Small Group 7- Secondary Hypertension, Stones

Question 1

1. Describe clinical presentations of renovascular disease.

Answer 1

recent increase in BP medication requirements
rise in creatinine in last year
no proteinuria
history of arteriolar disease/presences of bruits
dyslipidemia

Question 2

2. List the kidney disease that present with no proteinuria.

Answer 2

renal artery stenosis (>70% are considered significant)
obstructive nephropathy
on occasion HTN
(also negative dipstick with myeloma)

Question 3

3. Describe diagnostic tests for renovascular disease and explain which tests are structural and which tests are functional.

Answer 3

anatomical: Gold standard is arteriogram, but CT angiogram (contrast) and MRA are excellent (peripheral venous injection)

physiology/flows: duplex ultrasound (resistive index; measuring higher velocity); ACEI renogram- GFR is decreased in stenotic side (unhelpful in bilateral stenosis, costly, longer time); some MRA flow studies available (contrast can cause nephrogenic systemic fibrosis)

Question 4

4. Describe what imaging tests are best for stone disease.

Answer 4

spiral CT (no contrast)

Question 5

5. List disease associated with hypokalemia and hypertension and describe clinical findings which discriminate between theses diseases .

Answer 5

renovascular disease secondary to hyperaldosteronism
pheochrocytoma causing adrenergic shift into cells
Cushing’s syndrome causing excess glucocoritocoids and distal K excretion
primary hyperaldosternoism

would run serum aldosterone and plasma renin activity for ratio (common cause of secondary HTN)

Question 6

6. Describe what imaging tests are best for acute nephrolithiasis.

Answer 6

spiral CT (non contrast) is best
X-ray may show radio opaque stones (including Ca), not much resolution

Question 7

7. List therapies for acute nephrolithiasis.

Answer 7

pain meds, IV fluids (normal saline), possibly medical expulsive therapy (alpha blockers- tamsulosin)

Question 8

8. List reasons for hospitalization for acute nephrolithiasis.

Answer 8

1) unable to keep down fluids or pain meds
2) kidney failure
3) UTI
4) stone requiring urologic intervention based on CT (stone size important determinant)

Question 9

9. List stone types and associated systemic diseases.

Answer 9

Type I RTA associated with Ca++ stones

primary hyperparathyroidism associated with high Ca++ in serum and urine (Ca++ stones)

Question 10

10. Describe general and specific therapies for prevention of stone formation.

Answer 10

general: drink at least 2 L fluids a day, no caffeine or alcohol (diuretics)
specific: surgical removal of parathyroids for PTH; sodium bicarbonate or potassium citrate to correct the acidosis, citrate can inhibit stone formation