Other Renal disorders Flashcards
1
Q
what is the MC renal cancer (90-95% of renal cancers)?
A
Renal Cell Carcinoma
2
Q
Renal Cell Carcinoma is MC when and in who?
A
Peak incidence - 60s
2x as common in males
3
Q
cause of renal cell carcinoma?
A
Most common - sporadic tumors
Also linked to familial causes, dialysis-related acquired cysts
4
Q
risk factors of renal cell carcinoma
A
- Lifestyle - physical inactivity
- Chronic disease - HTN, chronic HCV, obesity, nephrolithiasis
- Substances - chronic analgesics, environmental toxins, smoking
5
Q
pathogenesis of renal cell carcinoma
A
- 75-85% - clear cell carcinoma- from epithelial cells of proximal tubules
- Papillary tumors - 10-15% - bilateral and multifocal
- Other categories - chromophobic, oncocytic, collecting duct tumors
6
Q
presentation of renal cell carcinoma
A
- gross or microscopic hematuria MC
- Flank pain or abd mass - 30%
- Classic triad - flank pain, hematuria, abd mass - 10% - Often sign of advanced disease
- Metastatic (cough, bone pain) - 20-30% at initial dx
7
Q
how are renal cell carcinoma MC found?
A
Often found incidentally on renal imaging in ax pts
8
Q
labs of renal cell carcinoma
A
Hematuria
Hematologic - anemia > erythrocytosis
Hypercalcemia - 10% of pts
9
Q
when hepatic dysfunction with elevated LFTs in the absence of metastases
what is this called?
A
Stauffer syndrome
10
Q
you found a solid renal mass upon imaging, what must you assume?
A
RCC until r/o
11
Q
imaging choices for renal cell carcinoma
A
US - often initial study
CT/MRI - most valuable imaging tests
12
Q
which imaging to order to look at the cancer mass itself
renal cell carcinoma
A
CT
13
Q
what imaging order is to evaluate IVC involvement
renal cell carcinoma
A
MRI or doppler US
14
Q
what imaging order if bony metastases suspected
renal cell carcinoma
A
bone scan
15
Q
what imaging order if brain metastases suspected
renal cell carcinoma
A
Brain imaging
16
Q
what is the Standard evaluation of suspected RCC
imaging and labs
A
- CT of abd and pelvis
- Chest imaging (CXR or chest CT)
- Initial Labs - renal function, hepatic function, CBC, UA, urine cytology
17
Q
staging of renal cell carcinoma
A
- stage 1 - < 7cm
- stage 2 - > 7cm
- stage 3 - 1LN
- stage 4 - >1 LN
18
Q
tx for RCC
A
surgical excision
* Radical nephrectomy - Removal of kidney, ipsilateral adrenal gland, adjacent lymph nodes
* May consider partial nephrectomy
* If metastatic - surgery is limited
* Limited effective chemotherapy for RCC
19
Q
what is the prognosis of RCC
A
confined to renal capsule > beyond renal capsule > LN involvement
20
Q
which renal cancer occurs mainly in pediatric patients and rare (5-6% of renal tumors)
A
Wilms Tumor (Nephroblastoma)
21
Q
most of Wilms Tumors (Nephroblastoma) are dx when? (what age)
A
In children < 15 years old - 95% of renal cancers
⅔ diagnosed before age 5; 95% before age 10
22
Q
cause of Wilms Tumor (Nephroblastoma)
A
- abnormal renal development → loss of tumor suppressor and transcription gene functions
- Usually sporadic - only 1-2% have a positive family hx
- Some rare genetic disorders are linked to Wilms Tumor
23
Q
how does wilms tumor (nephroblastoma) MC present as?
not s/s
A
single unilateral lesion
May be multifocal or bilateral
24
Q
s/s of Wilms Tumor (Nephroblastoma)
A
abd mass or swelling +/- other s/s
* Abd pain - 30-40% of pts
* HTN - 25 %
* Hematuria - 12-25% of pts
* Other s/s - fever, anemia, N/V
25
imaging choice for Wilms Tumor (Nephroblastoma)
**Abd US** is typical initial study
* Renal CT or MRI w/ contrast for further eval
* CXR or chest CT to look lung metastasis
26
labs for Wilms Tumor (Nephroblastoma)
CBC, CMP, UA, coag
* typically done to prep for surgery and look for complications
* May see anemia
* May see decreased GFR / increased BUN and Cr
27
tx for Wilms Tumor (Nephroblastoma)
**Surgical resection followed by chemotherapy** +/- radiation
28
prognosis of wilms tumor (nephroblastoma)?
can it happen again?
* Overall 5-year survival rate is **90%**
* More anaplastic, more metastasis - worse rates; 33% for stage 4 Wilms Tumor
* **Recurrent disease is possible**
* 15% - with favorable histology
* 50% - anaplastic tumors
* Post-relapse survival rates: 50-80%
29
what are the other primary renal tumors that are usually benign?
Oncocytomas
Angiomyolipomas
30
which benign primary remal tumor is Indistinguishable from RCC on imaging
Oncocytomas
31
which renal tumors rare benign tumors
Fat, smooth muscle, and blood vessels
Angiomyolipomas
32
Angiomyolipomas is MC in who? how to manage?
| imaging and tx
* **young to middle aged women**
* CT - may reveal fat component of mass
* Tx - if < 5 cm and asx = observation
* bleeding = embolization / nephrectomy
* > 5 cm = prophylactic embolization
33
Metastatic disease secondary from renal tumors is MC where?
* **Lung cancer** - MC (20%)
* Breast, stomach, kidney - 10% each
* Lymphoma may involve kidney - Diffuse infiltration rather than distinct mass
34
Urinary Stone Disease is MC in who and when?
* 2.5x more in **males**
* ~19% of men
* ~9% of women
* Usual presentation - **30s-50s**
35
risk factors of urinary stone disease
* **High protein and salt intake**
* **Inadequate hydration**
* High humidity and elevated temperatures
* Sedentary lifestyles
* Genetic predisposition
* GI malabsorption syndromes
* HTN, obesity, gout, excessive exercise, may all be linked
36
what are the types of urinary stones? what is the MC?
1. **Calcium oxalate** / Calcium phosphate
2. Uric acid stones
3. Struvite stones
4. Cystine stones
37
how are kidney stones visible on x-ray?
because of the calcium content in kidney stones
38
which urinary stone is MC in men and associated with gout, MetS
Uric acid stones
39
which urinary stone is associated with infection
struvite stones
40
which urinary stones are typically hereditary
cystine stones
41
where are stones grown that it would present asx or isolated hematuria
on renal papillae or in the urine collecting system
42
urinary stone disease usually become symptomatic upon entering ?
ureter
Stone size **does not** correlate with severity of symptoms
43
s/s of urinary stone disease
* often **sudden onset**
* Usually in **flank** - may radiate to abdomen or groin
* May be **episodic** - Typically diminishes after stone passes into bladder
* Urinary urgency and frequency - Especially if trapped at *ureterovesical junction*
* **N/V**
44
labs of urinary stone disease
**Hematuria (micro or gross)**
**Abnormal urine pH**
45
what is normal urine pH?
5.8-5.9
46
pt with suspected urinary stone disease has a urine pH of < 5.5, what type of stone could it be?
uric acid or cystine stones
47
pt with suspected urinary stone disease has a urine pH of 5.5 - 6.8, what type of stone could it be?
calcium oxalate stones
48
pt with suspected urinary stone disease has a urine pH of > 7.2, what type of stone could it be?
calcium phosphate or struvite stone
49
for pts who have recurrent stones or +FHx, what other additional labs could be done
**Metabolic evaluation** - Pt **decreases Na** and **protein**, **increases fluid intake**, then:
* 24 hr urine - volume, pH, Ca, oxalate, phosphate, Na, citrate
* Serum - PTH, calcium, uric acid, electrolytes, Cr, BUN
* *Litholink* - preset lab testing panel for stone evaluation
50
what imaging will diagnose most renal stones
Plain abdominal radiograph (KUB) and renal US will
*~ 85% of stones visible on x-ray*
51
> 60% of pts with acute pain will have stone where?
distal ureter
52
what imaging is often first used tool in evaluation
**Noncontrast CT**
Frequently ordered in ER setting
Virtually **all stones visible on CT**
53
tx for Urinary Stone Disease
_Acute renal colic_
**_Pain control_**
* NSAIDs - decrease ureteral smooth muscle tone
* Opioids may be necessary
Hydration - **oral hydration** preferred
* No benefit to forced IV hydration - may worsen pain
Alpha blocker - facilitate stone passage
* **tamsulosin**
* Short course of **steroids** (prednisone 10 mg QD x 3-5 days) may help
If obstructing + signs of infection → ***medical emergency***
54
CI, DDI, SE of Tamsulosin
* CI: hypersensitivity - with known **sulfa** allergy
* DDI: **anti-HTN** rxs, esp alpha-blockers
* May interact with paroxetine, cimetidine, PDE-5 inhibitors
* SE: **Orthostatic hypotension**, HA, dizziness, abnormal ejaculation, priapism
55
where would a stone lodge that would cause impediment for passage?
* ureteropelvic junction
* passage of ureter over iliac vessels
* ureterovesicular junction
56
what size of stone will pass spontaneously and what will not?
* < 5 mm - pass spontaneously
* >10 mm - do not pass
57
how does a Ureteroscopic Stone Extraction
work
* Small endoscope passes through ureter
* Stone “caught” with basket or a laser is used beforehand to break the stone up
* outpatient
58
which urinary stone intervention uses External energy source that sends energy waves that impact stone and causes it to break up
Most fragments then pass < 2 wks
Shock Wave Lithotripsy
*Less successful if large stone burden*
59
what must be cautious about with shock wave lithotripsy
women of childbearing age with
stone in lower ureter
60
which urinary stone disease intervention is done for larger calculi (>1.5 cm) or located in inferior pole? how does it work?
Percutaneous Nephrolithotomy
Needle is inserted into the appropriate renal calyx and ureteroscope is advanced directly into kidney (rather than through ureter)
61
prevention+management of urinary stone disease
* **Most importance - increased fluid intake**
* Goal - urine volume of **1.5-2 L**of urine/day
* Recommended to drink fluids with meals, 2 hrs after each meal, and prior to going to sleep as well as during the night
* Diet - **decrease Na and protein**
* Bran may decrease calciuria
* Do not decrease dietary calcium
62
cause of hypercalciruic stones from high Ca absorption in small bowel
what is this called?
Absorptive hypercalciuria
Increased urine Ca *even without* high dietary Ca intake
63
how to tx absorptive hypercalcuria
* **Thiazide** - decrease renal Ca excretion - No impact on absorption
* Cellulose phosphate - Binds to Ca and impedes small bowel absorption - Not used as often as thiazide diuretics
64
this cause of hypercalciuric stone is secondary to hyperparathyroidism
what is this called? what is this caused by? tx?
* **Resorptive hypercalciuria**
* Hypercalcemia, hypophosphatemia, elevated PTH
* tx of elevated PTH
65
which hypercalciuric stone cause is secondary to tubule inability to reabsorb Ca? presentation? tx?
| what labs are seen?
* **Renal hypercalciuria**
* Normal or low serum calcium, high urine calcium
* Secondary hyperparathyroidism possible
* Thiazide diuretics can be helpful
66
* Due to primary intestinal disorders
* Hx of chronic diarrhea - often have IBD
* Absorb oxalate more than calcium
what type of renal stone?
Hyperoxaluric Calcium Stones
67
tx for Hyperoxaluric Calcium Stones?
what should you avoid?
* stopping diarrhea, calcium carbonate
* Avoid excess ascorbic acid
68
Due to dietary purine excess or uric acid metabolic defects
what type of renal stone?
Hyperuricosuric Calcium Stones
69
tx for Hyperuricosuric Calcium Stones
purine restrictions
Allopurinol
70
Due to chronic diarrhea, chronic HCTZ, metabolic acidosis
what type of renal stone?
Hypocitraturic Calcium Stones
71
tx for Hypocitraturic Calcium Stones
Potassium citrate supplements reduce
Oral lemonade can also help
72
causes of Uric Acid Calculi
hyperuricemia, myeloproliferative disease, cancer, abrupt weight loss
Most have some degree of calcium and are therefore visible on x-ray
73
how does Pure uric acid present on xray?
radiolucent
74
urinary pH of uric acid calculi? tx?
**< 5.5**
* increasing pH >6.2 = increases uric acid solubility
* **Potassium citrate** - alkalizes urine
* **Allopurinol** 300 mg/day - if hyperuricemia
75
MC in women with recurrent UTIs with urease-producing organisms
what type of renal stone?
Struvite Calculi
76
what pathogens MC cause Struvite Calculi
**Proteus, Pseudomonas, Providencia**
*Not usually seen with E. coli*
77
May be discovered as staghorn calculus
what type of renal stone?
Struvite Calculi
78
Abnormal cystine excretion
May be genetic predisposition
Difficult to manage
what type of renal stone?
Cystine Calculi
79
urinary volume goal of Cystine Calculi?
3-4 L/d
80
tx for Cystine Calculi
Urinary alkalinization
goal pH >7.0
**Potassium citrate/bicarbonate**
81
radiolucent on x-ray
“Smooth-edged ground glass”
what type of renal stone?
Cystine Calculi
