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RENAL TUMORS

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Introduction

Understanding the kidneys

One of the major organs in the human body is the kidney. Both kidneys, for those who

have them, and a single kidney performs several physiological functions that help in retaining the

body at normalcy. Anatomically, each kidney is located on the right and left of the backbone,

attached to the upper back wall of the abdomen and just below the rib cage. Superior to the

kidneys is the adrenal gland, which rests above each kidney. A fibrous layer called the Gerota’s

fascia surrounds these two kidneys and the adrenal glands (Lote, 2012).

The primary function of the kidney is the filtration of blood that is supplied to it through

the renal arteries. This aids in the regulation of the water and electrolytes to remain in balance.

The filtration is done to remove the excess water, salts as well as other waste products, including,

urea, creatinine, uric acid in the form of urine. The urine is injurious to health if it continues to

stay in the body. Therefore, urine is passed out of the kidneys through the ureters located at the

renal pelvis and into a temporary storage known as the urinary bladder. Finally, the urine

ultimately gets out of the body through to the urethra (Lote, 2012).

There are other functions of the kidney. It regulates blood pressure through the activation

of the renin-angiotensin system, aided by the hormone renin, which it produces. The kidneys are

also crucial in the erythropoiesis through the hormone erythropoietin, which works hand in hand

with the bone marrow in the production of the red blood cells. The kidneys also produce the

calcitriol, which is the active form of vitamin D. gluconeogenesis is another process that the

kidney is involved. The other function the kidney takes part in is the regulation of the balance

between the acid and base. The kidney can do this through the nephrons as well as the collecting

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tubules. Therefore, any breakdown in the normal functioning of the kidneys leads to pathological

conditions that may affect a single function, or the whole function, as in kidney failure, and the

effect will be felt in the entire body. The pathology may come through various paths, leading to

separate or combined results as will be discussed in this research paper (Lote, 2012).

Understanding Renal Tumors

Pathophysiology

The cells of the human body react differently to particular stimulating factors. When the

cells of the kidney become malignant, they proliferate abnormally out of control, growing into a

tumor. Most often, these cancerous growths appear along the epithelial linings of the kidney

tubules. The cancerous growth occurs sporadically as well as from hereditary conditions.

However, both result in the alteration of chromosome 3p.The alteration is in the short arm.

Studies reveal that the most common cancer of the kidney, in about nine out of every ten people,

is the renal cell carcinoma (RCC). Pathologically, RCC grows, usually, as a single tumor.

However, in specific pathological presentations, two or more tumors may be present within one

kidney, or worse, different tumors in the separate kidneys (Lara & Jonasch, 2015).

Common Renal Tumors

Lara & Jonasch (2015) further reveal that the most common renal tumor is the clear cell

renal carcinoma, which is found in up to 7 out of 10 people who present with renal carcinoma.

The second most common carcinoma is the papillary renal cell Carcinoma, which gets its name

from its characteristic of forming papillae. Research reveals papillary renal carcinoma to be in

about a single case or two in every ten people with the RCC. The third most prevalent renal

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tumor is the chromophobe renal cell carcinoma. Research estimates that it accounts for about 5%

of the RCC.

In rare cases do we find RCC labeled as ‘unclassified.' This classification is because other

unique types of RCCs include neuroblastoma- associated RCC, renal medulla carcinoma, spindle

cell and mucinous cell carcinoma, collecting duct RCC, and the multinodular cystic RCC.

Others include the transitional cell carcinoma, Wilms tumor, which is common in children, and

the renal sarcoma (Lara & Jonasch, 2015).

Benign Kidney Tumors.

The benign kidney tumors do not metastasize. However, they can grow into sizes that

cause pathological conditions. Often, the benign tumors are treated by surgical removal or

through the same treatments used for the other cancers of the kidney. Besides, the choice of

treatment is determined by various factors, which may include size, the symptoms and the

location of the tumor.

The renal adenoma stands out as the most common benign tumor of the kidney. They are

characterized by slow growth, and they resemble the slow-growing RCCs. Often, it is hard to tell

it apart from the RCC. The other common benign renal tumor is the oncocytoma, which is also

at times difficult to tell apart from the other kidney tumors. Research reveals that oncocytomas

do not spread to the surrounding organs, so they often do not need surgery as a cure.

Angiomyolipoma is another benign tumor. They are rare. However, this cancer is often

seen in people with the tuberous genetic sclerosis, which also affects the skin, lungs, brain and

the eyes. Angiomyolipomas are made up of blood vessels, fat and smooth muscles. They only

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need treatment if they cause pain or bleeding. Otherwise, the management remains to be

monitoring.

Risk Factors for Renal Tumors

Renal tumors have many risk factors that work in combination to form the different

resultant pathologies. Rayner et al. (2016) have given the following risk factors that could make

a person more likely to develop cancer of the kidneys.

1. Smoking. The increased smoking behavior increases the chances of one developing the

disease and vice versa.

2. Obesity. Obesity changes the hormonal balance in the body, which may in turn overwork

the kidneys leading to RCC

3. Genetic predisposal. Presence of a positive family history of renal cancer means that the

subsequent generations have a higher risk of developing cancer. This is most common among

siblings, especially because of the directly shared genes. Diseases like the Von Hippel-Lindau

disease, tuberculosis sclerosis, the Birt-Hogg-Dube syndrome, the Cowden syndrome, and

hereditary renal oncocytoma also increase the risk of renal tumors.

4. Environmental exposure. Many studies have suggested that the environment in which one

works may expose him or her to substances like cadmium metal, organic solvents, and even

some herbicides, which are injurious to the kidneys.

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5. Hypertension. Some studies have hinted that certain anti-hypertensive drugs may raise the

risk of renal workload, which may lead to RCC. For example, diuretics have been suggested to

increase the risk of RCC.

6. Kidney disease. Advanced kidney diseases, for example, those that need continuous dialysis

make one at a high risk of developing renal disease.

7. Gender. Renal cancer is proven twice as common in men as compared to women. Scientist

suggests that this is because men are more at risk of smoking as well as working in places with

toxic chemicals.

8. Race. Research reveals that being an African American or Native American increases the

chances of developing renal cancer. However, scientists are still researching the reason behind

this risk is higher in these races.

The Symptoms of Renal Tumors.

Rayner et al. (2016) state that most often, the symptoms do not show at the early stages

of the disease until the later stages of the disease. In fact, researchers found out that renal tumors

are diagnosed when a patient is being examined for other conditions or health reasons. Therefore,

the tumor may be revealed on an ultrasound or a scan, for example, CT scan, before a person

experiences an anomaly in the body. Important to note is that the symptoms of the kidney tumors

are similar to the ones caused by other illnesses of the renal system, for example, kidney stones

and infections of the urinary bladder.

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Common symptoms, according to Rosette et al. (2008) include:

1. Hematuria. This is common as an early symptom. However, the quantity of blood in the

urine varies. Visible amounts of blood make the urine to have a characteristic of a pink

tint. Also, the blood may also be in minute quantities and thus, can only be detected in the

urinalysis lab test.

2. Anemia. This is a common symptom secondarily because of the hematuria or the

limitation of erythropoiesis or both. This anemic state also leads to fatigue, dizziness,

palpitations and generalized body malaise.

3. Weight loss. The loss of the body weight is commonly unexplained. The cancerous cells

out-compete the healthy blood cells for the nutrients present in the blood, resulting in the

weight loss. The weight loss is often accompanied by fever and fatigue.

4. Lump. Kidney tumors, especially those caused by RCC, may grow very large, producing

noticeable lumps that may present by extending outward from the body. Commonly, the

lump is localized low in the abdomen, either on the back or under the rib cage. However,

for the lump to be noticeable, the renal tumor must be equally large.

5. Lower back pain. When the tumor has grown, it stretches on the surrounding tissues

causing pain. The pain is felt in the lower back and laterally below the rib cage. The

character of the pain remains steady.

6. Fever. The fever often results from the process of the immune system fighting infection.

The temperature is persistent even after treatment of any other illness.

7. Pedal Edema. This symptom is secondary to the excess fluid formation in the interstitial

space as the hydrostatic and oncotic pressures become unbalanced and the restraining of

the venous return of blood.

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8. Generalized fatigue. This may be secondary to incomplete kidney function that also

leads to retained toxins. Besides, loss of blood also weakens the body.

Other symptoms may present singularly or in combinations. They include:

Loss of appetite

Bone pains.

When cancer has metastasized into other body parts, it may also present with the following:

 Shortness of breath

 Hemoptysis

 Skin lesions.

On physical examination, the patient often presents with gross hematuria and is pale with a

tumor size of 3-24 cm. Besides, there is general body wasting, pain in the flank and a palpable

mass on the abdomen.

Diagnosis

According to Rayner et al. (2016), it is essential to carry out the necessary confirmatory tests

that aid in diagnosis and staging the renal cancers. These tests include:

i. Urinalysis, primarily to detect hematuria.

ii. Kidney function tests to reveal the physiological status of the kidneys.

iii. Abdominal ultrasound to know whether the tumor is filled with fluids or is solidified.

iv. Intravenous pyelogram

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v. CT scan, which is preferred to intravenous pyelogram and ultrasound.

vi. Renal arteriogram to evaluate the levels of blood supply to the tumor. It usually helps in

diagnosing small tumors.

Illnesses That Can Lead To Misdiagnosis.

Two central diseases present the same way as the renal tumors and are commonly lead to

misdiagnosis of renal tumors. The first illness is the tuberculosis sclerosis complex (TSC) which

forms lesions in the kidney and looks similar to a cancer of the kidneys. The other disease is the

renal endometriosis, which is commonly confused with SRC. It is important to seek further

investigations to know the real diagnosis (Rosette et al., 2008).

Treatment of Renal Tumors.

The treatment of the renal tumors depends on the staging and health status of the patient.

However, stage I, stage II and stage III have a similar management. Depending on the doctor’s

judgment, these cancers are surgically removed through two major approaches:

a) The radical nephrectomy, where the whole kidney is removed. At times, like in stage

III, the surrounding lymph nodes may be removed as well.

b) Partial nephrectomy, which involves the removal of part of the kidney. This method is

preferred in tumors that are less than three inches in size.

After the surgery, adjuvant therapy follows. This treatment includes targeted therapy,

immunotherapy, chemotherapy, and radiotherapy. When the operation cannot be done due to

unavoidable reasons, local therapies like radiofrequency ablation, cryotherapy, and arterial

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embolization become the choice of management. Besides, for the smaller tumors, active

surveillance is also used (Bukowski & Novick, 2008).

For the stage four where the tumor has turned into widespread cancer, the management

depends on the level of spread as well as the state of health of the person. Surgery may still be

used as part of the control. However, the choice of treatment is by the use of a targeted therapy

regimen or cytokine therapy. Also, pain should be managed in all the stages, especially for the

fourth stage (Bukowski & Novick, 2008).

The Typical Work Up In Addressing Patients with Renal Tumors

It is vital that the patients get the analgesics as prescribed and monitor the pain. In

addition, the patients who need surgery should be prepared. The signs and symptoms of the

patients should be monitored and symptomatic treatments given for the side effects or adverse

chemotherapy reactions. The laboratory blood results should be monitored, especially for anemia

as well as any abnormal blood chemistry. Penultimately, the patients should be made aware of

the possible side effects of the drugs and radiations. Also, the patients should be encouraged on

compliance to treatment.

Screening Recommendations for Renal Tumors.

All the people who have inherited conditions in their family are often advised to go for

frequent screenings because they are at risk. , in most cases, another group that needs to go for

testing are those who have had long-term treatment of kidney diseases and have been put on

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dialysis for life. The third group that needs screening are those who have had radiations due to

kidney diseases. Chain smokers, the overweight and patients with heart conditions, should screen

for kidney cancers secondary to the fact that they are at a higher risk of developing renal tumors

(Lara & Jonasch, 2015).

The Support System in Renal Tumors.

The support system is a collaborative activity that includes the patient, healthcare

provider and the friends and relatives. It is essential to set up a support system or have the patient

to join the support groups. These groups decide on the frequency and the method to be used,

whether online or by the use of a phone. The main aim of the support group is to help the patient

in coping and in being optimistic by expressing their feelings and concerns. It is essential to

make them free of pain and allow them to remain physically comfortable. The patients who are

in the advanced stages of renal cancer and have few months to live should be advised on taking

hospice care. Besides, nursing care should majorly focus on reducing stress (Rayner et al., 2016).

Beneficial Referral of the patients with renal tumors.

The most beneficial referral of a patient with renal tumor comes by prioritization. For

example, the patients with a glomerular filtration rate, which is less than 30mL per minute, need

an urgent transfer to receive the living donor transplantation. In addition, patients who show

abnormal abdominal screening should always be referred for specialized treatment regardless of

the tumor size, because the surgical excision of the tumors that produce hormones is the only

remedy. Another beneficial referral is that of a patient who is above45 years and had hematuria

without any infection in the urinary tract. The same case to refer is a patient with above 45 years

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who keeps on having hematuria even after the successful treatment of urinary tract infections.

Lastly, all the patients who have had a positive history of any other malignancy need specialized

care and need to be referred to specialized care units (Rosette et al., 2008).

Ways in Optimizing Compliance of Patients with Renal Tumors.

Targeted sequential therapy is the standard treatment of renal cancers. The method uses

vascular and endothelial agents that target the growth factor. However, to maximize the patients’

adherence to the therapy, the tolerability profile of the patient should be known. With the

knowledge of the therapy, the prevention and management of the adverse event (AE) are critical.

The care nurses should educate the patients on their condition, AEs of the therapy and

compliance to treatment. It is also essential to have counseling sessions with the patient,

communicate openly, and relinquish the control of the counseling sessions and persuading the

patient to have hope in the healing process (Bukowski & Novick, 2008).

Conclusion

Renal tumors are now characteristic as compared to the early 1990s. Much needs to be

done concerning preventing the development of renal cancers, and worse, metastasis to the other

body systems. Prevention measures that include regular water intake, exercise, and healthy

dieting should remain the priority in any homestead (Rosette et al., 2008). It is paramount to see

a doctor earlier so that interventions are made, and the chances of cure increased. Lastly, support

to those with renal cancers should be advocated so that their prognosis is improved.

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References

Bukowski, R. M., & Novick, A. C. (2008). Clinical management of renal tumors. Totowa, NJ:

Humana Press.

Lara, P. N., & In Jonasch, E. (2015). Kidney cancer: Principles and practice.

Lote, C. J. (2012). Principles of renal physiology. New York, NY: Springer.

Rayner, H., Thomas, M., & Milford, D. (2016). Understanding kidney diseases.

Rosette, J. J. M. C. H., Sternberg, C. N., & Poppel, H. P. A. (2008). Renal cell cancer: Diagnosis

and therapy. New York: Springer.

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