Ch299: Renovascular Disease

Question 1

What region of the kidney has less blood supply and hence less oxygen: cortical or medullary?

Answer 1

Medullary region are at the margin of hypoxemia

Question 2

Predictive of systemic atherosclerotic disease events

Answer 2

urinary albumin excretion (UAE)

Increased UAE increases risk of atherosclerotic events

Question 3

Pharmacologic therapy to reduce UAE and risk of CV events

Answer 3

Statins

Question 4

Causes of large-vessel renal artery occlusive disease

Answer 4

1. Extrinsic compression of vessel
2. Fibromuscular dysplasia
3. Atherosclerotic disease

Question 5

The systemic effect produced by the kidneys, trying to restore the renal pressure secondary to disorders that reduced it

Answer 5

Systemic hypertension

Question 6

May present as hypertension in younger individuals (age 15-50) most often women

Answer 6

Fibromuscular dysplasia

Question 7

Prevalence of this condition increases with age and history of CAD and/or peripheral aortic or lower ext disease

Answer 7

Atherosclerotic renal artery stenosis (ARAS)

Question 8

Slows the rate of ARAS and improve clinical outcome

Answer 8

1. Intensive treatment of arterial BP

2. Statin therapy

Question 9

Treatment for renovascular hypertension

Answer 9

1. Agents that block renin-angiotensin system

2. Endovascular or surgical revascularization to restore renal blood flow

Question 10

T or F: Patients who underwent revascularization often don’t need to continue their antihypertensive drugs

Answer 10

False

Revascularization rarely lowers BP to normal

Question 11

Strong predictor of morbidity and mortality related CV events, independent of whether renal revascularization is undertaken

Answer 11

ARAS

Question 12

Vascular studies to evaluate renal arteries

Answer 12

1. Duplex ultrasonography
2. Magnetic resonance angiography (w/ gadolinium)
3. Computed tomographic angiography
4. Intraarterial angiography - considered “GOLD STANDARD” for diagnosis of large-vessel disease

Question 13

Treatment for FMD

Answer 13

Percutaneous renal artery angiography

Question 14

T or F: Renal revascularization is now often reserved for patients failing medical therapy or developing additional complications

Answer 14

True

Question 15

Factors favoring revascularization for renal artery stenosis

Answer 15

1. Progressive decline in GFR during treatment of systemic hpn
2. Medical failure
3. Rapid or recurrent decline in GFR in assoc with reduction in systemic pressure
4. Decline in GFR dueing therapy with ACE inhibitors or ARBs
5. Recurrent CHF in patient whom adequacy of LV function does not explain a cause

Table 299-2, p.1629

Question 16

T or F: Atheroembolic renal disease are often caused by angiographic procedures (coronary vessels)

Answer 16

True

Question 17

Definitive diagnosis for atheroembolic renal disease

Answer 17

Kidney biopsy

Question 18

Most common emboli to kidneys causing atheroembolic renal disease

Answer 18

Cholesterol crystals

Question 19

T or F: Once atheroembolic disease developed, anticoagulation should be continued.

Answer 19

False

Withdrawal of anticoagulation is recommended

Question 20

Role of statin therapy in atheroembolic dse in kidneys

Answer 20

MAY improve outcome

Question 21

Role of embolic protection devices in renal circulation

Answer 21

Unclear. Few trials failed to show major benefits

Question 22

Causes of thrombotic occlusion of renal vessels or branch arteries

Answer 22

1. Local vessel abnormalities (local dissection, trauma, vasculitis)
2. Hypercoagulability conditions (rare)
3. Distant embolic events (left atrium in AF, fat emboli fr large bone fractures)
4. Cardiac source (vegetations fr subacute bacterial endocarditis)
5. Systemic emboli (venous circulation in right-to-left shunt in patent foramen ovale)

Question 23

T or F: Acute arterial thrombosis do not produce flank pain and fever.

Answer 23

False

It produces flank pain, fever, leukocytosis, nausea, vomiting

Question 24

Diagnosis of renal infarction

Answer 24

MRI
CT angiography
CT arteriography

Question 25

Management of arterial thrombosis of kidney

Answer 25

1. Surgical reconstruction
2. Anticoagulation
3. Thrombolytic therapy
4. Endovascular procedures
5. Supportive care (including antihypertensive drug therapy)

Question 26

Postmortem findings in kidneys of pt with “malignant” hypertension

Answer 26

1. “Fibrinoid necrosis” - vascular lesions with breakdown of vessel wall, deposition of eosinophilic materials (fibrin), perivascular infiltrate
2. “Onionskin” lesions - larger interlobular arteries with hyperplastic proliferation of vascular wall cellular elements, deposition of collagen, separation of layers

Question 27

Mainstay of therapy for malignant hypertension

Answer 27

Antihypertensive therapy

Question 28

Renal abnormalities in malignant hypertension

Answer 28

1. Rising serum crea

2. Occasionally hematuria & proteinuria

Question 29

Gene responsible for predisposition of African-American population to subtle focal sclerosing glomerular disease

Answer 29

APOL1 previously identified as MYH9

Question 30

Afferent arteriolar thickening with deposition of homogenous eosinophilic material (hyaline arteriosclerosis) associated with narrowing of vascular lumina

Answer 30

Hypertensive nephrosclerosis