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Week 4 Flashcards

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1
Q

cause of diabetic nephropathy?

A

structural and functional changes to GBM hyperglycemia  inc GBM collagen type IV, inc fibronectin, inc reactive oxidative species, Increased circulating AGEs (normally excreted in urine)
glycosylation of proteins damage GBM (thickening)
2) Hemodynamic changes leads to glomerular hypertrophy (sclerosis)

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2
Q

classes of diabetic nephropathy?

A

Class I: isolated glomerular basement membrane thickening
Class II: mild to severe mesangial expansion (from glycation of membrane proteins)
Class III: at least one Kimmelstiel-Wilson lesion (intercapillary glomerulosclerosis)
Class IV: >50% global glomerular sclerosis

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3
Q

RFs for diabetic nephropathy?

A

family history, advanced age, concurrent HTN, poor glycemic control (>6.5%
HbA1c levels), ethnicity (increased incidence and severity in Blacks, Mexican-Americans, Pima Indians—often due to socioeconomic factors) obesity, smoking, oral contraceptives

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4
Q

ssxs of diabetic nephropathy?

A

albuminuria, occ hematuria, along with concurrent diabetic symptoms

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5
Q

what do you need to monitor in a diabetic nephropathy pt?

A 
microalbumin (normal 0-30): Immunologic measurement of microalbumin in urine is now considered a standard of care for management of diabetes mellitus and the early detection of diabetic complications.  
HbA1c levels (normal 4%-5.9%, prediabetes 6-6.4%, diabetes greater than or equal to 6.5%)
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6
Q

w/o intervention what % of DMT1 with repeated elevations will progress to ESRD?
% with DMT2 will progress to nephropathy?

A

DMT1: 80% will progress to ESR
DMT2: 20-40% with sustained levels will progress to nephropathy

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7
Q

concomitant diabetes related diseases aside from nephropathy?

A

neuropathy and retinopathy

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8
Q

goals for HbA1c, FPG, BP, postprandial BG, LDL, HDL, TGs for diabetic pts?

A 
HbA1c less than or equal to 6.5%
FPG less than 110 mg/dL
postprandial PG less than 140
BP less than 130/80
LDL less than 100 
HDL greater than 40 in men, greater than 50 in women
TGs less than 150
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9
Q

general guidelines for pre-diabetic pt?

A 
FPG 100-125
whole foods diet
sufficient sleep
exercise 150 min/wk
limit EtOH consumption
avoid tobacco
stress reduction
natural remedy support (?)
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10
Q

additional herbs and foods to tx diabetes?

A 
ginkgo
flax and pumpking seed
curcumin
guggul
chromium
ALA, vaccinium
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11
Q

renovascular dz is a major cause of what? associated with what other dz processes?

A

major cause of ESRD, esp in elderly

high-renin HTN associated w/increased rate of cerebro and CV complications

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12
Q

causes of renovascular HTN?

A 
atherosclerosis
fibromuscular dysplasias
polyarteritis nodosa
post-transplant stenosis
aortic dissection
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13
Q

prevention of renovascular HTN?

A 
lifestyle changes to reduce the risk of HTN
exercise
lose weight if overweight
dietary adjustments to help control HTN
modify sodium intake
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14
Q

pathogenesis of renovascular HTN?

A

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

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15
Q

PMHx of renovascular HTN?

A

GN, chronic PN, hydronephrosis, urolithiasis, renal trauma, radiation therapy to the abdomen, Wilm’s tumor

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16
Q

SSXS of renovascular HTN?

A

May be no symptoms
HA, fatigue, confusion, vision changes, angina-like chest pain, heart failure, hematuria, epistaxis, irregular heartbeat, ear noise or buzzing, pulmonary edema
Difficult to control HTN
Sudden aggravation of earlier well-controlled HTN in elderly
PE: Abdominal bruit over renal A
Signs of complications: left ventricular hypertrophy, hypertensive retinopathy

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17
Q

BP that gives you moderate and high clinical index of suspicion for renovascular HTN? labs you want to measure for renovascular HTN? challenge test for captopril challenge test? imaging for renovasular HTN?

A

moderate: BP >120 mmHg, HTN refractory to therapy
measure CBC, electrolytes, glucose, BUN, creatinine, UA, ECG, plasma renin
captopril challenge test
high: severe HTN w/progressive renal insufficiency, refractory to aggressive therapy, malignant HTN, elevated Cr
imaging: renal arteriography, doppler U/S of renal arteries, magnetic resonance angiography, CT

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18
Q

tx and management considerations of renovascular HTN?

A

1) Control BP with meds: diuretics, beta-blockers, Ca channel blockers, ACE inhibitors, angiotensin receptor blockers (ARBs) and alpha blockers—–response variable Monitor doses as needed!
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

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19
Q

complications of renovascular HTN?

A

early death, heart dz/MI/CHF, stroke, loss of vision

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20
Q

cause of benign HTN neprosclerosis? can progress to?

A

Chronic HTN damages microvasculature, glomeruli, tubules, interstitial tissues leading to nephrosclerosis. Over years may progress to end stage renal disease (common!)

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21
Q

RFs for benign HTN nephrosclerosis?

A

Risk factors: aging, poorly controlled HTN, DM, more common in blacks

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22
Q

findings on UA for benign HTN nephrosclerosis? imaging results?

A

UA: mild proteinuria, increasing BUN and creatinine levels, hyperuricemia
imaging: small KDs

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23
Q

ssxs of renal artery occulsion? UA findings? what can develop? imaging?

A

ssxs: flank pn, abd pn, fever, N/V
UA: hematuria
acute renal failure may develop
imaging: CT angiography

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24
Q

renal vein thrombosis leads to what? causes? ssxs? imaging?

A

leads to occlusion of 1 or both renal veins

causes: hypercoagulability, nephrotic syndrome, amyloidosis, E therapy, PG, SLE
ssxs: renal failure, occ N/V, flank pn, gross hematuria, decreased urine output
imaging: magnetic resonance venography, doppler U/S

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25
what is nephroptosis? theorized causes?
floating or falling KD KD drops greater than 5 cm upon supine to standing theorized to be dt lack of perirenal fat and fasical support and pt may also have longer than normal renal vascular pedicle
26
nephroptosis is MC in what gender, body habitus?
F 5-10:1, young and thin | more common on R side
27
64% of those with fibromuscular dysplasia of the renal artery have what other condition?
nephroptosis
28
RFs for nephroptosis?
excessive wt loss, frequent intense physical activity
29
ssxs of nephroptosis?
severe abd, CV, flank pn, vomiting in upright position from acute hydronephrosis kinked primal ureter, renal vessel lumen narrowing and resultant ischemia as well as visceral nerve stimulation from traction
30
what is a dietl crisis? how is pn relieved?
severe colicky flank pain, nausea, vomiting, chills, tachycardia, oliguria, hematuria and proteinuria pn relieved with upward movement of the KD, supine position
31
PE of nephroptosis?
KD palpable in ipsilateral lower abd
32
w/u of nephroptosis?
renal U/S, IV urography (erect and supine films), look for hydronephrosis
33
tx of nephroptosis?
surgical nephropexy for sx pts w/flank pn >1yr laprascopic nephropexy fro sx pts wear a truss, support connective tissue post-surgical support: HP arnica, ledum; ligaplex, vit C, vit A, zinc
34
ddx of nephroptosis?
urolithiasis, cholecystitis, spastic bowel, PN, ovarian cyst, appendicitis, diverticulitis
35
forms of acquired cysts?
simple or solitary cysts | acquired cystic KD dz
36
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
simple or solitary cyst
37
ddx of simple or solitary cyst?
malignancy, renal abscess, polycystic KD dz
38
ssxs of simple or solitary cyst?
flank or back pn, intermittent and dull, fever and malaise if infected, abd mass may be palpated or percussed, tender if infected
39
UA results simple or solitary cyst? U/S will show what? CT will show what?
normal UA, rare microscopic hematuria U/S - criteria for simple benign cyst, echo - free, sharply demarcated with smooth walls, enhanced back wall indicating good transmission through the cyst CT: smooth thin wall, sharply demarcated, should not enhance with contrast
40
tx of simple or solitary cysts?
if simple, leave alone constitutional HP if infected abx, may need perQ drainage (U/S guided) surgical excision may be required if obstructing ureter
41
multiple cysts found in patients without a hereditary link. Seen with patients on dialysis and CKD. “Dialysis Cysts” Theorized mechanisms of cyst development: tubule block and fluid accumulation; tubule hyperplasia from growth factors and activation of oncogenes; kidney atrophy from long standing ischemia leading to parenchymal acidosis.
acquired cystic kidney disease
42
7 forms of hereditary cystic KD dzs?
``` autosomal dominant polycystic KD dz autosomal recessive PKD medullary sponge KD medullary cystic KD dz juvenile nephronophthisis glomerulocystic KD dz multicystic dysplastic KD ```
43
Most common hereditary dz in US, almost always bilaterally enlarged kidneys with multiple cysts of various sizes. Incidence: 1:400-1000 persons, 6000 new cases/yr, SSX appear ~30-40yo: Most patients have normal kidney function until 4th decade 50% may also have hepatic, pancreatic, splenic or CNS arachnoid cysts
autosomal dominant polycystic KD dz
44
dx requirements for autosomal dominant polycystic KD dz?
15-39 : 3 cysts in both KDs; 40-59 : at least 2 cysts and positive FHx
45
ddx of autosomal dominant polycystic KD dz?
``` B/L hydronephrosis B/L RCC (rare) tuberous sclerosis simple cysts Von-Hippel Lindau syndrome ```
46
ssxs of autosomal dominant polycystic KD dz?
Pain over both kidneys due to infection, obstruction, hemorrhage, “drag” from heaviness Gross or microscopic hematuria; nocturia HTN (retinopathy can develop) Palpable, nodular kidney(s) Developing renal insufficiency: HA, N&V, weight loss If infected: fever, chills, tender kidney(s)
47
autosomal dominant polycystic KD dz will show what on labs? UA? imaging?
labs: increased EPO leading to increased Hgb and Hct, anemia from blood loss UA: proteinuria, hematuria, possibly pyuria and bacteriuria if infxn progressive uremia from renal insufficiency (increased BUN and Cr), dec GFR imaging: KUB shows enlarged renal shadows up to 5x size CT 95% accurate for dx, can detect cysts from 0.5 cm U/S can detect cysts from 1-1.5 cm, most cost effective START HERE MRI can differentiate RCC from cysts
48
complications of autosomal dominant polycystic KD dz?
``` gross hematuria nephrolithiasis HTN ESR increasing, intractable pn can also see cerebral aneurysm, MVP, aortic aneurysm, colonic diverticula ```
49
general tx measures for autosomal dominant polycystic KD dz?
low protein force fluids to 3000 mL or more per day to suppress vasopressin and control BP restrict caffeine flax oil reasonable physical activity - avoid strenuous activity or contact sports treat uremia, stones, infxn screen for and treat HTN, recommend ACEIs, antgiotension II receptor antagonist blockers possibly dialysis, renal transplantation, cystic decompression (for pn) constitutional HP - baryta carb, calc carb, phosphorous constitutional hydro conventional drug trials: somatostatin, everolimus
50
prognosis of autosomal dominant polycystic KD dz? cause of death typically?
for children very poor ssxs presenting after 35-40 yo are more favorable but may only live about 5-10 yrs post dx cause of death typically cardiac or neurologic
51
Mutation of PKHD1 gene (prenatal testing available) Rare, boys>girls Severity varies: may lead to death in newborn, if survive, may lead to ESRD and the need for Ki transplant by age 10 or 15. Some not diagnosed until age 2 Microcysts develop in medulla and cortex (look like pin-point dots) and dilatation of the collecting ducts. Over time, larger cysts develop with interstitial fibrosis and loss of renal function The disease is also associated with biliary dysgenesis. Leads to hepatomegaly and portal hypertension in most cases
autosomal recessive polycystic KD dz
52
ssxs of ARPKD?
abd pn, abd mass, polyuria, polydipsia, HTN, hepatomegaly, spleomegaly
53
UA of ARPKD? labs? imaging results? treatment?
UA: reduced urine osmolality, pyuria labs: hyponatremia, bilirubin and liver enzymes mb elevated, thrombocytopenia see on U/S: B/L lg echogenic KDs tx is supportive care
54
congenital but not diagnosed until 20s or 30s, rare, unknown cause, more common in F “Renal tubule duct ectasia” Cysts/sacs in tubules or collecting ducts, block urine flow. Often asx, but can cause urinary tract infections or stones (and associated sx) can lead to renal failure in 10% cases. Seen on US or CT
medullary sponge kd
55
Uncommon, slowly progressing kidney disease manifesting usually in teens with variable rates of progression to ESKD. Cysts are not always seen on U/S. Bland urine sediment with minimal proteinuria Three possible genetic causes: UMOD gene mutation (leads to gout), REN gene mutation (low BP, anemia, hyperkalemia, hyperuricemia) and MUC1 gene mutation (no distinguishing characteristics)
medullary cystic KD dz
56
Hereditary. Fluid filled cysts in corticomedullary region (loss of coricomedullary differentiation), causes fibrosis and thickening of tubular basement membrane. Normal to small kidneys. Hepatic fibrosis also often seen. Symptoms develop after one year of age, insidious onset of renal failure to ESKD
Juvenile nephronophthisis
57
ssxs of juvenile nephronophthisis?
polyuria, polydipsia, fatigue, nausea, anorexia, bone growth abnormalities, often Normal BP, NPH has also has eye (retinal degeneration) problems
58
UA and labs of juvenile nephronophthisis? dx? tx?
UA: low urine osmolality, proteinuria labs: hypernatriuria, hyponatremia, elevated Cr, anemia, metabolic acidosis, hypovolemia dx: (+) genetic test (NPHP1 deletion), U/S, renal bx tx by correcting volume and electrolyte imbalances, renal transplantation preferred therapy
59
Rare, usu diagnosed in neonatal period, more often unilateral. Enlarged kidneys with cysts on glomeruli. Can be associated with DMI and genetic conditions like Trisomy 13
glomerulocystic KD dz
60
Congenital mal-development where renal cortex is replaced by various sized cysts without remaining functional tissue. Bilateral manifestation would be incompatible with life. The cysts anchored in the renal parenchema resemble a bunch of grapes. The renal calyce is absent. Seen on U/S, then follow up radionucleotide imaging SSX palpable abdominal mass, abdominal pain, incontinence, recurrent UTI
multicystic dysplastic KD
61
autosomal dominant neurocutaneous dysplasia complex leading to increased vascular endothel. growth factor; resulting in retinal angiomas, hemangioblastomas, pheochromocytoma, islet cell tumors, renal cysts, epididymal cysts SSX begin in 2nd to 3rd decade. Eye: retinal hemorrhage, detachment, glaucoma. Headaches, ataxia
Von-Hippel Lindau syndrome
62
autosomal dominant Causes CNS lesions and white matter abnormalities as well as lesions in skin, heart, lungs, kidney, skeleton, liver. SSX seizures, mental retardation, adenoma sebacum (facial angiofibroma)
tuberous sclerosis
63
MC type of benign renal tumor? comes from where? located where? ssxs?
renal adenoma from glandular tissue small, well-differentiated glandular tumors of renal cortex asx, usu identified on autopsy or "incidentaloma" found during workup of another condition
64
5 other rare, benign renal tumors? (think different types of tissues)
``` leiomyomas hemangiomas lipomas, angiomyolipoma juxtaglomerular cell tumor renal pseudotumor ```
65
where does an adenocarcinoma/RCC come from 85% of the time? other 15%? what %age of pts will have mets if have RCC?
85% of the time from renal glandular tissue 15% of the time from transitional cell carcinoma in the renal pelvis 25-30% of pts will have METs at dz presentation (eek)
66
highest prevalence in ethnicity? lowest?
highest in black and Hispanic males | lowest in Asian Americans and Pacific Islanders
67
RFs of RCC?
``` smoking HTN chronic analgesic use (NSAID and non-NSAIDs) obesity toxin exposure (Cd, asbestos, Pb, gas, petroleum products, PAHs) cytotoxic chemo sickle cell dz nephrolithiasis nitrites in diet prior radiation therapy OCPs high coffee intake animal fat diet dialysis hysterectomy contrast IV ```
68
where does RCC specifically originate? what does it do to the shape of the KD?
originates from proximal renal tubular epithelium in the cortex leads to characteristic nodule, distorted, bulging shape of the KD
69
how can RCC spread?
direct invasion through renal capsule into adjacent structure or direct extension into renal vein
70
where does RCC mets to?
MC to the lung via lymph and blood | but can also go to bone, regional nodes, adrenal gland, brain, opposite KD, adjacent organs and/or subQ tissue
71
what can RCC also cause?
paraneoplastic syndrome: tumor can secrete other biologically active products - adrenocorticotrophic hormones, enteroglucagon, PRL, insulin, gondatropins can cause erythrocytosis, hypercalcemia, HTN, non-METs hepatic dysfxn
72
ssxs of RCC? sign in men?
the "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 ssxs of paraneoplastic syndromes sxs of mets: dyspnea, cough, seizure, bone pn
73
labs of RCC? UA? first imaging? method of choice for staging and extent of brain mets? helpful to see mets? useful for vascular extension? to monitor tx response?
labs: elevated ESR, normochromic/normocytic anemia, low serum iron, low TIBC, abn LFT, possibly increased alpha-fetoprotein or beta-HCG UA: gross or microscopic hematuria in 60% of cases imaging: U/S shows simple cysts, tumor thrombus CT is method of choice for staging and extent of brain mets CXR can be helpful to mets MRI useful for vascular extension PET to monitor response to systemic tx renal bx
74
tx and management of RCC?
1) Partial or Radical nephrectomy for localized stage I & II (<4cm tumor size)nGood evidence of efficacy: Coppin, et al. Cochrane database 2) Chemo and radiation ---not proven effective (chemo has only 5% response rate) 3) Biologic response modulators, eg interleukin-2 therapy, interferon alpha 4) Molecularly Targeted Therapies: Inhibitors of VEGF: eg bevacizumab, sunitinib. Inhibitors of mTOR: eg temsirolimus, everolimis 5) Pre- and post-surgical support tissue healing nutrients, modified citrus pectin 6) Adjuvant naturopathic care—health, nutrition optimization. Consider referral to ND with FABNO credential 7) Stage-specific follow up with repeat CT 8) Note: Clinical trials underway for RCC vaccination: TroVax
75
prognosis of RCC?
5 yr survival for stage I is 91-100% stage II is 74-96% stage III is 59-70% pts w/METs 16-32%
76
where does sarcoma of the KD arise from?
embryonic mesoderm thus why can also see sarcomas in bone, cartilage, fat, muscle, vasculature, blood
77
ssxs of renal sarcoma?
flank or abd pn, wt loss
78
types of renal sarcomas?
leiomyosarcoma, fibrosarcoma, liposarcoma, hemangiopericytomas, osteogenic sarcoma, malignant schwannomas
79
tx of renal sarcoma?
radical nephrectomy for localized dz is only effective therapy adjuvant chemo reduces incidence of local recurrence in pts w/resectable retroperitoneal sarcomas
80
what is a nephroblastoma? MC in what population? age? MC in what ethnicity? MC u/l or b/l? comes from where?
Wilms' Tumor mixed malignant tumor of KD that is more commonly seen in children, MC 3-4 yo, MC in African Americans and those with FHx most often U/L presentation abn proliferation of metanephric lastema cells, genetic predisposition
81
ssxs of nephroblastoma?
abdominal swelling, abd pain, hypertension, N/V, constipation, loss of appetite, SOB
82
PE for nephroblastoma? UA and labs? dx? tx?
``` PE: abd mass, HTN UA: hematuria labs: anemia dx: found on US or CT tx: removal, possibly chemo if higher staged ```
83
condition commonly mistaken for RCC?
xanthogranulomatous pyelonephritis - uncommon form of chronic recurrent PN, usu from renal stone
84
May result from pyelonephritis or chronic obstruction. More common in diabetics and those who had urological instrumentation. Clinical picture often previous PN that improves and then worsens, 75% of cases are e coli, but also Klebsiella, proteus, enterobacter SSX: fever/chills, N/V, abdominal and flank pan
renal corticomedullary abscess
85
secondary renal tumors (METs to KDs) include CA from where?
20% lung 12% breast 11% stomach 9% contralateral KD

Urology (9 decks)

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