MMD Renal and Urinary
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____ renal failure has a worsening of renal function over hours to days with retention of BUN and creatinine, while ___ renal failure has worsening renal function over months to years and is usally associated with small kidney size
What values are given from a urine dipstick?
- Specific gravity
- Leukocyte esterase
if you find proteins and casts in the urine which is more likely nephrotic syndrome or glomerulonephritis, or Acute tubular necrosis?
If you find hematuria with dysmorphic RBCs, RBC casts and protein what is more likely glomerulonephritis or neprhotic syndrome or acute tubular necrosis?
if you find pigmented granular casts and renal tubular epithelial cells in the urine is it Glomerulonephritis, Nephrotic syndrome or Acute tubular necrosis?
Acute tubular necrosis
If you find WBC (neutrophils and eosinophils) and WBC casts, RBCs and some protein what is the most likely diagnosis Interstitial nephritis (AKA pyelonephritis), Acute tubular necrosis of a wilms tumor?
Interstitial nephritis or pyelonephritis
Proteinuria is more than how many mg/24 hrs in an adult?
more than 150 to 160 mg/24 hrs
What is the neprhotic range for proteinuria?
>3.5 g/24 hrs. WOW THAT IS A S*** ton of protein! eep
What are some benign causes of protinuria?
What are Bence Jones proteins?
Immunoglobulin light chains (aka paraproteins produced by neoplastic plasma cells.) present in 2/3 of multiple myeloma cases also seen in lytic bone lesions and anemia these are filtered plasma proteins that can be seen in urine
What are 3 tyeps of filtered plasma proteins that can be apparent on a urinalysis OTHER than albumin?
- Myoglobin (from rhabdomyolysis)
- Hgb (from hemolysis)
- Bence Jones proteins (from cancer)
What two parts of the nephron could be damaged if there is a finding of protein in the urine?
- Glomerular damage- increased permiability across the glomerular basement membrane
- Tubular damage- faulty reabsobtion in teh proximal tubules (this includes acute tubualar necrosis and toxic injury)
Hematuria is defined as more than ___ RBCs per high powered field
What can give you a false + hematuria
Vitamin C, Beets, Rhubarb, bacteria, myoglobin
Does most hematuria have a renal or extrarenal eitiology?
Extrarenal 90% mostly from the bladder and lower urinary tract including infection and bladder cancer
What are some Glomerular causes of Hematuria?
- Immunoglobin A nephropathy
- Thin GBM dz
- Post infectious glomerulonephritis
- Systemic nephritic syndrome
What are some non-glomerular causes of hematuria?
Cysts, calculi, interstitial nephritis, renal neoplasm
The amount of plasma ultrafilterd acrossl teh glomerular capillaries (the amount of blood that passes through the glomeruli every minute) is called the ___
Glomerular Filtration Rate
What is the equation for GFR?
GFR = (urine concentration X urine flow)/plasma concentration
What is a normal GFR range?
150-250L/24 hrs or 100-120ml/min/1.73m^2 of the body surface area
___ is the muscle metabolism product that is found in the urine. Its creation should be (>, < or =) it's excretion
Creatinine it should be = to its excretion in a stable funcitoning kidney
What is normal creatinine clearance for a healthy young F
What is a normal creatinine clearance for a healthy young M
How would you calculate the estemated Creatinine clearance value? or the eCCl?
eCCl = (140-Age) X (mass in kg) X (0.85 if female)/ (72X serum creatine in mg/dL)
If the adult kidney is more than 9 cm in length on ultrasound then this indicates...
A. Significant irreversible renal disease
B. Kidney atrophy due to intrinisic kidney disease
C. I dunno??
D. Normal kidney
A. Significant irreversible renal disease
(this multiple choice question has been scrambled)
If there is a difference in size greater than 1.5 cm between the right and left kidney the pt has ___
unilateral kidney disease
a "string of pearls" in the kidney on ultrasound incidates what? (Bonus: what if you found a "string of pearls" on ovarian ultrasound?)
- Polycystic kidney disease
- or PCO if in ovaries
For Kidney hemorrhage or renal stones would you do a CT with or without contrast?
To evaluate the urinary tract, pelvicaliceal system or to localize stones in the UTI would you do a CT with contrast or without?
T or F an MRI can help you distinguish the renal cortex from the medulla
What is the most accurate imaging study for the diagnosis of renal artery stenosis?
What are some indications for a Renal Biopsy?
- Unexplained acute or chronic kidney disaseas
- acute nephritic syndrome
- Unexplained hematuria and protinuria
- Previously identified and treated lesion to plan future treatment
- Systemic disease with kidney dysfunction (SLE)
- Suspected organ rejection
What are some Relative contraindications to performing a renal biopsy?
- Solitary or ectopic kidney
- Horseshoe kidney
- Uncorrected bleeding disorder
- Severe uncontrolled HTN
- Renal infection
- Renal neoplasm
- Congenital anomalies
- multiple cysts
- uncooperative pt
Can you re-administer anticogulation therapy to a pt directly after a renal biopsy?
no you should wait 5-7 days
What are the treatments for uncomplicated protinuria?
- ACE inhibitors: decrease efferent arteriolar resistance (via a dilated efferetn arteriole) in comparison to afferetn arteriolar resistance leading to a decreased glomerular capillary pressure and decreased uriary protein excretion
- ARBS: Decreased proteinuria and derease progressive renal disese
___ is a sudden decrease in renal function leading to the inability to maintain fluid and electrolyte balance and to excrete nitrogenous wastes (as evident by a marked increase in creatinine)
Acute Renal failure
What are the 3 main types of acute renal failure?
- Prerenal azotemia
- Postrenal azotemia
- Intrinsic renal failure
What is the most common cause of Acute renal failure?
What is the pathophysiology of prerenal azotemia?
- Hypoperfusion: can be reversed with restoration of renal blood flow if there is no parenchymal damage
- if hypoperfusion persists it leads to ischemia and intrinsic renal failure
What are some eitiologies of hypoperfusion that may lead to prerenal azotemia?
- Decreased intravascular volume: hemorrhage, GI losses, dehydration, excessive diuresis, burns and trauma
- Change in vascular resistance: sepsis, anaphylaxis, ACEI, renal artery stenosis
- Decreased cardiac output: leading to decreased renal perfusion, cardiac shock, CHF, PE arrhythmias and valvular disaease
- Decreased delivery to the Kidney: renal artery stenosis
A really high BUN say of maybe something like... 20:1 would indicate what type of acute renal failure? (even though all ARF increases BUN ratio)
Does prerenal azotemia cause an increased or decreased GFR?
Pts with prerenal failure have a low fractional excretion of what ion?
What is the least common cause of acute renal failure?
Post renal azotemia
In this type of acute renal failure, obstructed urinary flow from both kidneys or a single functioning kidney is present. Obstruction can be constant or intermittent, partial or complete and is a reversible cause of renal failure
Post renal azotemia
What are some causes of post renal azotemia?
Urethral obstruction, bladder dysfunction or obstruction, obstruction of both ureters or renal pelvises, BPH, bladder, prostate or cervical cancer mets
What are some sx of Post renal azotemia?
- Anuria (with complete obstruction)
- polyuria (as in frequency) oligouria (with amnt)
- abdominal pain
Pts with post renal azotemia will have an (increased or decreased) urine osmolality, a (increased or decreased) urine Na and an (Increased or decresed) creatinine ratio
- Increased urine osmolaity
- Decreased urine Na
- Increased BUN:Cre
- NOTE: if it has been a few days then the kidneys get tired of concentrating the urine and have to let sodium out causing an increase in sodium
What is the treatment for post renal azotemia?
- Remove the obstruction (surgery, lithotripsy, etc)
- Bladder catherterization (if hydronephrosis and bladder enlargement
- Monitor lytes and keept the pt hydrated
With this type of ARF the parenchyma of the kidney is affected by definition
Intrinsic Renal failure
The majority of intrinsic acute renal failure caused by what?
Acute tubular necrosis 85% of cases
What are some causes of acute tubular necrosis?
- Nephrotoxin exposure: toxins can be exogenous like drugs or endogenous like myoglobinuria from rhabdomyolysis
Acute tubular necrosis due to ____ is caused by prolonged hypotension ro hypoxemia secondary to dehydration shock or sepsis
Which of the following drugs is NOT nephrotoxic?
A. Amphotericin B
(this multiple choice question has been scrambled)
What are some risk factors for a pt to be more sensitive to exogenous nephrotoxic drugs?
- Underyling renal damage
- Advanced age
- Diabetes Mellitus
- multiple myeloma
- repeated contrast exposure
A pt comes to you b/c they were found in a coma (still breathing) it is thought that they may have been there for some time because they were very dehydrated and slightly emaciated secondary to muscle wasting. They were found next to a bottle of jack daniels and an empty baggy with traces of cocaine. What is the most likely type of intrinisc renal failure?
A. Ishcemia from the cocaine?
B. Radiographic contrast media exposure
C. Muscle necrosis from prolonged inactivity and cocaine/alcohol use
D. diabetic nephropathy with dehydration compounded with NSAID use
BONUS: what would their urine look like?
- C. muscle necrosis from prolonged inactivity and cocain/alcohol use.
- Their urine would appear dark with increased phosphatemai and increased uricemia
"Muddy brown Casts"
Actue tubular necrosis
What should you avoid when treating a pt with acute tubular necrosis?
fluid overload and hyperkalemia
What are the 3 phases of acute tubular necrosis?
- Initial injury
- Maintenance: 1-3 wks to several months of cellular repair and removal of tubular debris oliguric or non oliguric
- Recovery: GFR rises, BUN and creatinine decrease
This type of intrinsic renal failure is characterized by interstitial inflammatory response with edema and possible tubular cell damage
What are some drugs that can cause interstitial nephritis
Penicillin, cephalosporins, sulphonamides, NSAIDs, rifampin, phenytoin, allopurinol, PPIs
What are some infectious causes of interstitial nephritis?
streptococcal, leptospirosis, CMV, histoplasmosis, Rocky mountain spotted fever
What are some immunologic causes of intrinsic nephritis
- Systemic lupus erythmatosus
- Sjogren's syndrome
Pt presents with acute renal failure. They have a fever, transient maculopapular rash, arthralgias and eosinophilia. Their urinalysis reveals RBC, WBC, WBC casts and protinuria. They state that they have sig recent PMH of streptococcal infection which they have?
Interstitial nephritis is causing their acute renal failure
What is Berger's disease what type of acute renal failure is it associated?
It is an IgA nephropathy and is associated with glomerulonephritis
What is Wegner's granulomatosis and what type of renal disesae does it cause?
It is a sytemic necrotizing vasculitis of small vessels affecting the upper airway, pulmonary and skin vessels, immune complexes are depositited on these tissues basement membranes leading to destruction. Glomerulonephritis
What are some causes of glomerulonephritis?
- IgA nephropathy (Berger's disease)
- cryoglobulinemic glomerulonephritis (assiciated with hep C)
- Membranoproliferative glomerulonephritis (if associated with pulmonary hemorrhage = good pastures syndrome)
- Wegner's granulomatosus= systemic necrotizing vasculitis of small vessels affecting the upper airway and pumonary and skin vessels
What are two signs/sx of glomerulonephritis?
HTN and edema (periorbital and scrotal)
What are some labs you should order if you suspect a glomerulonephritis?
- Urine: moderate protein <3g/d, RBC, RBC casts, WBC
- Compliment levels
- ASO titer
- AntiGBM antibody levels
- Antinuclear antibody titers
- Hepatitis serologies
- Consider ordering renal ultrasound or biopsy
What is the treatment for glomerulonephritis?
- High dose corticosteroids
- cytotoxic agents such as cyclophosphamide
- Plasma exchange in goodpasture disease until chemotherapy takes effect
What are some clinical manifestations of acute renal failure?
- N, V malaise
- pericardial effusion with friction rub
- arrhythmias secondary to hyperkalemia
- rales on lung exam secondary to hypervolemia
- abdominal pain and ileus
- platelet dysfuntion
- encephalopathic changes like asterixis confusion seizures
What labs should you order for a pt is acute renal failure?
- Increased BUN creatinine
- hyperkalemia, hyperphosphatemia
- EKG: peaked T waves, PR prolongation and QRS widening
- QT prolongation secondary to decreased calcium
- Anemia secondary to decreased erythropoetin production
- Platelet dysfunction secondary to uremic toxins- intrinsic platelet abnormalities and impairement of the platelet vessel wall interaction
____ is a progressive loss in renal function over a period of months to years
Chronic kidney disease or chronic renal disease
Name some glomerularnephropathies that can cause chronic renal failure
- Primary glomerular disease (IgA nephropathy)
- Secondary glomerular nephropathy (Diabetic nephropathy)
- Tubulointerstitial nephritis (drug hypersensitivity)
- Hereditary disease (polycystic kidney disease)
- Obstructive nephropathies (nephrolithiasis)
- Vascular disease (HTN, renal artery stenosis)
What is the most common tumor found in men?
Benign prostatic hyperplasia (BPH)
56 y.o. M reports that his urine stream has weakend. He also complains of nocturia, decreased force of stream and hesitancy. He also states he is having post void dribbling. On the basis of the pt's history what do you expect to find on his examination?
In most cases of BPH the prostate will have a smooth symmetric and firm elastic consistency. If you detect an irregular, harder nodule or lesion cancer must be supected.
What percentage of men with BPH are afflicted with occult prostate cancer?
How well does the size of the prostate corrolate with the symptoms in BPH?
not well. symptoms can arise because of small fibrous prostate as well as a large one. Addintonal symptoms can also develop as a result of median bar hypertrophy of the posterior vesicle neck, detrusor muscle decompensation or instability
Name 3 tests that can be used to determine the presence of BPH
- Intravenous urography IVU
- CT scan
What class of drugs is sued as first line treatment of BPH?
Name the most common surgical proceedure for the treatment of BPH
Transuretheral resection of the prostate (TURP)
Why is surgical correction of cryptorchism important/?
Surgical correctin is required to preserve fertility, but the procedure has not bearing on the future developement of testicular cancer. Surgery must be perfomed before age 5 to preserve fertility
What children have a high risk for cryptorchism?
Premature births have up to 20%prevalence
what is the most common cause of sytemic ED?
What are some sytemic conditions that can cause erectile dysfunction
Diabetes, hypercholesterolemia, heart disease, depression, renal failure, adrenal and thyroid dysfunction
Name some treatment for improving erectile dysfunction
Hormonal replacement, vacuum constriction device, vascular surgery, vasoactive thrapy, and penile prosthesis
33 y.o. male pt presents with a history of sudden onset right flank pain that was sharp and doubled the pt over. This was also assciated wtih nausea and vomiting and radiation of pain around the flank to the lower quadrant of the abdomen and scrotum. based on this history what is the likely diagnosis?
What is the test of choice for ruling out a kidney stone?
Spiral CT scan
What is one of the greatest factors in the prevention of kidney stones?
the amount of fluid intake by the pt. The more a pt is able to take in fluid the less likely he or she will develop a stone. If the pt has a history of a stone the recommendation is to try to double the amnt of fluids.
What percentage of renal calculi are radiopaque?
85% with 75% of calcium composed stones being opaque
What are the admission criteria for pts with renal calculi?
Infection with current obstruction, a solitary kidney and a complete obstruction, uncontrolled pain, intractable emesis, large stones. Only 10% of stones >6 mm pass spontaneously. Other indications include renal insufficency and a complete obstruction or urinary extravasation as demonstrated by IVP.
A urinary pH of 7.3 is conducive for the formation of what kind of stones?
struvite and phosphorus stones. Alkalotic ruin actually inhibits the fromation of uric acid and cystine stones. Conversly struvite and phosphate stones are inhibited by more acidic urine
What type of renal stone is caused by a genetic error?
cystine stones. These stones are produced becasue there is an error in the transport of amino acids that results in cystinuria
Whate is kidney stone formation most likely to occur?
the proximal portion of the collecting system
Name the 3 most common anatomical sites where kidney stones like to get stuck?
- uterovesicular junction
- crossing over the iliac vascular structures
- opening of the urethrovesicular junction
What are some symptoms of Chronic renal failure?
- Fatigue, weakness, malaise
- Anorexia, N/V, metallic taste, hiccups
- Irritability, difficulty concentrating, insomnia, memory deficit
- Pruritis, yellow skin, easily bruising
- decresaed libido, menstrual irregularities
- CP from pericarditis
- Note: symptoms develop slowly, are nonspecific and continue until renal failure is far advanced
54 y.o. M with diabetes presents with fatigue, wekaness and malaise. He states that it has been getting worse over the last 6-8 months although it has been going on for about a year. He said that he is just not as hungry as he was and that his wife has complained in his marked decrease in sexual interest in her (she thinks he is having an affair). He has a pertinent PMH of Intrinsic acute renal failure X2 once due to diabetes and NSAIDs and once due to diabetes and aminoglycosides. What does he have now and how would you treat? how would your treatment plan change if his creatinine clearance was 6mg/dL?
- He is in Chronic renal failure
- to start potassium restriction and sodium polystyrene sulfonate
- protein restriction
- phosphorus restriction
- magnesium restriction
- Dialysis when GFR is 10mL/min or creatinine is 8mg/dl OR 15ml/min or 6mg/dL if diabetic which our pt is so if his creatine was 6mg/dL we would have to have a conversation with him about geting on a transplant list and the initiation of dialysis.
___ is a fishy breath odor assiciated with chronic renal failure
___ is a pale white frost deposit found on the skin secondary to kidney failure and inability to excrete waste. Compounds and waste products excreted through small capillaries throught the skin.
What are some cardiovascular and pulmonary symptoms of chronic renal failure?
HTN, rales, cardiomegally, edema and peircardial friction rub
What are some labs you might find abnormal in chronic renal failure?
- Increases BUN creatinine
- Anemia (secondary to decresed erythropoiten)
- Metabolic acidosis (inability to secrete bicarb)
- Increased phosphatemia
- Urine with BROAD WAXY CASTS
- US: small bilateral echogenic kidneys
What electrolyte imbalence is the chronic renal failure pt at risk for if their GFR drops below 10-20ml/min?
- it can cause occur with cellular destruction (hemolysis or trauma)
- Dietary K (citris, fruit, salt substitutes containing K)
- Drugs that decrease K secretion (amiloride, triamterene, spironolactone, NSAIDs, ACEIs)
In CRF if the damaged kidney is unable to excrte the 1 mEq/kg/d of acid generated by dietary protein metabolism this condition ensues....
The majority of chronic kidney disease pts die of ____
Pericarditis in chronic renal failure is believed to be secondary to the retention of metabolic toxins and is an absolute indication to what treatment modality?
In chronic renal failure, CHF causes extracellular fluid overload, anemia and HTN which all increase the work of the myocardium and increase Oxygen demand and accelerate atherosclerosis The treatment to prevent this is ....
- H20 and Na restrictions
- Loop diuretics
- Ofthen in combo with thiazides (if the pts kidneys can tolerate)
What are the neurologic complications of chronic renal failure?
- When GFR is less than 10-15 mL/min
- Possibly secondary to aggregation of uremic toxins
- Sx: Lethargy, confusion and coma
- PE: Nystagmus, weakness, asterixis, hyperreflexia, stocking and glove neuropathy
What are some Dietery modifications that should be recommended/imposed upon a pt with chronic renal failure?
- Protein restriction: decreased albumin at the start of dialysis is strong predictor of mortality
- Na and H20 restriction: Recomended 2gNa/day with 1-2L H2O/day, Na intake >3-4 g/d or else edema HTN and CHF can ensue and it should be less than 1g/d b/c of volume depleteion and hypotension i.e you cant win muahahahaha
- K restriction: less than 50-60mEq/d
- Phosporus restriction: limit cola (no coca cola classic ne more) eggs, dairy, meat, add a phosphorus binder if GFR is less than 20-30 mgL/min
- Magnesium restriction: all laxatives (so if all these new diet changes give them constipation it is the finger and not the bottle) any acids with mg are contraindicated
What is the clinical indication for the initiation of dialysis in a pt with chronic renal failure?
- GFR 10mL/min or creatinine 8mg/dL
- if diabetic then: 15ml/min or creatinine 6mg/dL
Other than the GFR and creatinine what are some other indications for the initiation of dialysis in a chronic renal failure pt?
- Refractory hyperkalemia
- Fluid overload unresponsive to diuresis
- Severe metabolic acidosis (pH less than 7.2)
- Uremic syndrome (encephalopathy, pericarditis, coagulopathy)
- Neurologic symptoms (seizure or neuropathy)
Explain how peritoneal dialysis works
- Dialysate enters the peritoneal cavity through a catheter
- Fluids and solutes move across the capillary bed and between the viseral and parietal layers of the peritoneal membrane
- can have CAPD- continuous ambulatory peritoneal dialysis (pt exchanges dialysate 4-6X/day)
- Or CCPD- continuous ambulatory peritoneal dialysis (machine automatically performs exhange at night)
- This gives pts more autonomy
- Monitor nutritonal status frequently since large amnts of albmumin are removed
- Peritonitis with S. aureus is most common complication
What is the most common complicatin to peritoneal dialysis?
S. aureus peritonitis
Other than dialysis what is the other difinitive treatment for end stage renal disease?
If a pt who needs dialysis declines treatment what is their prognosis?
death within days to weeks
What are the 3 types of glomerulonephropathies
- Nepritic syndome
- Nephrotic syndrome
- Asymptomatic renal disease
36 y.o. M pt presents with periorbital and scrotal edema. on UA he is found to have dysmorphic RBCs, RBC casts and some protein. What does he have and what is the treatment?
- Acute glomerulonephritis
- Tx: BP and fluid overload control. salt and water restrictions
- dialysis PRN
30 y.o. F pt presents with oliguria and edema with mild hypertension. She works in a daycare and recently had impetigo and pharyngitis simultaneously about 2wks ago. Her UA shows coke colored urine, RBC, and RBC casts, and 1.3 g/d of protein. What is the next diagnostic study you would like to do and what do you think is her diagnosis?
- Dx: immunoflorescence shows IgE and C3 granular pattern along capillary basement membranes
- She has post infectious Glomerulonephritis
What is the treatment for post infectious glomerulonephritis?
- Na restrictions
40 y.o. F pt presents with peripheral edema, and salt retention their bloodwork shows a decreased serum albumin and total protein. Their UA shows 4.0 g/day of protein excretion with some epithelial cell casts and over fat bodies. What does she have?
Glomerulonephropathy. specifically Nephrotic syndrome
You have a pt with Nephrotic syndrome who is not hypercoaguable, but is having protein loss Edema and hyperlipidemia what treatments would you recommend?
- Protein loss: protein restriction (may decrease glomerulosclerosis) ACEI (reduce glomerular capillary pressure and proteinuria by decreasing effereten arterioloar resistance)
- Edema: Na restriction, Diuretics (dependant on the protein this large doses may be nessisary combo of loop diuretics and thiazides are best)
- Hyperlipidemia: dietary modification and exercise
How would you manage the hypercoaguable state associated with Neprhotic syndrome?
Anticoagulation for 3-6 months if it is recurrent then treat with anticoag indeffinitly
What causes a hypercoaguable state in pts with neprhotic syndrome?
losses of antithrombin 3, protein C and S in the urine and increased platelet activation this often leads to renal vein thrombosis
Red blood cell casts are pathopneumonic for
Hematuria with dysmorphic RBCs, RBC casts and protein
Proteins and lipids
Pigmented granular casts, renal tubular epithelial cells
Acute tubular necrosis
WBC (neutrophils or eosinophils) WBC casts, and RBC and some protein
Interstitial nephritsi or pyelonephritis
proteinuria >3.5g/24 hrs is chracteristic of what?
"muddy brown casts"
Who is more likely to get renal cancer men or women?
Medullary cell type kidney cancer is associated exclusively with ___
Sickle cell trait
What are the risk factors for renal cell carcinoma?
- Smoking!!!!! number 1 risk factor
- Obesity in women
- HTN due to chronic cellular damage at the kidney level
- End stage renal disease
- Acquired renal cystic disease
What are some condtions associated with renal cell cancer? Hint: they are all zebras.
- Von Hippel lindau: predispostion to multiple cancers cystic disease of the kidney and pancreas
- Tuberous sclerosis: can affect kidneys, GI tract, pancreas, skin
- Sickle cell trait: causes renal medullary tumor
- Hoseshoe kidney: congenital malformation that is usuallyu functioning but will rapidly cause renal failure
What is the classic triad of Renal cell carcinoma?
- Hematuria, flank pain and abdominal mass
- may lead to a diagnosis of cystitis but if associated with B symptoms CANCER untill proven otherwise
A varicocele on the right in a young man or a new onset varicocele on the left in an older man is a suspicious symptom for what?
Renal cell carcinoma
What are some paraneoplastic symptoms of renal cell carcinoma?
- Abnormal liver function (stauffers syndrome- abnormal liver enzyme dysfunction)
- Cachexia (wasting)
- Cushing's syndrome - too much cortisol usually peripheral, leads to wt gain fluid retention and fat redistribution
Pt has a flank tenderness that is not colicky in nature but is tender to palpation/manipulation is this characteristic of
C. Renal stone
D. finicky pt
A. renal cell carcinoma
(this multiple choice question has been scrambled)
What is Stauffer's Syndrome
abnormal liver function associated with Renal cell carcinoma
Where will there be lymphadenopathy in a pt with renal cell carcinoma?
Inguinal lymphadenopathy and supraclavicular lymphadenopathy
What are some lab findings for Renal cell carcinoma?
- Hematuria: often have frank RBCs
- Urinary neoplastic cells (on cytology, where pathology sees cancer and picks up 40% of incidentaloma RCC)
- Anemia- b/c EPO is not being produced and pt is peeing blood
- hepatic dysfunction
- elevated alk phos
- increased renin
What is the INITIAL test for abnormal UA with suspicion of RCC?
- Initial test for most kidney issues able to see size degree of volume in kidneys
- cystic or solid?
- if cystic take some of that... in other words "tap that ooooooo"
What is the Imaging study of choice for a suspected renal cell carcinoma that is solid?
- CT with oral and IV contrast
- Oral contrast for bowel mets
What is the gold standard diagnostic study for renal cell carcinoma?
- Recection of mass and histological specimin confirmation
- Clear cell: single kidney affected one tumor
- Papillary renal cell: bilateral kidneys with multiple tumors
- Chromophobic: 3-5% rare but best prognosis
- Medullary: occurs in sickel cell pts
- Collecting duct
Why is IVP not usually used in the diagnosis of renal cell carcinoma?
dye load is tremendous and the kidneys need to process it as the kidney fills up with dye it burdens the kidney. However it is an excellent test b/c it will outline the mass in teh kidney since the mass witll not fill with dye
When would you use an MRI as the imaging study of choice Dx of Renal cell carcinoma
- If the pt has a contrast contraindication.
- Those include: renal insufficiency, metforman, high dose ACEI, allergies to dye
Why would you do a CXR in a pt with RCC?
RCC likes to mets to lungs and so if you have any suspicion of that then do a CXR
If a pt with RCC has an abnormal alk phos or bone pain what diagnostic test should you do?
Bone scan for mets to bone
Surgery is curative in pts with renal cell carcinoma that have stages _____
stage I and II
What is a partial nephrectomy and when is it used?
- "wedge resection"
- Resect tumor and boarders and do if a pt has only one kidney or if there is bilateral kidney involvement or if the pt has a low functioning kidney
- Tumors need to be less than 4cm
Radical nephrectomy is the removal of....
- Nodes associated with kidney/ all diseased nodes
- Perirenal fascia
For RCC tumors less than 2cm what is another therapy option other than wedge resection?
- Ablative therapy
- cryotherapy and RF ablation
What is a helpful proceedure for VERY large RCC tumors pre-op
- a gel or sponge in renal artery to infarct the kidney it aids the surgeon to take out the kidney in a safe manner
What are some non surgical/adjuvent therapies for RCC?
- RCC dose not respond to cytotoxic chemotherapy!!!
- Targeted therapies: anti VEGF and mTOR inhibitors
- Immunotherapies: Stage IV
- Radiation therapy: Palliative, shrinks tumor and may make it amenable for resection, sometimes will induce spontaneous regression of CA
What are the most common places for RCC to mets?
- Regional nodes
- Adjacent organs
Stage I RCC has a ___ survial rate
Stage II RCC has a __ survival rate
State III RCC has a __ survival rate
Stage IV RCC has a _ survial rate
less than 10%
What is the Karnofsky preformance status?
- Was originally used for hospice care in determining how likely a pt was to need hospice. also used in evaluation of prognosis of pt with RCC. under 80% is a worse prognosis
- 100%: normal, no complaints, no signs of disease
- 90%: capable of normal activity few sx or signs of disease
- 80%: normal activity with some difficulty some signs or sx
- 70%: caring for self but not capable of normal activity or work
- 60%: requriring some help can take care of most personal requriements
- 50%: requries help often requries frequent medical care
- 40%: diabled, requires special care and help
- 30%: severely disabled, hospital admission indicated but no risk of death
- 20%: very ill urgently requiring hospital admission, reqruies supportive measure or treatmetn
- 10% morbid, rapidly progressive fatal disease process
- 0% death
What are two emergent complications to worry about with RCC and how do you treat each?
- Acute Renal failure: can lead to hyperkalemia so you need to treat and stabilize the heart emergently, hydrate but diurese in worst case
- Actue Adrenal insufficency: decreased steroid production from adrenal involvement leads to hypotension and shock
How often does an RCC pt need a CT scan post surgery?
every 3-6 months
What is another name for nephroblatoma?
___ is a pediatric kidney cancer tht is a malignant tumor arising from embryonal cells
__ is the most common renal maligancy in childhood
Familial wilms tumor is most often (unilateral or bilateral?)
What are some conditions associated with wilms tumor?
- Aniridia (no iris)
- Hemiphypertrophy (all organs and limbs are bigger on one side)
- Duplicated renal collecting system
- WAGR: anridia, genitourinary anomalies and MR
- Denys- Dash syndrome
- Klippel Trenaunay syndrome
- Beckwith- weidemann syndrome
Asymptomatic abdominal mass in a 2-5 y.o. child
wilms tumor! 90% present with asymptomatic abdominal mass.
What are some symptoms of a wilms tumor?
- asymptomatic abdominal mass
- abdominal pain
- gross hematuria
What are some PE findings of a wilms tumor?
- abdominal mass: will feel retroperitoneal flank mass with a large kidney that can take up 1/2 of the abdomen
- Prominent abdominal veins
- Increased abdominal girth
- microscopic hematuria
- other congenital anomalies
An elderly couple adopted a child from Africa and when they saw that the child has no iris they rushed the child to you for evaluation. What are you concerned about?
Where to wilms tumors tend to mets to?
- contralateral kidney
- Intra-abdominal sites
What lab studies should you order if you suspect a wilms tumor?
- CBC, CMP with calcium
- Coagulation studies (check bleeding, worry if liver dysfunction or von Willibrand dz)
- Catecholamine metabolites (check for pheochromocytoma)
- May require a bone marrow biopsy
Best imaging technique for wilms tumor extenstion into the IVC
___ confirms diagnosis of a wilms tumor
What kind of CT to you order for a child whom you suspect has a wilms tumor
CT scan of the abdomen and chest with oral and IV contrast
What are favorable findings on biopsy of a wilms tumor
epithelial, stromal and blastemal elements
What are unfavorable findings on wilms tumor histology
What is the treatment for a wilms tumor
- Surgery: pediatric urologist should perform the surgery, it is a radical nephrouterectomy
- they will also need lymph node dissection
- do wedge resection if it is bilateral
What are the non-surgical/adjuvant treatment options for wilms tumor
- Chemotherapy: stage I and II vincristine + pulse dose dactinomycin
- External beam radiation: Stage III and IV for tx of lung mets
What are some paraneoplastic syndromes associated with wilms tumor
- von willibrands dz
- ruputure of wilms tumor
What pt population is most likely to develop bladder cancer?
Men, african americans 69y.o. + who smoke
What are some risk factors for developing Bladder cancer?
- Occupational exposures
- Hx of pelvic irradiation, mostly for gyn tumors
- Chronic UTI
- Chronic indwelling catheter
- Cyclophosphamide exposure
- High fat diet
- Chronic dehydration
What r some conditions associated with bladder cancer
- Spinal cord injury with neurogenic bladder
- metastasis from other primary malignancy
- bladder diverticula
- urachaal remnant
What are some sx of Bladder cancer
- may be asymptomatic
- urinary voiding sx (freqency, urgency, dysruia)
- Abdominal or pelvic pain similar to UTI
- Anorexia or wt loss
- Flank pain
- abdominal mass
Where does bladder cancer like to mets
- first invades bladder wall then mets locally to the uterus vagina
- next the abdominal or pelvic wall
- finally distal to bone and soft tissue of the abdomen
70 y.o. M Pt presents with hematuria and pain like a UTI with some frequency and urgency. He has only every had one UTI before and you think it might be bladder cancer. What diagnostic studies should you order?
- Lab studies: urinalysis, urine culture, urine cytology, CBC, BMP, LFT/alphos for mets to bones and liver
- Cystoscopy with biopsy: makes diagnosis do a scraping with a fish hook and suction cells
- Determination of extent and staging is based on imaging: IVP, retrograde pyelogram, cytology, CT of abdomen and pelvis with IV contrast, CXR for mets
- Histology: transitional cell carcinoma, adenocarcinoma, small cell carcinoma, squamous cell carcinoma, in children its usually Rhabdomyosarcoma
What is the treatment for bladder cancer that is superficial and has not penetrated into the muscular layer of the bladder
- Transurethral resection of the bladder TURBT
- or TURBT +BCG if non-muscle invading but deeper than plain superficial
What s the Tx for bladder cancer that is muscle invasive
- Radical cystectomy with lymph node dissection: en bloc resection of the prostate and hysterectomy prophylactic
- bladder sparing cystecotmy is becomming more popular- if cut out bladder need to create ancillary tract like a peritoneal drain which can increase chance of infection or neurogenic problems
What are the non-surgical/adjuvant therapy for Bladder cancer?
- Chemotherapy: for all muscle invading tumors (M-VAC methotrexate, vinblastine, doxyrubicine, cisplatin) preoperatively, adjuvently for mets following cystectomy, for unresectable diseease or non surgical candidates
- STOP SMOKING!
___ is the narrowing or complete occlusion of one or both renal arteries
renal artery stenosis
Cases of renal artery stenosis in older men are usually caused by ___ while cases of renal artery stenosis in young women are usually ___
- Fibromuscular dysplasia
What causes renal artery stenosis in children
What are some comorbidities associated with renal artery stenosis
What are some risk factors for renal artery stenosis
- old age
- autoimmune Dz
- low socioeconomic status
- white men
is there a genetic component to renal artery stenosis
What are some associated conditions with renal artery stenosis
- high grade retinopathy (cotton wool spots on fundoscopic exam)
- Abdominal flank bruit
- atherosclerotic disease
- new onset HTN after 50
- Extrinsic compression on a renal artery
- Embolic disease
- Iatrogenic surgical mishap
Any time there is acute decrease in renal function after giving ACE inhibitors you should evaluate the pt for
renal artery stenosis (bilateral)
If you start a pt on an ACEI when should you check a metbolic panel
- ACE I can cause acute renal failure by decreaseing efferent pressure meaning the kidney is not perfusing meaning cant pass solute meaning suddent dramatic increase in creatinine
What is the tx for a pt who has acute renal failure following ACE I therapy
- they have bilateral renal artery stenosis
- discontinue the ACEI and hydrate treat with RAS
What test can your pt do at home to test for erectile dysfunction
postage stamp test
What are the Signs and Sx of renal artery stenosis
- Asymptomatic most of the time
- May have sx of actue hypertensive urgency/emergency (mental changes, headache, shortness of breath, visual changes, papilledema)
- Acute Renal failure
- Abdominal bruit
- Hypertensive retinopathy
- Bruit on PE
What lab studies would you do for renal artery stenosis
- Repeat BP
- Urinalysis: look for hematuria, protinuria, any sign of renal failure, casts
- Plasmin Renin
- Renal vein renin levels: perform during dye studies not commonly done unless you need to determine which kidney has RAS. Kidney with RAS will have increased renin production compared to nonaffected kidney
Pt has elevated serum renin. One kidney is known to have renal arter stenosis one does not. Which kidney is producing the renin
the affected kidney
What imaging studies would you do for renal artery stensosis
- Renal ultrasound with doppler
- Captopril nuclear renogram
- digital subtraction angiography (invasive) inject dye into arteries to look for FMD knotted ropy arteries gold standard
- MRA not done as much as CT
What is the gold standard test for fibromuscular displasia causing renal artery stenosis
- Digital subtraction angiography
- Inject dye into arteries to look for FMD
- will find knotted or ropy renal arteries
What is the treatment for renal artery stenosis?
- ACEI is DOC for HTN unless bilateral RAS
- control HTN
- Manage lipids
- Asprin or plavix
- Wt loss
- Smoking cessation
What is the surgical managment for renal artery stenosis
- PCTA: percutaneous transluminal coronary angioplasty with stenting, or surgical revascularization
- Aortorenal bipass: alternative is splenorenal or hepatorenal bypass
WHat is the follow up for stenting in renal artery stensosis
- Lifelong follow up and therapy
- At least every 6 mo BP renal function and UA provider must draw BMP 3-4 wks after starting ACEI
What is the peak age range for neprholithiasis
who is more likely to get renal stones males or females
Male caucasian males
If a stone moves into a ureter from the kidney what complications do you have to worry about
hydronephrosis that dialtes and leads to symptoms of decresed renal function and renal parenchymal damage
What are the risk factors for nephrolithiasis
- genetic susceptitibilty
- Type II DM
- Neurogenic bladder
- Low urinary volume
- work environment with high heat exposure
- outdoor activities in teh summer
What are some dietary contributors to nephrolithiasis?
- Low dietary calcium intake: need calcium to decrease kidney stones but calcium supplments increase stones wierd
- Calcium supplements
- High animal protein intake
- Low fluid intake
- Hight vitamin C intake (but OJ decreases stones)
- Low magnesium intake
- Low potassium intake
- Low vitamin B6 intake
What are some medications that can lead to nephrolithiasis
- Hypercalcemia: acetazolamine, CCBs, calcium supplements, phosphorus binding antacids, furosemide, corticosteroids, topiramate, triamterene, theophylline
- Hypoditraturia: thiazides and furosemide
- Hyperuricosuria: Probenecid, salicylates radio contrast dye and losartan
What are some conditions associated with neprholithiasis
- Inflammatory bowel disease
34 y.o. M landscaper presents with sudden very severe flank pain that makes tehm double over it radiated from his testicles throughout his abdomen as if he were kicked in teh balls. He also reports nausea.
Sx of nephrolithiasis
- may be asymptomatic
- flank pain often severe (usally sudden onset, may radiate to back groin or genitalia, pt will often point to kidney)
- urinary frequency or dysuria
- nausea with or without vomiting
- gross hematuria
PE signs of nephrolithiasis
- Pt is unable to sit still
- intestinal ilius
- CVA tenderness
- Occasional fever
- Best to rule out other causes of abdominal pain
What are some lab studies you would order for a suspected nephrolithiasis
- CBC to ruleout infection
- BMP plus calcium
- stone analysis
- 24 hour urine for metabolite abnormalities
- serum parathyroid levels
- urica acid levels
Eitiologies of a calcium phosphate stone
- increased calcium absrobtion or excretion
- chronic bowel disease
- poor GI citrate absorbtion
- Excess vitamin D or C
- alkaline urine
- calcium antacids
- chronic corticosteroids
- thiazide diuretics
Stones associated with UTI that have staghorn calculi usually made of magnesium amonium and or phosphate they occur in alkaline urine
Infection with urease producing bacteria can cause what type of renal stone
These stones occur with familial gout, IBD, high purine diet, acidic urine, myeloprolivertive disorders malignancy and chemo
uric acid stones
these stones occur with hereditary cystinuria
What imaging studies would you do for nephrolithiasis
- Non contrast helical CT is the test of choice
- Plain abdominal X ray 70% of calcium stones show up
- IVP but high dye load not optimal
- US will not show stone but will show hydronephrosis
What is the immediate treatment for a nephrolithiasis
- Rehydration: 3mm stones can pass most stones 5mm and more will not pass but may with time over 1cm WONT
- Pain control: NSAIDs tordol 30 mg IV 60 mg IM not PO, narcotics morphien dilaudid
- antiemetics: zofran
- Alpha antagonist blockers
What are some indications for urgent admission and consult for a pt with nephrolithiasis
- Anuria (no pee, most likely urethral obstruction where 2 kidneys are blocked sometimes a catheter will pass the stone but if not then call surgery)
- Renal failure
Pain control nephrolithiasis can include
- NSAIDs: toradol 30mg IV or 60mg IM not PO
- Narcotics (morphine, dilaudid, fentynyl)
Dispostion for a pt who has a small kidney stone less than 5mm and no hydronephrosis
- can d/c home
- continue hydration
- pain control narcotic nsaid combo like vicopro
- Expulsive therapy: alpha antagonist, CCB, corticosteroids
- strain urine
- avoid food triggers
- frequent follow up
- must pass stone within 4 wks
Plan and disposition for a pt with a larger kidney stone more than 5mm, hydronephrosis or uncontrolled pain or infection
- uruology intervention
- depends on location
- ESWL: uppper pol or renal pelvis less than 2cm
- URS: uretral or kidney stones
- Percutnatous nephrolithotripsy with loer pole large stone or UP junction
- Open surgery no longer frequently used
What f/u should you do on a pt with acute nephrolithiasis
- must document stone passage
- weekly or biweekly radiographs
- lab monitoring
What are some complications of acute nephrolithiasis
- acute obstruction
- renal failure
What would you like to do?
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