Quiz 2 - Nephropathies Flashcards
Diabetic nephropathy pathophy
1) glycosylation of proteins damage GBM (thickening)
2) Hemodynamic changes leads to glomerular hypertrophy (sclerosis)
Diabetic nephropathy RFs
family hx, advanced age, concurrent HTN, poor glycemic control (>6.5%
HbA1c levels), ethnicity (blacks, Mexican-Americans, Pima Indians—often due to socioeconomic factors) obesity, smoking, oral contraceptives
Diabetic nephro ssxs
albuminuria, occ hematurra
Diabetic nephropathy monitoring
**Microalbumin (random am sample or 24 hr collection)
Normal: 0-30 mg/d
Microalbuminuria: 30-300mg/d
Macroalbuminuria > 300 mg/d
**HbA1c
**ophthalmic + podiatry exams
Target values for DM pts
HbA1c FPG peak PPG BP lipids
A1C≤ 6.5% FPG <110 mg/dl peak postprandial PG <140 mg/dl BP < 130/80mmHg Lipids LDL <100, <70 mg/dl
in pts with CAD, HDL: >40 mg/dl men, >50 mg/dl women, TG: <150 mg/dl
Diabetic nephropathy natural TX
Ginkgo—protective against damage to glomerulus Flax and pumpkin seed Curcumin—antioxidant, renal protective Guggul Chromium Alpha lipoic acid, Vaccinium
Renovascular HTN secondary to
atheroscleorosis (secondary to HTN)
Renovascular HTN pathophys
Reduced blood flow causes affected kidney(s) to secrete renin, retain NaCl and H2O – inc BP
Renovascular HTN ssxs
HTN ssxs
PE: Abdominal bruit over renal A
Renovascular HTN complications:
left ventricular hypertrophy, hypertensive retinopathy
Labs Renovascular HTN
Severe HTN with progressive renal insufficiency, refractory to aggressive therapy, malignant HTN, elev creatinine
Captopril challenge test
administer ACE-i to watch effect on plasma renin
Tx Renovascular HTN
1) Control BP with meds:
2) Percutaneous angioplasty w stent
3) Surgical reconstruction of damaged artery
4) Surgical bypass of renal arteries
5) Treat atherosclerosis: guggal, garlic, EFAs, B vits
6) Vascular protectants: bioflavonoids, vaccinium
Benign hypertensive nephrosclerosis cause
chronic HTN
Renal artery occlusion/ thromboembolism
Leads to flank pain, abdominal pain, fever, N&V
Hematuria. Acute renal failure may develop
Seen on CT angiography
Renal vein thrombosis causes
hypercoagulability, nephrotic syndrome, amyloidosis, estrogen therapy, pregnancy, SLE
Seen on US and MR venography
NEPHROPTOSIS RFs
excessive weight loss, frequent intense physical activity
Nephroptosis Ssxs
severe abdominal, costovertebral, flank pain and vomiting in upright position from
1) acute hydronephrosis kinked proximal ureter
2) renal vessel lumen narrowing and resultant ischemia
3) visceral nerve stimulation from traction
Dietl Crisis
severe colicky flank pain, nausea, vomiting, chills, tachycardia, oliguria, hematuria and proteinuria
Pain relieved with upward movement of kidney, supine position
Nephroptosis work-up
US, IV urography
Nephroptosis Tx
surgical nephropexy, wear truss
Simple cysts ssxs
Flank or back pain, intermittent and dull; Fever and malaise if infected
Abdominal mass, may be palpable or percussed, tender if infected
Simple cysts Tx
Leave alone
If infected: antimicrobial tx, may need percutaneous drainage
Surgical excision if obstructing ureter
ADPKD SSx:
Pain over both kidneys due to infection, obstruction, hemorrhage, “drag” from heaviness
Gross or microscopic hematuria; nocturia
HTN (retinopathy can develop)
Palpable, nodular kidney(s)
Developing renal insufficiency: HA, N&V, weight loss
If infected: fever, chills, tender kidney(s)
ADPKD Imaging
- US Most cost effective``
- CT
- MRI can differentiate RCC from cysts
ADPKD complications
Gross hematuria Nephrolithiasis (20%) Hypertension ESRF Increasing, intractable pain Other possible findings in this population
ADPKD Tx
Low protein diet – 0.5-0.75 g/kg/d
Force fluids to 3000 ml or more per day (to suppress plasma vasopressin)
Restrict caffeine
Flax oil
Reasonable physical activity – avoid strenuous activity or contact sports
reat uremia, stones, infection when present
Screen for and treat HTN.
Poss tx: dialysis, renal transplantation
cystic decompression (for pain)
Constitutional HP: tumors, cystic—Baryta carb, Calc carb, Phos
Constitutional hydro
Conventional drug trials: somatostatin, everolimus (mTOR inhibitor)
ADPKD prognosis kids
poor.
ARPKD assoc with
biliary dysgenesis. Leads to hepatomegaly and portal hypertension in most cases
ARPKD severity
may lead to death in newborn
may lead to ESRD and the need for Ki transplant by age 10 or 15.
Von-Hippel Lindau syndrome
Autosomal Dominant
retinal angiomas, hemangioblastomas, pheochromocytoma, islet cell tumors, renal cysts, epididymal cysts
Tuberous sclerosis
CNS + heart, skin, lung lesions
seizures, mental retardation, adenoma sebacum
Renal Cell Carcinoms RFs
Cigarette smoking
Hypertension
Chronic analgesic use
Obesity:
Toxin exposure (Cd, asbestos, Pb, gasoline and petroleum products, PAHs)
Cytotoxic chemotherapy use in children (for malignancy, autoimmune dz)
HCV
Sickle cell disease
itrites in diet, prior radiation therapy, use of oral contraceptives
High coffee intake, animal fat diet, dialysis, hysterectomy, contrast IV
RCC mets to…
lung
also, bones, LNs, adrenals, kidney
RCC ssxs “classic triad”
gross hematuria, flank pain, palpable abd mass
ssxs of paraneoplastic syndrome
RCC Tx
1) Partial or Radical nephrectomy for localized stage I & II (<4cm tumor size)
2) Chemo and radiation —not proven effective
3) Biologic response modulators, eg interleukin-2 therapy, interferon alpha
4) Molecularly Targeted Therapies:
5) Pre- and post-surgical support tissue healing nutrients, modified citrus pectin
6) Adjuvant naturopathic care—health, nutrition optimization
8) Note: Clinical trials underway for RCC vaccination: TroVax
Nephroblastoma
“Wilm’s Tumor”
mixed malignant. Seen in children 3-4 yrs
Neohroblastoma ssxs
Presents as abdominal swelling, abd pain, hypertension, N&V, constipation,
Loss of appetite, SOB
mets to kidney from…
lung, breast, stomach, renal
