Nephrology Case Presentation

1
Nephrology Case Presentation

• Staci Smith DO
• November 20, 2009

2
Case Presentation

• 55 yo CM with CKD 3 ( baseline Cr 1.5-1.8)
  presents to GVH ER with nausea , vomiting, and
  inability to keep liquids or any medicines down
  since surgery last Friday. Pt noticed that his
  abdomen has become progressively larger . He has
  not been passing flatus or had any recent BM.
• Pt has been hypotensive with sbps in the 90s
• NG tube was placed in the ER with 1800 cc of
  green liquid output returned immediately.

3
Pertinent Review of Systems

• Positive for fatigue, decreased appetite and po
  intake, increased abdominal girth as well as ab
  pain (now 10/10)
• Decreased BMs and flatus
• Renal / Urinary specific
• Chronic foamy urine
• Positive bilateral renal carcinoma
• Decreased urinary output for past two days
• No recent OTC NAIDS
• No gross hematuria, known UTIs, recent contrast
  or colonic prep, incontinence, bph, history of
  stones, need for any dialysis

4
Outpatient Medications

• 1.Lisinopril / HCTZ 20 /12.5 one daily. 2.
  Glyburide 5 mg twice a day. 3. Neurontin 300 mg
  three times a day. 4. Aspirin 81 mg daily. 5.
  Multivitamin one p.o. daily. 6. Lantus 50 units
  subcutaneous p.m plus sliding scale insulin
• 7. Norvasc 10 mg daily. 8. Coreg 25 mg twice a
  day. 9. Plavix 75 mg daily. 10.Crestor 20 mg
  p.o. every p.m. 11.TriCor 145 mg daily

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Past Medical History

• 1. CKD 3 - baseline Cr 1.5-1.82. Bilateral renal
  masses, worrisome for renal cell carcinoma3.
  Hypertension 4. Coronary artery disease5.
  Hypercholesterolemia
• 6. MI 7. Peripheral vascular disease
• 8. Diabetes mellitus, type 2, insulin requiring
  9. Tobacco abuse

6
Patient History

• Past Surgical History
• 1. Right partial nephrectomy at OSU a week ago
  2. He has had heart catheterization with PTCA.
  3. Lipoma removal on the scalp. 4. Left lower
  extremity angioplasty in 2006
• Allergies
• none
• SHx
• Only positive for tobacco abuse x 30yrs, but quit
  one week ago
• FHx
• No family members on HD or immediate family with
  cancers
• Positive family history of DM and HTN

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Important History

• Notably, the pt has a history of bilateral renal
  masses since April 2009
• Partial right nephrectomy at OSU last Monday
• Previous poor outpatient follow up since April
  2009
• Seen at Cassano Nephro only once in initial
  consult
• Multiple phone calls to stress importance of
  timely follow up

8
ER Physical Exam

• VS BP 106/92- 92 HR, 96.7 F,15 RR, 95 on 2L
  oxygen
• Gen Appears uncomfortable no acute distress
• HEENT Atraumatic, normocephalic. EOMI. Sclerae
  anicteric. Mucous membranes are dry
• CV HRR without murmur, rub, click, or gallop.
  S1, S2
• Pulm CTAB without wheezing,rhonchi, or crackles
• Ab Distended. Positive bowel sounds. He does
  have lap trocar insertion site with mild
  erythema, and his belly has voluntary guarding.
• Ext No clubbing, cyanosis, or edema. No calf
  tenderness bilaterally. Distal peripheral pulses
  are 2/4. No Lindsays nails
• Neuro There is no asterixis. CN 2-12 GI

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ER Initial Labs

• 134 88 49 172
• 3.5 34 6.1
• No Ca, Mg, Phos, UA
• 20.5 15.0 474
• 46.3
• Cr back in Oct 2009 1.5

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ER Initial Labs

• CT scan without contrast
• high-grade small bowel obstruction at the level
  of the ventral hernia
• large amount of subcutaneous emphysema, small
  amount of retroperitoneal and smaller amount of
  intraperitoneal gas regional to the right kidney
  where there has been recent surgical
  intervention

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Cause of the Patients Acute Kidney Injury ?

• Multifactorial
• hypovolemia
• Secondary to GI loss with nausea and vomiting
• Poor po intake with outpatient diuretics (HCTZ)
• hypotension in the prescence of OP ACE-I
• Bp 90/46 in ER
• rule out urinary obstruction
• nurses unable to place Foley
• can bladder scan

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What is Acute Kidney Injury?

• An abrupt reduction in kidney function within 48
  hours
• absolute increase in serum creatinine of gt 0.3
  mg/dl
• a percentage increase of 50
• a reduction in urine output
• documented oliguria of lt 0.5 ml/kg/hr for gt 6
  hours
• realize that acute kidney injury may be a
  precursor to CKD, and CKD can also lead to AKI

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Stages of AKI
Stage Cr Criteria Urine Output Criteria
1 ? Serum Cr of gt0.3 mg/dl or increase to 150 - 200 from baseline lt0.5ml/kg/hr for gt 6hr
2 Increase serum creatinine to gt 200-300 from baseline lt0.5ml/kg/hr for gt12 hrs
3 Increase serum creatinine to gt300 from baseline (or serum creatinine 4.0mg/dl with an acute rise of at least 0.5 mg/dl) lt0.3ml/kg/hr x 24 hrs or anuria x 12 hr
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AKI RIFLE Criteria
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Initial Renal US Report May 2009

• Right kidney measures 11.04 x 7.25 x 7.25 cm
• no hydronephrosis seen
• 5.92 x 4.99 x 4.3 cm hypoechoic solid-appearing
  mass within the cortex of the superior pole
• lesion demonstrates mildly increased flow
• also a 2.26 x 1.95 x 2.70 cm either complex cyst
  with septation or two small adjacent cysts within
  the inferior pole of the right kidney
• Left kidney measures 11.42 x 5.06 x 5.82 cm
• exophytic 1.9 x 1.5 x 1.7 cm hypoechoic
  solid-appearing mass at the superior pole of the
  left kidney with vascular flow
• no hydronephrosis

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Initial CT Scan Report May 2009

• 5.8 x 4.2 cm partially exophytic mixed
  attenuation lesion arising from the superior pole
  of the right kidney
• most consistent with renal cell carcinoma until
  proven otherwise.
• Small exophytic lesion in upper pole of the left
  kidney
• 19 mm in diameter
• given its vascularity on the recent ultrasound a
  solid lesion is suspected

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Renal cell carcinoma
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Renal cell carcinoma

• originate within the renal cortex
• 80 to 85 of all primary renal neoplasms
• transitional cell carcinomas
• renal pelvis are the next most common 8
• in 2009, approximately 57,800 people will be
  diagnosed
• 13,000 will die from RCC in the United States
• worldwide mortality exceeds 100,000 per year
• eighth most common cancer
• typically fourth to sixth decade of life

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Incidence rates are rising three times faster
than mortality rates

• Survival has improved over time

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Renal cell carcinoma

• Risk factors
• Smoking- two fold increase
• Occupational exposure
• cadmium, asbestos, and petroleum by-products
• Acquired cystic diseases of the kidney
• 30 times greater in dialysis patients with
  acquired polycystic disease
• malignancy typically after at least 8 -10 yrs of
  dialysis
• After transplant

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Renal cell carcinoma

• Risk factors
• PCKD- RCC often bilateral
• Alcohol
• Cytotoxic chemotherapy/ prior radiation
• Unopposed estrogen
• Uncontrolled hypertension

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Genetic factors Von Hippel Lindau

• Autosomal dominant
• abnormalities in chr 3pq
• increased formation of vascular tumours (mostly
  benign) called hemangioblastomas and risk for
  renal carcinomas and pheochromocytomas

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Reed syndrome

• Multiple cutaneous and uterine leiomyomatosis
  syndrome
• hereditary leiomyoma and renal cell cancer
  syndrome
• characterized by cutaneous leiomyomas, uterine
  fibroids, and renal carcinomas
• renal tumors are aggressive
• metastasize and death in patients in their 30s

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Renal Cell Carcinoma

• History
• Often zero point zero clues
• Twenty-five to thirty percent of patients are
  asymptomatic
• found on incidental radiologic studies
• Classic triad is not common only 10
• flank pain
• hematuria
• flank mass
• indicative of advanced disease

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Renal Cell Carcinoma

• History
• Weight loss (33)
• Fever (20)
• Hypertension (20)
• Hypercalcemia (5)
• Night sweats
• Malaise
• Varicocele
• usually left sided, due to obstruction of the
  testicular vein (2 of males)

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Renal Cell Carcinoma

• Physical
• Gross hematuria
• Hypertension
• Supraclavicular adenopathy
• flank or abdominal mass with bruit
• 30 present with metastatic disease
• evaluation for metastatic disease
• lung (75)
• Varicocele and findings of paraneoplastic
  syndromes raise clinical suspicion for this
  diagnosis.

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Differential Diagnosis of RCC

• NHL
• Pyelonephritis
• Abscess
• Angiomyolipoma -benign
• Oncocytoma -benign
• Metastasis from distant primary
• Metastatic melanoma

• Renal adenoma benign
• Renal cyst
• Renal infarct
• Sarcoma
• Transitional cell carcinoma of renal pelvis

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Renal cell carcinoma

• challenging tumor because paraneoplastic
  syndromes
• hypercalcemia
• erythrocytosis
• nonmetastatic hepatic dysfunction (Stauffer
  syndrome)
• polyneuromyopathy
• amyloidosis
• dermatomyositis
• hypertension

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Labs to consider

• Urine analysis
• CBC count with differential
• Renal profile
• Liver function tests (AST and ALT)
• Calcium
• Erythrocyte sedimentation rate
• Prothrombin time
• Activated partial thromboplastin time

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Imaging often incidentally discovered

• CT scan
• imaging procedure of choice for diagnosis and
  staging
• Ultrasonography
• MRI
• PET
• mets
• Bone Scan
• Especially high alk phos

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Procedures and Subtypes of RCC

• Percutaneous cyst puncture and fluid analysis
• 5 histologic subtypes of rcc
• clear cell (75)
• chromophilic (15)
• chromophobic (5)
• oncocytoma (3)
• collecting duct (2)
• very aggressive,often younger pts

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Staging of RCC

• Robson modification of the Flocks and Kadesky
  system
• Stage I - Tumor confined within capsule of kidney
  
• Stage II - Tumor invading perinephric fat but
  still contained within the Gerota fascia
• Stage III - Tumor invading the renal vein or
  inferior vena cava (A), or regional lymph-node
  involvement (B), or both (C)
• Stage IV - Tumor invading adjacent viscera
  (excluding ipsilateral adrenal) or distant
  metastases

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Robson staging system
34
Treatment

• probability of cure is related directly to the
  stage
• more than 50 of patients with renal cell
  carcinoma are cured in early stages

35
Surgical treatment of RCC

• Surgery is curative in the majority of patients
  without metastatic RCC
• Preferred treatment for patients with stages I,
  II, and III disease
• Also used for palliation in metastatic disease
• Radical nephrectomy
• most commonly performed standard surgical
  procedure today
• complete removal of the Gerota fascia and its
  contents, including a resection of kidney,
  perirenal fat, and ipsilateral adrenal gland,
  with or without ipsilateral lymph node dissection

36
Surgical treatment of RCC

• Laparoscopic nephrectomy
• Advantages
• less invasive procedure, incurs less morbidity,
  and is associated with shorter recovery time and
  less blood loss
• Disadvantages
• concerns about spillage and technical
  difficulties in defining surgical margins

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Treatment of RCC

• no hormonal or chemotherapeutic regimen is
  accepted as a standard of care
• options are surgery, radiation therapy,
  chemotherapy, hormonal therapy, immunotherapy, or
  combinations of these
• IL-2-T-cell growth factor and activator and
  natural killer cells
• Interferon alpha
• Sutent-Sunitinib
• multi-kinase inhibitor
• high response rate (40 )
• Sorafenib Nexavar
• kinase and vascular endothelial growth factor
  (VEGF) multireceptor kinase inhibitor
• advanced renal cell carcinoma

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Treatment

• For previously untreated patients
• low or intermediate risk
• sunitinib or the combination of bevacizumab and
  interferon alpha

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Treatment Recommendations

• Radical nephrectomy
• most widely used approach
• preferred procedure when there is evidence of
  invasion into the adrenal, renal vein, or
  perinephric fat
• Partial nephrectomy
• for smaller tumors
• particularly valuable in patients with bilateral
  or multiple lesions
• If renal dysfxn
• Elderly patients with significant comorbid
  disease
• increases the risk of surgery
• ablative techniques
• cryoablation, radiofrequency ablation

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What happened to the patient?

• Ordered records from OSU
• Cr post op was 2.5
• Did not required sx for incercerated hernia
• Reduced at bedside
• Aggressive IVF hydration
• Cr improved daily
• Peak Cr 6.1 11/16
• 5.27 3.76 3.27 3.16

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Learning Points

• Stages of CKD

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Renal Cell Carcinoma Learning Points

• History
• Often zero point zero clues
• Twenty-five to thirty percent of patients are
  asymptomatic
• found on incidental radiologic studies
• Classic triad is not common only 10
• flank pain
• hematuria
• flank mass
• indicative of advanced disease

43
Learning Points Renal Cell Carcinoma

• About 25-30 of patients have metastatic disease
  at diagnosis
• fewer than 5 have solitary metastasis
• surgical resection is recommended in selected
  patients with metastatic renal carcinoma

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Thank You )
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• Resources
• Up to date
• http//emedicine.medscape.com/article/281340-treat
  ment