Renal Vascular Disease

Question 1

Most common cause of secondary HTN and pathophysiology behind it

Answer 1

renal artery stenosis

decrease in blood flow to juxtaglomerular apparatus -> activation of RAAS system -> HTN

Question 2

2 causes of renal artery stenosis

Answer 2

1. atherosclerosis (2/3rds of cases) - most often in elderly men, bilateral in 1/3rd cases
2. fibromuscular dysplasia - often seen in young women, bilateral in 50%

Question 3

Clinical features of renal artery stenosis

Answer 3

• sudden onset HTN, often severe and in patient with no family hx, refractory to medical therapy may cause malignant HTN
• decreased renal function
• abdominal bruit (esp in fibromuscular dysplasia)

Question 4

How to dx renal artery stenosis

Answer 4

• renal arteriogram = gold standard, BUTTTTTTT contrast dye is nephrotoxic so avoid in renal failure
• MRA (magnetic) newer test, not nephrotoxic
• duplex doppler U/S of renal arteries

Question 5

Treatment for renal artery stenosis

Answer 5

• revascularization with percutaneous transluminal renal angioplasty (PRTA) is INITIAL TREATMENT for most patients, better success with fibro musc than athero
• bypass surgery of revasc unsuccessful
• conservative: ACE inhibitors, CCBs, alone or in combo to revasc

Question 6

Clinical features of RVT

Answer 6

decreased renal perfusion (can lead to renal failure), flank pain, HTN, hematuria, and proteinuria

Question 7

RVT can be seen in what clinical settings?

Answer 7

nephrotic syndrome (most commonly from membranous nephropathy), renal cell carcinoma, pregnancy, trauma, dehydration

Question 8

how to diagnose RVT

Answer 8

selective renal venography or IVP

Question 9

how to treat RVT

Answer 9

anticoagulate!!!! also prevents PE

Question 10

What is atheroembolic disease of renal arteries

Answer 10

SHOWERRRRRS of cholesterol crystals that dislodge form plaques in large arteries and embolize to the renal vasculature…can occur in other organs as well

Question 11

How is HTN harmful to kidneys?

Answer 11

systemic HTN increases capillary hydrostatic pressure in the glomeruli leading to bengin or malignant sclerosis…MCC of ESRD under what….??

DIABETES BITCH

Question 12

benign vs malignant nephrosclerosis

Answer 12

benign - mild to moderate Cr increase, microscopic hematuria, mild proteinuria
malignant - RAPID decrease in renal function, accelerated HTN due to diffuse renal injury….can lead to proteinuria, hematuria, RBC and WBC casts, sometimes nephrotic syndrome
can also present with microangiopathic hemolytic anemia

Question 13

Which area of kidney is most affected in sickle cell nephropathy and what does it lead to?

Answer 13

papilla

leads to papillary necrosis -> renal failure/high frequency of UTI
also leads to nephrotic syndrome or ESRD…can also affect tubules which inhibits concentration of urine

Question 14

What meds can be helpful in sickle cell nephropathy

Answer 14

ACEI