Renal Feirstein Flashcards
What is the epidemiology of RCC
M>W
avg onset 64 y/o
73% have a 5 year survival
What are the RF for RCC
SMOKING
HTN, obesity, chronic dialysis, increased ASA, NSAID, or APAP use, genetics, toxin exposures
What is the pathology of RCC
MC* clear cell: 3p deletion
Papillary/chromophilic (type 1 good prog, type 2 aggressive)
Chromophobe (oncocytic)
What is the triad associated with RCC
Hematuria
Flank pain
Abdominal mass
What are other symptoms of RCC
scrotal varicocele weight loss ascites pulmonary emboli (IVC) mets to lungs, lymph, bone, liver, brain paraneoplastic syndrome
How do you diagnose RCC
**abdominal CT w/ wo contrast
but can also use MRI
Tissue biopsy
to eval mets: bone scan, CT chest, MRI w/ contrast, or PET
How do you treat RCC
Localized (stage I-III): surgery is curative
Advanced (stage IV): systemic Tx, surgery, and radiation
What is a “small renal mass”
<4cm and enhances on contrast imaging
<2cm: usually benign (10% RCC)
4+cm: small% benign, 20-30% RCC
What are predictors of malignancy in a small renal mass
Male
increasing tumor size
What can be used to diagnose small renal masses
renal CT/MRI w/wo CMp CBC renal function tests chest imaging (mets?) \+/- biopsy **involve urology!
How do you manage a small renal mass
surgery!
<3cm: thermal ablation w/ biopsy
<2cm: imaging q 3-6 months for 2 yrs, then q 6-12 months
<1cm: surveillance
What is the MC primary pediatric renal tumor
Wilms Tumor (<15 y/o) -abnormal renal development and loss of tumor suppressor gene function
What does Wilms look like
Solitary
surrounded by enhancing pseudocapsule
made of blastemal, stromal, and epithelial cells
Wilms tumor usually presents with
Abdominal mass, otherwise asymptomatic
rarely: abd pain, fever, HTN, hematuria
What is needed to definitively diagnose Wilms tumor
Biopsy (need histologic confirmation)
but, start w/ US, then CT or MRI before invasive biopsy
**check the other kidney!!
Labs done for Wilms tumor include
renal and liver function tests
UA, calcium, CBC, coags
refer to peds and get chest imaging for mets
Why check coags in Wilms tumor
because many have associated Von Willebrand factor bleeding disorder
What is the outcome of Wilms tumor
90% 5 year survival rate with chemo and surgical excision
BUT, increased risk for premature death as adult d/t chemo and radiation
What should we do for surveillance in Wilms tumor patients
CXR, abd US, CT
q 6-8 weeks during treatment
q3 months for 2 years
q 6 months for 2 years after that
What is renal vascular disease
a cause of secondary HTN (due to atherosclerotic disease* or fibromuscular dysplasia) associated with target organ injury (LVH, renal fibrosis)
What are important Ddx for renal vascular disease
thromboembolic renal disease (in old and hypercoagulable, w/ flank pain, leukocytosis, n/v, HTN, renal decline)
Microvascular injury 2/2 HTN (hypertensive nephrosclerosis, arteriolonephrosclerosis)
When should you consider renal vascular disease as a diagnosis
Young onset, severe/resistant HTN, acute rise in BP SrCr increase >30% s/p ACE/ARB mod-severe HTN w/ flash pulm edema New onset Stage II HTN >55 y/o abdominal bruits
What do renal vascular disease labs show
increased BUN/Cr
How do you diagnose renal vascular disease
**renal arteriograph
also doppler, CTA
MRA last resort d/t complications with gandolinium
When do you order diagnostic testing
only if intervention will be completed!
What is atherosclerotic RAS
atherosclerosis leading to decreased renal blood flow involving the aorta or proximal main renal artery
- it is a cardiac risk equivalent!
- onset usually >45 y/o
What are RF for atherosclerotis RAS
HLD
smoking
50+ y/o
comorbid CAD/PAD
How do you diagnose atherosclerotic renal artery stenosis
60-75% luminal occlusion
How do you treat ARAS
treat HTn
monitor CKD
secondary prevention (STATINS! ASA, stop smoking)
What is fibromuscular dysplasia
non-inflammatory, non-atherosclerotic disorder leading to arterial stenosis, occlusion, aneurysm, dissection, or tortuosity AKA decreased renal blood flow
What does FMD involve
distal main renal artery (unlike atherosclerotic which involves proximal) or intrarenal branches
What does FMD show on angiography
multifocal (string of beads) vs focal (circumferential stenosis)
What is the clinical presentation of FMD
HA pulsatile tinnitus neck pain flank/abd pain HTN TIA bruits
How do you treat FMD
ACE/ARB (need SrCr q6 mo, and duplex q6-12 mo)
*Angioplasty (need duplex and SrCr @ 1st post-op, q6 mo for 2 years, then every year)
Why are ACE/ARB contraindicated in RAS
normally, stenosis decreases renal perfusion and autoregulation (mediated by angiotensin II) maintains GFR
If you block angiotensin II, you stop autoregulation and decrease GFR= AKI
BUT, stenosis is what causes renal vascular disease (stenosis) SO
be cautious, but ACE/ARB are 1st line for RAS
What must you monitor in RAS patient on ACE/ARB
SrCr, to ensure it doesnt rise above 30%
What are complications of renovascular disease
renal artery dissection
hemorrhage (capsular perforation)
atheroembolic disease leading to HTN and kidney failure
Who most likely benefits from surgery
Short duration of BP prior to diagnosis
meds dont control BP (intolerant to meds)
recurrent flash pulmonary edema/HF
