1
Q
What are the two main purposes of the kidneys?
A
- filter nitrogenous products of metabolism from the blood
2. maintain water and electrolyte homeostasis
2
Q
The kidney produces two hormones that have nothing to do with its excretory function. What are they ?
A
- erythropoietin: stimulates bone marrow to produce RBD
- active form of Vit D that the kidney makes from the inactive form consumed in the diet or formed by the skin on exposure to sunlight.
3
Q
What are the two distinct zones in a kidney?
A
- outer layer called the cortex
2. an inner layer called medulla.
4
Q
The cortex is composed of 1 milion nephrons. Filtration takes place in the nephron of the kidney, which has two parts…what are they?
A
- the flomerulus
2. the tubule
5
Q
The walls of golerular capillaries are composed of 3 layers of cells. Define them
A
- endothelial layer: allows passage of proteins through openings called fenestrae
- the basement membrane: traps the lager proteins molecules and does not allow them into the filtrate
- Epithelial layer: compose of modified epithelial cells called podocytes. They have a number of radiating foot-like processes and slit diaphragms that form narrow channels that futher restrict the molecules that pass into the filtrate.
6
Q
What do you call the capsule that surrounds a glomerulus? And the space within the capsule surrounding the glomerulus?
A
Bowman’s capsule
Bowmans space
7
Q
Where does the two-step filtration process of waste products take place in the kidney?
A
It is in the nephrons of the kidney
8
Q
Define the two-step filtration process.
A
- capillaries of the glomeruli filter 120-180 liters of fluid per day. This glomerular filtrate, flow’s into Bowman’s capsule that surrounds the glomerular tuft.
- The filtrate flows into the tubule where the other step of filtation occurs- which involves reabsorption of the filtrate .
This concentrated fluid remains in the urine.
9
Q
What action forces urine downward from the kidney through the ureter to the bladder? What stops urine from flowing back-upwards
A
Peristaltic contractions.
Sphincter muscles at the ureterovesical junction
10
Q
What hormones are used to control the amount of salt and water that are reabsorbed by the kidneys during the filtration process?
A
- ADH- produced by the pituitary when the blood concentration of sodium rises. IT acts on the kidney to retain water until the concentration of sodium falls to normal. It is controlled by the hypothalamus
- Aldosterone causes the kidney to retain sodium, its produced from the adrenal gland and is controlled by the hypothalamus.
- Renin- produced by the kidneys, triggers the formation of angiotensin in the bloodstream when the blood volume or blood pressure falls. This controls salt levels and HTN. This is activated when the kidneys are not getting enough blood.
11
Q
What is the most common evidence of renal disease in terms of abN production of kidneys?
A
There is an excess amount of protein being products: ie: Proteinuria in a 24hr collection.
12
Q
What are two common benign causes for proteinuria
A
- exercise, fever, stress, excessive cold, vaginal contamination
- orthostatis proteinuria- condition in which individual has proteinuria when upright and does not occur when pt is in supine.
13
Q
Define microalbuminuria
A
Small amount of albumin in the urine,
14
Q
Define hematuria and the difference bertween gross and microscopic
A
RBC or frank blood in the urine
gross indicates the blood can be seen with the naked eye
micro indicates that the RBC can be seen with microscope
15
Q
What are the 5 most common causes of hematuria?
A
- stones
- nephritis
- tummors - bening/malignant
- prostate disease
- benign familial hematuria
- menstruation can cause isolated hematuria.
16
Q
What is Pyuria and what causes it?
A
the presence of WBC (pus) in the urine.
caused by infection or inflammation ie: cystitis, urethritis, or prostatitis
17
Q
when do you see casts?
A
they are formed when a protein produced by nephrons gels around whatever is in its vicinity.
can be RBC, WBC, or granular casts or fatty casts.
18
Q
What is a hyaline cast?
A
empty casts,- just the gelled protein.
19
Q
Name the most common cause for the following cast presence:
- RBC cast
- WBC cast
- Epithelial casts
- granular casts
- fatty casts
- waxy casts
A
- glomerulonephritis
- inflammatory conditions, glomerulonephritits, pyelonephrotos, interstitial cystitis
- nephritic syndrome, tubular injury, glomerulonephritis
- glomerulonephritis
- nephritic syndrome
- advanced renal failure
20
Q
Define the term Dysuria
A
discomfort on urination, used to refer specifically a burning sensation felt in the urethra on urination.
usually a sxs of urethritis and/or cystitis
21
Q
What is meant by the term retention?
A
bladder being incompletely emptied at each voiding.
Caused by prostate enlargement, neurlogical disease, DM, cystocele, and some Rx.
22
Q
Define Azotemia, and its cause
A
Refers to an elevation of blood urea nitrogen (BUN) and creatinine levels.
- intrarenal causes
- pre-renal causes d/t failure of blood to reach kidney for filtration
- post renal cause - d/t obstruction to urinary flow after it leaves the kidney
23
Q
What is Uremia?
A
the condition resulting from the advances stages of kidney failure.
sxs secondary to renal damage: anemia, weight loss, weakness, nausea and vomiting, excessive bleeding, edema, convulsions, coma.
24
Q
What is Oliguria and its causes?
A
decreased urine output. <500ml in 24 hr.
- dehydration
- total urinary tract obstruction
- severe infection leading to shock
- medications
25
What is Anuria?
Clinically less than 100ml of urine in 24 hrs.
| caused by drop in BP, d/t shock or hemorrhage or possibly obstruction.
26
What is renal colic?
Sharp pain in back/groin caused by spasm of the ureter as a stone is being forced from the kidney to the bladder.
27
How does one characterize nephrotic syndrome?
Heavy proteinuria accompanied by edema, hyperlipidemia, hypercoagulability, and hypoalbuminermia.
>> The glomeruli are damaged and therefore cause them to be more permeable to protein molecules
28
What testing can be done through a blood test to determine Renal problems/
1. BUN- depends on the kidneys efficiency and amount of protein consumed.
2. Creatinine- measures kidney function,
3. creatinine clearance- volume of plasma cleared of creatinine per min. (usually requires 24 hour collection)
4. Cystatin C - sensitive early marker for chronic kidney disease
29
What is creatinine
Waste product of muscle metabolism
30
What is cystatin C
a protein that inhibits the action of substances that break down proteins in the body. It is filtered in the glomeruli. then reabsorbed. If the kidneys are not functioning these levels are increased.
31
What is KUB?
An xray of the abdo (Kidney, ureter, bladder).
| May show stones
32
What is a cystoscopy?
allows for a direct look inside the bladder and urethra, it is also used to inspect the prostate.
used to delinate many bladder conditions such as infection, hematuria, adbomal cells in urine samples or painful urination
33
What is IVP and what is it used for?
IVP= intravenous pyelogram
procedure where iodine-containing substance is injected and an Xray is used to watch it pass through the kidneys.
- the speed in which the substance is excreted allows meaure of kidney funciton and comparison
34
What is a Retrograde Pyelogran
A small catheter is placed in a ureter, dye is injected through the catheter and xrays taken.
- used when pt is allergic to IV contact in IVP.
35
What are Renal scans?
similar to IVP but substance that kidney is excreting is labeled with radioactive isotope and scan is done with gamma camera. '
used to show blood flow and organ function.
36
What is ultrasonography of the kidneys
painless, noninvasive procedure that uses sound waves to delineate structures in the urinary system.
detect: hydronephrosis, kidney stones, diffuse renal disease and other abN.
]differentiates between solid cystic lesions.
37
What is CT scanning used to detect
| ?
dx kidney and uretral stones, pyelonephritis, urinary obstruction and malignancy
38
What is MRI used to detect>
staging renal cancers, evaluating renal masses seen on CT or u/s and evaluate renal vascular disease.
39
What is renal angiography and why is it used?
speclialized xray of blood vessels of the kidneys. Contrast medium, introduced into the blood stream by catheter, to show renal arteries to be better seen on X-ray.
used for tumors, blood clots, stenoses, aneurysms of the renal artery.
40
What would you use the following tests for?
1. flow studies
2. urethral pressure recordings
3. cystometry
1. measure actual flow of urine
2. dx outflow obstruction
3. delineate total bladder capacity, ability to contract, initiation/ihibitation of voiding and the presence or absence of residual urine.
41
Infections of the lower urinary tract in females are usually in what form?
Cystitis or urethritis.
sxs are: frequency, dysuria, and sometimes hematuria.
tx'ed: abx
42
What are the typical causes of lower urinary infections in men?
urethritis or prostatitis
Urethritis: caused by specific infections or non-specific. >usually both contracted by sexual exposure
Prostatitis is caused by intestinal bacteria either acute: sxs similar to custitis or chronic.
tx'ed with abx
43
What is interstitial Cystitis?
syndrome of urinary frequency and severe irritative voiding sxs with no indication of infection-
dx: cystoscopy reveals inflammed and ulcerated bladder wall. biopsies required to rule out carcinoma insity.
affects: middle age females associated with incontinentce.
- tx'ed: Rx, or procedures (DMSO, bladder dilation, etc). varies in success. Can remove bladder as last resort.
44
What are some consequences of ulceration and inflammation of the bladder wall?
leads to
1. diminished capacity
2. hematuria
3. painful urination
45
What is vesicoureteral reflux ?
what causes it'?
Why is it bad?
1. a congenital disorder that allows the backward flow of urine from the bladder to the kidney.
2. Caused by abN of ureterovesical sphincter.
3. when urine moved up, bacteria in the bladder is transmitted to the kidneys causing persisten UTI, if not tx'ed can cause loss of renal function.
46
How is vesicoureteral reflux treated?
mild cases are usually self-corrected, surgical correction for severe causes
47
How is bladder cancer different from other cancers?
often viewed as a chronic disease necessitating lifelong surveillance. Its the most expensive to tx
Not all cancers are created equal, males have a higher prevelance but higher survival rate.
48
What are risk factors associated to bladder cancer?
1. SMOKING
2. age, ^ with age
3. race- caucasians have a high risk
4. gender
5. fx
6. personal hx (recurrance rate is ^)
7. chemo for other cancers, ^ risk
8. occupation- ^ risk with exposure to cacinogens.
49
Bladder cancer occurs in what forms? (order from most frequent to lease)
1. Transitional cell carcinoma (TCC) 95%
2. squamous cell (3%)
3. adenocarcinoma (2%)
4. small cell and others (<1%)
50
Define TCC.
can be superficial tumors growing on the bladder lining or they can be aggressive tumors prone to invade through the bladder wall and spread.
Superficial tumors are easily treatable, but have tendency to recur
51
How is bladder cancer treated>
1. removal of superficial tumor by curettage or laser ablation by cystoscopy, then check if muscle is invaded. biopsies taken.
2. instillation of therapeutic agents into the bladder
3. removal of the bladder.
52
Define Superficial bladder cancer
Confined to the transitional cell lining of the bladder
stage Ta and grade G1 are usually papillary tumors that grow outward into the bladder.
friable and bleed easily.
recurrant- not invasive
53
Define Carcinoma in Situ (CIS) of the bladder
always a high grade tumor,
agressive in growth patterns,
if untx'ed its a precursor to a lethal muscle infiltrating tumor
flat tumor- often difficult to find. liked to multiple papillary tumors
54
Define Invasive bladder cancer
When its found beyond the urothelium, in the lamina propria or muscle.
higher level of genetic abN than non-invasive.
55
After cancer bladder removal, intravesical therapy is done one a week for several weeks. What is this process>
filling the bladder wiht a solution containing treating agents. BCG, is the standard agent (its a bacterial organis), it triggers a local immune reaction that precents recurrance of bladder tumors.
Can also use thiotepa, mitoycin-C and doxorubicin.
56
Define the term neurogenic bladder
describe any dysfunction of the urinary bladder resulting from congenital abnormality, injury or lesions of the central or peripheral nervous system.
57
What causes neurogenic bladder?
1. MS
2. spinal injury or surgery
3. cerebral vascular disease
4. parkinsons
5. DM
6. meningomyelocele
7. amyotrophic lateral sclerosis (ALS)
8. disc herniation
9. pelvic surgery
58
What is meant by neurogenic bladder is dependent upon the level of the neurological disease and/or deficit?
the higher the spinal cord the causative lesion is, the most spastic the bladder is. Conversely, the lower the spinal cord lesion, the more flaccid the bladder is.
59
What is Acute Pyelonephritis?
caused by infection, often bilateral, of the pelvis parenchyma of the kidney.
- usually caused by intestinal tract bacterial
- beging with bacterial infection in the bladder, when there is obstruction or incomplete emptying, the bacterial multiple unabated. and will stay in the bladder unless theres backflow up the ureters.
dx: urine culture will show causative bacterium
- tx'ed with abx
60
What is hydronephrosis?
dilation of the renal pelvis and calyces due to obstruction to the outflow of urine.
if unilateral, it is often unnoticed since unaffected kidney remains function.
tx'ed with relief of obstructions. HTN or dimished renal function will con't after tx/
61
What typically causes urinary tract obstructions?
1. urinary stones
2. PBH
3. congenital abN
4. tumors
>> Complete obstruction willl cause acute renal failure
62
Define Congenital urinary tract abnormalities
congenital abN of the urogenital tract that arise as a result of a developmental defect that occurs during gestation.
Affects size, shape and or posisiton of kidneys.
Usually an incidental finding.
Only will tx if obstructing
63
What is Medullary Sponge Kidney?
| What are sxs?
A disorder in which the terminal collecting ducts that drain urine into the renal pelvis are dilated, which slows passage of urine from the kidneys.
sxs: Asxs, but can cause hematuria or pyuria.
tx: avoid dehydration to reduce risk of stones.
64
What is nephrocalcinosis?
a condition marked by calcium deposition in kidney tubules, parenchyma and sometimes glomeruli.
characterized by insidious onset and progression.
kidney stones often occur, and cause renal tubule obstruction, and causes atrophy in kidney cortext.
tx by reversing the hypercalcemia or causative of the disorder.
Kidney transplant is only option for sevvere renal insufficiency
65
What is nephrosclerosis?
results from prolonged existence of HTN, which causes atherosclerosis in the arteries wihtin the kidneys. Can be benign, senile or malignant
66
# Define:
1. benign nephrosclerosis
2. senile nephrosclerosis
3. malignant nephrosclerosis
1. asssociated with
67
What are the early signs for diabetic kindey disease?
DM pt are prone to develop diabetic nephropathy. Characterized by mild proteinuria then progresses to chronic renal failure.
Tx with ACE inhibitor to slow progression.
68
What are the two forms of Polycystic Kidney disease?
1. autosomal dominant polycystic kidney disease (ADPKD)
| 2. Autosomal recessive polycystic kidney disease. (ARPKD)
69
How id ADPKD characterized?
how is it dx'ed?
How it is tx'ed?
numberous cysts in both kidneys. The cysts, gradually increase in size until the replace all functioning tissues.
- different levels of expression of the disease
Dx: if Fx +ve, 3 cysts in each kidney is +ve dx. If no evidence of cysts by 30, will not later manifest
- Can also be dx'ed with genetic testing.
tx: None, dialysis or transplat will eventually be needed.
70
Kidneys affected by Polycystic kidney disease have grape-like clusters of cysts. Define these cysts
Contain clear watery fluid, blood, or pus. Between the cysts used to be normal tissue which is now obly atrophic sclerotic tissues.
71
What are 5 other conditions associated with PKD?
1, HTN
2. mitral valve prolapse
3. berry aneurysm of the circle of Willis
4. diverticula of colon
5. hiatal hernia
72
What are 5 characteristics that are associated with a more rapidly progressive ADPKD?
1. dx at young age
2. male gender
3. gross hematuria
4. HTN
73
Define ARPKD
rare- manifest in childhood. Cyst arise from the collecting ducts and are small than those seen with ADPKD.
kidney failure before adulthood.
congenital liver fibrosis also occurs.
- tx'ed with dialysis and transplant.
74
What is Alport syndrome
inherited disorder, manifests in early childhood with hematuria
characterized by sensorineural hearing loss and progressive nephropathy leading to renal insufficiency.
75
What is Benign familial hematuria?
Inherited in an autosomal dominant manner.
- most common cause of microscopic hematuria in Asxs pt with normal findings on urologic evalutation.
good prognosis
76
Nephrogenic Diabetes insipidus can be either acquired or inherited. What can cause the acquired disorder?
1. bloackage in urinary tract
2. high calcium levels
3. low potassium levels
4. certain drugs
77
Nephrogenic Diabetes insipidus can be either acquired or inherited. What can cause the inherited disorder?
X-linked recessive or an autosomal recessive manner.
78
how is Nephrogenic Diabetes insipidus characterized?
kidney tubules that do not respond to the antidiuretic hormone vasopressin. This causes a very large amount of dilute urine- leads to dehydration.
79
What is chronic pyelonephritis?
Chronic interstitial nephritis caused by recurrent or persistent infection of the kidney(s)
infections occur d/t anatomic abomaly in a pt's urinary tract. It causes obstruction of flow, or can be one that allows reflux of urine.
slow progression.
Causes scarring and contracting of the parenchyma over the damaged calyces.
80
What else can cause chronic pyelonephritis-type disorders
1. exposure to led or Ca
2. radiation
3. metabolic abnormalities
4. systemic disease.
81
What is Glomerulonephritis?
Refers to group of diseases that affect the structure or function of glomeruli and can be acute or chronic.
82
primary glomerulonephritis is an inappropriate immune response in the glomeruli and is due to what? (2)
1. antigen/antibody complexes becoming trapped in one or more layers of the glomerular capillary membrane
2. antibodies that are specifically directed agasint or are deposited on the basement membrane of the glomeruli
83
What can cause secondary glomerylonephritis? (7)
1. DM
2. immune-mediated disoders
3. infections
4. cancer
5. congential defects
6. medication
7. drug abude
84
How is Glomerulonephritis dx'ed?
By kidney biopsy. light microscopy will show the amount and type of glomerular involement
1. focal lesions = <1.2 glomeruli
2. diffuse lesions = 1/2->1/2 of the flomeruli
3. global lesions= all parts of the flomerulus
4. segmntal lesions =part of flomerulus
85
Whats the difference between immonofluorescence and electgron microscopy evaluation?
immonofluorescence demonstrates immune deposits
microscopy allows intracellular and basement membrane abnormalities to be seen.
membranous lesions = basement membrane is infiltrated
proliferative lesions = ^ in glomerular cell number
86
What is meant by the terms sclerosis and crescent?
used to describe specific abnormalities seen with some of the chronic glomerulonephropathies.
```
cresent= half moon collection of cells and matric material that accumulates in Bowmens space
scleoris = replacement of the delicate structure of glomerulu by collaging, mesangial matrix, and fibrous materials.
```
87
There are 9 types of glomerulonephritis. Name them
1. post-infection
2, IgA nephropahy (Berger's disease)
3, Minimal Change disease (Nil Disease)
4, Focal segmental glomerulosclerosis
5. anti-glomerular basement membrane disease/Goodpasture's syndrome
6. Renal Vasculitits,
7. membranous nephropathy
8. membranoproliferative flomerulonephritis
9. rapidly progressive glomerulonephritis
88
Define kidney stones
abN concretions, urually composed of mineral salts, which form in the urinary tracts. can form anywhere but usualy occur in the kidney.
if passed very small, theres no sxs but can be recongnized in urine as "gravel".
if they attach to the calyceal tissue, they will become larger
89
What are the four major types of renal stones?
1. calcium oxalate and/or phosphate (75%)
2. magnesium ammonium phosphate (15%)
3. uric acid (6%)
4. cystine (2%)
90
what is the usual cause of stone formation?
usually caused by increased urinary concentration of the offending mineral. The urine becomes supersaturated with the substance that then precipitates out of the urine and begins the stone formation process.
91
whats a stone former?
someone who passes stones repeatedly
| usually they have underlying condition responsible for the problem.
92
How are stones removed?
1. open surgery
2. cystoscopic basket
3. lithotripsy
a) ESWL- shock waves to shatter
b) percutaneous ultrasonic lithotripsy - shattered by ultrasound transducer and removed
c) laser- pulses of laser light to shatter stone.
93
How can someone prevent stones?
diet therapy, increase fluid intake, and tx with Rx to reduce particular types of stone formation.
94
How is acute renal failure (ARF) characterized?
1. rapid reduction of glomerular filtration rate
2. rapid rise of serum creatinine and BUN
3. reduced urine volume
95
Many cases of ARF caused by disroders outside the kidneys, that interfere with blood flow before it gets to the kidneys. What are the most common pre-renal causes?
1. volume depletion
2. congestive heart failure
3. advanced liver disease
96
Intra-renal causes of ARF are disorders that affect the integrity of the glomeruli or tubules, such as acute tubular necrosis (damage/blockage of renal tubules) or glomerulonephritis. How can injury to the tubules occur? (3 examples)
1. ischemia
2. endogenous toxing- heme from myoglobing resulting from ++ muscle damage or intravascular hemolysis, uric acid
3. exogenous toxins- radiocontrast media, platinum, aminoglycosides and other drugs.
97
How is ARF tx'ed?
if it last more than a few days- tx with dyalisys
98
Define chronic kidney disease, and how its characterized
occurs when there is permanent impauirment of the kidney function.
The classification of severity is based on the glomerular filtration rate (GFR) and is divided into stages, (1-5)
99
What are the most common causes for Chronic kidney disease?
diabetic nephropathy and glomerulonephritis, (1/3)
| other: vascular renal disease, chronic pyelonephritis and PKD
100
What are the sxs for chronic kidney disease?
until function has dropped by 50% there is few sxs.
| First ones are nocturia,
101
The rate of progression from CRF to ESRD can be greatly slowed with effective tx such as what?
1. control of blood sugars and use of ACE inhibitor in diabetics
2. control of blood pressure-
3. specific therapy for the renal disease causing CRF
102
what are the two types of dialysis methods?
1. hemodialysis: membrane is the dialysis machine
2. peritoneal dialysis: pt's peritoneum is used as the membrane.
both use a method of diffusion across a semi-permeable membrane to remove waste products from the blood. Impurities are pulled through the membrane by dialysate fluid .
Main cause of death is Cardiovasular disease.
103
What is kidney transplate
the surgical replacement of a diseased kidney with a donated kidney.
Best tx for End-stage renal failyre.
lifelong immunosuppresive therapy is required to prevent rejection of kidney.
Donor and recipient are matched by ABO blood group and HLA
104
What are the most frequent causes of death in kidney transplant recipients?
bacterial, viral, fungal or other infection.
some individuals will experience chronic graft rejection with progressive HTN and deteriorating renal function. Replantation may be required.
immunosupppressive drug are also associated with higher incidence of cancer.
105
What is nephrectomy and why is it done?
Removal of kidney d/t
1. chronic infection
2. trauma to kidney
3. renal cancer
4. tuberculosis
prognosis is good, if other kidney is fully functional.
106
What is cystectomy and why is it done?
removal of urinary bladder. Most common reason is advanced bladder malignancy. other causes:
1. intractable interstitial cytitis
2. incurable urinary tract infection in a dysfunctional bladder.
107
When a bladder is removed, another form of urinary diversion is constructed. What methods are available?
1. urostomy/ileal condiut- most common.
2. continent pouch
3. orthotopic neobladder- employed is urethra is not removed. usually may require catheter.
108
Are renal cysts of concern? why?
Not usually an issue, usually are found incidentally. If too big it may cause pain, and will need to be drained.
Yo'ull just need to confirm a benign cyst vs renal carcinoma, using an IVP with u/s.
109
Are benign tumors of the kidney common?
no, there are rare. Most solid tumors are malignant.
ALU 201
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