java barcode scanner library RENAL ARTERY STENOSIS in Objective-C

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RENAL ARTERY STENOSIS
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ESSENTIALS OF DIAGNOSIS
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Produced by atherosclerotic occlusive disease (80 90% of patients) or fibromuscular dysplasia (10 15%) Hypertension Acute renal failure in patients starting therapy with an ACE inhibitor
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General Considerations
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The two most common forms of renal artery stenosis are atherosclerotic ischemic renal disease and fibromuscular dysplasia The prevalence of this condition has been estimated only by autopsy and angiographic studies Approximately 5% of Americans with hypertension suffer from renal artery stenosis Atherosclerotic ischemic renal disease accounts for nearly all cases of renal artery stenosis It occurs most commonly in those over 45 years of age with a history of atherosclerotic disease Other risk factors include renal insufficiency, diabetes mellitus, tobacco use, and hypertension
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Treatment
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Treatment of atherosclerotic ischemic renal disease is controversial Options include medical management, angioplasty with or without stenting, and surgical bypass Angioplasty might reduce the number of antihypertensive medications but does not significantly change outcome in comparison to patients medically managed Stenting produces significantly better angioplastic results However, blood pressure is equally improved, and serum creatinines are similar at 6 months of observation Angioplasty is equally as effective as, and safer than, surgical revision Treatment of fibromuscular dysplasia with percutaneous transluminal angioplasty is often curative
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Balk E et al Effectiveness of management strategies for renal artery stenosis: a systematic review Ann Intern Med 2006 Dec 19;145(12):901-12 Epub 2006 Oct 24 [PMID: 17062633] Bloch MJ et al Clinical insights into the diagnosis and management of renovascular disease An evidence-based review Minerva Med 2004 Oct;95(5):357 73 [PMID: 15467512] Kalra PA et al Atherosclerotic renovascular disease in United States patients aged 67 years or older: risk factors, revascularization, and prognosis Kidney Int 2005 Jul;68(1):293 301 [PMID: 15954920] Korsakas S et al Delay of dialysis in end-stage renal failure: prospective study on percutaneous renal artery interventions Kidney Int 2004 Jan;65(1):251 8 [PMID: 14675057] Nordmann AJ et al Balloon angioplasty versus medical therapy for hypertensive patients with renal artery obstruction Cochrane Database Syst Rev 2003;(3):CD002944 [PMID: 12917937] Safian RD et al Renal artery stenosis N Engl J Med 2001 Feb 8;344(6):431 42 [PMID: 11172181]
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Clinical Findings
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A Symptoms and Signs
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Patients with atherosclerotic ischemic renal disease may have refractory hypertension, new-onset hypertension (in an older patient), pulmonary edema with poorly controlled blood pressure, and acute renal failure upon starting an ACE inhibitor In addition to hypertension, physical examination may reveal an audible abdominal bruit on the affected side Fibromuscular dysplasia primarily affects young women Unexplained hypertension in a young woman is reason to screen for this disorder
B Laboratory Findings
Laboratory values can show elevated BUN and serum creatinine levels in the setting of significant renal ischemia
C Imaging
Abdominal ultrasound discloses asymmetric kidney size when one renal artery is affected out of proportion to the other Three prevailing methods used for screening are Doppler ultrasonography, captopril renography, and magnetic resonance angiography (MRA) Doppler ultrasonography is highly sensitive and specific (> 90% with an experienced ultrasonographer) and relatively inexpensive However, this
Kidney Disease
CMDT 2008
GLOMERULONEPHROPATHIES
Abnormalities of glomerular function can be caused by damage to the major components of the glomerulus: the epithelium (podocytes), basement membrane, capillary endothelium, or mesangium The damage is often manifested as an inflammatory process A specific histologic pattern of glomerular injury can be seen on renal biopsy, one of the most helpful techniques available for defining the cause of glomerular disease Clinically, hematuria, proteinuria, hypertension, and a reduced GFR are typical findings of glomerular diseases presenting as nephritic syndromes; heavy proteinuria (> 35 g/24 h), hypoalbuminemia, hyperlipidemia, and edema are typical findings of glomerular diseases presenting as nephrotic syndromes
is due to volume overload rather than vasoactive substances such as angiotensin II, whose levels are low
B Laboratory Findings
1 Serum chemistries There are no serum chemistries characteristic of nephritic syndrome, but certain special tests are often performed depending on the history and the results of the preliminary evaluation These include complement levels, antinuclear antibodies (ANA), cryoglobulins, hepatitis serologies, ANCA, anti-GBM antibodies, antistreptolysin O (ASO) titers, and C3 nephritic factor (Figure 22 2) 2 Urinalysis The urinalysis shows red blood cells These may be misshapen from traversing a damaged capillary membrane so-called dysmorphic red blood cells Red blood cell casts and moderate degrees of proteinuria are also characteristic of the urinary sediment Placing the patient in a lordotic position for an hour increases sensitivity for finding red cell casts in the next urine specimen 3 Biopsy Renal biopsy should be considered if there are no other contraindications to biopsy (eg, bleeding disorders, thrombocytopenia, uncontrolled hypertension) Rapidly progressive glomerulonephritis is likely when over 50% of glomeruli contain crescents The type of disease can be categorized according to the immunofluorescent pattern and appearance on electron microscopy (Table 22 9)
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