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PATH2420 > Week 9 - Diseases of the Kidney and Urinary Tract > Flashcards

Week 9 - Diseases of the Kidney and Urinary Tract Flashcards

1
Q

Where are the kidneys located?

A

the retroperitoneum, mid-back; protected by lower ribs

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2
Q

The kidney’s are essential for life and receive approx. what percentage of blood supply from the heart?

A

25%

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3
Q

What is the function of kidneys?

A

-Filter blood into urine, excreting waste products
-Regulation of water, salt, calcium, phosphorus, blood pH, and others
-endocrine function
o Renin: regulation of blood pressure
o Erythropoietin: regulation of red blood cell production
o Regulates vitamin D metabolism

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4
Q

What are the 4 main microscopic components of the kidney?

A
  1. Glomerulus
  2. Tubules
  3. Interstitium
  4. Blood vessels
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5
Q

What is the functional unit of filtration?

A

Glomerulus (Glomeruli)

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6
Q

Describe the glomerulus

A

-Tuft of capillaries, with afferent (inward) and efferent (outward) arterioles
-Capillaries are lined by glomerular basement membrane (GBM)
-Surrounded by double lining of epithelial cells, called the Bowman’s capsule
-Bowman’s space is between the epithelial layers, and is also known as the urinary space
-The capillary endothelial cells contain fenestrations (sieve-like holes)
-Allows passage of fluid and small molecule (water, electrolytes)
-Restricts passage of larger molecules (proteins) and blood cells
-Glomerular basement membrane (GBM) surrounds endothelial cells
-Aids in filtration, as physical barrier, and charge barrier
-The GBM and endothelial cells are then surrounded by podocytes
-Podocytes contain foot processes with filtration slits

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7
Q

Describe filtration in the glomerulus

A
  • Blood in capillary space passes through:
    o Fenestrations in capillary walls
    o Glomerular basement membrane
    o Podocyte filtration slits
  • Fluid now in the urinary space (Bowman’s space) needs to be concentrated; enters the proximal convoluted tubule
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8
Q

Describe the urinary system

A
  • Urine is emptied from collecting system into the renal pelvis
  • Travels down the ureter into the bladder
  • Exits via the urethra
  • Renal pelvis, ureter, bladder is lined by urothelium
    o 5-7 layers of epithelial cells
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9
Q

How is urine concentrated?

A
  • From the renal corpuscle, fluid enters the proximal convoluted tubule
  • PCT has resorptive and secretory abilities
    o Specialized epithelial cells reabsorb about 2/3 of the filtered salt and water
    o Also resorb other molecules (glucose, amino acids, potassium, urea, etc.)
  • Filtrate enters loop of Henle after proximal tubule
    o U-shaped tube which creates concentration gradient in the kidney
    o This allows further reabsorption of water and salt (across the gradient)
  • Filtrate enters distal convoluted tubule and then collecting ducts
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10
Q

What is the most common malignancy of the kidney?

A

Renal cell carcinoma

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11
Q

What percentage of adult cancers is renal cell carcinoma?

A

3%

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12
Q

What is the typical demographic for renal cell carcinoma?

A

Typically older patients (ages 50-60s) and more common in males (M:F ratio is 2:1)

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13
Q

What are the risk factors for renal cell carcinoma?

A

o Tobacco Smoking
o Obesity
o Hypertension
o Unopposed estrogen
o Exposure: asbestos, petroleum products, heavy metals
o Chronic kidney disease and acquired cystic disease
o Rarely can be related to syndrome/familial condition

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14
Q

What are the classic triad of renal cell carcinoma (presents in 10% of patients with larger tumours)

A

-Flank pain
-Palpable mass
-Hematuria (may be microscopic)

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15
Q

Describe the presentation of renal cell carcinoma?

A
  • Classic triad
  • May present with fever, feeling unwell, weakness, weight loss
  • Most tumours are discovered incidentally by imaging
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16
Q

How is renal cell carcinoma treated?

A

Surgery - nephrectomy - partial or total (removal of kidney)

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17
Q

How does RCC present macroscopically?

A

yellow with areas of hemorrhage (red; photo of mass shown)

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18
Q

How is prognosis of RCC based?

A

On staging and tumour subtype

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19
Q

Is it uncommon for metastasis to be present when RCC is discovered?

A

No

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20
Q

What is the most common malignancy of the bladder?

A

Urothelial Carcinoma

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21
Q

What are the risk factors for urothelial cancer?

A

o Cigarette smoking (most important)
o Industrial exposure to some chemical compounds (aryl amines)
o Parasitic infection (Schistosoma haematobium)
 Seen in endemic areas (Egypt, Sudan)
o Drugs - Long term analgesics, heavy long-term exposure to immunosuppressive drug
o Irradiation (usually many years later)

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22
Q

What is the typical demographic for urothelial cancer?

A
  • More common in males (M:F ratio 3:1)
  • More common in older patients (aged 50 to 80s)
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23
Q

Where does urothelial carcinoma arise?

A

urothelium (epithelium lining the urinary tract)
o May occur in renal pelvis or ureter

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24
Q

How does Urothelial Carcinoma present?

A
  • Most often painless hematuria
  • Sometimes urinary symptoms
    o Urinary frequency
    o Burning with urination
    o Urinary urgency
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25
Q

UC can be Low grade or High grade, describe Low grade urothelial carcinoma

A

o Slow growing
o Papillary
o Minimal atypia
o Frequently recur
o Usually not aggressive
o Rarely invasive

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26
Q

UC can be Low grade or High grade, describe High grade urothelial carcinoma

A

o More aggressive
o May be flat or nodular
o High recurrence rate
o More atypical
o More likely to invade
o May metastasize

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27
Q

What is the treatment for urothelial carcinoma?

A
  • For low grade, non-invasive, or minimally invasive tumours
    o Local excision, often repeated numerous times as recurrence is common
    o For more extensive tumours: intravesical chemotherapy or BCG
  • For high grade or muscle invasive tumours
    o Cystectomy (resection of the bladder)
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28
Q

Describe pyelonephritis?

A

inflammation of the kidney - usually an infection of the kidney - it is a common disease affecting the kidney and can be divided into acute or chronic pyelonephritis.

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29
Q

Acute pyelonephritis is usually a _____ infection of the kidney

A

Bacterial

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30
Q

What are the symptoms of acute pyelonephritis?

A

o Fever
o Flank / back pain
o Nausea / vomiting
o Associated bladder infectious symptoms such as:
 Pain with urination
 Urinary frequency
 Urgency

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31
Q

What is often the cause of acute pyelonephritis?

A
  • Usually due to bladder infection
    o Ascending infection
    o May be due to obstruction or reflux
  • May be due to spread in the blood
    o Hematogenous
32
Q

What are the risk factors for acute pyelonephritis?

A
  • Urinary tract obstruction
  • Instrumentation (indwelling catheter)
  • Vesicoureteral reflux
  • Pregnancy
  • Gender and age (often young females)
  • Diabetes
  • Immunosuppression / immunodeficiency
33
Q

What is the treatment of acute pyelonephritis?

A

antibiotics (usually resolves)

34
Q

How do you diagnose acute pyelonephritis?

A

urine culture, or urinalysis is also informative

35
Q

How do you diagnose acute pyelonephritis?

A

urine culture, or urinalysis is also informative

36
Q

Describe chronic pyelonephritis

A

Chronic inflammation and scarring of the kidney

37
Q

What are the causes of chronic pyelonephritis?

A

o (Long term) Reflux
o Long term obstruction
o Recurrent infection

38
Q

What are the typical ascending infectious agents responsible for acute pyelonephritis?

A

 E. coli
 Proteus
 Enterobacter (all commonly found in bowel flora)

39
Q

Describe acute renal failure

A

occurs over hours to days
- Can be reversible if underlying cause is treated

40
Q

Describe chronic renal failure

A

occurs over prolonged time
- Progressive, irreversible destruction of kidney
- Loss of function
- May have no symptoms until late in disease course

41
Q

List the causes of acute renal failure

A

Pre-renal: a process that results in decreased blood flow to the kidney
- Decreased BP (especially rapid)
- Dehydration
- Severe hemorrhage
Renal: process involving damage to the kidney
- Drugs, toxins, infection, inflammation, ischemic acute tubular injury, acute glomerulonephritis
Post-renal: obstruction of flow of urine
- Kidney stones

42
Q

List the causes of chronic renal failure

A

Pre-renal
- Hypertension, diabetes, vasculitis
Renal
- Primary glomerular diseases
- Chronic tubulointerstitial disease
Post-renal
- Chronic urinary tract obstruction (enlarged prostate, malignancy)

43
Q

What are the signs and symptoms/clinical presentation of renal failure?

A
  • Azotemia (increased blood urea nitrogen [BUN] and creatinine)
  • Edema / swelling
  • Electrolyte disturbances
  • Metabolic acidosis (low blood pH)
  • Anemia (low hemoglobin)
  • Hypertension
  • Bone disease
44
Q

Describe end stage renal disease

A
  • Eventual end point of kidney diseases
    o Especially if left untreated or poorly treated
  • Sclerosis of glomeruli
  • Scarring/fibrosis of interstitium
  • Loss of tubules (tubular atrophy)
  • Chronic inflammation
  • Thickened arteries
45
Q

What is the treatment for renal disease?

A
  • Lifestyle modification
    o Balanced diet, avoid sodium, potassium, phosphate
    o Exercise
  • Medication
    o Control hypertension and diabetes
    o Diuretics to help with fluid balance
    o Specific medications to treat underlying kidney disease
  • Dialysis when kidney function declines to end stage renal disease
  • Kidney transplant
46
Q

Define renal disease

A

A condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance.

47
Q

Define glomerulopathy

A

Glomerulopathy is a set of diseases affecting the glomeruli of the nephron.

48
Q

Describe diseases of the glomerulus (glomerulopathy)

A
  • Important cause of renal disease
  • Glomerular disease will affect the rest of the kidney
  • Can be divided into primary and secondary glomerulopathies
  • Results in damage to glomerular basement membrane
    o Impairs filtration
49
Q

Describe the mechanism of glomerular injury

A
  • Most often due to abnormal immune mechanisms
    o Antibodies reacting in situ within the glomerulus
    o Deposition of circulating preformed antigen-antibody complexes within the glomerulus
50
Q

Define primary glomerulopathies

A

affect the glomerulus alone or primarily

51
Q

Define secondary glomerulopathies

A

systemic diseases (affect multiple organs), which affect the kidney
o ex. Diabetes, systemic lupus erythematosus, vasculitis

52
Q

Describe the manifestations of glomerular injury

A
  1. Nephritic syndrome (hematuria, azotemia, variable proteinuria, oliguria, edema, hypertension)
  2. Nephrotic syndrome (proteinuria >3.5 g/day, hypoalbuminemia, hyperlipidemia, lipiduria)
53
Q

What is the most common cause of acute renal failure (acute kidney injury)?

A

acute tubular injury/necrosis

54
Q

Most forms of tubular injury also involve/affect what

A

the interstitium

55
Q

What are the common causes of tubular injury/necrosis?

A

o Ischemia: decreased or interrupted blood flow
 Often due to decreased blood volume
o Toxic injury to tubules
 Endogenous agents: myoglobin, hemoglobin, monoclonal light chains, bile
 Exogenous agents: drugs, radiocontrast dyes, heavy metals, organic solvents

56
Q

Acute tubular injury/necrosis happens because tubule cells are sensitive to what?

A

ischemia and vulnerable to toxins

57
Q

What is a major cause of end stage renal disease?

A

hypertension

58
Q

Vascular diseases of the kidney are due to what?

A
  • Atherosclerosis
    o Narrowing of arteries due to plaque buildup
    o Leads to decreased blood flow to the kidney
    o Kidney atrophy
    o Chronic kidney failure
    o Risk of thromboembolism (clot), with renal infarct
  • Hypertension
    o Major cause of end stage renal disease
    o Leads to nephrosclerosis (sclerosis of renal arterioles, small arteries
    o Scarring of glomeruli
    o Chronic tubulointerstitial injury
    o Decrease in renal mass
    o Decline in renal function
59
Q

What is the general clinical course for patients affected by ATI (acute tubular injury)

A
  • Initial inciting event – medical or surgical event
  • Decreased urine output
  • Rise in BUN and creatinine
  • Electrolyte abnormalities and metabolic acidosis
  • Urine volume increases with recovery
    o Loss of water, sodium, potassium as tubules are still damaged
  • Outcome related to magnitude and duration of ATI
  • Most patients who survive initial event recover completely
60
Q

Urine exits bladder via what?

A

urethra

61
Q

Ureters and bladder are lined by what?

A

urothelium (5-7 layers)

62
Q

What is urinary tract reflux called?

A

Vesicoureteral reflux (urine from bladder into ureters)

63
Q

List the complications of vesicoureteral reflux

A

o Urinary tract infection, pyelonephritis
o Hydroureter/hydronephrosis
o Chronic renal failure (if advanced)

64
Q

What is the cause of vesicoureteral reflux?

A
  • May be due to anatomical defect (often congenital)
65
Q

What is the treatment of vesicoureteral reflux?

A

o Conservative treatment: some cases will resolve as child grows
o Surgical reimplantation of ureter

66
Q

What is the treatment for urinary tract stones?

A
  • Wait for stone to pass
    o Drink fluids
    o Pain management
  • Lithotripsy (sound waves shatter stones)
  • Surgical removal
67
Q

Urinary tract stones are commonly called what?

A

kidney stones

68
Q

Someone presents with abdominal pain and hematuria, what is the likely diagnosis and what will aid in diagnosing?

A

Urinary tract stones, and imaging (ultrasound, X-ray, CT scan)

69
Q

Describe the presentation of someone with urinary tract stones

A
  • May be asymptomatic
  • May cause severe renal colic, abdominal pain
  • May cause significant kidney damage
  • Hematuria (blood in urine)
70
Q

Urinary tract stones predispose patients to what?

A

infection

71
Q

Most urinary tract stones form where?

A

kidney

72
Q

Urinary tract stones are composed of what?

A

calcium oxalate/calcium phosphate (most common), struvite (magnesium ammonium phosphate), uric acid, cystine

73
Q

Urinary tract stones affect who more commonly?

A

men more than women and those 20-30 years old

74
Q

Urinary tract obstruction can be what?

A
  • Intrinsic (lesions of urinary tract)
    o Stones
    o Congenital / acquired strictures
    o Tumors of urinary tract
    o Functional disorders (often neurogenic)
  • Extrinsic (external compression)
    o Pregnancy
    o Inflammation/scarring of surrounding organs
    o Tumours in surrounding organs
75
Q

What is the clinical presentation of someone with urinary tract obstruction?

A
  • In acute obstruction, often have flank pain (renal colic)
  • Unilateral/partial obstruction may be asymptomatic
    o Unaffected kidney can maintain renal function
  • Chronic obstruction results in chronic kidney disease
  • Predisposition to bacterial seeding and urinary tract infections
    o Obstruction
    o Urinary reflux
    o Urinary stasis

PATH2420 (12 decks)

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