Lecture 6: Other Renal Disorders Flashcards
When are renal cell carcinomas most common and in who?
- Usually in males
- 60s
Most common type of renal cancer.
What is the primary cause of RCCs?
Idiopathic, sporadic.
What are the risk factors for developing RCCs?
- Poor lifestyle
- Chronic diseases (chronic kidney stones)
- Substance abuse (smoking esp)
analgesics are specifically more toxic to kidneys.
Smoking is the biggest risk factor!!!!!
What is the primary type of RCC?
- Clear cell carcinoma
- Arise from epithelial cells of proximal tubule
75-85% of all RCCs
What is unique about a papillary tumor?
- Usually bilateral
- Usually multifocal
What are the S/S of RCCs?
- Hematuria (#1)
- Flank pain or abdominal mass
- Metastatic disease symptoms (cough, bone pain)
Usually, the tumor is found incidentally and asymptomatically
What is the classic triad of RCCs?
- Hematuria
- Flank pain
- Abdominal mass
What CBC findings are expected in a patient with RCC?
- Anemia (MC)
- Erythrocytosis
Anemia is due to either heavy hematuria or cancer taking up tissues that make EPO.
Erythrocytosis: pretends to be EPO tissue
What is stauffer syndrome?
Hepatic dysfunction with elevated LFTs in the absence of metastases
Kidneys are in close proximity to the liver.
If I see a solid renal mass, what should I suspect and order?
- Any solid renal mass is guilty until proven innocent!
- Initial with US, but preferred CT or MRI.
- MRI or US w/ doppler is to check for IVC involvement.
What is the standard evaluation for a suspected RCC?
Labs and imaging
- CT abd/pelvis
- CXR/CT chest
- CMP, CBC, UA, urine cytology
Liver: possible metastases or stauffer syndrome
Chest cavity: metastases
CBC: anemia or erythrocytosis
How do the 4 stages of RCC progress in general?
- Increasing in size
- Stage 3 invades the IVC.
- Stage 4 involves regional lymph nodes
What is the primary treatment for RCC?
- Surgical excision via radical nephrectomy
- Can consider partial.
- Chemo is not very effective.
Radical involves removal of kidney, ipsilateral adrenal gland, and adjacent lymph nodes
What is the survival rate of an RCC confined to the capsule?
90-100%
Who is nephroblastoma/Wilms tumor most common in?
Pediatric patients who are otherwise healthy.
What is the etiology of a nephroblastoma and characteristics?
- Abnormal renal development
- Loss of tumor suppressor and transcription gene functions
- Generally sporadic.
- Presents as a single unilateral lesion usually.
What are the primary S/S of a nephroblastoma?
- Abd pain (MC)
- HTN
- Hematuria
- Fever, anemia, N/V
Abd mass symptoms.
What is the preferred initial study for nephroblastoma?
Abd US
What is the primary treatment for nephroblastoma?
Surgical resection followed by chemo
High survival unless advanced.
Cancer can relapse, so monitoring is required.
What is difficult about diagnosing an oncocytoma?
A generally benign tumor that is indistinguishable from RCC on imaging.
Trreatment is identical.
Who is an angiomyolipoma MC in?
Middle-aged women
How is an angiomyolipoma treated?
- Bleeding = embolization or nephrectomy
- > 5cm = prophylactic embolization
Usually benign, but bleeding risk increases if big
What are the most common metastases for secondary renal cancer?
- Lung (MC)
- Breast, stomach, kidney
- Lymphoma (sometimes)
AKA lung cancer metastasizing to the kidney.
Who are kidney stones more common in?
- Males, esp 30s-50s
What are the risk factors for urinary stone disease?
- High protein and salt intake
- Inadequate hydration
- High humidity and elevated temps
Primary goal is to prevent the crystals from clumping
What are the 2 primary substances that kidney stones are made of?
- Calcium Oxalate
- Calcium Phosphate
Calcium is visible on XRAY
KUB XRAY
What is the most common urinary stone not made of calcium?
Uric acid stones (gout)
When do urinary stones cause symptoms?
Entering ureter
Stone size does not correlate with symptom severity.
What are the S/S of urinary stone disease?
- Acute, severe pain in the flank (often episodic)
- Urinary urgency and frequency
- N/V common
Pain often follows the flank down the ureter.
What are the lab abnormalities associated with urinary stone disease?
- Hematuria
- Abnormal pH
Higher pH = calcium or struvite
Lower pH = uric acid or cystine
If a patient presents with recurrent stones/FMHx, what tests can we order?
Patient must first decrease Na and protein intake, with increased fluid intake, and then you can order:
- 24 hour urine
- Serum PTH/calcium/uric acid/lytes/BUN/Cr
- Litholink panel
What are the primary imaging modalities for kidney stones?
- KUB XRAY
- Renal US
- Noncontrast CT (in ER)
A noncon CT can detect all stones
What is a staghorn calculus?
- Renal pelvis involvement
- 2 Calyces involvement
What is the treatment for urinary stone disease presenting as acute renal colic?
- Pain Control (NSAIDs or opioids)
- Hydration (voluntary)
- Alpha blocker (tamsulosin)
- Steroids (maybe)
If obstruction + signs of infection = emergency
What is the MOA of tamsulosin and the main SEs?
- Alpha-1 antagonist
- Orthostatic hypotension, HA, dizziness, abnormal ejaculation, or priapism
Caution with other anti-HTNs
At what size do urinary stones tend to get stuck and where?
- > 10 mm generally do not pass.
- Uteropelvic junction
- Passage of ureter over iliac vessels
- Ureterovesicular junction
Should pass within 4 weeks!
What is ureteroscopic stone extraction?
Small endoscope with a laser or mesh basket
OP procedure usually.
What is shock wave lithotripsy?
- Energy waves to break up stone.
- Usually works on smaller stones.
- Avoid in women of childbearing age!
What is percutaneous nephrolithotomy?
- For large stones or inferiorly located.
- Needle with ureteroscope to pull out the stone
Requires incision in the flank
How do you prevent kidney stones?
- Drink water frequently
- Eat bran (can decrease calciuria)
- DO NOT DECREASE dietary calcium
Decreasing Na and protein is better for preventing stones.
What is the primary cause of hypercalciuric stones?
Absorptive hypercalciuria, characterized by increased urine Ca even without high dietary Ca intake.
High Ca absorption in small bowel.
What can be given to treat hypercalciuric stones?
- Thiazide diuretics (decreases calciuria)
- Cellulose phosphate
What is resorptive hypercalciuria and its treatment?
- Secondary to hyperparathyroidism.
- Presents with hypercalcemia, hypophosphatemia, and elevated PTH
- Need to treat elevated PTH. (Cinacalcet?)
What is renal hypercalciuria and its treatment?
- Secondary to tubule instability in reabsorbing Ca
- Presents with normal or low serum calcium, but high urine calcium
- Treated with thiazides
What are hyperoxaluric calcium stones and the usual precipitating factors and the treatment?
- Primarily oxalate stones.
- People with intestinal disorders, such as IBD.
- Treatment is stopping their diarrhea or calcium carbonate.
Avoid excess ascorbic acid
A result of absorbing more oxalate than calcium.
What causes hyperuricosuric calcium stones?
- Dietary purine excess or uric acid metabolic defects.
- Purine restriction works well, but can use allopurinol as well.
Avoid meat and alcohol?
What causes hypocitraturic calcium stones and treatment?
- Chronic diarrhea, HCTZ, or metabolic acidosis.
- Either drink lemonade or potassium citrate supplements
What are uric acid calculi usually caused by?
- Hyperuricemia
- Myeloproliferative disease
- Cancer
- Abrupt weight loss
High cell turnover => uric acid
Usually still visible on XRAY due to some calcium.
What pH are uric acid calculi and treatment?
- Generally < 5.5 (they have acid in the name)
- Boosting the pH can make them easier to pass.
- Treatment: potassium citrate or allopurinol.
Who are struvite calculi MC in?
- Women with recurrent UTIs with urease-producing organisms
- Can present as staghorn calculi
What is a cystine calculi?
- Abnormal cystine excretion 2/2 genetic predisposition
- Can prevent stones by upping urine pH to > 7
- Treated with potassium citrate or bicarb.
- Often described as smooth-edged ground glass on XRAY (FYI)
Need to pee 3-4L/day!!!!!
