Lecture Schedule
RENAL
Renal Cell Carcinoma (RCC) | Transitional Cell Carcinoma (TCC) | Renal Vascular Hypertension | Reflux Nephropathy | Hemolytic-Uremic Syndrome | Autosomal Dominant Polycystic Kidney Disease | Autosomal Recessive Polycystic Kidney Disease | Simple cysts | Oxalosis | Vasculitis/Subacute Bacterial Endocarditis/AIDS Nephropathy | Self-Assessment Quiz
- Responsible for more than 85% of primary renal neoplasms.
- Clinical presentation may be hematuria.
- Renal mass may be an incidental finding on imaging study.
- Renal cell carcinoma arises in the renal cortex, has a propensity to invade the renal vein and can extend into the IVC up to the heart.
- Regional lymph nodes may be enlarged. Hematogenous spread to lungs may occur, too. Metastatic disease often as multiple nodules in the lungs.
- Ball-like mass of renal cortex; tumor enhances less than normal parenchyma.
- Engorged, tumor-filled renal vein with extension to IVC.
- Look for metastatic disease.
- Somewhat spherical, yellowish gray mass, 20% are cystic.
- Solid fascicles of clear cells with fine fibrovascular septae.
- Comprise more than 90% of tumors that arise from the urinary tract, other cell types include squamous cell and adenocarcinomas
- Clinical presentation includes hematuria and irritative bladder symptoms such as dysuria, urinary frequency and urgency.
- The hematuria may be episodic, gross or microscopic. May be an incidental finding on urinalysis.
- TCC may arise from the renal calyces, pelvis, ureters, bladder, urethra and urothelium lined ducts in the prostate.
- The tumor can extend to the pelvic sidewalls and metastases can go to the lungs, bones and liver.
- The tumor can cause ureteral obstruction leading hydronephrosis, unilateral or bilateral depending on its location.
- Multiple modalities, CT, MRI, cystography, IVP can demonstrate the tumor
- Tumors appear as filling defects in the urinary tract.
- Appearance depends on the size of the tumor and whether it is polypoid or sessile.
- In cases of renal artery stenosis, inflow to the glomerulus is low. The renin-angiotensin axis kicks in causing constriction of the efferent arteriole, resulting in hypertension.
- Several modalities are used to evaluate for renal vascular hypertension.
- Patients often receive baseline ultrasound first.
- Look for renal sizes.
- Then, nuclear medicine imaging with DTPA (filtration agent) and Hippuran (tubular agent) can assess glomerular filtration rate (GFR) and effective renal plasma flow.
- Do baseline study with DTPA and Hippuran, then give an ACE-inhibitor, captopril. If renal artery stenosis is present, captopril causes filtration to go down (DTPA study) and tubular secretion (Hippuran) to improve. Hard to get a good excretion (washout) with an ACE-inhibitor in a patient with renal artery stenosis, because there is no pressure head to the glomerulus.
- Further study with an arteriogram can assess renal artery anatomy (degree of stenosis, position of stenosis). During angiography, angioplasty could potentially be done to open up a stenotic lesion.
- Found in young women.
- This disease can also affect the carotid arteries.
- Atherosclerosis, more often at origin of renal arteries.
- Fibromuscular dysplasia.
- Intimal.
- Medial.
- Periarterial fibroplasia.
- Destructive changes to kidneys secondary to reflux (+/- infection) of urine from bladder to the kidneys.
- Common in young girls, secondary to short course of ureter as it tunnels through bladder wall.
- Often girls outgrow reflux; our challenge is to recognize its presence to prevent its destructive effects.
- Younger child: May be difficult to recognize. Can present with irritability and fever. Requires clean (catheterized) urine to diagnose
- Older child: May have more classic symptoms. Can present with fever, pain with urination, frequency of urination.
- Voiding cystourethrogram (VCUG)
- Contrast instilled into the bladder distending the bladder. Fluoroscopically monitor voiding. Bladder pressures are high during urination, reflux often occurs then.
- Severity and volume of reflux can be evaluated which directs therapy.
- Mild reflux may need constant antibiotics and close follow up.
- High grade reflux may need surgery with ureteral re-implantation.
- Ultrasound/Nuclear Medicine
- Look for renal size, evidence of scars, hydronephrosis, stone, renal function.
- Cortical scar overlying distorted calyces.
- Tubular atrophy and interstitial fibrosis.
- Glomerulosclerosis.
- Most common cause of renal failure leading dialysis.
- Often in children less than 2 years of age.
- Often after recent flu-like illness: irritability, bloody diarrhea, acute renal failure.
- Ultrasound: normal to large kidneys with hyperechoic cortex.
- Microangiopathy with endothelial swelling and thrombosis of renal arterioles.
- Spontaneous recovery is complete in up to 85% of patients.
- Inherited renal abnormality, often not discovered until early or middle adulthood.
- Hypertension, proteinuria, and hematuria often present.
- Renal failure ensues, requiring dialysis or renal transplantation.
- Patients have high risk of subarachnoid hemorrhage, secondary to cerebral aneurysms.
- Strong family history of renal cystic disease in at least one parent and approximately 1/2 of siblings (autosomal dominant transmission). Family members should be screened for involvement.
- Large kidneys (13-20cm) with multiple cortical cysts of varying sizes.
- Cysts may have internal hemorrhage or wall calcifications.
- Cysts may be present in the liver, pancreas, or spleen.
- Screening of family members
- Stillbirth or death shortly after delivery secondary to pulmonary hypoplasia..
- Renal failure in childhood.
- Periportal fibrosis with portal hypertension beginning at 8-12 years of age.
- Often parents have no knowledge of disease in themselves.
- 25% risk of inheriting disease.
- Kidneys appear large, echogenic without macroscopic cysts.
- Benign and generally asymptomatic
- Simple cysts are often a incidental finding on ultrasound or CT.
- One of the conditions that causes cortical calcinosis of the kidneys.
- May lead to renal failure and small, poorly functioning kidneys.
- Tubular and interstitial deposition of oxalate crystals.
- Kidneys are large, echogenic, poorly functioning.
Updated: October 9, 19100
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