Block VII, Week VII

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is congenital mesoblastic nephroma benign or malignant, and in which age group is it MC found?: benign
MC found in children (at birth)
why must a congenital mesoblastic nephroma be removed?: 1. they are huge
2. very vascular (huge blood supply), cause a hemodynamic effect
what are the three components of a Wilm's tumor?: 1. blastema
2. primitive tubules
3. mesenchyme
why is a Wilm's tumor called an "index cancer?": because it occurs equally among all races and geographic distributions
are most renal tumors in adults benign or malignant?: malignant
(benign renal tumors are uncommon)
what three components make up an angiomyolipoma?: 1. fat
2. smooth muscle
3. thick-walled blood vessels
what disorder are angiolipomas commonly associated with?: tuberous sclerosis
is an angiolipoma benign or malignant?: benign
which benign renal tumor may acheive a very large size but never metastasizes?: oncocytoma
what is the differential diagnosis when considering an oncocytoma?: RCC
what is the MC renal neoplasm in adults?: RCC
what is the sex preference of RCC?: M:F = 3:1
RCC is MC diagnosed at what age?: 6th and 7th decade
when would RCC be seen in an individual under 40yrs?: if the following are present:
*von-hipple-Lindau syndrome
*sickle cell disease/trait
which variant of RCC is found in individuals with sickle cell disease/trait?: collecting duct variant
risk factor for RCC?: smoking
where in the kidney is RCC MC found?: poles
(unless von-hipple-Lindau, then it is found bilaterally)
why can RCC result in the complication of acute HF?: it tends to invade the renal vein
most RCCs have which histologic pattern?: normal clear cell/granular cell
the normal cell/clear cell variant of RCC is associated with what chromosomal abnormality?: 3p-
the basophilic variant of RCC tends to have what pattern?: papillary
chromosomal anomaly associated with the basophilic variant of RCC?: +7
+17
-Y
which variant of RCC is easily confused with an oncocytoma?: chromophobic variant
chromosomal abnormality associated with the chromophobic variant of RCC?: chromosome loss
what is the prognosis of the sarcomatoid pattern of RCC?: poor
what is the prognosis of the chromophobic and basophilic variants of RCC?: better than other forms of RCC
two common sites of RCC metastasis?: lung
bone
what 4 types of paraneoplastic syndromes can an RCC produce?: 1. polycythemia (EPO release)
2. hypercalcemia (parathyroid hormone release)
3. hypertension (renin release)
4. Cushings syndrome (ACTH release)
what is a common presenting sign of RCC, detected in the UA?: painless hematuria
what tests can be used for the clinical diagnosis of RCC?: XRay
CT scan
MRI scan
Surgical exploration
characterize carcinoma of the collecting duct: very aggressive, rapidly fatal within wks to months
carcinoma of the collecting duct is associated with?: sickle cell disease/trait
(CA usually manifests at a younger age if associated with this)
if a patient has a urothelial carcinoma of the renal pelvis, what else should we be looking for?: bladder cancer
(commonly coexist)
which two carcinomas are known as the "great masqueraders?": 1. RCC
2. melanoma
mets to the kidney are very uncommon. what other organ sees very little to no mets?: heart
what are the three buffering systems used to maintain a normal pH?: 1. Protein buffer system
2. Bicarbonate buffer system
3. buffering in skeletal muscle system
what is the main mechanism via which the kidney generates new bicarb used for pH buffering?: excretion of [H+] as NH4+
what are 4 causes of respiratory acidosis when the lungs and airway are normal?: 1. CNS depression
2. Neuromuscular impairment
3. ventilators
4. iatrogenic events
what are three causes of respiratory acidosis when the lungs and airway are abnormal?: 1. upper airway obstruction
2. lower airway obstruction
3. pulmonary perfusion deficit
4 causes of respiratory alkalosis?: 1. hypoxemia (hyperventilation)
2. stimulation of chest receptors?
3. CNS stimulation
4. Drugs
2 GI disorders that are causes of normal anion gap metabolic acidosis?: 1. pancreatic fistula
2. diarrhea
2 renal disorders that are causes of normal anion gap metabolic acidosis?: 1. renal tubular acidosis
2. aldosterone deficiency
four CATEGORIES of causes for high anion gap metabolic acidoses?: 1. uremia
2. ketoacidosis
3. toxins
4. lactic acidosis
three events that precipate ketoacidosis (which causes high anion gap metabolic acidosis)?: 1. diabetes
2. alcoholism
3. starvation
three toxins that cause high anion gap metabolic acidosis?: 1. methanol
2. ethylene glycol
3. salycilates
4 causes of low urinary Chloride metabolic acidosis?: 1. loss of gastric acid
2. post diuretic therapy
3. post hypercapnia
4. Cl- wasting diarrhea
4 causes of high urinary chloride metabolic acidosis?: 1. hyperaldosteronism
2. Cushing's syndrome
3. Bartter's syndrome
4. Gitelman's syndrome
what constitutes a low and high urinary chloride metabolic acidosis?: low <10 mEq/L
high >20 mEq/L
what is the new value for a normal anion gap?: 6.6 (+/- 4) mEq/L
what is the "rules of 5" that Dr. Danielson preaches regarding acid/base disturbances?: 1. determine pH status
2. determine whether primary process is respiratory, metabolic or both
3. calculate anion gap
4. check the degree of compensation
5. determine the delta gap (whether there is a 1:1 relationship between anions in the blood)
what are the three layers of urothelium?: 1. Umbrella (superficial single cell layer)
2. intermediate cell layer (up to 5 cells thick)
3. basal cell layer
what is seen in the lamina propria?: *lots of CT
*rich vascular, lymphatics
*some elastic fibers and nerves
what is a common congenital malformation of the ureters that usually is asymptomatic?: double (bifid) ureters
what is extrophy of the bladder?: bladder opens to the exterior of the body (developmental defect)
in what manner are bladder diverticuli acquired?: congenital or acquired
which sex is cystitis MC in?: Females
(shorter ureters)
what is the triad of s/s seen in cystitis?: 1. frequent urination
2. lower abdominal pain at symphysis
3. dysuria
chronic cystitis may result in what bladder consequences?: fibrosis and bladder wall inelasticity
what are the two types of ureteritis?: 1. ureteritis follicularis
2. ureteritis cystica
histological difference between: 1. ureteritis cystica 2. ureteritis follicularis: 1. mucosa with multiple small cysts, filled w/clear fluid, lined with transitional epithelium
2. lymphoid aggregates in lamina of ureter
what 3 bacteria MC cause urethritis?: 1. Gonococcus
2. mycoplasma
3. chlamydia
what is Reiters syndrome?: autoimmune disorder resulting in a triad of:
- urethritis
- arthritis
- conjunctivits
nests of transitional epithelium in the lamina propria (that are seen in cystitis glandularis and cystitis cystica) are called?: Von Brunns nests
regarding cystitis glandularis and cystitis cystica: is this a benign or malignant proliferation of transitional epithelium?: benign
which variant of cystitis is associated with indwelling catheters?: polypoid cystitis
which cystitis variant is caused by gas-producing bacteria and has an increased incidence in diabetics?: emphasematous cystitis
what must we worry about in a case of hemorrhagic cystitis?: the cause (commonly CIS of bladder)
what is a Hunners ulcer seen in?: Interstitial cystitis
in interstitial cystitis: what is a characteristic micro cell seen in the interstitium?: mast cells
T/F: interstitial cystitis is the result of prior bacterial infections?: FALSE
unclear etiology, but they know it is not from bacterial causes.(antibiotics also are not helpful)
three symptoms of interstitial cystitis?: 1. PAIN
2. hematuria
3. urinary frequency
Michaelis-Gutmann bodies are associated with?: malakoplakia
what is the MC neoplasm of the bladder in the US?: TCC (>95%)
what are the three variations of TCC of the bladder?: 1. transitional cell Papilloma
2. Transitional cell carcinoma
3. transitional cell variant
what is the MC bladder neoplasm in third world countries?: Squamous Cell Carcinoma (due to schistomonas infx)
which TCC of the bladder has the best prognosis?: papillary and exophytic
which TCC of the bladder has the worst prognosis?: CIS
what is the difference between hyperplasia and dysplasia of the bladder urothelium?: *hyperplasia - TC>7 cells thick. may or may not progress to dysplasia or CA
*dysplasia - cytologic atypia, mitotic activity, may or may not be associated with hyperplasia and/or malignancy
occupational exposures that increase the risk of TCC?: analine dyes
phenols
naphol
arsenic
other risk factors for TCC besides occupational?: 1. tryptophan metabolites
2. smoking
3. cyclophosphamine treatment
presenting s/s of TCC?: *asymptomatic in some*
otherwise, painless hematuria
which sex in TCC MC in?: males
age group that has highest incidence of TCC?: 6th-7th decades
(rare in children, young adults)
what is meant by the fact that TCC has a proposed "field effect?": TCC of the bladder is often accompanied by other urothelial carcinomas
a TCC that starts as well differentiated and papillary can progress to?: poorly differentiated and invasive
what characterizes CIS of the bladder?: 1. highly aggressive
2. malignant
3. hasn't invaded basement membrane
SCC is high in third world countries because of?: schistosoma infection
in cystitis: what is the causative bacteria in >90% of cases?: E.coli
according to Dr. Young: what constitutes an uncomplicated UTI?: 1. occurs in an anatomically normal urinary tract
2. simple to cure w/Abx
3. little effect on long term renal function
according to Dr. Young: what constitutes a complicated UTI?: occurs in an abnormal urinary tract or has a complication of some sort.
what is the F:M ratio in UTI occurance?: F:M - 50:1
two reasons for females having UTIs more commonly?: 1. urethra is closer to anal opening
2. urethra is shorter
are UTIs seen more or less commonly in pregnancy?: MORE commonly (4-6% incidence)
why are postmenopausal women more likely to get a UTI vs. premenopausal women?: estrogen deficiency alters vaginal flora (loss of lactobacilli and more E.coli)
what is the classical difference between acute cystitis and acute pyelonephritis?: cystitis - no fever >101 degrees F
pyelonephritis - high fever, flank pain
what are the clinical signs of a UTI in an elderly patient?: *few or no classical sx.*
- no fever with pyelonephritis
- decreased urinary ouput
- more GI sx. (N/V)
what is the urinary output like in the classical presentation of UTIs?: increased
in diagnosing a UTI: what does the leukocyte esterase test look for?: pyuria
in diagnosing a UTI: what does the nitrite test look for?: bacteriuria
what two signs must be present in order to diagnose a true UTI?: 1. bacteriuria (>10^5/mL)
2. pyuria 9>10 leukocytes/HPF)
antibiotic Tx. for acute uncomplicated cystitis?: 3 days of TMP/SMX (or FQs)
antibiotic tx. for acute uncomplicated cystitis in diabetics older than 65?: 7-14 days of TMP/SMX (or FQs)
what defines recurrent cystitis?: >2 UTIs/yr
three antibiotic treatment strategies for recurrent cystitis?: 1. prophylactic antibiotics
2. continuous antibiotics
3. postcoital antibiotics
treatment of choice for uncomplicated pyelonephritis?: 14 days of TMP/SMX (or FQ)
how does the treatment plan change if Enterococcus is found in the urine?: switch abx. to cover Gram (+) organisms
in pyelonephritis: when would we admit to the hospital?: *N/V
*other toxic s/s
*presence of underlying illness (ie. diabetes)
two follow up tests used in the management of complicated UTIs?: 1. urine culture 1-2 wks. after therapy begins
2. radiology if urine is still infected
*if still infected: Abx. therapy extended 14 more days*
which abx. would a UTI be more likely to be resistant to: amoxicillin or FQs?: amoxicillin
which abx. would a UTI be more likely to be resistant to: amoxicillin or cephalosporins?: amoxicillin
which abx. would a UTI be more likely to be resistant to: cephalosporins or TMP/SMX?: cephalosporins
which abx. would a UTI be more likely to be resistant to: TMP/SMX or FQs?: TMP/SMX
when would asymptomatic bacteriuria be treated? (2 instances): 1. pregnancy
2. before urologic surgery
vitamin C reduces the risk of UTIs caused by what bacteria?: Enterococcus faecalis
probiotics attempt to restore which normal flora?: lactobacilli
(normal flora inhibits pathogen mvmt from rectum)
which Gram (+) bacteria is the second most common bacteria found in UTIs? (MC bacteria is Gram (-)): Staphylococcus saprophyticus
what are the bacteria more commonly found in male UTIs?: 1. Proteus
2. Providentia
3. Enterococcus
*still see E.coli*
what is the role of secretory IgA in host defense against UTIs?: interferes with bacterial adhesion
what is the role TLR-4 in host defense against UTIs?: recognizes LPS and recruits neutrophil influx
what is the role TLR-11 in host defense against UTIs?: detects infection: provokes an inflammatory response and bacterial clearance
what role does urease production have on promoting a UTI?: urease alkalinizes the urine, creates favorable growing environment for pathogens
two UTI pathogens that produce urease?: Proteus
Klebsiella
what do iron siderophores do?: chelate iron and thereby enhance bacterial iron uptake
which UTI pathogen is CNF-1 (cytotoxic necrotizing factor) found in?: E.coli
function of cytotoxic alpha-hemolysin (HlyA): depresses chemotaxis of PMNs
structure used for attachment by: 1. gram (-) UTI pathogens? 2. gram (+) UTI pathogens?: 1. pili (fimbrae)
2. carbohydrate polymers (polysaccharides)
what charge does the surface of the bacteria have? significance?: negative charge
host cells are negatively charged as well -> see repulsion of like charges -> therefore bacteria need pili to attach to host cells
which type of pili/fimbrae attach to the urethra?: Type I fimbrae
which receptors on the target tissue mediate the attachment of type I fimbrae?: mannose receptors
which type of pili/fimbrae mediate attachment to the bladder?: P fimbrae (class III)
what type of fimbrae bind the Forssman glycolipid?: Type I pili + FimH tip
the papE protein binds to what on the bladder wall?: fibronectin
which type of fimbrae mediate attachment to the kidney?: P fimbrae + PapG tip
the PapG adhesin tip found on P fimbrae specifically binds to which host receptors?: globoside receptors in the kidney
why do the bacteria switch fimbrae once they have reached the bladder?: allows them to avoid phagocytosis
which bacteria is well known to raise pH and precipate struvite crystals?: Proteus mirabilis
(produces urease)
which class of diuretics does acetazolamide belong to?: carbonic anhydrase inhibitors
which class of diuretics do chlothalidone and metolazone belong to?: thiazide and thiazide-like diuretics
which class of diuretics does ethacrynic acid belong to?: loop diuretics
which class of diuretics do bumetanide and torsemide belong to?: loop
two examples of osmotic diuretics?: mannitol
urea
MOA of osmotic diuretics?: increase urine volume by osmotically retaining water in the nephron
two locations in the nephron where osmotic diuretics work best?: proximal tubule
descending portion of the loop of Henle
(2 areas most permeable to H2O)
when on osmotic diuretics: which electrolytes have an increased secretion?: ALL
(Na+, K+, Ca++, Mg++, Cl-, HCO3-, phosphate)
what happens to renal blood flow when on osmotic diuretics?: increased
when on osmotic diuretics: what is the effect on increased renal blood flow on GFR?: there is little effect on the GFR
unique adverse effects of osmotic diuretics?: 1. expansion of ECF (edema, pulmonary edema)
2. hypotension, hypertension, CHF
3. headache, dizziness, blurred vision
when are osmotic diuretics contraindicated?: in patients with active intracranial bleeding
why are osmotic diuretics indicated in acute attacks of glaucoma?: they decrease intraocular pressure
where do carbonic anhydrase inhibitors work?: in the proximal tubule
why is carbonic anhydrase so important to inhibit?: it is integral in the reabsorption of bicarb (without it all bicarb is lost in the urine)
what is the mechanism behind carbonic anhydrase inhibitors decreasing renal blood flow and GFR?: *increased solute load in tubule at macula densa
*this stimulates tubuloglomerular feedback mechanism
*results in increased afferent arteriolar resistance
*results in decreased GFR and RBF
why are carbonic anhydrase inhibitors associated with hypersensitivity and skin rash?: they are sulfonamide derivatives
what acid/base disturbance is an adverse effect of carbonic anhydrase inhibitors?: metabolic acidosis
would carbonic anhydrase inhibitors cause hyper- or hypo- kalemia?: hypokalemia
three reasons carbonic anhydrase inhibitors are weak diuretics?: 1. Na+ not absorbed in proximal tubule is reabsorbed in distal tubule.
2. only proximal tubule has lots of carbonic anhydrase
3. decreased GFR causes limited efficacy
MOA of thiazide diuretics?: inhibits NaCl symporter in distal convoluted tubule
what effect do thiazide diuretics have on excretion of the following ions: 1. Na+ 2. Cl- 3. K+ 4. H+ 5. Ca++: 1. increased
2. increased
3. increased
4. increased
5. decreased
what effect to thiazide diuretics have on renal blood flow?: none
compare the effects of the following diuretics in regards to Ca++ excretion 1. thiazide 2. loop: 1. decreased Ca++ excretion
2. increased Ca++ excretion
why must caution be used when prescribing a thiazide diuretic to a patient with gout?: may cause hyperuricemia
why are thiazide diuretics not effective when CrCl<30-40/min?: cannot concentrate in PT lumen
MOA of loop diuretics?: inhibit Na+/K+/Cl- cotransport in the thick ascending portion of the loop of henle
effects of loop diuretics on GFR?: none
(blockage of tubuloglomerular feedback)
which loop diuretic has erratic and unpredictable oral bioavailability?: furosemide
how is the dose of loop diuretics adjusted in renal insufficiency?: increase dose
regarding loop diuretics: what is meant when it is said that maximal naturesis occurs?: ceiling effect: increasing the dose does no good.
which adverse effect is associated with ethacrynic acid?: ototoxicity
what can be prescribed along with loop diuretics to reduce or prevent hypokalemia?: ACE inhibitors
Name 3 potassium sparing antibiotics?: 1. spironolactone
2. triamterene
3. amiloride
MOA of spironolactone?: inhibit aldosterone mediated Na+/K+ exchange in the distal nephron
MOA of triamterene and amiloride?: inhibits Na+ mvmt through Na+ channels in the collecting duct
K+ sparing diuretics have a higher risk of causing hyperkalemia in what kinds of patients?: patients with:
1. diabetes
2. renal insufficiency
3. ACE inhibitors
4 side effects of spironolactone?: 1. gynecomastia
2. decreased libido
3. impotence
4. hirsutism
which class of diuretics is the most potent?: loop
second most potent class of diuretic?: metolazone (thiazide like diuretic)
what is the estimated FENa of a person on Loop diuretics?: 15-25%
explain post diuretic NaCl retention and how it can be minimized.: once diuretic influence wears off NaCl is retained until next dose of diuretic. Can be minimized with NaCl dietary restriction.
what is the mechanism behind edema that has become refractory to a particular diuretic?: delayed drug absorption due to intestinal edema
solution to edema that has become refractory to a particular diuretic?: switch to torsemide or bumetanide (better bioavailability)
which 2 drugs are known to compete with the diuretic and inhibit diuretic secretion into the proximal tubule?: 1. NSAIDs
2. probenecid
when loop and thiazide diuretics are combined, which one should be administered first to achieve greater efficacy?: thiazides first
(this blocks downstream sites)

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