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primary HTN
mcc of HTN
secondary HTN
causes include: apnea, bruits, bad kidneys, catecholamines, drugs, diet, endocrine
renal artery stenosis (RAS)
signs: patient has a primary disease +/- azotemia
bruit is heard over the renal arteries
atherosclerotic
m/c RAS, > 45 y/o
diffuse > focal
fibromuscular
RAS m/c in females < 50 y/o; abnormal development of fibrous collagen and smooth muscle
AKI with ACEi/ARB
what is something common in the medical history of a patient with RAS?
fibromuscular dysplasia
looks like a string of beads on film
arteriography
gold standard for diagnosing RAS
ACE/ARB +/- diuretic
medical treatment for all patients with RAS
closely monitored
in patients with B/L RAS taking ACEi/ARB for treatment must be...
angio +/- stent, bypass
surgical treatment for RAS
only if med tx has failed, patient has recurrent CHF, etc
resection of the pressor kidney
treatment of last resort for RAS
renal vasculitis
Inflammation of blood vessels in kidneys- leads to stenosis
polycystic kidney disease (PCKD/PKD)
mutation (PKD1/2); buildup of abnormal substances in kidneys/other tissues driving abnormal cell growth, cyst formation & expansion, progressive loss of nephrons
autosomal dominant
m/c form of PCKD, may not be clinically evident until 30s/40s
autosomal recessive
infantile onset of PCKD
s/s of PCKD, don't need them all!!
flank pain, ballotable mass, HTN, hematuria
liver
m/c extra renal manifestation of cysts in PCKD occurs in what organ?
CKD, UTIs, kidney stones
renal manifestations of PCKD
mitral valve prolapse
cardiac manifestation of PCKD
cerebral berry aneurysms
associated brain anomaly in PCKD, most severe of extrarenal manifestations
US or CT
what imaging can be used to dx PCKD?
Tolvaptan
Vasopressin V2-receptor (V2R)
antagonist; can lower cyst burden & preserve kidney function
serious liver disease
CI to taking Tolvaptan
renal cysts
rare, usu asymptomatic , incidence and size increase with age
simple renal cyst
benign, round, well defined, thin walled, fluid filled renal cyst
complex renal cyst
Inc P (cancer), irregular shape, thicker wall, inc density/solid, septations
Pheochromocytoma
a benign tumor of the adrenal medulla that causes the gland to produce excess catecholamines; HTN & hyperadrenergic spells
palpitations, perspiration, pain in the head
triad of symptoms from a pheo
metanephrines and catecholamines
step 1 of diagnosing a pheo involves biochemical screening (urine or blood) looking for....
CT/MRI of abdomen/pelvis
if biochemical screening is (+), step 2 of diagnosing a pheo is ....
PET scan
if pheo tumor is large & there is a concern for mets, do a ....
surgery
optimal treatment of a pheo
alpha blockers (phenoxybenzamine)
med that is always given FIRST in patients with a pheo
beta blocker
after adequate alpha blockade in pt with pheo, add a...
CCB
can be given as a solo drug tx option for a pheo
metyrosine
direct catecholamine blocker sometimes used in patients with a pheo
renal infarct
under-reported 2/2 similarity to other conditions- abd/flank pain, hematuria
cardioembolic thrombi, post AAA repair
causes of renal infarct
angiography
gold standard for dx renal infarct
wedge-shaped perfusion defect
what can be seen in patients with a renal infarct on a CT with contrast?
anticoagulation
main treatment for renal infarct
renal papillary necrosis (RPN)
ischemia of renal pyramids/collection ducts; always 2/2 to something else
sickle cell, obstruction, diabetes, analgesics
name some causes of RPN
hint: SODA acronym
necrotic tissue in urine
how is RPN diagnosed?
ring shadow
an IVP will show a ______ in patients with RPN
renal cell carcinoma (RCC)
m/c cancer of the kidney, usu in proximal tubule & usu sporadic
smoking
major risk factor for RCC
hematuria, flank pain, mass
triad of renal cell carcinoma (RCC)
paraneoplastic syndrome of RCC
erythrocytosis, HTN, hypercalcemia
US, CT, MRI
dx of RCC
nephrectomy, +/- chemo, immunotherapy, radiation
tx of RCC
bladder cancer
painless hematuria (>3 rbcs), voiding, mass, systemic symptoms if very advanced
transitional/urothelial
mc form of bladder cancer
smoking, male
risk factors for bladder cancer
cytoscopy with biopsy
dx of bladder cancer
superficial/non-muscle invasive bladder cancer tx
bladder resection (TURBT), chemo (cisplatin), immunotherapy (BCG)
high rate of recurrence
a cytoscopy f/u is needed in after superficial bladder cancer is treated. Why?
deep/muscle invasive bladder cancer treatment
radical cystectomy with urinary diversion (urostomy, indiana pouch, orthotopic neobladder)
renal pelvis/ureteral tumors
rare, commonly associated w bladder cancer;
risk factors include smokers, exposure to Thorotrast
transitional cell
mc histology of renal pelvis/ureteral tumors
biopsy, CT urography or IVU/P
dx of renal pelvis/ureteral tumors
Nephroblastoma (Wilms tumor)
abn tumor suppressor genes cause primitive (blast) renal cells to develop into cancer; children, <10 y/o, seen with other malformations
painless, palpable abdominal mass
mc sign of wilms tumor
US/CT/MRI
dx of wilms tumor
biopsies - very fragile tumor, could spill cells
what should be avoided in nephroblastomas and why?
chest
m/c site of metastases (if it occurs) in patients with nephroblastoma
renal agenesis
absence of one or both kidneys
unilateral renal agenesis (URA)
prognosis depends on function of formed
kidney, can be clinically silent in early life (other kidney will attempt to compensate which can lead to hyperfiltration & CKD)
bilateral renal agenesis (BRA)
incompatible with extrauterine life beyond days/weeks; often associated with other developmental abnormalities
Potter sequence (oligohydramnios)
what is a common cause of renal agenesis?
congenital hypoplasia
low # of nephrons in miniature, histologically normal kidney, can lead to CKD & failure to thrive
renal ectopia
kidneys in abn location- low lumbar, iliac, pelvic; most asymptomatic, need to eval the urinary tract
simple
congenital ectopy -kidney on correct side but abnormal position
crossed
congenital ectopy -
kidney crosses the midline +/- fusion to other kidney
horseshoe kidney
kidneys fused across midline, typically @ inferior poles; pelvis & ureters are separate
duplex ureters/collecting system
two separate ureters with two separate
insertions or fuse before inserting into
bladder (Y) shaped
no intervention required if asymptomatic
w/out complications
nephroptosis
floating kidney
vesicoureteral reflux (VUR)
abnormal flow of urine from the bladder back into the ureters
medullary sponge kidney (MSK)
rare congenital dilation/cysts of the terminal tubule /collecting ducts
swiss cheese appearance
recurrent stones, UTIs
is MSK shows symptoms, what are they?
patient might not show any symptoms
interstitial cystitis (IC)
chronic inflammation of submucosa & muscularis layer of bladder; sharp pain improved with bladder emptying
cytoscopy
how is IC diagnosed?
diffusely reddened surface epithelium, Hunner's ulcer
cytoscopy of interstitial cystitis will often show...
amytriptyline
considered first line medicinal tx of IC; antidepressant with pain control
cystitis
bladder inflammation, lower tract; m/c cause is fecal contamination (E. coli)
uncomplicated cystitis
healthy, non preg, adult, woman
complicated cystitis
comorbidities, pregnant, male, anatomic abnormality, recent instrumentation, hospital acquired, extremes of age
UA of cystitis
leukocyte esterase, nitrites, cloudy
abx (bactrim)
primary treatment of cystitis
Pyridium (phenazopyridine)
analgesic that relieves lower urinary tract mucosal pain, burning, urgency & frequency; only use for 2 days, may turn urine orange
pregnant, pre op urologic surgery, recent renal transplant
when does asymptomatic bacteriuria need to be treated?
pyelonephritis
upper tract, ascending, kidney infection; UTI with fever, chills, CVAT
leukocytosis
CBC of pyelonephritis will show...
WBC casts
UA of pyelonephritis will show...
Fluoroquinolones (cipro/levo)
treatment of pyelonephritis if discharged