Renal Diseases (Renal Artery HTN/Stenosis; Wilm's Tumor) - Exam 2 Flashcards
what is the most common secondary cause of HTN?
renal artery stenosis
a woman < 40 y/o that is NOT pregnant and has HTN, may have what HTN?
renal HTN
adult >60 y/o and has HTN that is difficult to treat, may have what HTN?
renal HTN
what exam can you do to dx renal artery HTN?
fundoscopy
what will you see on fundoscopy for renal artery HTN?
AV nicking/copper wiring
hemorrhage seen on fundoscopy is more of a reflection of what?
severity of the HTN
nicking seen on fundoscopy is more of a reflection of what?
chronicity of the HTN
what is the main cause of renal artery stenosis?
atherosclerosis
what is the most important risk factor for atherosclerosis?
hyperglycemia and excess of carbohydrate consumption
what cause of renal artery stenosis is primarily seen in women < 40 y/o?
fibromuscular dysplasia
___ stenosis is more significant than unilateral stenosis?
bilateral stenosis of the renal arteries
renal artery stenosis commonly seen in who?
46 y/o w/ hx of atherosclerotic disease
also common in elderly with atherosclerosis
risk factors of renal artery stenosis?
- ***Atherosclerosis (M/C)
- ***DM
- CKD
- tobacco use
- HTN
some pts with ESRD have a concomitant dx of what?
atherosclerotic renal artery stenosis (ARAS)
atherosclerotic renal artery stenosis (ARAS) associated with what?
increased mortality compared to all other causes of ESRD, except DM
what are the 2 most common causes renal artery stenosis?
atherosclerosis, renal fibromuscular dysplasia
what do you see in renal fibromuscular dysplasia?
beads/nodes in the artery
decreased renal perfusion in the kidney leads to what?
increased renin production, which in turn forms angiotensin II
increased renin production, forms what?
angiotensin II
angiotensin II causes what and also stimulates the production of what?
AT II causes vasoconstriction directly and also stimulates aldosterone production, which causes salt and water retention
what is significant stenosis?
Stenosis that causes hemodynamic changes with a reduction in renal perfusion pressure is called critical stenosis
in humans, hemodynamically significant stenosis is defined by more than what?
more than 70% angiographic stenosis or 50-70% angiographic stenosis associated with a resting mean pressure gradient >10mmHg, systolic hyperemic pressure gradient >20mmHg or renal fractional flow reserve less than 0.8
what are the 2 major goals of the evaluation of the hypertensive pt?
To recognize clinical clues for secondary forms of HTN
To identify evidence of target organ damage from the HTN
how to identify evidence of target organ damage from HTN?
direct fundoscopy for HTN retinopathy
abdominal bruits
what organ is the most easy to identify for damage from HTN?
the eyes -> she retinopathy
when see someone with retinopathy, hey most likely also have what?
nephropathy
what is the unilateral model of renal stenosis mediated by?
it is renin-mediated
what is the bilateral model of renal stenosis mediated by?
it is volume mediated
signs and sx’s of renal artery stenosis?
severe refractory HTN (BP >180)
abrupt acceleration of stable HTN
severe HTN in generalized atherosclerosis
systolic-diatonic bruit in epigastrium
flash pulmonary edema
unexplained renal dysfunction d/t ACEI or ARBs
retinopathy (on funds exam)
what is the flash pulmonary edema due to?
consequence of HTN
what suggests pulmonary edema?
sudden onset of SOB with BP >200mmHg and lungs full of crackles during inspiration í all suggest pulmonary edema
sudden onset of azotemia after ACEI or ARB suggests what?
RVHT, esp bilateral RAS or RAS with a solitary functioning kidney
women presenting <30 y/o with HTN, should be suspected of having what?
RVHT d/t fibromuscular dysplasia
by definition, RVHT requires what?
an elevation of BP d/t the activation of the RAAS in the setting of renal artery occlusive disease
the dx of RVHT can be made only if what improves?
if BP improves after a correction of RAS, thereby making RVHT a retrospective dx
what electrolyte will be low in RVHT?
K - will have hypokalemia
what is a surrogate marker for RVHT?
hypokalemia
why does hypokalemia occur in RVHT?
b/c aldosterone increases, causing Na to increase and K decreases
if see someone with high Na and low K, what should you suspect?
hyperaldosternosim
why do alcoholics have hypokalemia?
b/c they have hypoMg and hypoMg and hypoK go hand in hand
must correct hypoMg first, before correct hypoK
is RVHT only seen in people with renal dysfunction?
NO!!!
RVHT may be seen in pts with or without renal dysfunction
-Can have RVHT with normal renal function (normal Cr)
what may there be a presence of in RVHT?
mild-to-moderate proteinuria
what is a strong clinical clue for hemodynamically significant renal artery disease?
azotemia follow the admin of an ACEI or ARB
imaging studies for RVHT?
MRA, Spiral (Helical) CT Scan, Duplex U/S Scan, Renal Artery Angiography
MRA improves what?
MAGNETIC RESONANCE ANGIOGRAPHY
Use of gadolinium MRA has been shown to significantly improve the images of the distal arteries and accessory renal arteries
can MRA be used in renal dysfunction?
Yes, but AVOID in those with Cr < 30
why avoid MRA in Cr <30?
b/c the gadolinium causes development of nephrogenic fibrosing dermopathy (NFD) and nephrogenic systemic fibrosis (NSF)
MRA not useful in detecting what? as compared to what?
FMD as compared to renal angiography
what is bad about using spiral CT scan for diagnosing RVHT?
b/c contrast must be used
spiral CT can for diagnosing RVHT only recommended for what pts?
pts with CrCl > 60ml/min
what is preferred when screening for FMD/
CT angio
what does Duplex U/S for RVHT dx provide?
renal resistive indices -> approximates the amount of renal artery impedance
what is a drawback of Duplex U/S for RVHT dx?
it is operator dependent
what is the GOLD STANDARD tyconfirm hemodynamically significant RAS?
renal artery angiography
can you use renal artery angiography if pt has renal failure?
NO!!!
when do you perform renal artery angiography?
Perform when:
- Definitive diagnosis is required
- Interventional procedure being considered
what are the tx goals of RAS?
optimal control of HTN, reduction of risks of cardiovascular events, preservation of renal function
what is the preferred tx for RAS?
medical therapy
what does medical tx for RAS include?
ACEIs and ARBs, statins and antiplatelet therapy, CCBs
what must you closely monitor for with ACEIs and ARBs?
electrolytes and Cr
ACEI use associated with decreased what?
- Death
- MI/stroke
- Number of hospitalizations for heart failure
- Pts. Requiring dialysis
what medication is considered primary therapy for RAS?
ACE/ARBs
ACE did show twice the number of what when treating RAS?
twice the number of epodes of AKI
CCBs are effective at what?
lowering BP
CCBs maintain what?
Maintain renal blood flow through vasodilation in afferent arteriole
CCBs have more favorable effect on what?
renal function (AKI) compared to ACE
CCBs can be used safely in what?
bilateral RAS (w/out concern for decline in GFR)
ACEI/ARB C/I in what RAS?
bilateral stenosis
what is the initial choice for tx in pts with FMD?
percutaneous renal artery intervention - for younger pts with FMD
what does percutaneous renal artery intervention control?
controls HTN and prevents progressive renal disease in FMD
percutaneous renal artery intervention preferred over what?
over surgical therapy
renal artery bypass as tx for RAS?
early reports suggest survival benefits for RAS pts who did this vs medical therapy, but not good study
most pts who have this have unsuccessful bypass or show extensive atherosclerosis disease in aorta that needs additional repair
recommended medical therapy for RAS?
ACE/ARBS, CCBs, and beta blockers + statins and antiplatelets
first line!!!
percutaneous revascularization tx for who that has RAS?
hemodynamically significant RAS and any of the following:
-Recurrent CHF or flash pulmonary edema
- Accelerated, resistant or malignant HTN and intolerance to meds
- Asymptomatic bilateral or single functioning kidney
- Progressive CKD and bilateral or single functioning kidney
balloon angioplasty with bailout stent placement for who with RAS?
FMD pts if necessary
surgical revascularization recommended in who with RAS?
- FMD associated with complex disease or microaneurysms
- ARAS and multiple small renal arteries or early primary branching of main renal artery
- ARAS in combo with pararenal aortic reconstruction
what is Wilm’s tumor?
nephroblastoma in children
wilm’s tumor is second most common cause of?
abdominal tumor in children
most occurrences of wilm’s tumor are what?
sporadic
small portion of wilm’s tumor due to what?
malformation syndromes
bilateral wilm’s tumors present when?
at younger age
wilm’s tumor commonly at what age?
b/w ages 2-5 years old
clinical findings of wilm’s tumor?
painless palpable abdominal mass (M/C)
microscopic hematuria
how is wilm’s tumor usually found?
incidentally by parents or provider
mass in wilm’s tumor is what?
- Smooth and firm
- Well demarcated
- Rarely crosses midline
- Can extend inferiorly into pelvis
what do 25% of pts with wilm’s tumor have at presentation?
HTN
Labs for wilm’s tumor?
- CBC: usually normal (some may have anemia secondary to hemorrhage into tumor)
- BUN/Cr: usually normal
- UA: may show some blood or leukocytes
what imaging is done for establishing the presence of the wilm’s tumor?
U/S or CT - establish presence of infrarenal mass
what is essential to evaluate in pt with unilateral wilm’s tumor?
Essential to evaluate other kidney for presence/function and if it has Wilm’s tumor
what is the best imaging for wilm’s tumor?
abd CT
U/S with doppler used for what with wilm’s tumor?
evaluate the IVC for presence or extent of tumor propagation
what should be imaged for mets for wilm’s tumor?
liver and lungs
use what imaging when checking for pulmonary mets for wilm’s tumor?
chest CT
most mets with wilm’s tumor occur where?
pulmonary (80%)
liver (15%)
what resection for wilm’s tumor?
en bloc resection
avoid tumor spillage -> this can increase staging and treatment
what determines tx for wilm’s tumor?
histology and staging
favorable histology for wilm’s tumor?
classic triphasic Wilm’s tumor and its variants
- Loss of heterozygosity of chromosomes 1p and 16q
- adverse prognostic factors in pts with favorable histology
unfavorable histology of wilm’s tumor?
presence of diffuse anaplasia (extreme nuclear atypia)
RARE!!!
following excision and pathology of wilm’s tumor, w hat occurs?
pt is assigned a stage that defines further therapy
overall cure rate for wilm’s tumor?
90%
survival rates for wilm’s tumor improved by?
Intensifying treatment during initial phase
Shortening overall duration -> 24 wks vs. 60 wks
stage III or IV tx for wilm’s tumor?
require radiation to tumor bed and metastatic sites
- Chemotherapy -> begin 5 days after surgery
- Radiation -> within 10 days after surgery
stage V tx for wilm’s tumor?
this is a bilateral wilm’s tumor
- Possible bilateral renal biopsies
- Followed by chemo and second-look renal sparing surgery
- Radiation may also be necessary
stage 1-2 FH and stage 1 UH for wilm’s tumor tx?
dactinomycin and vincristine
stage 3-4 FH and 2-4 focal anaplasia for wilm’s tumor tx?
dactinomycin, vincristine, and doxorubicin with radiation
stage 2-4 UH (diffuse anaplasia) for wilm’s tumor tx?
vincristine, doxorubicin, etoposide, and cyclophosphamide with radiation
