CHAPTER 7- THE URINARY TRACT

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The most common location of an ectopic kidney is within the pelvis.

Acute pyelonephritis

inflammation of kidneys. Bacteria more commonly spread from the lower urinary tract. Referred to as an ascending infection.

von Hippel-Lindau disease

inherited disorder characterized by tumors of the central nervous system and orbits. Patients with this syndrome also have the propensity to develop cysts within the kidneys, RCC and pheochromocytomas. Symptoms of a brain / eye tumors.

Emphysematous Pyelonephritis

rare, life threatening. Diabetes mellitus, immunocompromised patient. fever, flank pain, leukocytosis. bacterial formation allows gas to accumulate within the renal parenchyma. E-coli is the most common culprit.

Chronic Pyelonephritis

recurrent kidney infections or chronic obstruction may lead to scarring of the calices and renal pelvis. Can lead to xanthogranulomatous pyelonephritis and end stage renal disease. Children with hx of vesicoureteral reflux are at increased risk.

Acquired Kidney Disease

result of chronic hemodialysis. increased risk for developing RCC. Clinical findings of CRF.

The gradual decrease in renal function over time. Kidneys that fail to function normally will lead to end-stage renal disease.

Chronic Renal Failure

Urolithiasis, congenital abnormality, hematoma, neoplasm, ureteropelvic junction obstruction, ureterocele

Intrinsic causes of hydronephrosis

cortical thinning

Reduction in the thickness of the renal cortex is;

Exophytic

Renal cysts that appear to be projecting out away from the kidney

Bacteriuria

Acute pyelonephritis UTI

asymptomatic until third to fourth decade of life. decreased renal function UTI Renal calculi Flank pain Hematuria Palpable abdominal mass

Autosomal Dominant Polycystic Kidney Disease (ADPKD)

dilation of the renal collecting tubules. often recognized in fetus. clinical findings of renal failure. Abnormal liver function tests because of hepatic disease.

Autosomal Recessive Polycystic Kidney Disease (ARPKD)

Glomerulonephritis

Caused by a distant infection such a strep throat or an autoimmune reaction. (lupus) Smoky urine, hematuria, proteinuria, fever, hypertension, azotemia.

Hypercalcemia, hyperparathyroidism, UTI, hx of urinary calculi

Clinical Findings of Nephrocalcinosis

Asymptomatic. May produce pain or hematuria.

Clinical Findings of Oncocytoma

pyuria, bacteruria, fever, flank pain, leukocytosis

Clinical Findings of Pyonephrosis

elevated BUN, elevated creatinine, oliguria, hypertension, leukocytosis, hematuria, edema and hypovolemia.

Clinical findings of ARF

Epilepsy and skin lesions of the face.

Clinical findings of Tuberous Sclerosis

flank pain, bacteriuria, pyuria, leukocytosis, dysuria, urinary frequency

Clinical findings of acute pyelonephritis

asymptomatic in most individuals. Patient may have hx of tuberous sclerosis. Pain, hematuria and hypertension can occur with hemorrhage of the mass.

Clinical findings of angiomyolipoma

diabetes mellitus, malaise, elevated BUN and creatinine, fatigue, hypertension, hyperkalemia

Clinical findings of chronic renal failure

Development of renal abscess, pyonephrosis, xanthogranulomatous pyelonephritis, emphysematous pyelonephritis, chronic pyelonephritis.

Complications of acute pyelonephritis

Renal Hemangioma

Consists of a mass of blood vessels. Most often asymptomatic and during the third or fourth decade of life. Hemorrhage of the mass can lead to pain and hematuria. Small, hyperechoic mass.

Renunculi or ranunculi.

Each kidney is formed when two embryonic parenchymal masses combine. These kidney tissue masses are referred to as;

Benign prostatic hypertrophy, neurogenic bladder, pelvic masses, pregnancy, retroperitoneal fibrosis, surgery, trauma, urethritis.

Extrinsic causes of hydronephrosis

Angiomyolipoma

It is most common benign renal tumor. consist of blood vessels, muscle and fat. may be referred to as renal hamartoma.

Specific gravity

Low: renal failure and pyelonephritis High: dehydration

Urolithiasis

Made of calcium oxalate and frequently found in males. can form in kidney or bladder. A stone that completely fills and takes on the shape of the renal pelvis is called a staghorn calculus.

Renal sinus

Minor calices, major calices, renal pelvis and infundibula.

early, first trimester obstruction of ureter. no normal functioning kidney tissue present. Bilateral, fatal.

Multicystic Dysplastic Kidney Disease (MCDK)

False Positive Hydronephrosis

Overdistention of the urinary bladder, parapelvic cysts, a prominent renal vein, extrarenal pelvis may all be the source. Use color doppler and use post void imaging.

difficult to differentiate from hydronephrosis.

Peripelvic cysts originate in the renal sinus

Peritoneal dialysis uses a solution that is instilled into the abdomen via a catheter. Through diffusion and osmosis the solution allows for the filtration of waste. cause minimal amount of ascites.

Renal Failure and Dialysis

Most common renal mass. anechoic mass, spherical, smooth walls, posterior acoustic enhancement, no internal echoes.

Simple Renal Cyst

difficult to differentiate from prominent renal pyramids.

Small cortical cysts are within the cortex

bilateral enlarged kidneys, numerous cortical renal cysts. possible cysts identified in the pancreas, liver and spleen.

Sonographic Findings of ADPKD

bilateral, enlarged echogenic kidneys. Loss of corticomedullary differentiation.

Sonographic Findings of ARPKD

Solid, hyperechoic mass. May produce acoustic shadowing. Tend to be multiple and bilateral with tuberous sclerosis.

Sonographic Findings of Angiomyolipoma

Small, echogenic kidneys. Cortical thinning. Loss of normal corticomedullary differentiation. Renal cysts may be seen as well.

Sonographic Findings of Chronic Renal Failure

Gas or air within the renal parenchyma. Dirty shadowing or reverberation artifact coming from renal parenchyma.

Sonographic Findings of Emphysematous Pyelonephritis

Fungal balls appear as hyperechoic, nonshadowing, mobile structures within the renal collecting system

Sonographic Findings of Fungal Disease

unilateral, smooth walled, noncommunicating cysts of varying sizes located within the renal fossa. compensatory hypertrophy of the contralateral kidney

Sonographic Findings of MCDK

Medullary: echogenic renal pyramids-medullary sponge kidney. Cortical: echogenic foci within the cortex

Sonographic Findings of Nephrocalcinosis

Isoechoic, hyperechoic or hypoechoic mass. May also contain a hypoechoic central scar. May mimic RCC because of the central scar.

Sonographic Findings of Oncocytoma

Schistosomiasis; bladder wall thickening. Hydatid cyst: depends on the stage of its maturation, as it may appear completely anechoic, contain a daughter cyst with internal debris or as a complex mass with calcifications.

Sonographic Findings of Parasitic Urinary Tract Infection

Bilateral renal cysts, bilateral angiomyolipomas.

Sonographic Findings of Tuberous Sclerosis

Hydronephrosis Staghorn calculus Perinephric fluid collection

Sonographic Findings of Xanthogranulomatous pyelonephritis

Multiple renal cysts. Cysts maybe complex and have mural nodules (sign of RCC) cysts within the pancreas. Pheochromocytoma may be present.

Sonographic findings of Von Hippel-Lindau Syndrome

can appear anechoic, hypoechoic or complex. Gas shadows or dirty shadowing may be present within the mass.

Sonographic findings of a renal or perinephric abscess

Kidney will appear small initially during end stage renal disease with some small cysts. With time kidneys may enlarge, small cysts noted throughout the renal parenchyma.

Sonographic findings of acquired renal cystic disease

may appear normal, renal enlargement, focal areas of altered exhotexture, compression of the renal sinus.

Sonographic findings of acute pyelonephritis

Echogenic focus with acoustic shadowing. Twinkle sign hydronephrosis and dilation of ureter may be present

Sonographic findings of urolithiasis

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The most common location for a stone to become lodged in the urinary tract is the ureterovesicular junction, near the urinary bladder.

Parasitic Urinary Tract Infections

The most common renal parasitic infection is from schistosomiasis, which is a worm enters the body by penetrating the skin. Persistent fever with hematuria, flank pain, pyuria, dysuria, recent travel out of country,

9th week of gestation. 11 and 13 weeks.

The nephron begins to function by the ___ of gestation although urine production begins between ____ weeks

medium to low level echoes surrounding the central sinus. The normal cortex is more hypoechoic than or isoechoic to liver or the spleen. IT should measure more than 1 cm in thickness.

The renal cortex appears as;

echogenic appearance

The renal sinus is central in the kidney and has an

Kidneys and ureters Bladder and urethra

The urinary system consist of the upper urinary tract and lower urinary tract

Determining the Level of Urinary Tract Obstruction

Urine is created within the kidneys, travels down the ureters, collects in the bladder and exists in the urethra. Dilation of the urinary tract occurs proximal to the level of obstruction. If there is distention of the ureter and dilation of the renal collecting system with a normal urinary bladder, the level of obstruction must be proximal to the urinary bladder, either within the ureter or at the level of ureterovesicular junction.

columns of Bertin.

Within the cortex, the triangular shaped medullary pyramids are noted and separated by the;

Oncocytoma

a benign renal tumor that is often found in men in their 60s. Second common mass after the angiomyolipomas.

Medullary sponge kidney

a congenital disorder characterized by the accumulation of calcium within abnormally dilated collecting ducts located within the medulla

Xanthogranulomatous pyelonephritis

a rare chronic form of pyelonephritis that is typically the result of a chronic obstruction and subsequent infection. Dull or persistent flank pain. pyuria, hematuria, fever, leukocytosis.

Tuberous Sclerosis

a systemic disorder that leads to the development of tumors within various organs.

Henoch-Schonlein Purpura

autoimmune, inflammatory vascular disease that mostly affects children and can permanently damage the kidneys.

8-13 cm in length, 2-3 cm in the anteroposterior dimension and 4-5 cm in width.

In adult kidneys typically measure;

small, echogenic kidneys w/ lobulated borders. Renal scar appears as an echogenic area within the kidney that extends from the renal sinus through the renal parenchyma.

Sonographic findings of chronic pyelonephritis

enlarged kidneys with increased echogenicity. (acute) Prominent renal pyramids. (acute) small echogenic kidney(s) (chronic)

Sonographic findings of glomerulonephritis

hydronephrosis. pus and debris appear as internal, layering, and low level echoes within the dilated collecting system.

Sonographic findings of pyonephrosis

Perinephric Abscess

collection of purulent material that has leaked through the capsule into the tissue surrounding the kidney. High fever, flank pain, leukocytosis, pyuria, hematuria.

Hydronephrosis

dilation of the renal collecting system secondary to the obstruction of normal urine flow. Dilation of the calices, infundibula, and renal pelvis. May be referred to as pyelocaliectasis.

Nephron

The functional unit of the kidney is;

renal capsule

The innermost covering of the kidney is the;

12 weeks gestation

The kidneys initially develop within the pelvis and ascend into the fetal abdomen by;

Renin

The kidneys work to regulate blood pressure by producing the enyzme;

acute tubular necrosis. with acute tubular necrosis the kidney suffer from ischemic damage and subsequent cell destruction.

The most common cause of acute renal failure is;

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The most common congenital anomaly of the urinary tract is the duplex or duplicated collecting system.

Renal medulla and renal cortex

The parenchyma of the kidney consist of the;

the abdominal aorta that are located below the level of SMA

The renal arteries are branches of;

medullary nephrocalcinosis

the accumulation of calcium within the medulla of the renal parenchyma caused by hyperparathyroidism. It may also be caused by a congenital defect known as medullary sponge kidney.

Pyonephrosis

the condition of having pus within the collecting system of the kidney. most likely caused by obstructive process or infection that leads to urinary stasis.

Gerota fascia

the fibrous envelope of tissue that surrounds the kidney and adrenal gland

Renal medulla

the inner part of the parenchyma that is responsible for absorption. It includes the renal pyramids.

Renal Fungal Disease

the most common cause of fungal urinary tract infection. Candida albicans.

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Tuberous sclerosis is associated with multiple, bilateral renal angiomyolipomas.

WBC (elevated)

UTI

Pyuria

UTI Usually accompanied by bacteria

Nephrocalcinosis

Accumulation of calcium within the renal parenchyma. Two forms; medullary and cortical nephrocalcinosis.

Hematuria

Acute and chronic pyelonephritis. Hypernephroma (renal cell carcinoma), renal infarction and trauma.

Proteinuria

Benign and malignant masses. glomerulonephritis. infection. nephrotic syndrome. urinary calculi.

flank pain, bacteriuria, pyuria, leukocytosis, dysuria, urinary frequency, history of VUR

Clinical findings of chronic pyelonephritis

Immunocompromised pt, diabetes, intravenous drug abuse or long-standing indwelling catheter, infant with indwelling catheter, flan pain, fever, chills.

Clinical findings of renal fungal disease

Hematuria, renal colic, oliguria, uti

Clinical findings of urolithiasis

Cortical Nephrocalcinosis

occurs within the cortex. Maybe caused by hyperparathyroidism, AIDS or association with some malignancies.

Urinary pH (abnormal)

urinary calculi (composition of stones)

Renal cortex

the outer part of the renal parenchyma that is responsible for filtration