Quiz 2

Question 1

Major indications for dialysis?

Answer 1

ARF, CRF (creatinine clearance < 8ml/min), anuria

Question 2

What are the 2 major forms of dialysis?

Answer 2

Peritoneal (intracorporeal) and hemodialysis and hemofiltration (extracorporal).

Question 3

What do both of the 2 major forms of dialysis do?

Answer 3

Replace function of glomeruli with a semi-permeable membrane.

Question 4

Do you generally use peritoneal dialysis or hemodialysis first?

Answer 4

Generally peritoneal before hemodialysis.

Question 5

What are the 3 types of peritoneal dialysis?

Answer 5

1. CAPD (continuous ambulatory peritoneal dialysis)
2. CCPD (continuous cyclic peritoneal dialysis)
3. IPD (intermittent peritoneal dialysis)

Question 6

Benefits of peritoneal dialysis over hemodialysis?

Answer 6

1. Greatly reduced protein losses
2. Much better control of K+ and phosphorous levels
3. Rarely need water and sodium restriction because 2 L per d removed in the peritoneal fluid

Question 7

Causes of structural changes in diabetic nephropathy?

Answer 7

1. Glycosylation of proteins damage GBM (thickening)
2. Hemodynamic changes –> glomerular hypertrophy (sclerosis)

Question 8

Result of structural changes dt diabetic nephropathy?

Answer 8

Structural and functional changes to GBM dt hyperglycemia –> inc GBM collagen type IV, inc fibronectin, inc reactive oxidative species, increased circulating AGEs (normally excreted in urine)

Question 9

How to monitor diabetic nephropathy?

Answer 9

• Microalbumin (random am sample or 24 hr collection)
• HbA1c levels (measuring glycated hemoglobin—average level of glucose an RBC has been exposed to in its 120 day life-cycle)

Question 10

Microalbumin normal and abnormal ranges?

Answer 10

Normal: 0-30 mg/dL

Microalbuminuria: 30 - 300 mg/dL

Macroalbuminuria: >300 mg/dL

Question 11

Target lab values for diabetes management?

Answer 11

• A1C ≤6.5%
• FPG <110 mg/dl
• Blood pressure < 130/80mmHg
• Lipids: LDL <100, HDL: >40 mg/dl men, >50 mg/dl women, TG: <150 mg/dl

Question 12

Definition of hypertensive nephropathy and nephrosclerosis? Major cause?

Answer 12

Narrowing of the arteries that carry blood to the kidney. MC cause is atherosclerosis.

Question 13

Hypertensive nephropathy/nephrosclerosis pathogenesis?

Answer 13

Reduced blood flow causes affected kidney(s) to secrete renin, retain NaCl and H2O⇒inc BP Hypersecretion of renin also caused by sodium depletion, hemorrhage, shock, CHF, renal artery stenosis

Question 14

Treatment and management of hypertensive nephropathy/nephrosclerosis?

Answer 14

1. Control BP with meds: diuretics, beta-blockers, Ca channel blockers, ACEis, ARBs. (ACEIs most effective in both managing HTN and slower progression of renal disease in African Americans)
2. Percutaneous transluminal angioplasty (insertion of a stent)
3. Surgical reconstruction of damaged artery
4. Surgical bypass of renal arteries in cases of fibromuscular hyperplasia
5. Treat atherosclerosis: guggal, garlic, EFAs, B vits
6. Vascular protectants: bioflavonoids, vaccinium

Question 15

What is nephroptosis?

Answer 15

• Kidney drops >5cm upon moving from supine to standing position.
• Theorized to be due to lack of perirenal fat and fascial support. Also pts have longer than normal renal vascular pedicle.
• More common in females 5-10:1, young and thin, more common on right side.
• 64% of those with fibromuscular dysplasia of renal artery have nephroptosis.

Question 16

S/sxs of nephroptosis:

Answer 16

Severe abdominal, costovertebral, flank pain and vomiting when moving into upright position.

Question 17

What is a Dietl crisis and why does it occur?

Answer 17

Dietl Crisis: severe colicky flank pain, nausea, vomiting, chills, tachycardia, oliguria, hematuria and proteinuria. Occurs d/t nephroptosis.

Question 18

What are renal cysts?

Answer 18

Epithelium-lined cavities filled with fluid or semi-solid material, developing from tubular elements.

Question 19

Tell me all about simple or solitary cysts.

Answer 19

• 65-70% of all renal masses usu found incidentally, often located in outer cortex and contain fluid consistent with an ultrafiltrate of plasma.
• Usu asymptomatic, but may become infected, or if large may block ureter and cause hydronephrosis.
• Average size: 10cm.

Question 20

Autosomal Dominant Polycystic Kidney Disease (ADPKD)?

Answer 20

• Most common hereditary dz in US.
• Bilaterally enlarged kidneys with multiple cysts of various sizes.
• 1:400-1000 persons, 6000 new cases/yr.
• Symptoms appear >40 yo.
• 50% may also have hepatic, pancreatic, splenic or CNS arachnoid cysts.
• Most patients have normal kidney function until 4th decade.

Question 21

Cystogenic process of ADPKD?

Answer 21

• Mutation in renal tubule cell causes cellular division until cysts develop.
• As cysts enlarge, they destroy anatomy and cause progressive functional impairment, may get infected, bleed, etc.

Question 22

Dx of ADPKD?

Answer 22

• 15-39 yo: at least 3 cysts in both kidneys
• 40-59 yo: at least 2 cysts
• AND (for all): positive FHx

Question 23

S/sxs of ADPKD?

Answer 23

• Pain over both kidneys due to infection, obstruction, hemorrhage, “drag” from heaviness.
• Gross hematuria HTN (retinopathy)
• Nocturia
• Palpable, nodular kidney
• Renal insufficiency: HA, N+V, weight loss
• If infected: fever, chills, tender kidney(s)

Question 24

Labs in ADPKD?

Answer 24

• Inc erythropoietin, leading to inc HGB and HCT
• Anemia from blood loss
• Proteinuria, hematuria, possibly pyuria and bacteriuria
• Progressive uremia from renal insufficiency (BUN and creatinine)

Question 25

Imaging in ADPKD?

Answer 25

* KUB—enlarged renal shadows up to 5X size * CT—95% accurate for dx, can detect cysts from 0.5cm * US—can detect cysts from 1-1.5cm (Most cost effective, usu start here) * MRI can differentiate Renal Cell Carcinoma (RCC) from cysts

Question 26

ADPKD naturopathic tx?

Answer 26

1. Low protein diet - 0.5-0.75 g/kg/d 2. Force fluids to 3000 ml or more per day (to suppress plasma vasopressin) 3. Restrict caffeine 4. Flax oil 5. Reasonable physical activity - avoid strenuous activity or contact sports 6. Treat uremia, stones, infection when present 7. Screen for and treat HTN. Recommended ACE inhibitors, Angiotensin II receptor antagonist blockers 8. Poss tx: dialysis, renal transplantation, cystic decompression (for pain) 9. Constitutional HP: tumors, cystic—Baryta carb, Calc carb, Phos 10. Constitutional hydro 11. Conventional drug trials: somatostatin, everolimus (mTOR inhibitor)

Question 27

MC type of benign renal tumor?

Answer 27

Renal Adenoma. Most common. Small, well-differentiated glandular tumors of renal cortex. Asymptomatic and usually identified at autopsy. Some can metastasize.

Question 28

Adenocarcinoma or Renal Cell Carcinoma (RCC or RCA) risk factors?

Answer 28

* Cigarette smoking * Chronic analgesic use * ADPKD * Obesity * Toxin exposure (Cd, Pb, asbestos, PAHs) * Coffee * Animal fat diet * Dialysis, hysterectomy, contrast IVU, Von Hippel-Landau dz

Question 29

RCC pathogenesis?

Answer 29

* RCC originates from the proximal renal tubular epithelium in the cortex. Tumor is nodular, distorted, bulges the shape of the kidney.

Question 30

S/sxs of RCC?

Answer 30

* "Great masquerader" * Classic triad: gross hematuria, flank pain, palpable abd mass * Fever, weight loss, HTN * In males: possible L varicocele from blockage of L testicular vein * Sx of metastasis: dyspnea, cough (lung), seizure (brain), bone pain

Question 31

How does RCC spread?

Answer 31

* Direct invasion through the renal capsule into adjacent structures, or; * Direct extension into the renal vein.

Question 32

Where does RCC most commonly metastasize to?

Answer 32

* Metastasizes via lymph and blood vessels, most commonly the lung * Also bone, regional nodes, adrenal gland, brain, opposite kidney, adjacent organs, subcutaneous tissue. * 25-30% of patients have metastatic disease at presentation.

Question 33

Nephroblastoma (Wilms' Tumor) definition?

Answer 33

* A mixed malignant tumor of the kidney which is seen more often in children than adults, median 3.5 yrs. * Abnormal proliferation of metanephric blastema cells, genetic predisposition.

Question 34

Ssx of nephroblastoma?

Answer 34

Presents as abdominal mass, abd pain, hypertension, hematuria, anemia.