Nephrology Exam
What are the top 5 functions of the kidneys?correct answer-remove waste
-control BP by secreting renin which initiates RAAS
-stimulates RBC production by secretion of EPO
-maintains bone health by secreting calcitriol --> reducing Ca2+ loss
-controls pH
What make up about 90% of all renal cancers?correct answerrenal cell carcinoma (parenchyma)-
includes adenocarcinomas
What are the types of renal cancers?correct answer-renal cell carcinoma (includes adenocarcinoma)
-transitional cell carcinoma - renal pelvis (linked with cigarette smoking)
-wilms' tumor
renal sarcoma- originated from vasculature or connective tissue of kidney
Describe the presentation of a patient with renal cell carcinoma.correct answer-*gross or microscopic
hematuria*
-flank pain or mass
-fever, weight loss
-solid renal mass on imaging
-night sweats, fever, malaise, weight loss
-*erythrocytosis but anemia is more common*
-*hypercalcemia*
-*stauffer syndrome* - hepatic dysfunction in absence of liver metastasis
What are risk factors for renal cell carcinoma?correct answer-*cigarette smoking is the only
environmental risk factor*
-obesity, HTN, acquired cystic kidney disease associated with dialysis, ADPKD
-familial causes
Which renal cancer is associated with paraneoplastic syndrome?correct answerrenal cell carcinoma
-Paraneoplastic syndrome is symptoms due to remote effects of cancer
What is the best initial test for renal cell carcinoma?correct answer-US because it is inexpensive, without
radiation and high sensitivity
,-then do CT or MRI
-then *biopsy or nephrectomy*
-bone scan if metastasis is suspected
What is the treatment for renal cell carcinoma?correct answer-*surgery is gold standard* - partial or
radical- curative in stages 1-3
-resistant to chemo or radiation
Describe renal cell carcinoma staging.correct answerI: confined to renal capsule and <7cm
II: confined to renal capsule and >7cm
III: extends through renal capsule but not through fascia; renal vein, IVC, or regional nodal involvement
IV: extends through fascia or with distant metastasis
What is Wilms' tumor?correct answer-nephroblastoma
-most common renal malignancy in *children*
-African Americans are more at risk
Describe the presentation of a patient with Wilms' tumor?correct answer-abdominal swelling or mass
w/o other symptoms- rarely crosses midline
-abdominal pain
-hematuria
-HTN
-may have subcapsular hemorrhage (fever, rapid abd enlargement, anemia, HTN)
Which patients should be screened for Wilms' tumor?correct answer-Beckwith-Wiedmann syndrome
every 3 months until age 7
-WAGR syndrome every 3 months until age 5
Describe the workup in a patient with a Wilms' tumor?correct answer-*US* then CT or MRI
-*evaluate for lung metastasis*
-SCr, CMP, UA, maybe coagulation studies if indicated
Describe the staging of a Wilms' tumor.correct answerI: limited to kidney and completely excised w/o
rupture or biopsy- renal capsule intact
II: tumor extends through renal capsule but all is removed- vessels outside kidney contain tumor - OR
"local spillage on removal"
III: residual tumor confined to abd - involvement of abd lymph nodes- "diffuse" contamination by
rupture- microscopic margins positive post resection
,IV: hematogenous metastasis at any site
V: bilateral renal involvement
How are Wilms' tumors treated?correct answer-*surgical excision*
-CTX (chemotherapy) with low risk tumors
-XRT (radiation) for advanced stage and histology
What is the prognosis of Wilms' tumor?correct answer5 year survival of 90%
follow with CT - pulmonary and abdominal Q3mo/2 years then Q6mo/2 more years
What is ADPKD?correct answerAutosomal dominant polycystic kidney disease
-cysts increase with age
-most common hereditary disorder in the US
Describe the presentation of ADPKD.correct answer-often have HTN and abdominal mass (palpable
kidneys)
-*family history*
-abdominal/ flank pain
-hematuria
-Hx of UTI/ nephrolithiasis
What genetic mutations were found for ADPKD?correct answerPKD1 and PKD2
-PKD1 has worse prognosis and faster progression of disease
How is ADPKD treated?correct answertreat symptoms
-Abd/ flank pain: *cyst decompression/drainage/ removal and analgesics*
-Hematuria: *bed rest, hydration*
-renal infection: *ABX- fluoroquinolones, bactrim, chloramphenicol*
-nephrolithiasis: *hydration*
-HTN: *cyst decompression and aggressive pharmacotherapy to prolong ESRD*
-cerebral aneurysms and other vascular problems may occur
-Vasopressin receptor antagonist can slow worsening of kidney function
-avoid caffeine, low protein, low salt diet
A patient has a urinalysis done and it comes back with Bence Jones protein, what might they have?
correct answermultiple myeloma
, -Bence Jones protein is light chain Ig - causes renal toxicity and obstruction
-*hypercalcemia* is also found
How is multiple myeloma treated?correct answer-correct hypercalcemia
-volume repletion
-chemo for MM
How much of the total body water does ICF make up? Which ions are found there?correct answer2/3
K+, Phosphate, Sulfate
How much of the total body water does ECF make up? Which ions are found there?correct answer1/3
Na+, Cl-, Bicarb
How much of the ECF does plasma make up?correct answer1/4
How much of the ECF does the interstitial fluid make up?correct answer3/4
What is a normal serum osmolality?correct answer290 mosm/kg H2O
What is the gold standard for evaluating renal electrolytes?correct answer24 hour urine collection
What does low (<1%) FENA indicate?correct answer-fractional excretion of Na+ (FENA)
-renal reabsorption (prerenal)
What does high (>1%) FENA indicate?correct answer-fractional excretion of Na+ (FENA)
-renal wasting (intrinsic)
What is an osmolar gap?correct answer-difference between serum osmolality and calculated osmolality
*>10 mm/kg* indicated gap
-suggests unmeasured fluids such as ethanol, ethylene glycol, methanol
How is serum osmolality calculated?correct answershould = 285-295 mmol/kg
What is the normal physiologic response to hypernatremia?correct answerincreased thirst mechanism
What usually causes hypernatremia?correct answer-free water loss, hypotonic fluid loss (diabetes
insipidus), urinary loss, GI loss, and insensible loss
-renal losses of glucose or osmotic diuresis with mannitol
-non renal losses such as excessive sweating, excessive bowel movements, osmotic diarrhea
Describe the presentation of a patient with hypernatremia.correct answer-*dehydration
-positive orthostatic hypotension*
-flushed skin
What are the top 5 functions of the kidneys?correct answer-remove waste
-control BP by secreting renin which initiates RAAS
-stimulates RBC production by secretion of EPO
-maintains bone health by secreting calcitriol --> reducing Ca2+ loss
-controls pH
What make up about 90% of all renal cancers?correct answerrenal cell carcinoma (parenchyma)-
includes adenocarcinomas
What are the types of renal cancers?correct answer-renal cell carcinoma (includes adenocarcinoma)
-transitional cell carcinoma - renal pelvis (linked with cigarette smoking)
-wilms' tumor
renal sarcoma- originated from vasculature or connective tissue of kidney
Describe the presentation of a patient with renal cell carcinoma.correct answer-*gross or microscopic
hematuria*
-flank pain or mass
-fever, weight loss
-solid renal mass on imaging
-night sweats, fever, malaise, weight loss
-*erythrocytosis but anemia is more common*
-*hypercalcemia*
-*stauffer syndrome* - hepatic dysfunction in absence of liver metastasis
What are risk factors for renal cell carcinoma?correct answer-*cigarette smoking is the only
environmental risk factor*
-obesity, HTN, acquired cystic kidney disease associated with dialysis, ADPKD
-familial causes
Which renal cancer is associated with paraneoplastic syndrome?correct answerrenal cell carcinoma
-Paraneoplastic syndrome is symptoms due to remote effects of cancer
What is the best initial test for renal cell carcinoma?correct answer-US because it is inexpensive, without
radiation and high sensitivity
,-then do CT or MRI
-then *biopsy or nephrectomy*
-bone scan if metastasis is suspected
What is the treatment for renal cell carcinoma?correct answer-*surgery is gold standard* - partial or
radical- curative in stages 1-3
-resistant to chemo or radiation
Describe renal cell carcinoma staging.correct answerI: confined to renal capsule and <7cm
II: confined to renal capsule and >7cm
III: extends through renal capsule but not through fascia; renal vein, IVC, or regional nodal involvement
IV: extends through fascia or with distant metastasis
What is Wilms' tumor?correct answer-nephroblastoma
-most common renal malignancy in *children*
-African Americans are more at risk
Describe the presentation of a patient with Wilms' tumor?correct answer-abdominal swelling or mass
w/o other symptoms- rarely crosses midline
-abdominal pain
-hematuria
-HTN
-may have subcapsular hemorrhage (fever, rapid abd enlargement, anemia, HTN)
Which patients should be screened for Wilms' tumor?correct answer-Beckwith-Wiedmann syndrome
every 3 months until age 7
-WAGR syndrome every 3 months until age 5
Describe the workup in a patient with a Wilms' tumor?correct answer-*US* then CT or MRI
-*evaluate for lung metastasis*
-SCr, CMP, UA, maybe coagulation studies if indicated
Describe the staging of a Wilms' tumor.correct answerI: limited to kidney and completely excised w/o
rupture or biopsy- renal capsule intact
II: tumor extends through renal capsule but all is removed- vessels outside kidney contain tumor - OR
"local spillage on removal"
III: residual tumor confined to abd - involvement of abd lymph nodes- "diffuse" contamination by
rupture- microscopic margins positive post resection
,IV: hematogenous metastasis at any site
V: bilateral renal involvement
How are Wilms' tumors treated?correct answer-*surgical excision*
-CTX (chemotherapy) with low risk tumors
-XRT (radiation) for advanced stage and histology
What is the prognosis of Wilms' tumor?correct answer5 year survival of 90%
follow with CT - pulmonary and abdominal Q3mo/2 years then Q6mo/2 more years
What is ADPKD?correct answerAutosomal dominant polycystic kidney disease
-cysts increase with age
-most common hereditary disorder in the US
Describe the presentation of ADPKD.correct answer-often have HTN and abdominal mass (palpable
kidneys)
-*family history*
-abdominal/ flank pain
-hematuria
-Hx of UTI/ nephrolithiasis
What genetic mutations were found for ADPKD?correct answerPKD1 and PKD2
-PKD1 has worse prognosis and faster progression of disease
How is ADPKD treated?correct answertreat symptoms
-Abd/ flank pain: *cyst decompression/drainage/ removal and analgesics*
-Hematuria: *bed rest, hydration*
-renal infection: *ABX- fluoroquinolones, bactrim, chloramphenicol*
-nephrolithiasis: *hydration*
-HTN: *cyst decompression and aggressive pharmacotherapy to prolong ESRD*
-cerebral aneurysms and other vascular problems may occur
-Vasopressin receptor antagonist can slow worsening of kidney function
-avoid caffeine, low protein, low salt diet
A patient has a urinalysis done and it comes back with Bence Jones protein, what might they have?
correct answermultiple myeloma
, -Bence Jones protein is light chain Ig - causes renal toxicity and obstruction
-*hypercalcemia* is also found
How is multiple myeloma treated?correct answer-correct hypercalcemia
-volume repletion
-chemo for MM
How much of the total body water does ICF make up? Which ions are found there?correct answer2/3
K+, Phosphate, Sulfate
How much of the total body water does ECF make up? Which ions are found there?correct answer1/3
Na+, Cl-, Bicarb
How much of the ECF does plasma make up?correct answer1/4
How much of the ECF does the interstitial fluid make up?correct answer3/4
What is a normal serum osmolality?correct answer290 mosm/kg H2O
What is the gold standard for evaluating renal electrolytes?correct answer24 hour urine collection
What does low (<1%) FENA indicate?correct answer-fractional excretion of Na+ (FENA)
-renal reabsorption (prerenal)
What does high (>1%) FENA indicate?correct answer-fractional excretion of Na+ (FENA)
-renal wasting (intrinsic)
What is an osmolar gap?correct answer-difference between serum osmolality and calculated osmolality
*>10 mm/kg* indicated gap
-suggests unmeasured fluids such as ethanol, ethylene glycol, methanol
How is serum osmolality calculated?correct answershould = 285-295 mmol/kg
What is the normal physiologic response to hypernatremia?correct answerincreased thirst mechanism
What usually causes hypernatremia?correct answer-free water loss, hypotonic fluid loss (diabetes
insipidus), urinary loss, GI loss, and insensible loss
-renal losses of glucose or osmotic diuresis with mannitol
-non renal losses such as excessive sweating, excessive bowel movements, osmotic diarrhea
Describe the presentation of a patient with hypernatremia.correct answer-*dehydration
-positive orthostatic hypotension*
-flushed skin
