mindmap - UTI

UTI

• definitions
  • Bacteriurea
    • bacteria in urine
    • may be asymptomatic / symptomatic
  • UTI
    • presence of a pure growth of >10^5 organisms per mL of frsh MSU
    • lower UTI
      • urethritis
      • cystitis
      • prostatitis
    • upper UTI
      • pyelonephritis
• classifications
  • uncomplicated
  • recurrent
    • with different organism
  • relapsing
    • same organism
• risk factors
  • female
  • sex
  • exposure to spermicide in female
  • pregnancy
  • menopause
  • immunosuppression
  • urinary tract
    • obstruction
    • stones
    • catheter
    • malformations
• diagnosis
  • urine cultures
  • bacteia in gram-stained uncentrifuged urine
  • urinalysis
    • pyuria
    • leukocyte esterase
    • leukocyte casts
      • acute phelonephritis
• symptoms
  • acute pyelonephritis
    • symptoms develop quickly hours/ days
    • systemic manifestations
      • febrile
      • chills
      • rigor
      • nausea
      • vomiting
      • diarrhea
    • pain on palpation
      • deep
      • renal angle
    • oliguria if ARF
  • cystitis
    • dysurea
    • frequency
    • urgency
    • suprapubic pain
    • urine
      • cloudy
      • malodorous
      • sometimes bloody
    • systemic signs
      • usually absent
    • 1/3 patient have silent upper UTI as well
  • prostatitis
    • flu-like symptoms
    • low backache
    • few urinary symptoms
    • swollen / tender prostate on DRE
• organisms
  • E-coli main organism in uncomplicated
    community acquired UTI (70-80%)
    urologic manipulation, calculi, obstruction
    • E-coli
    • Proteus
    • Klabsiella
    • Enterobacter
    • Serratia
    • Psudomonas
    stone formation and calculi
    • proteus
    • Klabsiella

mindmap - Renal obstructions

Urinary Outflow Obstruction

• Renal stones
  • general characteristics
    • "urolithiasis" is calculus formation
      at any level in the urinary collecting system
      most often arising in the kidney
      very frequent - 1% of all autopsies
      men>women symptomatic urolithiasis
  • pathogenesis
    • types of stones
      • 80%
        • Ca-Oxalate
          • metabolic disorder
        • Ca-Oxalate plus Ca-Phosphate
      • 10%
        • magnesium ammonium
          phosphate (struvite)
          • urea-splitting organisms
      • 6-9%
        • uric acid
          • after chemotherapy
          • medications
            • salicylates
          • gout
        • cystine
          • hypercystinemia
          • inherited metabolic disorder
      causes of formation obscure
      the most important cause being
      increased urine concentration
      
      
      • supersaturation
      also, hypercalcemia very important
      • high Na diet
      • loop diuretic
      • cushing's
      • hyperthyrodism
      • vitD excess
      struvite almost always with UTI
  • morphology
    • stones unilateral in 80%
    • common site of formation
      • renal pelvis
      • calyces
      • bladder
    • huge stone - staghorn calculi
      • usually struvite
  • clinical course
    • stones may be present without symptoms
    • smaller stones more likely to produce symptoms
    • renal colic
      • flank pain
      • radiating toward groin
    • gross hematuria
    • may cause ulceration and bleeding
      • predisposing to UTI
    • may cause fluid retension
• hydronephrosis
  • general characteristics
    • dilation of renal pelvis and calyces
    • atrophy of parenchyma
    • caused by obstruction
      of urine outflow
      • sudden
      • insidious
    • common causes
      • congenital
        • atresia of urethra
        • valve formation
        • aberrant renal artery compressing ureter
        • renal ptosis with torsino
        • kinking of ureter
      • acquired
        • foreign bodies
          • calculi
          • necrotic papillae
        • tumours
          • BPH
          • Ca of prostate
          • Blatter tumour
          • Ca of cervix
        • inflammation
          • prostatitis
          • ureteritis
          • urethritis
          • retroperitoneal fibrosis
        • neurogenic
          • spinal cord damage
            with palaysis of bladder
        • normal pregnancy
          • mild and reversible
  • pathogenesis
    • even with complete obstruction, Glomerular Filtration goes on for some time
    • filtrate diffuse back into renal interstitium and perirenal space
    • ultimately return to lymph and veins
    • affected calyces and pelvis become dilated
    • high pressure transmitted back into the collecting ducts
    • compress renal vasculature
    • papillae most affected by pressure
    • inirial functional disturbance - impaired concentrating ability
    • later, glomerular damage occurs
    • serious irreversible damage with...
      • 3wks with complete obstruction
      • 3 months with partial obstruction
    • obstruction also triggers interstitial indlammatory reaction
      • fibrosis of interstitium
  • morphology
    • bilateral hydronephrosis
      • uremia
      • renal dailure
      • bladder distension and hydroureter
    • unilateral
      • massive kidney
      • obliteration of papillae and flattening of pyramids
    • the ureters may also be dilated
      • hydroureter
  • clinical course
    • bilateral complete obstruction
      • anuria
      • bladder distension if block is below bladder
    • incomplete obstruction
      • frequrea
      • polyurea
      • dilute urine

mindmap - renal vascular problems

Vascular Diseases of the Kidney

Diseases affecting

Renal Blood vessels

• Thrombotic Microangiopathies
  • general features
    • describe lesions seen in various clinical syndromes
    • common causes include
      • childhood Hemolytic Uremic Syndrome (HUS)
        TTP (Thrombotic Thrombocytopenic Purpura)
        Adult HUS
  • pahogenesis
    • HUS
      • endothelial injury and activation
      • intravascular thrombosis
    • TTP
      • acquired defect in proteolytic cleavage of vWF multimers
      • familial TTP
    • childhood HUS
      • 75% follow Shiga-toxin-producing E-coli
        Shigella dysentriae type 1
        renal glomerular endothelial
        cells is target of toxin
        
        
        • increased adhesion of leukocytes
        • increased endothelin production
        • loss of endothelial NO
        • endothelial damage
        thrombosis occurs
  • morphology
    • thrombotic microangiopathy
      fibrin thrombi
      widening of subendothelium
      lysis of mesangium
  • clinical course
    • Childhood HUS
      • sudden onset
      • after GI / Flulike prodromal episode
      • bleeding manifestations
        • hematemesis
        • melena
    • severe oligurea
    • hematuria
    • prominent neurologic changes
    • one of main causes of ARF in children
    • if dyalisis done properly in early stage, patient mostly recover in matter of weeks
    • long-term prognosis
      • 25% of children evantually develop renal insufficiency due to scarring
  benign Nephrosclerosis
  • general characteristics
    • always associated with hyaline arteriosclerosis
    • frequency and severeity increases with Hypertension / DM.
    • present at autopsy in many people >60 years (although benign)
  • pathogenesis
    • many renal diseases cause hypertension
       - which is in turn associated with nephrosclerosis
      often seen superimposed to other renal other primary kidney lesions
  • morphology
    • gross
      • 
        symmetrically atrophic
        diffuse fine granularity that resembles grain leather
    • microscopic
      • 
      • hyaline arteriosclerosis
      • pink hyaline thickening at expence of basal lumina
      • loss of cellular detail
      • narrowing of lumen
  • clinical course
    • rarely cause any problems
      however some population susceptible
      • African americans
      • may lead to uremia and death
      all person with the lesion usually
      show some level of functional impairment
      • loss of concentration of urine
      • diminished GFR
      • Mild proeinuria
  Malignant Hypertension
  Malignant Nephrosclerosis
  • general features
    • less common in US
    • only happen in 5% of people with high BP
    • may arise de novo or appear in a person with mild Hypertension
    • happens more frequently in less developed countries
  • pahogenesis
    • some form of vascular damage to kidneys
    • long standing benign hypertension
    • evantual injury to arteriolar walls
      • increeased permeability
        of small vessels to
        • fibrinogen
        • other plasma proteins
        increased endothelial injury
        platelet depots.
  • morphology
    • gross
      • pinpoint petechial hemorrhages
      • flea-bitten appearance
    • microscopic
      • fibrinoid necrosis of arterioles
        homogeneous, granular eosinophilic vessel walls
        onion-skin appearance - hyperplastic arteriosclerosis
  • clinical course
    • medical emergency
    • early symptoms related more to ICP increase
      • headache
      • nausea
      • vomiting
      • visual impairment
      • scotomas
    • diastolic pressures >120 mmHg
    • papilledema
    • encephalopathy
    • renal failure
    • CVS abnormalities
    • proteinurea
    • micro/macroscopic hematurea
    • 50% survive for 5 years
    • 90% deaths made from uremia
    • 10% death from cerebral hemorrhage / Cardic failure