AVN of the Hip

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Avascular Necrosis (AVN) is the death of bone tissue as a result of the lack of blood supply to the bone and its surrounding tissue; in this case, specifically the hip area. This blood supply often leads to collapse of the bone, and if it occurs in a joint space - the collapse of the entire joint.

Causes of AVN:

Trauma to the hip

Steroid Use

Heavy Drinking

Sickle Cell Anemia

Gaucher's disease

Lupus

Decompression disease - bends

Cancer tx - chemo/radiation therapy.

Symptoms of AVN of the hip:

Pain in the groin, thigh, and knee. This pain usually worsens with standing or walking.

Testing for AVN

Hip Radiographs, early stages of AVN may not be a prominent on radiographs as compared to later stages of AVN being evident of radiographs.

MRI of the hip can show early bone degeneration's that may be a result of AVN.

Laboratory test such as bone biopsy may also be used as additional resources.

TX:

Medications - NSAIDS - for pain relief

Rest - restriction of physical activities

Physical Therapy to improve range of motion

Surgery such as decompression, bone reshaping, bone transplant, and joint replacement

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Polycystic Kidney Disease

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Polycystic Kidney Disease is an autosomal dominant genetic disorder. It is the most frequent cause of renal failure among adults. It is also responsible for 6-8% of dialysis patients in the United States. Polycystic Kidney Disease is a multisystemic progressive disorder that is characterized by the formation and enlargement of renal cysts in the kidney and other adjacent abdominal organs such as: liver, pancreas, and spleen. It is also characterized by the bilateral cystic dilation of the renal tubules, which may lead to end-stage renal disease. Hepatic cysts, cerebral aneurysms, and cardiac valvular abnormalities are also possible. The disease can be classified either PKD1 and PKD2. PKD1 is expressed as an abnormality in the short arm of chromosome 16. PKD2 is expressed as an abnormality in the long arm of chromosome 4.

PKD is slightly more severe in males than in females.
PKD symptoms generally increase with age.
The major causes of morbidity is the progressive renal dysfunction, and results in grossly enlarged kidneys and kidney failure.
Over half of patients with PKD undergo kidney transplant by the age of 60 years old.

Signs/Symptoms:
A decrease in urine concentration.
Hypertension
Abdominal Pain - flank or back: related to kidney enlargement, cystic enlargement, bleeding, perinephic hematoma, or urinary tract infections.
Hematuria
Palpable bilateral abdominal flank mass
Pallor
Uremic fetor
Dry skin
Edema

Testing
Lab Tests such as serum chemistry profile; including calcium and phosphorus, a complete blood cell count, urinalysis, urine culture, uric acid determination, and intact parathryoid hormone value.

Ultrasound is the most widely accepted imaging technique for diagnosis of PKD because it does not use radiation or contrast material. It can diagnosis cysts up 1-1.5cm, as well as detect extrarenal abdominal features.
CT scan is a more sensitive imaging modality because it can detect renal cysts as small as 0.5cm but because of the use of radiation and contrast material it is not routinely used for diagnosis.
MRI is more sensitive than either ultrasound or CT, especially in determining the difference between PKD and Renal Cell Carcinoma. It is also the best imaging tool for monitoring kidney size after the patient has undergone treatment in order to assess progress.
Intravenous Urography (IVP) was once the most widely used and popular tool for diagnosing PKD. However, with the evolution of ultrasound, IVP has been replaced mainly because of its requirements of contrast material and radiation doses.

Medical Therapy for treatment of PKD
Control Blood Pressure
Use of ACE inhibitors
Control associated disorders hyperkalemia, hyperphosphatemia, hypocalcemia, hyperparathyroidism, acidosis).
Treat urinary tract infections
Reduce abdominal pain, avoid use of anti-inflammatory NSAIDS
Patients with PKD and End Stage Renal Disorder may need to undergo hemodialysis, peritoneal dialysis, or renal transplantation.

Surgical Intervention for treatment of PKD
Surgical drainage of infected cysts may be necessary if the infection has not responded to antibiotics. This is often done under the guidance of ultrasound.
Surgical removal of one or more renal cysts for pain management purposes.

Prognosis
PKD patients should maintain a low sodium diet, and avoid any contact sports that would apply direct trauma to the kidney's. These patient's should have their blood pressure regularly monitored as well as renal ultrasounds every 1-2 years. PKD1 patients will typically require renal replacement therapy by the age of 53, whereas, PKD2 patients will usually hold until 68.

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