Renal #3 (Nephrotic, RAS, Wilm's)

Question 1

Nephrotic syndrome is kidney disease characterized by what 4 things?

Answer 1

-Proteinuria
-Hyperlipidemia
-Hypoalbuminemia
-Edema

Question 2

There are three common etiologies of Nephrotic Syndrome. Explain the following three:
-Minimal Change Disease:
-Membranous Nephropathy:
-Focal Segmental Glomerulosclerosis:

Answer 2

-Minimal Change: MCC in children. Loss of negative change of basement membrane.

-Membranous: MCC in Caucasian Males > 40.

-Focal: In setting of hypertension, Heroin, HIV. African Americans MC

Question 3

What is the MC secondary cause of nephrotic syndrome in adults?

Others?

Answer 3

MC: Diabetes Mellitus

Others: SLE, Amyloidosis, Hepatitis, Sjogren’s, Infections, Malignancy

Question 4

Symptoms of Nephrotic Syndrome

Answer 4

-Generalized edema (peri orbital MC in children) usually worse in the morning
-Frothy urine
-Ascites
-Anemia, DVT

Question 5

What is seen on UA in a patient with nephrotic syndrome (also something specific seen on microscopy)

Answer 5

-Proteinuria causing foamy urine, lipiduria
-Microscopy: oval Maltese cross-shaped fat bodies (fatty casts)

Question 6

What is the gold standard diagnostic for nephrotic syndrome?

It is DIAGNOSTIC for nephrotic syndrome

Answer 6

Urine albumin: creatinine ratio
–24 hour urine protein > 3.5g

Question 7

Although renal biopsy gives a definitive diagnosis for nephrotic syndrome, what do you see in minimal change disease? How about membranous nephropathy?

Answer 7

Minimal Change: Podocyte damage on electron microscope

Membranous: thick basement membrane

Question 8

Management for nephrotic syndrome
-First line for Minimal Change Disease
-Edema Reduction
-Proteinuria Reduction
-Hyperlipidemia

Answer 8

-Minimal Change: Glucocorticoids
-Edema: Diuretics, 1 liter fluid and sodium restriction
-Proteinuria: ACE or ARBs
-Hyperlipidemia: diet and statin therapy

Question 9

Renovascular Hypertension (Renal Artery Stenosis) is the MCC of ________.

Explain this.

Answer 9

Secondary hypertension

Decreased renal blood flow leads to activation of the RAAS

Question 10

What are the common etiologies in the following populations of RAS?
-Elderly
-Women < 50

Answer 10

-Elderly: Atherosclerosis

-Women < 50: Fibromuscular dysplasia

Question 11

Symptoms and who you should suspect RAS in

Answer 11

-headache and hypertension < 20 years or > 50 years
-HTN resistant to 3 or more drugs
-Abdominal bruit
-Develops acute kidney injury after starting an ACE

Question 12

What is one non-invasive diagnostic that can be done to evaluate for RAS

Answer 12

-CT angiography

Question 13

However, the gold standard diagnostic for renal artery stenosis is….

What is great about this procedure?

Answer 13

-Renal catheter angiography: Revascularization can be performed at the same time if stenosis is present

Question 14

There are surgical and medical options for treatment for RAS. Explain the medical options

There is a time when you do NOT use the first-line medical options. Explain this as well.

Answer 14

-ACE or ARBs

-However, they are contraindicated if bilateral stenosis is present or if the patient only has one kidney because they can lead to AKI (lower renal blood flow and GFR)

Question 15

What is the definitive surgical management for RAS

Answer 15

-Revascularization (angioplasty or bypass)

Question 16

If creatinine > 4, > 80% stenosis, or creatinine increases with an ACE inhibitor, what surgical option should you recommend

Answer 16

Angioplasty with stent

Question 17

A nephroblastoma (Wilm’s Tumor) is MC seen in who?

This is the MC ….

Answer 17

MC seen in children within the first 5 years of life

MC abdominal mass in children

Question 18

A Wilm’s Tumor may be associated with other GU abnormalities, chromosome 11 abnormalities, and the acronym WAGR is used. What does this stand for?

Answer 18

Wilms Tumor
Aniridia (absence of iris)
GU malformations
Retardation (mental)

Question 19

Symptoms of a Wilm’s Tumor

Answer 19

-Palpable abdominal mass MC manifestation
-Mass does not cross the midline (unlike neuroblastoma)
-Hematuria
-Constipation
-anorexia, fever, nausea, vomiting, etc.

Question 20

best initial test for a Wilm’s Tumor

Answer 20

Abdominal US

Question 21

The most accurate diagnostic done for a Wilm’s Tumor is ….

Where is the MC site for METS

Answer 21

-CT with contrast or MRI

LUNGS

Question 22

Treatment for a Wilm’s Tumor

Answer 22

-Total nephrectomy followed by chemotherapy!