BY DR.MANUSHA,

BATCH 2K9

PATIENT WITH KIDNEY DISEASE MAY HAVE A VARIETY OF CLINICAL PRESENTATIONS:

1.S/S THAT DIRECTLY POINT TO KIDNEY

EG:GROSS HAEMATURIA

2.EXTRA RENAL MANIFESTATIONS LIKE EDEMA,HYPERTENSION,SIGNS OF URAEMIA

3.ASYMPTOMATIC(MANY) :INCIDENTAL FINDINGS LIKE RAISED SERUM CREATININE,PROTEINURIA/MICROSCOPIC HAEMATURIA,ETC

BY CAREFUL HISTORY TAKING WE CAN ASSESS THE DISEASE DURATION

BY PHYSICAL EXAMINATION AND SPECIFIC INVESTIGATIONS THE CAUSE(S) FOR THE ACUTE OR CHRONIC ILLNESS CAN BE IDENTIFIED

HENCE THE DD FOR AKI/CKD IS NARROWED

KNOWING THE DISEASE DURATION PROVIDES PROGNOSTIC INFORMATION TO GUIDE THE MANAGEMENT OF AKI/CKD

DEFINITIONS:

AKI:

AKIN CRITERIA:INCREASE IN SERUM CREATININE BY 0.3MG/DL(27MICROMOL/L) OR >1.5TIMESTHE BASELINE VALUES WITHIN 48 HRS

RIFLE AND KDIGO CRITERIA:INCREASE OF >1.5 TIMES THE BASELINE VALUES WITHIN 7 DAYS

CKD:

NKF-K/DOQI NAD KDIGO:GFR<60ML/MIN/1.73M2 OR EVIDENCE OF KIDNEY DAMAGE SUCH AS ALBIMINURA OR ABNORMAL RADIOGRAPHIC FINDINGS WHICH ARE PRESENT FOR THREE MONTHS OR MORE

MANY NUMBER OF DISEASES DOESN’T FIT THIS CRITERIA.

EG:RPGN

BEST ASSESSMENT OF DISEASE DURATION IS DONE BY COMPARING CURRENT AND PREVIOUS LEVELS OF S.CREATININE

EG:

WHEN NO PREVIOUS INVESTIGATIONS ARE AVAILABLE CERTAIN FINDINGS FROM HISTORY AND CLINICAL EXAMINATION SUGGESTS THE DURATION OF DISEASE LIKE

1.RECENT ONST OF S/S

EG:ANASARCA,DISCOLORED URINE

2.OLIGURIA INDICATES ACUTE DISEASE COZPROLONGED OLIGURIA IS NOT ENCOUNTERED EVEN IN ADVANCED CKD PRIOR TO THE NEED FOR MAINTAINEENCE DIALYSIS

3.INCREASE OF S.CREATININE ON A DAILY BASIS –ACUTE ILLNESS EG:ATN

WHILE STABLE VALUES AFTER INITIAL EVALUATION –CKD EG:PRERENAL DISEASE

4.RADIOLOGIC FINDINGS:SMALL KIDNEYS INDICATE CKD WHILE NORMAL SIZE DOESN’T RULE OUT CKD

ECHOGENICITY INCREASED IN CKD

HYDRONEPHROSIS,MULTIPLE RENAL CYSTS CAN HELP IN FURTHER EVALUATION

ANEMIA AND HYPERPHOSPHATEMIA ARE ASSIOCIATED WITH CKD BUT NOT SPECIFIC

INJURY BIOMARKERS(EARLY PREDICTORS –EVEN PRIOR TO THE RAISE IN S.CREATININE)

EG:1.URINARY NGAL

2.KIM-1

3.IL-18

CAUSES AND CLASSIFICATION:

URINE FORMATION OCCURS IN 4 SEQUENTIAL STEPS-

1.BLOOD FROM RENAL.A TO GLOMERULI

2.ULTRAFILTRATE OF PLASMA FROM GLOMERULI INT TUBULES

3.REABSORPTION AND/OR SECRETION OF SOLUTES

AND REABSORPTION OF FILTERE WATER

4.URINE LEAVING THE TUBULAR FLUID----RENAL PELVIS-----URETER---BLADDER-----URETHRA

KIDNEY DISEASE MAY BE CAUSED BY THE INTERFERENCE OF ANY OF THE ABOVE STRUCTURES/FUNCTIONS.

IDENTIFYING PRERENAL OR POST REANAL CAUSE IS OF UTMOST IMPORTANCE COZ THEY MAY BE READILY REVERSIBLE

EARLY RECOGNISTION OF RPGN IS OF PROGNOSTIC VALUE

CLASSIFICATION OF AKI-

1.PRERENAL(DECREASED RENAL PERFUSION)

2.INTRINSIC RENAL

a.RENAL VASCULAR

b.GLOMERULAR

c.TUBULOINTERSTITIAL DISEASE

3.POSTRENAL(OBSTRUCTIVE)

PRERENAL

1.ACUTE:a.ACUTE HYPOVOLEMIC STATES.

EG-ACUTE HAEMORRHAGE,DIARRHOEA,UNREPLENISHED INSENSIBLE LOSSES

b.DECREASED EFFECTIVE CIRCULATING VOLUME

EG-CARDIORENAL SYNDROME AND HEPATORENAL SYNDROME

c.ALTERATIONS IN RENAL VASCULAR AUTOREGULATION

EG-USE OF NSAIDS,IODINATED CONTRAST.

2.CHRONIC:ONGOING HEART FAILURE AND CIRRHOSIS

INTRINSIC RENAL

INTRINSIC RENAL VASCULAR:

ACUTE :1.SMALL VESSEL VASCULITIDES-MAHA INCLUDING TTP,SCLERODERMA AND MALIGNANT HYPERTENSION

LARGE VESSEL INVOLVEMENT:RENAL INFARCTON FROM EITHER AORTIC DISSECTION/SYSTEMIC THROMBOEMBOLISM/RENAL ARTERY ANEURYSM

RENAL VEN THROMBOSIS ASSOCIATED WITH MASSIVE PROTEINURIA IN THE SETTING OF NEPHROTIC SYNDROME

CHRONIC-

NEPHROSCLEROSIS--POLYMORPHISMS ON APOL1 GENE ON 22CHRM---GLOMERULAR SCLEROSIS AND TUBULOINTERSTITIAL FIBROSIS

RENAL A. STENOSIS(ATHEROSCLEROSIS/FIBROMUSCULAR DYSPLASIA)-----ISCHEMIC NEPHROPATHY

RENAL ARTERY DISSECTION/ANEURYSM(FIBROMUSCULAR DYSPLASIA/PAN)------RECCURENT THROMBOEMBOLI----RECCURENT RENAL INFARCTS----LOSS OF KIDNEY FUNCTION

INTRINSIC GLOMERULAR DISEASE-

PRIMARY-IDIOPATHIC

SECONDARY-PARANEOPLASTIC SYNDROMES,DRUG INDUCED/PART OF SYSTEMIC RHEUMATOLOGICAL MANIFESTATIONS

TWO PATTERNS

NEPHRITIC PATTERN-ASS WITH INFLAMMATION ON HPE,ACTIVE URINE SEDIMENT WITH DYSMORPHIC RBCS,OTHER CELLULAR CASTS

NEPHROTIC PATTERN NOT AAS WITH INFLMTN,BUT NEPHROTIC RANGE PROTEINURIA(>3.5G/24HR PROTEIN )IS SEEN WITH INACTIVE URINE SEDIMENT

INTRINSIC TUBULOINTERSTITIAL DISEASE

1.ACUTE-

MULTIPLE MYELOMA---ACUTE INTERSTITIAL NEPHRITIS AND CAST NEPHROPATHY

TUMOURLYSIS SYN(HIGH TUMOR BURDEN LYMPHOMA/FOLLOWING CHEMO)------ACUTE URATE NEPHROPATHY

FOLLOWING PHOSPHATE CONTAINING BOWEL PREPARATION---ACUTE PHOSPAHTE NEPHROPATHY

2.CHRONIC

MC CAUSE PKD

NEXT ARE NEPHROCALCINOSIS,SARCOIDOSIS,SJOGRENS SYN,REFLUX NEPHROPATHY(IN CHILDREN AND YOUNG ADULTS),AND MEDULLARY CYSTIC KIDNEY DISEASE(AD INHERITENCE)

REDUCTION IN GFR REQUIRES B/L OBS ----PROSTATIC HYPERPLASIA/CANCER OR METASTATIC CANCER

RETROPERITONEL FIBROSIS IN UNEXPLAINED HYDRONEPHROSIS

EPIDEMIOLOGY

DEVELOPED ATN AND PRE RENAL DISEASE

DEVELOPING COUNTRIES; SNAKE BITES, EARTH QUAKES, INFECTIONS LIKE LEPTOSPIROSIS

PRESENTING FEATURES: PATIENTS WITH AKI/CKD PRESENT WITH ONE OR MORE OF THE FOLLOWING FEATURES

1.S/S OF DIMINISHED RENAL FUNCTION

EDEMA,HTN,DECREASED URINARY OUTPUT

2.S/S SYMPTOMS OF PROLONGED RENAL FAILURE

WEAKNESS,EASY FATIGUABILITY,ANOREXIA,VOMITINGS,CHANGES IN MENTAL STATUS, AND SEIZURES

3.LAB FINDINGS-RAISED S.CREATININE,HYPERKALEMIA

4.URINE ANALYSIS-ALBUMINURIA AND /OR ABN URINE SEDIMENT

5.INCIDENTAL FINDINGS-PKD/ RADIOGRAPHIC IMAGING FOR OTHER REASON

6.DIAGNOSTIC S/S-

SYSTEMIC S/S AND FINDINGS-FEVER,ARTHRALGIA AND PUL LESIONS-----VASCULITIS/LUPUS

U/L FLANK PAIN-MC WITH OBS,INFARCTN/INFCTN

ANURIA(<50ML/DAY)-SEV SHOCK,B/L UT OBS,PREG RELATED CORTICO NECROSIS/B/L R.A OBS(DISS A.ANEUR)

EDEMA,HTN,HEMATURIA WTH RBC CASTS,RAPIDLY RAISING S.CREAT--AGN/RENAL VASCULITIS

EDEMA,HEAVY PROTEINURIA,LIL /NO HEMATURIA--NON PROL GN(DIABETIC,MEMB.MIN CHANGE)

EVALUATION-

CAREFUL HISTRY TAKING(REVIEW OF MEDICATIONS) AND PHY XMNTN

2.ESTMTN OF GFR

3.URINANALYSIS

4.RENAL IMAGING

5.SEROLOGICAL TESTING

6.RENAL BIOPSY

.

1.HISTORY TAKING-PRVIOUS RADIOCONTRST XPOSURE,REVIEW OF MEDICATIONS,H/O DM

2.PHY XMNTN-SIGNS OF VOL CONTRACTN /+NCE OF PROF DIA RETNPTHY

3.ASSESSMNT OF GFR- S.CREAT IN MILD DECRIMENTS IN ESTIMATED GFR(45-60 ML/MIN/1.73 MSQ)-S.CREAT SHUD BE REPEATED IN 4-8 WEKS, IF IT IS STABLE, FOLLOW IT INTERMITTENTLY. IN PTS WITH S/S OF RAPEDLY PROG DIS. RENAL BIOPSY DONE.

THE eGFR FRM CREATNINE IS USED IN PTS WITH STEADY STATE AND MAY LEAD TO ERRORS IN ESTIMATN OF KIDNEY FUNCTION IN DISEASED PTS

4.URINE ANALYSIS:A)DIPSTICK(TEST FR PROT, PH, GLUC, HB,LEUCOCYTE ESTERASE, SP.GRAVITY) B)MICROSCOPIC XMINATN

PRESENCE OF MUDDY BROWN GRANULAR CASTS AND TUBULAR -DIAGNOSTIC OF ATN(EITHER AS A SOLE CAUSE OR ASS WITH AG VASCULITIS)

DYSMORPHIC RBCS AND RBC CAST--SOURCE OF HEMATURIA--GLOMERULUS

IN NON GLOMERULAR HEMATURIA IN +NCE OF RISK FACTORS FOR UT MALIGNANCY,AGE>40YRS---URINE CYTOLOGY IS THE APPROPRIATE INITIAL STEP

NEPHROTIC RANGE PROTEINURIA ASS WITH >90% OF ALBUMIN ---MORE PROBABLY INDICATIVE OF GLOMERULAR DISEASE

(PROBABILITY INCREASES WITH +NCE OF DYSMORPHIC RBCS,RISING S.CREAT,HTN)

EXCEPTIONS NEPHROTIC RANGE PROTEINURIA WHICH DOESNT INDICATE GLOMERULAR DISEASE IN MASSIVE BENC JONES PROTEINURIA AND IN GROSS HEMATURIA(GLOBINS ARE HIGH)

NORMAL URINANALYSIA-

ACUTE-PRE RENAL DISEASE,UT OBS,HYPERCAL,ACUTE PHOS NEPHRPTHY AND MYELOMA CAST NEPHRPATHY

CHRONIC -NEPHROSCLEROSIS,UT OBS,CRS,HRS

LARGE HEMOGLOBINURIA WITH NO/FEW RBCS--PIGMENT NEPHRPTHY(RHABDOMYOLYSIS/SEVERE HEMOLYSIS)

NO SIGNIFICANT PROTEINURIA WITH DIPSTICK TEST BUT RAISED VALUE OF SPOT PROTEIN CREATININE RATIO---PARAPROTEINS(POSITIVELY CHARGED)

POSITIVE LEUKOCYTE ESTERASE---NO EVIDNC OF UTI---STERILE PYURIA ----INTERSTITIAL NEPHRITIS

--URINE NA+ EXCRETN-

NORMAL<20MEQ/L

CAN AS LOW AS 1MEQ/L IN CASE OF SEV HYPOVOL WITH NORML RENAL FUNCTION

AKI--WITH OLIGURIA --MEASUREMENT OF URINENA+ EXCRETN AND FENa ----DISTINGUISHES PRERENAL AKI FROM ATN

IN PRRERRENAL AZO--TUB FUNCTN INTCT—INCREASED SODIUM AVIDITY IS DUE RENAL HYPOPERFUSN

CKD---NOT INDICATIVE --IN CKD ---CONCNTRTNG CAPACITY OF KIDNEY DECREASES

FENA INCREASES ACC TO INTAKE

URINE VOL--IMP PARAMETER IN PTS WITH KID DISEASE.

IN PTS WITH NON OLIGURIC ATN THE URINE VOL IS NORMAL

OLIGURIA <0.3ML/KG/HR OR <500ML/DAY---MAY/NOT SEEN IN AKI

ANURIA INDICATIVE OF SEV AKI WHICH REQUIRES DIALYSIS

PROGNOSIS OF NONOLIG AKI>OLIG/ANURIC AKI

RADIOLOGIC STUDIES-

UT OBS,KIDNEY STONES,RENAL CYST/MASS, CHARACTERISTIC FINDINGS OF RENAL VASCULAR DISEASE AND VESICO URETERIC REFLUX IN CHILD

HELICAL CT---FLANK PAIN AND POSSIBLE UROLITHIASIS

GAD---NEPHROGENIC SYS FIBROSIS---GAD BASED IMAGING SHOULD BE AVOIDED IN PTS WITH AKI/CKD

SEROLOGIC TESTING:

WITH OTHER RENAL INVSTGTNS-----FURTHER CHARACTERISES THE ETIOLOGY OF KID DISEASE

RENAL BIOPSY-WHEN NON INVASIVE INVSTGTNS HAVE FAILED TO DIAGNOSE THE CONDITION

MAJOR INDICATIONS IN ADULT PATIENTS ARE-

1.NEPHROTIC SYNDROME

2.ACUTE NEPHRITIC SYNDROME

3.UNEXPLAINED ACUTE/RAPIDLY PROGRESSIVE KID DIS

4.PROGRESSIVE CKD OF UNKNOWN ETIO

5.UNEXPECTED DETERIORATION OF GEN CNDTN OF A PT WITH KNOWN CKD

SUMMARY:

1.PTS PRESENTS WITH DIFF CLINICAL PRESNTATIONS.COMPONENTS OF DIA APPROACH-

1.CAREFUL HSTRY TAKING,PHY XMNTN,ASSESSMNT OF RENAL FUNCTN,URINANALYSIS,IMAGING STUDIES,SEROLOGY AND BIOPSY IF NECCESSARY

2.DEF OF AKI AND CKD

3.CLASSIFICATION OF AKI-PRERENAL,ITRINSIC RENAL AND POST RENAL.

4.PTS WITH AKI/CKD MAY PRESENT D/T DIMINISHED KID FNCTN/PROLONGED RENAL DISEASE,LAB FINDNGS--RAISED S.CREAT,HYPERKALEMIA,ALBUMINURIA,ACTIVE URINARY SEDIMENT

,RADIOGRAPHIC FINDNGS

5.ONCE KID DIS DISCOVERED----ASSESS THE DEGREE OF DYSFUNCTION AND IDNTFY THE CAUSE

REVIEW OF MEDICATIONS,GLYCEMIC CNTRL,PHY XMNTN,ETC

IN PTS WITH RAISED S.CREAT WITH UNCLEAR ETIO DO USG ABD

PT WITH NORMAL RENAL IMAGING WITH MINIMAL PROTEINURIA AND BENIGN URINE SEDIMENT ---FURTHER EVALUATION REQUIRED

----SPEP AND UPEP SHOULD BE DONE ----ABNOR-----IMMUNOFIXATION OR SERUM FREE LIGHT CHAIN ASSA

PTS WITH HIGH RISK OF MULTIPLE MYELOMA---INTIAL EVALUATION WITHSPEP,UPEP,IMMUNOFIXATION,SERUM LIGHT CHAIN ASSAY

FOR PTS WITH UNREMARKABLE INITIAL WORK UP FURTHER EVALUATION IS REQUIRED

AMONG PTS WITH MILD DECREMENTS IN EGFR (45-60ML/MIN)----REPEAT S.CREAT AFTER4-8 WKS

IF S.CREAT IS STABLE--- EVALUATE INTERMITTENTLY