Symptoms of Diabetic nephropathy
- Occult hematuria
- Concurrent diabetic symptoms
What test is standard of care for management of diabetes mellitus?
Immunologic measurement of microalbumin in urine
How can we assess diabetic nephropathy
-Quantitative measurement of albuminuria
What lab test other than albumin do you need to run on patients with diabetic nephropathy?
What are concurrent symptoms patients with diabetic nephropathy have?
Proteinuria in diabetics can be due to what other dz?
-What do you look for?
- Glomerular Dz
- Look for urine sediments (cells, casts)
What are natural treatment approaches to diabetes
- Flax and Pumpkin Seed
- Curcumin (antioxidant, renal protective)
- Alpha Lipoic Acid
What is a major cause of ESRD, especially in the elderly?
What are steps toward preventing Hypertensive Nephropathy and Nephrosclerosis?
- Lifestyle changes may reduce the risk of hypertension
- Exercise to improve cardiac fitness
- Lose weight if overweight
- Dietry adjustments to help control hypertension
- Modify sodium
What are symptoms of Hypertensive Nephropathy?
- Repeated elevated BP
- Ha, fatigue, confusion
- Vision changes, angina like chest pain
- heart failure
- Difficult to control HTN
- Irregulat heartbeat
What are signs that indicate complications of hypertensive NEPHROPATHY?
- Left ventricular hypertrophy
- Hypertensive retinopathy
- Abdominal Bruit over renal AA
What laboratory result shows moderate clinical suspicion of hypertensive nephropathy
- Diastolic > 120mm Hg,
- HTN refractory to therapy
What laboratory result shows high clinical suspicion of hypertensive nephropathy
- Plasma Renin
- Catopril Challenge Test
What is the treatment for hypertensive nephropathy?
- Control BP with meds
- Percutaneous transluminal angioplasty (insertion of stent)
- Surgical reconstruction of damaged artery
- Surgical bypass of renal arteries in fibromuscular hyperplasia
- Treat atherosclerosis: guggal, garlic EFA, B vit
- Vascular protectants: bioflavonoids, vaccinium
What is nephroptosis?
- Floating/Falling Kidney
- Kidney drops >5cm upon moving from supine to standing position
Sx of nephroptosis include what?
- Severe abdominal, costovertebral and flank pain
- N/V in upright position
- Pain relieved with upward movement of the kidneys, supine position
What cases N/V in upright position in the case of nephroptosis?
- Acute hydronephrosis kinked proximal ureter
- Renal Vessel lumen narrowing and resultant ischemia
- Visceral nerve stimulation from traction
Physical exams for nephroptosis?
Kidney palpable in ipsilateral lower abdomen
Workup for nephroptosis?
- Renal U/S
- IV Urography
- look for hydronephrosis
Two treatments for nephroptosis?
- Surgical Nephropexy for symptomatic pt with flank pain
2. Laparoscopic nephropexy
Symptoms of simple or solitary cysts
- Intermittent/dull flank or back pain
- Fever malaise if infection
- Abdominal Mass (tender if infected)
Labs for simple or solitary cysts
- Normal UA
- Rarely Hematuria
U/S for simple or solitary cysts
Criteria for simple benign cyst:
- echo-free, sharply demarcated with smooth walls.
- Enhanced back wall indicating good transmission thru the cyst
What is Autosomal Dominant Polycystic Kidney Disease
- Most common hereditary Dz in US
- Bilaterally enlarged kidneys with multiple cysts
- Poor prognosis
Criteria for dx of ADPKD:
- 15-39 yo
- 40-59 yo
- 15-39: atleast 3 cysts in both kidneys
- 40-59 yo: at least 2 cysts
For both: positive FHx
common differentials for cystic kidneys?
- bilateral renal tumor(rare)
- tuberous sclerosis
- Von- Hippel Laindau syndrome
Sx of Polycystic Kidney Disease?
- Pain over both kidneys due to infection
- Gross hematuria
- Palpable Nodular Kidney
- Renal insufficiency will see HA N/V and weight loss
- Infection: fever, chills, tender kidneys
What lab findings do you see in Polycystic Kidney Disease?
- Increased erythropoietin leading to increased HGB and HCT
- Anemia from blood loss
If renal insufficiency (Increased BUN and creatinine)
Why would you run a U/S vs. CT for polycystic kidneys
What about MRI?
U/S detects cysts from 1-1.5 cm, its cost effective, good place to start
CT: 95% accurate and detects small cysts 0.5cm
MRI differentiates Renal Cell Carcinoma from Cysts
6 complications of Polycystic kidneys
- ) Gross Hematuria: rupture cyst into renal pelvis/stone/UTI, recurrent bleeding suggest renal carcinoma
- ) Nephrolithiasis
- )Hypertension: cyst-induced ischemia activates renin-angiotensin
- ) ESRF: 50% progress to RF
- ) Cerebral Aneurysm, MVP, colonic diverticula
11 Treatments for Polycystic Kidneys
- Low protein diet
- Forced fluid to >3000ml/day
- Restrict caffeine
- Flax Oil
- Reasonable Physical Activity-avoid strenuous
- Treat uremia, stones, infx
- Screen for/tx HTN
- Possible dialysis, renal transplant, cystic decompression
- Constitutional homeopathy (baryta, calc, pos)
- Constitutional Hydro
- Conventional drugs (somatostatin, mTOR inhibitors)
What is acquired Renal Cystic Disease?
Multiple cysts found in patients without a hereditary link.
-seen w/ patients on dialysis and CKD
What is the most common benign kidney tumor?
What is renal adenomas appearance?
Small, well-differentiated, glandular tumor or renal cortex
-Pt is asymptomatic usually
What is the name of the renin secreting tumor that causes hypertension
Juxtaglomerular Cell Tumor
Where does renal cell carcinoma and adenocarcinoma arise from?
What percentage of primary malignant renal tumors does this account for?
- Glandular tissue
Most common site of metastasis for RCC or RCA
- lymph node
- adrenal gland
- opposite kidney
What is paraneoplastic syndrome
- Non-metastatic hepatic dysfunction
-tumors secrete biologically active products
What are two types of cancer staging
- Robson System (Stage I-IVB0
2. Tumor-Node metastasis (TNM)- more commonly uses
What do we use to grade cancers?
-4 grades based on nuclear characteristics (levels of differentiation)
What is the presentation for Adenocarcinoma and Renal Cell Carcinoma
- Great masquerader
- Classic triad: Gross hematuria, flank pain, palpable abdominal mass
- fever , weight loss, HTN
Males: possible L varicocele
What are symptoms that suggest RCC and RCA metastasized?
- Bone pain
What are the expect laboratory results for RCC and RCA?
- Elevated ESR
- Gross microscopic hematuria
- Low serum Iron
- Low TIBC
- Abnm lLFT
- Increased alpha-feto protein
Discuss the Imaging you would preform in RCC and RCA
- US: Defines simple cysts/tumor/thrombs (done first)
- CT: method of choice for staging and extent of brain mets
- CXR: useful for Mets, radio nucleotide useful for bone mets. MRI useful for vascular extension
- Pet: monitors response to systemic therapy
Treatment for RCC and RCA
- Partial or Radical Nephrectomy for localized Stage I/II
- Chemo and Radiation-not proven effective
- Biologic Response Modulators
- Interleukin and Interferon
- Molecularly Targeted Therapies
Inhibitors of VEGF + mTOR
- Adjuvant Naturopathic care
- Stage-specific follow up with repeat CTs
What is a nephroblastoma
- Wilms’ Tumor
- Mixed malignant tumor of kidneys MC in children
-Abnormal Proliferation of metanephric blastema cells
Symptoms of Nephroblastoma (Wilms’ Tumor)
- Genetic Predisposition
- Abdominal Mass
- Abdominal Pain
Gold Standard DX of Nephroblastoma (Wilms’ Tumor)
U/S or CT
Treatment for Nephroblastoma
- Surgical Removal
- Chemo for higher stages
What is Sarcoma of the Kidney
arise from embryonic mesoderm thus in bone, cartilage, fat, muscle, vascular and blood
6 Types of Sarcoma of the Kidney
- Leiomyosarcoma (female)
- Osteogenic Sarcoma
- Malignant Schwannomas
Sarcoma of the Kidney SX
- Flank/abdominal pain
- Weight loss
Treatment for Sarcoma of the kidney
- Radical nephrectomy for localized disease is the only effective treatment
- Adjuvant chemo reduces incidence of local reccurence
MC secondary renal tumors metastasize from wherE?
- Lung (20%)
- Breast (12%)
- Stomach (11%)
- Contralateral Renal (9%)
SX of Secondary Renal Tumor
- Albuminuria and hematuria
- Rare to have renal insufficiency and pain
Signs that show high clinical suspicion for hypertensive nephropathy
- Refractory to aggressive therapy
- Severe HTN with progressive renal insufficiency
- Malignant HTN
- Elevated Creatinine
What labs must you run on a patient you suspect hypertensive nephropathy
- Renal arteriography
- Doppler US of renal arteries