Renal Vascular Diseases

Info

🌱 來自: Huppert’s Notes

Renal Vascular Diseases🚧 施工中

Renal Vascular Diseases

Renal artery stenosis

•   Etiology: Majority of cases are due to atherosclerosis, most others are due to fibromuscular dysplasia (often in young women, 50% bilateral, can be hereditary). Renal artery narrowing and subsequent RAAS activation causes renovascular hypertension.

•   Clinical features: Early or medication-refractory hypertension (i.e., uncontrolled HTN on three antihypertensives including a diuretic); abdominal bruits on exam

•   Diagnosis: Duplex ultrasound, CTA, or MRA

•   Treatment:

-   Treat hypertension with ACE inhibitor/ARB, plus diuretic

-   Consider revascularization with stent or endarterectomy if there is high chance of benefit or high risk of complications (e.g., rapid progression of disease, recurrent flash pulmonary edema, medical therapy not tolerated or ineffective, bilateral disease with declining kidney function)

Hypertensive nephrosclerosis

•   Etiology: Sclerosis of the tubulointerstitial, glomerular, and vascular spaces due to genetic predisposition and chronic hypertension

•   Clinical features: Presents with two distinct clinical courses defined as benign or malignant:

-   Benign nephrosclerosis: Most often seen in African Americans with high-risk APOL1 genotypes, preceding hypertension, thickening of glomerular afferent arterioles; presents as mild ↑Cr elevation, microscopic hematuria, mild proteinuria

-   Malignant nephrosclerosis: Rapid decrease in renal function with severe hypertension → Markedly elevated BP (papilledema, cardiac decompensation, CNS findings), renal abnormalities (rapid ↑Cr, proteinuria, hematuria, RBC/WBC casts, microangiopathic hemolytic anemia)

•   Treatment: Control blood pressure

Renal vein thrombosis

•   Etiology: Can result from systemic inflammation or prothrombotic state (e.g., nephrotic syndrome, carcinoma, trauma, pregnancy/OCPs), extrinsic compression, trauma

•   Clinical features: Evidence of decreased renal perfusion (rising Cr, decreased urine output, hypertension) and renal injury (hematuria, proteinuria)

•   Diagnosis: Duplex ultrasound, CTA, MRA

•   Treatment: Consider thrombolysis/thrombectomy or anticoagulation based on clinical severity

Thrombotic microangiopathy (TMA)

•   Etiology: Syndrome of microangiopathic hemolytic anemia, low platelets, and organ injury; most often due to TTP and atypical HUS; can also result from HUS, APLS, scleroderma renal crisis, malignant hypertension, pregnancy (HELLP/preeclampsia). Also see Hematology/Oncology Chapter 7.

•   Diagnosis: Thrombi and fibrin accumulation in capillaries on glomerular biopsy

•   Treatment: Treat underlying cause. Plasma exchange if TTP.