Other Renal Disorders Flashcards
What is the MC kidney cancer and when is it dx?
Renal cell carcinoma
90-95% of renal cancers
4% of cancers
60 yo MC
2x as common in men
What is the MC cause of renal cell carcinoma?
Sporadic MC
but there is familial cause
Also inactivitivty
Chronic disease causing inflammation
NSAIDs
What is the biggest risk factor for renal cell carcinoma?
Smoking
What is the MC renal cell carcinoma? What is the other cause?
75-85% are clear cell carcinomas
Arise from PT
Other cause (10-15%) is papillary tumors
also some other types
What is the MC symptom of renal cell carcinoma?
Hematuria - occurs in 50-60%
Often is brown, because it is further down
What is the classic triad of renal cell carcinoma and how common is it?
Flank pain
Hematuria
Abdominal mass
rare though
HAF the MC cancer
What is the MC way renal cell carcinoma is found?
Incidentally on renal imaging b4 symptoms
What would cough and bone pain suggest for renal cell carcinoma?
Metastis :(
seen in 20-30% on initial dx
What are the lab findings of renal cell carcinoma?
MC hematuria 60%
Anemia or erythrocytosis (from blood loss)
Hypercalcemia (metastasis)
Stauffer syndrome
What is stauffer syndrome?
Hepatic dysfunction with elevated LFTs secondary to renal cell carcinoma (not metastisis)
Why do you have anemia in renal cell carcinoma?
Losing too much blood
Can tack away tissue of kidney that makes erythropoietin
Why do you sometimes see erythrocytosis?
Differentiated cancer can retain characteristics of original tissue making erythropoietin
What is the initial imaging of renal cell carcinomas?
US (start here)
CT of abdomen and pelvis and MRI is most valuable
sometimes doppler US, bone scan, brain imaging (if AMS)
What labs should you get for renal cell cariconma?
renal function, hepatic function (abnormal = stauffer syndrome sometimes), CBC (do they have anemia), UA, urine cytology
all of these reaffirm dx, but do not confirm it
What differs the CT in polycystic kidney versus renal cell carcinoma?
Polycystic = cysts everywhere on kidney, well defined margins
RCC: bumpy margins, not as well defined
What is the treatment for an isolated renal cell carcinoma?
Surgical excision including the kidney, ipsilateral adrenal gland, and adjacent lymph nodes (in case they spread their)
-can consider partial nephrectomy
If metastatic renal cell carcinoma, what is the treatment?
Stage IV, surgery does not improve outcomes
Limited effect of chemotherapy :(
What is the 5 survival rate for renal cell carcinoma confined to the renal capsule, beyond the renal capsule, and lymph node involvement?
90-100%
50-60%
0-15% :(
What is a nephroblastoma?
Wilms Tumor seen in pediatric patients
Kids like having a blast
What is the MC renal cancer in peds?
Nephroblastoma
2/3 before 5
95% before 10
What causes nephroblastoma?
Sporadic loss of renal development and loss of tumor suppressor and transcription gene functions, leading to a single unilateral lesion most commonly
What are the s/s of nephroblastoma?
Abdominal pain (MC)
HTN
Hematuria
fever, anemia, N/V
often think it is a stomach bug
What is the initial imaging of nephroblastoma?
Abdominal US
then you can
Renal CT or MRI
What labs do you order for nephroblastoma?
CBC, CMP, UA, coag studies
sometimes see anemia and decreased GFR and increased BUN and Cr
What is the treatment of nephroblastoma?
surgical resection and then chemo
what is the 5 year survival rate of nephroblastoma?
90%
What is a complication of nephroblastoma?
Recurrent disease
15% with favorable histology
50% anaplastic tumor
50-80%: post-relapse survival rates
this is why you need chemo!
What is an oncocytoma?
Rare kidney tumor that is often benign - but looks like an RCC on imaging
What do we do with oncocytoma?
Treat it as if it was cancer and remove it
What is an angiomyolipoma?
Fat, smooth muscle, and blood vessel cancers
MC in young-middle age women
CT reveal fat component
How do you treat angiomyoploma?
<5 cm = observe
If bleeding, embolize and nephroctomy
> 5cm prophylatic embolization
What is the MC metastatic?
Lung is MC
also can be breast, stomach, or other kidney
What are kidney stones aka?
nephrolithiasis
Who is kidney stones MC in?
2.5 x more common in men
usually 30-50, but can be younger or older
What are risk factors for kidney stones?
Inadequate hydration
High protein
High salt
All of these can lead to crystals
Often in patients that have sensory issues
also sedentary lifestyle
What envirnoment leads to kidney stones?
High humidity and temperature
What are the MC types of kidney stones? less common ones?
Calcium stones make up 85%
Uric acid stones (8%)
Struvite stones (infections)
Cystine stones: heridtary
What are the s/s of kidney stones?
Sometimes asymptomatic
Severe flank pain that raps to the front of the abdomen to the bladder
-continuous or episodic (smooth muscle contracts)
- urinary incontinence
-N/V from pain
Can cause isolated hematuria
Move to the urterer -size does not change
When do symptoms typically stop for kidney stones in women?
At the bladder
What is the MC lab of kidney stones?
Hematuria (micro or gross) 90%
What stones make lower urine pH?
Uric acid or cystaline
What stones make higher urine pH?
calcium stones or struvite stone
When do you workup a patient with kidney stones?
Recurrent kidney stones
Fx
How do you work up a patient with kidney stones?
First, decrease Na, protein, increase fluid intake then do the following labs:
24 hr urine
Serum blood work (kidney function, PTH)
Litholink (preset so you don’t have to worry)
What dx kidney stones? Pregnant patients?
Plain abdominal radiograph and renal US in preggos (85% visible) 65% already make it to distal ureter
KUB (kidney, ureter, bladder)
Noncontrast CT in ER - show up all types of stones
What does a stone look like on xray or CT?
bright white spot (like bone = calcium)
What are staghorn calculus?
Look like a branch of cauliflower - sticks up through renal pelvis and goes into the calyces
How do you manage kidney stones?
Pain control of flank:
NSAIDs
Opioids if intense pain
Hydration: oral, don’t force IV it can make it worse pain - but may be necessary if severe dehydration
Alpha blocker
prednisone (relieve swelling and pain)
What is the preferred alphablocker for kidney stones?
tamsulosin
What is tamsulin MOA?
Blocks alpha-1 receptors
opens urinary track and
What are the Ci of tamsulin?
Hypersensitivity and sulfa allergy
Caution with anti-HTN drugs d/t additive effect
What are the SE of tamsulin?
Orthostatic hypotension, HA, dizziness, abnormal ejaculation, priapism
Typically not worried about in acute problems
Where do stones tend to get stuck?
Uretropelvic junction MC
Also ureter over iliac vessels, ureterovesicular junction
What size do stones tend to pass and when do they not pass? When do you intervene?
Pass at 5 mm
Don’t pass at 10 mm
intervention if does not pass in 4 weeks, large stone, severe symptoms
Explain the process of a ureterscopic stone extraction?
Take a camera, through the urthera, bladder, into urter, catch stone with a basket tool or laser, have a stent
If there is a pretty big stone, what do you use for extraction that does not involve surgery?
Shock wave lithotripsy
Explain shock wave lithotripsy
External energy waves that break stone
Individual stone fragements pass spontaneously w/in 2 weeks
If super large, may have issue
caution in women of childbearing age, may be preggo and dmg a fetus
Why does shock therapy not lead to kidney damage?
Waves focus on the stone
What is the most invasive surgery for a kidney stone and when is it done?
Percutaneous nephrolithotomy
done for massive stones >1.5cm or in the inferior pole of kidney and stuck
Explain Percutaneous nephrolithotomy
Needle inserted into the back
Advance into the kidney
Scope through the needle
Pull the stone through the needle
Done under radioscopic guidance
What is the most important thing for stop getting future kidney stones from forming?
1.5-2L of urine a day (need more water than that)
-drink fluids throughout the day
-constant water to stop crystals from clumping into a stone
What should you include and decrease in diet for kidney stones?
Include bran
Don’t reduce calcium intake
Cut down on protein and sodium
If a patient has recurrent kidney stones, what can you recommend to see what type of stone?
Urinary strainer so that you can see the type of stone
What are hypercalcuric stones caused by?
Absorptive hypercalcuria (see increased urine calcium w/out high dietary intake of Ca)
What meds can help with hypercalcuric stones?
Thiazide dieurtics
Cellulose phosphate (specifically binds calcium and impedes small bowel abs)
What causes resporptive hypercalcuria and what do you see?
hyperparathyroidism
see hypercalcemia, hypophosphotemia, and elevated PTH
What is renal hypercalcuria and how is it treated?
Normal or low serum calcium with high urine calcium
can develop 2ndary hyperparathryoidism
Treated with thiazides
What is hyperoxaluric calcium stone and symptoms?
Mainly oxalate, but there is still Ca2+ - abs oxalate more than calcium because of diarrhea not allowing time to abs calcium
history of chornic diarrhea and often IBD
How do you treat hyperoxaluric calcium stone?
manage diarrhea so you don’t poop out too much calcium
calcium carbonate (tums)
avoid excess ascorbic acid (vitamin C)
What are hyperuricosuric calcium stone?
mainly uric acid but some calcium
problems with uric acid metabolism or too many purines
How do you treat hyperuricosuric calcium stone?
Reducing purine intake including less beer and meat
Allopurinol (reduces uric acid)
What is hypocitraturic calcium stones?
Due to chronic diarrhea
Have potassium citrate or lemonade to help (low citrate)
What is uric acid calcuil and what is it seen in?
Often does not show up in xray because no calcium
caused by too much uric acid - too much purines, chemo, abrupt weight loss causing cell death
low urinary pH
How to treat uric acid calcuil?
potassium citrate (raises pH)
allopurinol
When is struvite calculi often seen?
Recurrent UTIs in women
Seen in bacteria with P in it
Proteus, psedomonas, providencia (not typically E coli)
What stone is MC to form staghorn calculus?
struvite calculi
What are cystine calculi?
Genetic predisposition
How do you treat cystine calculi?
Difficult to manage
Goal urinary pH very high >7
3-4L of urinary volume a day!
