Renal Flashcards
Renal Cell Carcinoma: Epidemiology
MC primary renal malignancy
M>F
6-8th decade
Renal Cell Carcinoma: Risk Factors
SMOKING
htn obesity chronic dialysis toxic exposures heavy aspirin, acetaminophen, nsaids genetics
Renal Cell Carcinoma: Pathology
MC: clear cell papillary (chromophilic) chromophobe oncocytic collecting duct (bellini's duct) unclassified
Clear Cell RCC
deletion of chromosome 3p
proximal tubule
usually solid
Papillary RCC
proximal tubule
type 1: good prognosis
tupe 2: aggressive
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
Paraneoplastic Syndromes
anemia hepatic dysfunction fever hypercalcemia cachexia erythrocytosis secondary amyloidosis thrombocytosis polymyalgia rheumatica
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)
Renal Cell Carcinoma: Diagnostics: evaluation of metastasis
bone scan
CT chest
MRI w/ gad
PET or PET/CT
Renal Cell Carcinoma: Treatment: stage I, II, III
surgery is curative
Renal Cell Carcinoma: Treatment: stage IV
systemic therapy
surgery
radiation
Management of a Small Renal Mass: predictors of malignancy
male sex
increasing tumor size
Management of a Small Renal Mass: <2cm
20-40% benign
<10% high-grade RCC
<1% present with/develop mets
Management of a Small Renal Mass: 4+cm
5-10% benign
20-30% high-grade or advanced RCC
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
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)
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
