidneys (glomerular or post-glomerular), ureter, bladder, prostate, urethra, menstruation (in women)
65
What are is an etiologic DDx of hematuria?
"Medical" * medications/foods * infection * coagulopathies * glomerular nephritis * congenital anomalies "Surgical" * nephrolithiasis * tumour (benign or malignant) * trauma
66
What is the timing you would expect for blood originating from the bladder or prostate?
early
67
What is the timing you would expect for blood originating from the bladder neck?
late
68
What is the timing you would expect for blood originating from ureters/kidney?
total
69
What would alert you that hematuria is from a systemic instead of a GU cause?
Myoglobin/hemoglobin could be from crush injuries Fever Sepsis History of infection Bleeding elsewhere (nosebleeds, rectal, INR, PTT etc..) Pain (renal colic? flank pain?) Constitutional symptoms (weight loss, night sweats) Medication (ASA, statins..) Malignancy risk factors (smoking, occupational, FHx, radiation, cyclophosphamide Tx) Proteinuria (present --\>glomerular nephritis)
70
What blood/urine tests to order with hematuria?
* CBC/Diff (infection?) * Hb (loss of blood) * Urinanalysis (proteins..) * Microscopic analysis of urine (RBCs, WBCs, casts, crystals) * urine culture (infection) * urine cytology (malignancy) * PTT, INR, platelets (coagulopathy) * creatinine (renal function
71
What signs/symptoms/findings would you expect for renal colic?
* SEVERE, paroxysmal flank pain, maybe radiating to the groin * Writhing/inability to sit still * gross or microscopic hematuria * nausea +/- vomiting
72
What signs/symptoms/findings would you expect for bladder cancer?
* Painless total hematuria * Constitutional symptoms (fatigue, wt loss, fever) * You'd be able to see it on cystoscopy
73
What signs/symptoms/findings would you expect for kidney cancer?
- hematuria - flank pain/ CVA tenderness - palpable mass - paraneoplastic syndromes (Stauffer, hypercalcemia, anemia, HTN, polycythemia)
74
What is the big advantage of CT and MRI over U/S?
Better spatial resolution!!
75
What does a retrograde IV pyelogram show you?
The upper urinary tract.. the patency of the tract, whether it is blocked etc...
76
What are stone inhibitors in the urine?
citrate, magnesium, RNA...other things
77
What is the initial treatment of acute renal colic?
Pain/Nausea management * narcotics * NSAIDS (inhibit prostaglandin) * anti-emetics Hydration Anti-spasmotics (alpha blockers) Antibiotics * if infection is suspected, BUT hematuria +pyuria alone do not suggest infection--\> wait for the urine culture to come back
78
Is hydronephrosis with nephrolithiasis an emergency?
No. All stones have some degree of hydronephrosis.
79
Why isn't IVP used anymore?
* Time consuming (requires laxative preparation) * Anatomic detail not as good as CT * contrast is nephrotoxic
80
Options for th surgical treatment of large stones?
Extra-corporeal shock wave lithotripsy Retrograde ureteoscopy (lithotripsy, basket extraction, stent insertion) Percutaneous antegrade nephrolithectomy

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