A 47-Y-old man has an excretory urogram for investigation of microscopic hematuria, discovered on a routine urine analysis. He is apparently healthy and entirely without complaints. Kidneys are of normal size, with calcification and collection of dye in dilated medullary structures. Some E-, BUN, creatinine, Ca+, P- and uric acid are normal. Creatinine clearance is 103 ml/min. Urine analysis reveals rare RBCs and no protein.Which of the following is/are true of this patient?a. There is significant chance that symptomatic renal stones will developb. There is significant chance that he has hypercalciuriac. He is likely to
This document provides definitions and overview of various cystic kidney diseases including simple cysts, autosomal dominant polycystic kidney disease (ADPKD), autosomal recessive polycystic kidney disease (ARPKD), acquired cystic kidney disease, Alport's syndrome, medullary sponge kidney, medullary cystic kidney disease, and renal phacomatosis associated with tuberous sclerosis and Von Hippel-Lindau disease. It describes the clinical features, pathogenesis, diagnosis, and management of these conditions.
Similar to A 47-Y-old man has an excretory urogram for investigation of microscopic hematuria, discovered on a routine urine analysis. He is apparently healthy and entirely without complaints. Kidneys are of normal size, with calcification and collection of dye in dilated medullary structures. Some E-, BUN, creatinine, Ca+, P- and uric acid are normal. Creatinine clearance is 103 ml/min. Urine analysis reveals rare RBCs and no protein.Which of the following is/are true of this patient?a. There is significant chance that symptomatic renal stones will developb. There is significant chance that he has hypercalciuriac. He is likely to
Similar to A 47-Y-old man has an excretory urogram for investigation of microscopic hematuria, discovered on a routine urine analysis. He is apparently healthy and entirely without complaints. Kidneys are of normal size, with calcification and collection of dye in dilated medullary structures. Some E-, BUN, creatinine, Ca+, P- and uric acid are normal. Creatinine clearance is 103 ml/min. Urine analysis reveals rare RBCs and no protein.Which of the following is/are true of this patient?a. There is significant chance that symptomatic renal stones will developb. There is significant chance that he has hypercalciuriac. He is likely to (20)
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A 47-Y-old man has an excretory urogram for investigation of microscopic hematuria, discovered on a routine urine analysis. He is apparently healthy and entirely without complaints. Kidneys are of normal size, with calcification and collection of dye in dilated medullary structures. Some E-, BUN, creatinine, Ca+, P- and uric acid are normal. Creatinine clearance is 103 ml/min. Urine analysis reveals rare RBCs and no protein.Which of the following is/are true of this patient?a. There is significant chance that symptomatic renal stones will developb. There is significant chance that he has hypercalciuriac. He is likely to
4. Solitary or multiple, fluid-filled
Cysts develop from any part of nephron, usually cortical
Incidental finding on U/S or IVU
Incidence:
o 2%patients < 50 Ys old
o 11%patients 50-70 Ys old
o >20%elderly patients
Usually not loculated and tend to bulge out from renal
surface
May grow to considerable size(>10cm)
Usually harmless
Occasionally require percutaneous drainage; because of
persistent loin pain
5.
6. Incidence: 1: 1000
Genes:
o PKD 1 gene(86%): on chromosome 16
o PKD 2 gene(10%): on chromosome 4
AD, yet some sporadic cases are commonly seen
Pathophysiology:
o Early ↑ of Plasma ADH, to compensate for ↓ concentrating
ability hypertension and renal insufficiency
o Cysts development induce renal ischemia and + RAS
hypertension
o ↑ Angiogenesis(fragile vessels across cyst walls) rupture
Pain ±hematuria
7. Cysts develop from all segments of nephron(including
Bowman’s capsule), during the teenage Ys, presentation is
in 4th or 5th decades
Diagnostic Criteria for ADPKD
2 Cysts (unilateral/or/
bilateral)
< 30 Ys old
2 Cysts(in each kidney) 30-59 Ys old
4 Cysts(in each kidney) > 60 Ys old
8. Clinical Features:
o Asymptomatic(~1/3)
o Abdominal/Loin Pain or Mass
o Hypertension
o UTI
o Renal calculi(10%)
o Macroscopic hematuria
o Not all patients(~1/3), develop ESRD onset of CRF varies
widely:25-60 Ys
Common Associations:
o Liver cysts(70%), hepatic fibrosis(rare)
o Pancreatic Cysts(10%)
o Berry Aneurysms(>20% in +ve F.H., 5% in –ve F.H.), 4% risk of
rupture if size >10mm, do: MRA every 3 Ys
o MVP, or A.I.
o Anemia of CRF/or Polycythemia due to ↑ erythropoeitin activity
o Diverticular disease
Increase incidence of malignancy
9. No strategies to prevent formation and progression of cysts;
the aim is instead at: monitoring for & treating
complications, as well as providing appropriate couselling
Treatment of hypertension(to ≤ 125/75mmHg): ACE-Is, ARBs
Treatment of UTI: Lipophilic Antibiotics with cyst-penetrating
ability(ciprofloxacin, trimethoprim, clindamycin, vancomycin,
clotrimazole)
Treatment of painful cyst:
o Cyst fluid aspiration/drainage(U/S-guided)
o Cyst de-roofing: Excision of outer wall(Fibreoptic-guided/open
surgery)
o Ethanol-induced sclerosis
Treatment of enlarged kidney:
o Avoid tight corsets
o Avoid wearing belts and seat belts
o Avoid playing contact sports
10. AR, chromosome 6
Genes:
o Fibrocystin
o Polyductin
Cysts develop from DCT and CDs
Incidence: 1: 10,000 births
ESRD usually develops early in childhood; sometimes it
may be delayed to 20 Ys of age or rarely, may never occur
Poor prognosis
Genetic counseling
11. Clinical presentation:
Bilateral abdominal masses in infancy
Polyurea
Enuresis
Hyponatremia
Hyperchloremic metabolic acidosis
Hepatic fibrosis in all cases, progressing to portal
hypertension
Hypertension
Pulmonary hypoplasia(major cause of death in 1st year
of life)
14. In the rudimentary kidneys of patients with ESRD,
especially the scarred kidneys
Cysts usually develop from PCT/DCT
Incidence:
o >5% At onset of RRT
o >80% After 10 Ys of dialysis
Asymptomatic
Cyst hemorrhage: Flank pain, anemia, hematuria
Risk Factors:
o Duration of ESRD
o Male gender
o Black race
o Chronic hypokalemia
15. Malignant change(RCC), with an annual incidence
of 1%, less often to be metastatic, but with high
5-year mortality rate
Renal U/S, CT, MRI:
Demonstration of cysts in Kidneys which are not
enlarged
Suspicious cyst findings for RCC:
Septa formation
Solid material
Contrast enhancement
16.
17. Incidence: 1: 5000
X-Linked, dominant
Absence of alpha-5 chain of type IV collagen
Abnormal GBM(basket-weave appearance)
Absent Good-Pasture Ag in GBM; predisposition
to anti-GBM GN after transplantation(graft
failure)
18. Deafness(sensorineural, bilateral)
Microscopic hematuria, proteinuria
NS(30%)
CRF, in all affected males(not in female carriers)
Ocular abnormalities in 40%(Lenticonus, retinal
flecks, cataract
Macro thrombocytopenia
Leiomyomata(rare)
D.D. with benign familial hematuria(thin
membrane nephropathy)
19. Sporadic
Benign course: less likely to progress to ESRD
Cysts develop from medullary and papillary CDs
The ectatic C.Ds may calcify Classical
Nephrocalcinosis(50%)
Upper UTI and renal calculi may be present
Microscopic hematuria and hypercalciuria
± Hyperparathyroidism
20.
21.
22. They are 2 different terms used for 2 similar diseases;
which differ only in their age of onset and mode of
inheritance
Cysts occur in medullary DCT
Patients have:
Tubulo-IN
Salt-wasting
Progressive CRF
23. FN MCKD
AR AD, uncommon
ESRD in childhood or before 20 Ys
of age(15%)
ESRD in 3rd,4th decade
Extrarenal manifestations:
a. Retinitis pigmentosa(10-15%)
b. Cerebellar ataxia
c. Liver fibrosis
d. Nocturnal Eneuresis
NOT associated with extrarenal
manifestations
Hypertension is present
24. AD, chromosome 9 or 16
Multiple Hamartomas: Skin, CNS, eyes, kidneys and heart
Incidence: 1: 10,000
Clinical findings:
Intracranial tumors/calcifications:
Epilepsy: 80%
MR: 50%
Renal cysts/? RCC(5%)
Skin lesions:
o Shagreen patches
o Ash-leaf spots
o Adenoma Sebaceum(angiofibromas)
29. A 55-Y-old man undergoes IVP, as part of work-up of
HTN. A 3-cm solitary radiolucent mass is noted in
the left kidney; the study otherwise is normal. The
man complains of no symptoms referable to the
urinary tract and examination of urinary sediment
is within normal limits.
Which of the following studies should be performed
next?
a. Repeat IVP in 6-Months
b. Early-morning urine collections for cytology (3
samples)
c. Selective renal arteriography
d. Renal U/S
e. CT scanning with contrast enhancement of the
left kidney
30. A 55-Y-old man undergoes IVP, as part of work-up of HTN. A 3-cm
solitary radiolucent mass is noted in the left kidney; the study
otherwise is normal. The man complains of no symptoms
referable to the urinary tract and examination of urinary
sediment is within normal limits.
Which of the following studies should be performed next?
a. Repeat IVP in 6-Months
b. Early-morning urine collections for cytology (3
samples)
c. Selective renal arteriography
d. Renal U/S {to differentiate simple cyst from
RCC}
e. CT scanning with contrast enhancement of the left
kidney
31. A 49-Y-old woman with known PKD and serum creatinine
of 3.0 mg/dl, comes to the ER because of abdominal
and flank pain. She passed blood-tinged urine the day
before. Examination revealed a BP of 180/105, pulse
of 92 bpm and a T o of 38 o C. Large bilateral upper
quadrant masses are palpated; the right is somewhat
tender. Bowel sounds are normal. Plain film of
abdomen reveals large upper quadrant masses
bilaterally. A few areas in the upper pole of the right
kidney have complex echoes and no solid masses are
seen.
Urine analysis shows 1+ protein, RBCs > 100/HPF
Which of the following is the most likely cause of the
patient’s condition?
a. Renal infarction
b. UTI
c. Renal cell carcinoma(RCC)
d. Hemorrhage into a renal cyst
e. Arteriovenous(AV) malformations
32. A 49-Y-old woman with known PKD and serum creatinine of
3.0 mg/dl, comes to the ER because of abdominal and flank
pain. She passed blood-tinged urine the day before.
Examination revealed a BP of 180/105, pulse of 92 bpm and
a T o of 38 o C. Large bilateral upper quadrant masses are
palpated; the right is somewhat tender. Bowel sounds are
normal. Plain film of abdomen reveals large upper quadrant
masses bilaterally. A few areas in the upper pole of the right
kidney have complex echoes and no solid masses are seen.
Urine analysis shows 1+ protein, RBCs > 100/HPF
Which of the following is the most likely cause of the patient’s
condition?
a. Renal infarction
b. UTI
c. Renal cell carcinoma(RCC)
d. Hemorrhage into a renal cyst {pain+echoes+RBCs}
e. Arteriovenous(AV) malformations
33. A 47-Y-old man has an excretory urogram for
investigation of microscopic hematuria, discovered
on a routine urine analysis. He is apparently healthy
and entirely without complaints. Kidneys are of
normal size, with calcification and collection of dye
in dilated medullary structures. Some E-, BUN,
creatinine, Ca+, P- and uric acid are normal.
Creatinine clearance is 103 ml/min. Urine analysis
reveals rare RBCs and no protein.
Which of the following is/are true of this patient?
a. There is significant chance that symptomatic renal
stones will develop
b. There is significant chance that he has hypercalciuria
c. He is likely to have impaired urine concentrating
ability
d. His condition is likely to progress to chronic ESRD
e. His children have a 50% chance of experiencing the
same condition
34. A 47-Y-old man has an excretory urogram for
investigation of microscopic hematuria, discovered
on a routine urine analysis. He is apparently healthy
and entirely without complaints. Kidneys are of
normal size, with calcification and collection of dye
in dilated medullary structures. Some E-, BUN,
creatinine, Ca+, P- and uric acid are normal.
Creatinine clearance is 103 ml/min. Urine analysis
reveals rare RBCs and no protein
All of the following is true of this patient, except:
a. There is significant chance that symptomatic renal
stones will develop
b. There is significant chance that he has hypercalciuria
c. He is likely to have impaired urine concentrating
ability
d. His condition is less likely to progress to chronic ESRD
e. His children have a 50% chance of experiencing the
same condition {MSK is a congenital, not hereditary}
35. A 60-Y-old man with ESRD from chronic GN,
presents with acute onset of gross hematuria
and mild flank pain. He has been on dialysis for
4 Ys and his course has otherwise been
uneventful. He was afebrile and the hematuria
resolved without intervention.
Which of the following is most appropriate now?
a. Renal U/S
b. CT
c. Angiography
d. IVP
e. None of the above
36. A 60-Y-old man with ESRD from chronic GN,
presents with acute onset of gross hematuria
and mild flank pain. He has been on dialysis for
4 Ys and his course has otherwise been
uneventful. He was afebrile and the hematuria
resolved without intervention.
Which of the following is most appropriate now?
a. Renal U/S
b. CT {ACKD has 10% incidence of malignancy, CT will be
useful in diagnosis and also for staging}
c. Angiography
d. IVP
e. None of the above