Renal Flashcards by Alixandria Keller

Renal Cell Carcinoma: Epidemiology

MC primary renal malignancy

M>F

6-8th decade

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Renal Cell Carcinoma: Risk Factors

SMOKING

htn
obesity
chronic dialysis
toxic exposures
heavy aspirin, acetaminophen, nsaids
genetics

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Renal Cell Carcinoma: Pathology

MC: clear cell
papillary (chromophilic)
chromophobe
oncocytic
collecting duct (bellini's duct)
unclassified

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Clear Cell RCC

deletion of chromosome 3p
proximal tubule
usually solid

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Papillary RCC

proximal tubule

type 1: good prognosis
tupe 2: aggressive

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Renal Cell Carcinoma: Clinical Presentation

asymptomatic until advanced disease

MC: HEMATURIA
ABDOMINAL MASS
FLANK PAIN

weight loss
L side scrotal varicocele
IVC involvement (LE edema, ascites, hepatic dysfunction, pulmonary emboli)
metastasis (lungs, lymph nodes, bone, liver, brain)
paraneoplastic syndromes

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Paraneoplastic Syndromes

anemia
hepatic dysfunction
fever
hypercalcemia
cachexia
erythrocytosis
secondary amyloidosis
thrombocytosis
polymyalgia rheumatica

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Renal Cell Carcinoma: Diagnostics

Preferred test:
abdominal CT with/without contrast

MRI if US or CT nondiagnostic/contraindicated

Definitive diagnosis: 
tissue biopsy (nephrectomy, partial nephrectomy)

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Renal Cell Carcinoma: Diagnostics: evaluation of metastasis

bone scan

CT chest

MRI w/ gad

PET or PET/CT

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Renal Cell Carcinoma: Treatment: stage I, II, III

surgery is curative

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Renal Cell Carcinoma: Treatment: stage IV

systemic therapy

surgery

radiation

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Management of a Small Renal Mass: predictors of malignancy

male sex

increasing tumor size

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Management of a Small Renal Mass: <2cm

20-40% benign
<10% high-grade RCC
<1% present with/develop mets

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Management of a Small Renal Mass: 4+cm

5-10% benign

20-30% high-grade or advanced RCC

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Management of a Small Renal Mass: Diagnostics

1st line: renal CT
2nd line: MRI
without then with IV contrast

CMP, CBC (paraneoplastic syndrome)

renal function (CKD)

chest imaging (malignancy, mets)

biopsy

urology

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Management of a Small Renal Mass: Treatment Options

surgery (partial nephrectomy)

thermal ablation (<3cm)

surveillance (<2cm)
with imaging and mets evaluation every 3-6mo for 2 years – then every 6-12mo

surveillance (<1cm)

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Wilms Tumor: Epidemiology

95% of primary renal malignancies in children under 15yo

sporadic

Wilms Tumor: Pathology

abnormal renal development

loss of function of tumor suppressor genes

Wilms Tumor: Features

solitary lesion

surrounded by pseudocapsule

composed of 3 cell types:

blastemal cells
stromal cells
epithelial cells

Wilms Tumor: Clinical Presentation

abdominal mass

less common:
abdominal pain
hematuria
fever
hypertension

Wilms Tumor: Diagnostics

definitive diagnosis: histologic confirmation (surgical excision, biopsy)

initial study:
abdominal US

CT or MRI w/ contrast

Labs: 
renal function
UA
liver function
Ca
CBC
coag studies

**be sure to evaluate contralateral kidney

Wilms Tumor: Treatment

refer to peds cancer

chest imaging for mets

chemotherapy and surgical excision

surveillance
CXR, abd US, chest/abd/pelvic CT
-every 6-8wk during therapy
-every 3 months x 2 years
-every 6 months x 2 years

Wilms Tumor: Prognosis

5 yr survival: 90%

inc risk of premature death in adulthood due to secondary neoplasms and other late complications

Renovascular Disease

cause of secondary HTN

MC: atherosclerotic RAS
fibromuscular dysplasia

associated w/ accelerated target organ injury

LVH
renal fibrosis

When to consider renovascular disease

young onset severe or resistant acute rise over stable value serum creatinine >30% after ACE-I or ARB HTN w/ recurrent episodes of flash pulmonary edema stage II HTN onset after 55yo HTN w/ diffuse atherosclerosis, unilateral small kidney, asymmetric renal size abdominal bruit

Renovascular Disease: Diagnostics

Labs: elevated BUN, Cr Imaging: - MC: CTA - GOLD STANDARD: renal arteriography - duplex doppler US - MRA **CTA is not great at picking up distal vessels (fibromuscular dysplasia)

Renovascular Disease: Atherosclerotic Renal Artery Stenosis

aka ischemic nephropathy >age 45 comorbidities: CAD, PAD

Renovascular Disease: Atherosclerotic Renal Artery Stenosis: Etiology

reduced blood flow to kidney involves - aortic orifice - proximal main renal artery

Renovascular Disease: Atherosclerotic Renal Artery Stenosis: Risk Factors

hyperlipidemia cigarette smoking age >50yo

Renovascular Disease: Atherosclerotic Renal Artery Stenosis: Diagnosis

luminal occlusion of at least 60-75%

Renovascular Disease: Atherosclerotic Renal Artery Stenosis: Treatment

treat the HTN monitor CKD CV secondary prevention revascularization (angioplasty w/ or w/out stenting or bypass)

Renovascular Disease: Fibromuscular Dysplasia

women

Renovascular Disease: Fibromuscular Dysplasia: Etiology

noninflammatory, nonatherosclerotic disorder leading to arterial stenosis, occlusion, aneurysm, dissection and arterial tortuosity reduced blood flow to kidney usually involves distal main renal artery or intrarenal branches

Renovascular Disease: Fibromuscular Dysplasia: Angiographic Classification

multifocal (string of beads) vs focal (circumferential or tubular stenosis)

Renovascular Disease: Fibromuscular Dysplasia: Clinical Presentation

HA pulsatile tinnitus neck pain flank or abd pain HTN cervical or abd bruit TIA stroke

Renovascular Disease: Fibromuscular Dysplasia: Medical Management

ACE-I or ARB F/U with: -serum creatinine every 6mo -duplex US every 6-12mo

Renovascular Disease: Fibromuscular Dysplasia: Surgical Management

``` angioplasty F/U with duplex US and serum creatinine at -1st post op visit -every 6 mo x 2 yrs -annually ```

Renovascular Disease: ACE-I's and ARBs

renal perfusion dec due to stenosis autoregulation maintains GFR -- inc in efferent arteriolar resistance medical blockade of angiotensin II formation blunts autoregulation --> reduced GFR --> possible AKI

Renovascular Disease: Surgical Treatment: Complications

renal artery dissection capsular perforation hemorrhage atheroembolic disease

Renovascular Disease: Surgical Treatment: most likely to benefit

short duration of BP elevation prior to dx failure of medical therapy to control BP intolerance to medical therapy recurrent flash pulmonary edema and/or refractor HF