Chapter 272 - Renovascular Disease

Question 1

Vascular disorders that commonly

threaten the blood supply of the kidney

Answer 1

large-vessel atherosclerosis,

fibromuscular diseases, and embolic disorders

Question 2

predictive of

systemic atherosclerotic disease events.

Answer 2

Rates of urinary albumin excretion (UAE)

Question 3

reduces UAE and risk of cardiovascular events

Answer 3

statins

Question 4

causes of Large-vessel renal artery occlusive disease

Answer 4

extrinsic
compression of the vessel, intimal dissection, fibromuscular dysplasia
(FMD), atherosclerotic disease (most common)

Question 5

considered a specifically treatable

“secondary” cause of hypertension.

Answer 5

renal artery stenosis

Question 6

common and often has only minor hemodynamic

effects

Answer 6

Renal artery stenosis

Question 7

reported in 3–5% of normal subjects presenting

as potential kidney donors without hypertension

Answer 7

FMD

Question 8

It may present clinically
with hypertension in younger individuals (between age 15 and
50), most often women

Answer 8

FMD

Question 9

does not often threaten kidney function,
but sometimes produces total occlusion and can be associated with
renal artery aneurysms

Answer 9

FMD

Question 10

common in the general population (6.8% of a community-based
sample above age 65).

The prevalence increases with age and for
patients with other vascular conditions such as coronary artery disease
(18–23%) and/or peripheral aortic or lower extremity disease (>30%).

Answer 10

Atherosclerotic renal artery stenosis (ARAS)

Question 11

It appears to slow these rates of total occlusion in ARAS and
improve clinical outcomes

Answer 11

Intensive treatment of arterial

blood pressure and statin therapy

Question 12

results of Critical levels of stenosis

Answer 12

reduction in perfusion pressure
that activates the renin-angiotensin system, reduces sodium excretion,
and activates sympathetic adrenergic pathways

Question 13

characterized by angiotensin dependence in the
early stages, widely varying pressures, loss of circadian blood pressure
(BP) rhythms, and accelerated target organ injury, including left
ventricular hypertrophy and renal fibrosis

Answer 13

systemic hypertension

Question 14

treatment of renovascular HPN

Answer 14

agents that block the renin-angiotensin system and
other drugs that modify these pressor pathways

restoration of renal blood flow by either endovascular or surgical
revascularization

Question 15

tend to affect both the post-stenotic
and contralateral kidneys, reducing overall glomerular filtration rate
(GFR) in ARAS.

Answer 15

ARAS and systemic hypertension

Question 16

When kidney function is threatened by large-vessel

disease primarily

Answer 16

ischemic nephropathy

Question 17

Moderately

reduced blood flow that develops gradually

Answer 17

reduced GFR and limited oxygen consumption with preserved tissue
oxygenation

Question 18

what happens with more advanced disease in ARAS and systemic HPN

Answer 18

reductions

in cortical perfusion and frank tissue hypoxia develop

Question 19

It develops in patients with other risk factors for atherosclerosis
and is commonly superimposed upon preexisting small-vessel
disease in the kidney resulting from hypertension, aging, and diabetes.

Answer 19

ARAS

Question 20

Nearly 85% of patients considered for renal revascularization have
what stage and what rate of GFR

Answer 20

stage 3–5 chronic kidney disease (CKD) with GFR <60 mL/min per
1.73 m2

Question 21

strong predictor of morbidity- and
mortality-related cardiovascular events, independent of whether renal
revascularization is undertaken.
Diagnostic approaches to renal

Answer 21

presence of ARAS

Question 22

Levels of renin activity are therefore subjected to what?

Answer 22

timing,

the effects of drugs, and sodium intake

Question 23

Renal artery velocities by Doppler
ultrasound _____ generally predict hemodynamically important
lesions (>60% vessel lumen occlusion)

Answer 23

> 200 cm/s

although some treatment trials
require velocity >300 cm/s to avoid false positives

Question 24

has predictive value regarding the viability of the kidney

It remains operator- and institution-dependent

Answer 24

renal resistive

index

Question 25

has a strong negative predictive value when | entirely normal.

Answer 25

Captopril-enhanced | renography

Question 26

less often used, as gadolinium contrast has been associated with nephrogenic systemic fibrosis

Answer 26

Magnetic resonance angiography (MRA)

Question 27

provides excellent vascular images | and functional assessment, but carries a small risk of contrast toxicity.

Answer 27

Contrast-enhanced computed tomography | (CT) with vascular reconstruction

Question 28

treatment for patients with FMD that are commonly younger females with otherwise normal vessels and a long life expectancy

Answer 28

percutaneous renal | artery angioplasty

Question 29

Medical therapy for Renal Artery Stenosis

Answer 29

blockade of the renin-angiotensin system, attainment of goal BPs, cessation of tobacco, statins, and aspirin

Question 30

Follow-up requires surveillance for progressive occlusion criteria??

Answer 30

worsening renal function and/or loss of BP control

Question 31

often reserved for patients failing | medical therapy or developing additional complications

Answer 31

Renal revascularization

Question 32

major complications in renal revascularization

Answer 32

renal artery dissection, capsular perforation, hemorrhage, | and occasional atheroembolic disease

Question 33

can be catastrophic and accelerate both hypertension | and kidney failure, precisely the events that revascularization is intended to prevent

Answer 33

atheroembolic | disease

Question 34

they are more likely to recover function after restoring blood flow

Answer 34

Patients with rapid loss of kidney function, sometimes associated with antihypertensive drug therapy, or with vascular disease affecting the entire functioning kidney mass

Question 35

treatment for hypertension is refractory to effective therapy

Answer 35

revascularization

Question 36

arise most frequently as a result of cholesterol crystals breaking free of atherosclerotic vascular plaque and lodging in downstream microvessels.

Answer 36

Emboli to the kidneys

Question 37

suspected in >3% of elderly subjects | with end-stage renal disease (ESRD) and is likely underdiagnosed

Answer 37

Atheroembolic renal disease

Question 38

risk factors for atheroembolic renal disease

Answer 38

males with a history of diabetes, hypertension, | and ischemic cardiac disease

Question 39

precipitating events in atheroembolic renal disease

Answer 39

angiography, vascular surgery, anticoagulation with heparin, thrombolytic therapy, or trauma

Question 40

days where clinical manifestations of this syndrome (atheroembolic disease) commonly develop

Answer 40

between 1 and 14 days

Question 41

Systemic embolic disease manifestations

Answer 41

fever, abdominal pain, and weight loss

Question 42

cutaneous manifestations of systemic embolic disease

Answer 42

livedo reticularis and localized toe gangrene

Question 43

require dialytic support

Answer 43

Progressive renal failure

Question 44

laboratory findings of systemic embolic disease

Answer 44

rising creatinine, transient eosinophilia (60–80%), elevated sedimentation rate, and hypocomplementemia

Question 45

Definitive diagnosis for systemic embolic disease

Answer 45

kidney biopsy demonstrating microvessel occlusion with | cholesterol crystals that leave a “cleft” in the vessel

Question 46

can lead to | declining renal function and hypertension

Answer 46

Thrombotic occlusion of renal vessels or branch arteries

Question 47

causes of thrombosis

Answer 47

local vessel abnormalities, such as local | dissection, trauma, or inflammatory vasculitis

Question 48

patchy, transient areas of infarctions

Answer 48

segmental | arteriolar mediolysis

Question 49

distant embolic events that causes thromboembolic renal disease

Answer 49

left atrium in patients with atrial fibrillation fat emboli originating from traumatized tissue, most commonly large bone fractures

Question 50

Cardiac sources that causes thromboembolic renal disease

Answer 50

vegetations from subacute bacterial endocarditis venous circulation if right-to-left shunting - patent foramen ovale

Question 51

Clinical manifestations of acute arterial thrombosis

Answer 51

flank pain, | fever, leukocytosis, nausea, and vomiting

Question 52

sign of kidney infarction

Answer 52

lactate dehydrogenase (LDH) rise to extreme levels

Question 53

sign of kidney infarction, both kidneys affected

Answer 53

renal function will decline precipitously with | a drop in urine output

Question 54

Diagnosis of | renal infarction

Answer 54

vascular imaging with MRI, CT | angiography, or arteriography

Question 55

Options for interventions of newly detected arterial occlusion

Answer 55

surgical reconstruction, anticoagulation, thrombolytic therapy, endovascular procedures, antihypertensive drug therapy

Question 56

treatment for unilateral disease - arterial dissection with thrombosis

Answer 56

supportive care | with anticoagulation

Question 57

It is potentially | catastrophic, producing anuric renal failure

Answer 57

Acute, bilateral occlusion of kidney

Question 58

rapidly progressive BP elevations with target organ injury including retinal hemorrhages, encephalopathy, and declining kidney function.

Answer 58

“Malignant” Hypertension note: mortality rates in excess of 50% over 6–12 months

Question 59

Postmortem studies of such patients identified vascular lesions, with breakdown of the vessel wall, deposition of eosinophilic material including fibrin, and a perivascular cellular infiltrate.

Answer 59

fibrinoid necrosis

Question 60

separate lesion was identified in the larger interlobular arteries in many patients with hyperplastic proliferation of the vascular wall cellular elements, deposition of collagen, and separation of layers

Answer 60

“onionskin” lesion.

Question 61

It can led | to obliteration of glomeruli and loss of tubular structures.

Answer 61

fibrinoid necrosis

Question 62

mainstay of therapy for malignant | hypertension

Answer 62

Antihypertensive therapy

Question 63

It most commonly develops in patients with treated hypertension who neglect to take medications or who may use vasospastic drugs, such as cocaine

Answer 63

Malignant hypertension

Question 64

findings in renal abnormalities

Answer 64

rising serum creatinine hematuria and proteinuria biochemical findings: evidence of hemolysis (anemia, schistocytes, and reticulocytosis) and changes associated with kidney failure.

Question 65

African-American males

Answer 65

more likely to develop rapidly progressive hypertension and kidney failure than are whites in the United States

Question 66

type of Genetic polymorphisms common in the African-American population predispose to subtle focal sclerosing glomerular disease, with severe hypertension developing at younger ages secondary to renal disease in this instance

Answer 66

APOL1

Question 67

lesser degrees of hypertension induce less severe, but prevalent, changes in kidney vessels and loss of kidney function large portion of patients reaching ESRD without a specific etiologic diagnosis are assigned the designation

Answer 67

hypertensive nephrosclerosis

Question 68

Pathologic examination for hypertensive nephrosclerosis

Answer 68

afferent arteriolar thickening with deposition of homogeneous eosinophilic material (hyaline arteriolosclerosis) associated with narrowing of vascular lumina

Question 69

Clinical manifestations of hypertensive nephrosclerosis

Answer 69

``` retinal vessel changes associated with hypertension (arteriolar narrowing, arteriovenous crossing changes), left ventricular hypertrophy, and elevated BP ```