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Tuesday urology conference
2/12/2014
By Dr. Anas HindawiMGH PGY 3 Urology Resident
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Vitals T: 38 ,P 90 ,BP 150/90
P.E :
Chest : bilat. basal crackles
Abdomen : soft ,enlarged
Palpable bilat. Mildly tender masses
Bilateral CVA tenderness /more on the left/
DRE normal
Lower extremeties +2 pitting oedema
Labs :
Bun41 ,Cr3 ,electrolytes140 ,3.8 ,104 ,21
Hg/Hct11.5/35.6 ,MCV 82
U/Aturbid amber ,+1 LE ,6-8 rbc ,numerous wbc
U/CxEcoli /ESBL/ > 100.000 CFU ,Sensitive on Amikacin & Imipinem
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Next ?
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IV Antibiotics
percutaneous drainage /unroofing/
partial nephrectomy
simple unilateral nephrectomy
radical unilateral nephrectomy
bilateral nephrectomy
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ADULT POLYCYSTIC KIDNEY
DISEASE
Adult polycystic kidney disease is an autosomal dominant hereditarycondition /bilateral in 95% /
5% to 10% of ADPKD cases are due to spontaneous mutations without apositive family history
ADPKD 3rdleading cause for ESRD
Accounting for 5% to 10% of all dialysis cases
Affecting chromosomes 16 and 4
Do not appear until after age 40 ,no preference of sex or race
May be associated with cysts in other organs
Risk of renal cell carcinoma is the same of general population
Smith and Tanagho's General Urology, 18th EditionAdult Renal Cystic Disease: Current Update on Pathogenesis, Cross sectional Imaging Findings and Management
AUA update series 2013 ,volume 32 ,lesson 2
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Adult Renal Cystic Disease: Current Update on Pathogenesis, Cross sectional Imaging Findings and
Management
AUA update series 2013 ,volume 32 ,lesson 2
Pathogenesis
It is now established that hereditary renal cysticdiseases, so-called ciliopathies, are secondary togenetic abnormalitiesthat influence the formationandfunctionof primary ciliaof the renal tubular epithelialcells resulting in inappropriate epithelial proliferation andsubsequent development of renal cysts.
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Clinical findings
Symptoms:
Pain over one or both kidneys
Gross or microscopic total hematuria
Colic may occur if blood clots or stones arepassed
Abdominal mass Infection
Vesical irretability
Smith and Tanagho's General Urology, 18th Edition
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Clinical findings
Signs:
Palpable kidney/s with or without nodularity
Tenderness justified by infection
HTN in 60-70 % Cardiomegaly
Fever with pyelonephritis or infected cyst
Uremia ,anemia and weight loss
Laboratory Findings hematopoieticdepression accompanying uremia,proteinuriaandmicroscopic (if not gross) hematuriawith developping renalimpairment
Smith and Tanagho's General Urology, 18th Edition
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Clinical findings
X-Ray Findings
Enlarged on a plain film of the abdomen, even as much as five times normal The calyces are broadened and flattened, enlarged, and often curved, as theytend to hug the periphery of adjacent cysts.
Ultrasonography 1smethod of investigation non expensive ,safe and effective
CT scanning ADPKD is characterized by bilateral enlarged kidneys with innumerable cysts of
various sizes ,in addition complications related to ADPKD, such as cyst infection,hemorrhage or rarely cyst rupture
Extrarenal manifestations of ADPKD including hepatic, pancreatic, seminal
vesicle and splenic cysts; intracranial arterial aneurysms; aortic aneurysms;abdominal wall hernias; colonic diverticulosis; and aortic/mitral valve abnormalitiescan be diagnosed
Adult Renal Cystic Disease: Current Update on Pathogenesis, Cross
sectional Imaging Findings and Management
AUA update series 2013 ,volume 32 ,lesson 2
Smith and Tanagho's General Urology, 18th Edition
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Complications of ADPKD
Refractory HTN
Chronic pain
Stones
Tumour
Cysts rupture Pyelonephritis /most common complication/
Intracranial Berry aneurysms rupture
Campbell walsh urology 10th edition
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General mesaures
the new drugs target fluid secretion, whereasothers target cellular growth and proliferation of
the cysts
ACEI's & ARB's
NSAID's has to be avoided
Narcotics has to be limited
Campbell walsh urology 10th edition
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Surgical managment of ADPKD
There is no evidence that excision or decompression of cystsimproves renal function
In patients infected with gas forming organisms
Recurrent, recent or refractory infections who are about to undergorenal transplantation ,In this setting, nephrectomy will minimize therisk of post-transplant infection when immunosuppressive agentsare administered to prevent rejection .
Patients with a staghorn calculus causing recurrent UTIs in a
relatively nonfunctioning kidney.
Hemodialysis and ultimately renal transplantation is the treatment ofchoice for patients with ADPKD and renal failure
Uptodate :Urinary tract infection in autosomal dominant polycystic
kidney disease ,literature review by Mar 2013
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Pyelonephritis & ADPKD
30 % to 50 % of ADPKD Distinguishing between infections of the bladder, renal parenchyma, and cystsis important
Often leads to serious complications, including perinephric abscess,septicemia, and death.
Predisposing factors include age, female sex, and recent instrumentation ofthe urinary tract.
Most commonly caused by gram-negative enteric organisms.
Diagnosis of these infections may be difficult since some patients do not havebacteriuria.
Eradication of cyst infections with conventional antibiotic therapy can be difficultdespite in vitro sensitivity of responsible organisms to the agents administered.
Where fever persists beyond 1-2 weeks of appropriate antibiotic therapy,percutaneous or surgical drainageof infected cysts should be considered.Where there is end-stage disease, nephrectomy may be indicated
American Journal of Kidney Diseases ,Volume 10, Issue 2, August 1987, Pages 8188
Polycystic Kidney Disease Treatment & Managemen ,Author: Roser Torra, MD, PhD; Chief
Editor: Vecihi Batuman, MD, FACP, FASN
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References
Campbell walsh urology 10th edition
Smith and Tanagho's General Urology, 18th Edition
Urology Board review 4th edition
Adult Renal Cystic Disease: Current Update on Pathogenesis, Cross sectional Imaging Findingsand Management ,AUA update series 2013 ,volume 32 ,lesson 2
Uptodate :Urinary tract infection in autosomal dominant polycystic kidney disease ,literature
review by Mar 2013
American Journal of Kidney Diseases ,Volume 10, Issue 2, August 1987, Pages 8188
Pubmed : Polycystic Kidney Disease Treatment & Managemen ,Author: Roser Torra,
MD, PhD; Chief Editor: Vecihi Batuman, MD, FACP, FASN
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Thank you
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