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• The kidneys are a pair of bean-shaped

organs, each about the size of a fist.
• They are attached to the upper back
wall of the abdomen. One kidney is
just to the left and the other just to
the right of the backbone.
• The lower rib cage protects the
kidneys
• Small glands called adrenal
glands sit above each of the kidneys.
• Each kidney and adrenal gland is
surrounded by fat and a thin, fibrous
layer known as Gerota’s fascia.
What are the functions of the kidney
1. Main function - acts as a ‘filter’
a) To remove toxic and waste products
b) To remove excess water
2. Maintain internal balance of acid and base
3. Maintain calcium and phosphate
4. To produce hormones
a) Erythropoeitin – in red cell production
b) Active Vitamin D – neccessary to maintain strong
healthy bones
• The kidneys’ main job is to filter the blood
coming in from the renal arteries to remove
excess water, salt, and waste products.
• These substances become urine.
• Urine leaves the kidneys through long slender
tubes called ureters, which connect to the
bladder.
• The place where the ureter meets the kidney is
called the renal pelvis.
• The urine is then stored in the bladder until
you urinate (pee).

• They help control blood pressure by making a
hormone called renin.
• They help make sure the body has enough red
blood cells by making a hormone
called erythropoietin. This hormone tells the
bone marrow to make more red blood cells.

• Kidney cancer is a cancer that starts
in the kidneys.

The types of kidney cancer are classified according to
the nature of the cancer cells.

• Renal cell carcinomas: It is the most common type of
kidney cancer that develops in the cortex layer. It is a
violent tumor and it can spread to other parts of the
body.
• Transitional Cell Carcinoma: It is the second common
type of kidney cancer that develops in the renal
pelvis.
• Wilm’s Tumor: It is also known as nephroblastoma
and occurs to the children under the age of 4.
• Clear cell renal cell carcinoma . This is the most common form
of renal cell carcinoma. About 7 out of 10 people with RCC
have this kind of cancer. When seen under a microscope, the
cells that make up clear cell RCC look very pale or clear.
• Papillary renal cell carcinoma. This is the second most
common subtype – about 1 in 10 RCCs are of this type. These
cancers form little finger-like projections (called papillae) in
some, if not most, of the tumor. Some doctors call these
cancers chromophilic because the cells take in certain dyes and
look pink under the microscope.
• Chromophobe renal cell carcinoma.This subtype accounts for
about 5% (5 cases in 100) of RCCs. The cells of these cancers
are also pale, like the clear cells, but are much larger and have
certain other features that can be recognized.
• Renal sarcoma. Renal sarcomas are a rare type of
kidney cancer that begin in the blood vessels or
connective tissue of the kidney. They make up less
than 1% of all kidney cancers.
• Benign (non-cancerous) kidney tumors. Some
kidney tumors are benign (non-cancerous). This
means they do not metastasize (spread) to other
parts of the body, although they can still grow and
cause problems.
• Renal adenoma. The most common benign kidney
tumors. They are small, slow-growing tumors that
are often found on imaging tests (such as CT scans)
when the doctor is looking for something else.

• Oncocytoma. Benign kidney tumors that can
sometimes grow quite large. Oncocytomas do not
normally spread to other organs, so surgery often
cures them.
• Angiomyolipoma. They often develop in people with
tuberous sclerosis, a genetic condition that also
affects the heart, eyes, brain, lungs, and skin. These
tumors are made up of different types of connective
tissues (blood vessels, smooth muscles, and fat). If
they aren’t causing any symptoms, they can often
just be watched closely. If they start causing
problems (like pain or bleeding), they may need to
be treated.

Pathophysiology
• Kidney cancer originates in the kidney in two
principal locations: the renal tubule and
the renal pelvis.
• Most cancers in the renal tubule are renal cell
carcinoma and clear cell adenocarcinoma.
• Most cancers in the renal pelvis are
transitional cell carcinoma.
Signs and Symptoms
• Blood in the urine (making the urine slightly
rusty to deep red)
• Pain in the side that does not go away
• A lump or mass in the side or the abdomen
• Weight loss
• Fever
• Feeling very tired or having a general feeling
of poor health
• Smoking:
Cigarette smoking is a
major risk factor.
Cigarette smokers are
twice as likely as
nonsmokers to develop
kidney cancer. Cigar
smoking also may
increase the risk of this
disease.

• African descent








• alterations in the VHL gene
• chronic kidney disease
requiring dialysis (over
5 years)

• obesity

• hypertension

• male (twofold greater
risk than women)


• exposure to cadmium, asbestos, and
trichloroethylene (a manmade metal degreaser used
in automobile and tool production).


• Physical exam: The doctor checks general signs of health and
tests for fever and high blood pressure. The doctor also feels
the abdomen and side for tumors.
• Urine tests: Urine is checked for blood and other signs of
disease.
• Blood tests: The lab checks the blood to see how well the
kidneys are working. The lab may check the level of several
substances, such as creatinine. A high level of creatinine may
mean the kidneys are not doing their job.
• Intravenous pyelogram (IVP): The doctor injects dye into a
vein in the arm. The dye travels through the body and collects
in the kidneys. The dye makes them show up on X-rays. A
series of X-rays then tracks the dye as it moves through the
kidneys to the ureters and bladder. The X-rays can show a
kidney tumor or other problems.
• CT scan (CAT scan): An X-ray machine linked to a computer takes a
series of detailed pictures of the kidneys. The patient may receive
an injection of dye so the kidneys show up clearly in the pictures.
A CT scan can show a kidney tumor.
• Ultrasound test: The ultrasound device uses sound waves that
people cannot hear. The waves bounce off the kidneys, and a
computer uses the echoes to create a picture called a sonogram. A
solid tumor or cyst can be sorted out using a sonogram.
• Biopsy: In some cases, the doctor may do a biopsy. A biopsy is the
removal of tissue to look for cancer cells. The doctor inserts a thin
needle through the skin into the kidney to remove a small amount
of tissue. The doctor may use ultrasound or X-rays to guide the
needle. A pathologist uses a microscope to look for cancer cells in
the tissue.
• Surgery: In most cases, based on the results of the CT scan,
ultrasound, and X-rays, the doctor has enough information to
recommend surgery to remove part or all of the kidney. A
pathologist makes the final diagnosis by examining the tissue
under a microscope.
TREATMENT
Partial Nephrectomy (Nephron-
Sparing Surgery
• Removing only the cancer and
some surrounding healthy tissue-a
procedure called a partial
nephrectomy-is now considered
the standard of care for the
treatment of small renal cancers.
The main benefit of this approach
is that kidney function is preserved,
which is particularly valuable for
patients who:
• already have poor kidney function
• have only one kidney
• have lesions in both kidneys
(bilateral)
• have an increased tendency to
develop cancer in the other kidney
(inherited diseases)

• it involves removing
most of the
surrounding fat of the
kidney and isolating
and clamping of the
artery going to the
kidney ( renal artery)
as well as the vein
draining from the
kidney ( renal vein) .
The purpose of this is
to render the kidney
free of flowing blood
while one cuts into the
kidney tissue to excise
around the tumor.



• It involves inserting rigid
tubes (ports) through 3 or
4 tiny (0.5-1cm) holes in
the body wall .Long rigid
instruments and a camera
are placed through these
ports thereby enabling one
to operate with the help of
seeing the image on a TV
screen.
• The kidney or other tissue
is placed in a bag when it
has been dislodged from its
attachments inside the
body and one of the
incisions is extended on
the skin to pull the bag
through
• Arterial embolization is a type of local therapy that
shrinks the tumor. Sometimes it is done before an
operation to make surgery easier. When surgery is
not possible, embolization may be used to help
relieve the symptoms of kidney cancer.
• The doctor inserts a narrow tube (catheter) into a
blood vessel in the leg. The tube is passed up to
the main blood vessel (renal artery) that supplies
blood to the kidney. The doctor injects a substance
into the blood vessel to block the flow of blood into
the kidney. The blockage prevents the tumor from
getting oxygen and other substances it needs to
grow.
• Radiation therapy (also called radiotherapy) is
another type of local therapy. It uses high-energy
rays to kill cancer cells. It affects cancer cells only
in the treated area. A large machine directs
radiation at the body. The patient has treatment at
the hospital or clinic, 5 days a week for several
weeks.
• A small number of patients have radiation therapy
before surgery to shrink the tumor. Some have it
after surgery to kill cancer cells that may remain in
the area. People who cannot have surgery may
have radiation therapy to relieve pain and other
problems caused by the cancer.
• a type of systemic therapy. It uses
substances that travel through the
bloodstream, reaching and affecting
cells all over the body. Biological
therapy uses the body's natural ability
(immune system) to fight cancer.

• Chemotherapy is also a type of
systemic therapy. Anticancer drugs
enter the bloodstream and travel
throughout the body. Although useful
for many other cancers, most
anticancer drugs have shown limited
use against kidney cancer.
• Pazopanib- for relapsed or medically unresectable
stage IV RCC.
• Bevacizumab- is a monoclonal antibody that
binds and neutralizes circulating VEGF.
• Temsirolimus- , this medication is a potent and
specific inhibitor of the mammalian target of
rapamycin protein, which is crucial for cell growth
regulation and division. Temsirolimus is a first-line
therapy for patients with relapsed medically
unresectable stage IV RCC and for those who have
relapsed after first-line treatment with sunitinib or
sorafenib.
• Sorafenib- first tyrosine kinase inhibitor
approved by the FDA for the treatment of
RCC in 2005, sorafenib has a role in
blocking VEGF and other receptors.
Coadministration of warfarin may increase
the international normalized ratio and/or
the risk of bleeding.
• Sunitinib- Approved by the FDA for the
treatment of stage IV RCC in 2006, this MKI
blocks the VEGF receptors and others.
STAGES
OF
KIDNEY
CANCER
• The tumor is 7 cm
or smaller and is
only located in the
kidney. It has not
spread to the lymph
nodes or distant
organs


• The tumor is larger
than 7 cm and is
only located in the
kidney. It has not
spread to the lymph
nodes or distant
organs

Either of these conditions:
• A tumor of any size is
located only in the kidney.
It has spread to the
regional lymph nodes but
not to other parts of the
body (T1, T2; N1; M0).
• The tumor has grown into
major veins or perinephric
tissue and may or may not
have spread to regional
lymph nodes. It has not
spread to other parts of
the body

Either of these conditions:
• The tumor has spread to areas beyond Gerota's
fascia and extends into the adrenal gland on the
same side of the body as the tumor, possibly to
lymph nodes, but not to other parts of the body
• The tumor has spread to any other organ, such as
the lungs, bones, or the brain
NURSING
MANAGEMENT
• 1 week before surgery, instruct your patient not to take
anticlotting medications.
• Teach your patient about the post-op use of incentive
spirometry and splinting of his incision.
• Explain the position of your patient's wound and the
limitations he may experience:
-partial nephrectomy: the wound will be directly below the ribs,
running front to back of the affected side
-laparoscopic nephrectomy: there will be multiple keyhole stab
wounds on the abdomen
-radical nephrectomy: there will be an abdominal wound and
possibly a chest wound and drains.
• Offer emotional support and explain to your patient that his
body will adapt to having only one functioning kidney.
• Assess your patient's wound regularly for
redness, inflammation, or swelling and
approximation of the suture line.
• Assess his dressing frequently.
• Reinforce and change his dressing as
needed.
• Measure and record output from all drains
(possible chest tube care for radical
nephrectomy).
• Instruct your patient concerning his pain
control with patient-controlled analgesia or
epidural or I.V. pain medication.
• Encourage and assist him with turning and
deep breathing while splinting the incision.
• Encourage him to perform incentive
spirometry.
• Measure your patient's urine output.
• Monitor his chemistry, especially serum
creatinine levels.
• Make sure TED hose and sequential
compression devices are used correctly.
• Assist your patient to begin walking
immediately post-op.

• Teach your patient proper hand-washing
techniques.
• Explain wound care and that bruising
around the incision site and bilateral
swelling of extremities is common.
• Instruct your patient not to drive, lift
anything, or engage in strenuous or sexual
activity until his 2-week follow-up
appointment.
• Encourage him to consume 2 L of water per
day to maintain hydration.
• Instruct him to take a stool softener as
ordered to avoid straining during bowel
movements.
• Explain the need for regular lab work to
monitor the remaining kidney's function.
• Teach your patient when he should contact
his healthcare provider:
-the wound is painful, red, or inflamed
-fever, pain in the back, or chills are present
-urine is foul smelling or cloudy
-one leg is painful and swollen.

• Administer prescribed analgesics as needed by
the patient.
• Prepare for nephrectomy as indicated.
• Provide symptomatic treatment for adverse
effects of chemotherapeutic drugs.
• Watch the patient for signs and symptoms of
pulmonary, neurologic, and liver dysfunction.
• Monitor laboratory test results for anemia,
polycythemia, and abnormal blood chemistry.
• Watch for adverse effects of radiation or
chemotherapy.
• Monitor the patient’s degree of pain and
assess the effectiveness of analgesics.
• Tell the patient what to expect from
surgery and other treatments.
• Explain the possible effects of radiation
and drug therapy.
• Stress the importance of compliance with
any prescribed outpatient treatment.
• Encourage the patient to express his
anxieties and fears and remain with him
during periods of severestress and anxiety.