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NBME 21 Answers

nbme21/Block 3/Question#12

A 55-year-old man with hypertension comes to the ...

Left renal artery atherosclerosis

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 +3  upvote downvote
submitted by rocmed(-3),

Can't renal cell carcinoma cause invasion of the renal artery, obstructing blood flow (resulting in a bruit), thereby upregulating RAAS and increasing blood pressure?

rocmed  And isn't smoking also a risk factor for RCC? +  
lispectedwumbologist  It is but RCC tends to present later in life (6th or 7th decade). In a 55 year old smoker, atherosclerosis of the renal artery is am much more common cause of bruits +  
seagull  Hypertension is also a risk factor of an atherosclerosis leading to more inflammation. Eventually dilation (aneurysm) might occur... if im wrong then ignore this +  
seagull  Hypertension is also a risk factor of an atherosclerosis leading to more inflammation. Eventually dilation (aneurysm) might occur... if im wrong then ignore this +  
illogical  Renal Cell Carcinoma has a tendency to invade the Left Renal **Vein** (Pg 134, Pathoma 2018). Thus it has an association w/ obstructed drainage of the Left Spermatic Vein leading to a varicocele. Renal artery stenosis is more commonly due to atherosclerosis (almost 85-90%) or fibromuscular dysplasia. +6  
ratadecalle  With RCC and renal vein invasion you would see B/L lower edema and venous collaterals in the abd wall (Uworld). Also he has a severe headache and confusion which are signs of a hypertensive emergency. +  

 +0  upvote downvote
submitted by usmleuser007(90),

For RCC: (As per UWORLD)

Symmetric bilateral lower extremity pitting edema and tortuous abdominal veins are concerning for an inferior vena cava (IVC) obstruction, which, in the setting of a left-sided flank mass, suggests renal cell carcinoma (RCC) with extension into the IVC.  RCC accounts for >90% of all malignancies arising in the kidney and is highly associated with smoking.  Patients with RCC classically have a triad of flank pain, palpable mass, and hematuria, although many remain asymptomatic until the disease is advanced. RCC is a highly vascular tumor that invades the renal vein in up to 25% of cases.  IVC obstruction can occur due to intraluminal extension and thrombus formation, rather than mass effect from the tumor itself. 

The obstruction can occur acutely or gradually over time.  In chronic cases, collateral venous circulation may develop based on the site of the obstruction.  Prominent abdominal wall collateral veins, as in this patient, suggest obstruction of the upper segment of the IVC.

nor16  high blood pressure, i.e. Hypertension, risk factors for atheroscl., bruit !!! over left abdomen, secondary art. Hypertension. they always want the renal artery stenosis (like vWF in coag. disorders...) +  

 +0  upvote downvote
submitted by usmleuser007(90),

Just realized that renal cell carcinoma isn't the correct answer b/c it invaded the venous circulation and not the arterial. BP may not be affected as much. if RCC were the answer then then there would have been edema present and/or renal HTN.

sympathetikey  Also, just thinking out loud, in the case of RCC, it's the kidney tissue that's dysplastic & moving, so technically the renal artery itself isn't dysplastic, right? +