iiiapproach to the patient with renal disease -...
TRANSCRIPT
![Page 1: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/1.jpg)
Approach to the patient with renal disease III .renal disease III .
Dr Lívia Jánoskuti
![Page 2: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/2.jpg)
Complaints, which are directly referable to the urinary tract/1.
• Dysuria-difficulty or pain associated with voiding.Causes:inflammation, stones, tu
• Incontinence-uncontrollable voiding .Paradoxic incontinence-bladder distension caused by incontinence-bladder distension caused by mechanical or functional obstruction-small, frequent, involuntray „overflow „voiding
• Enuresis:unintentional voiding of urin, usually at night-no gross urologic abnormalty
![Page 3: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/3.jpg)
Complaints/2
• Oliguria-low urin flow < 400ml/day Dehydration,reduced effective plasma volumen(heart failure, cirrhosis),renal insuff.,obstruction of the urinary tractinsuff.,obstruction of the urinary tract
• Polyuria-high urin output>1500ml/day Diabetes- mellitus, insipidus, hyperaldosteronism,hyperCa,chr. ren. insuff. salt losing type
• Nocturia-excessive night time passage of urine. Edema,renal insuff,partial obstruction of the bladder
![Page 4: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/4.jpg)
Important features of the history in the
patients with renal disease(RD)• Familial RD:polycystic kidney,hereditary
nephritis, renal calculi
• SystemicD:SLE,diab.mell.hypertension,sic• SystemicD:SLE,diab.mell.hypertension,sickle cell anaemia
• Toxic exposure:heavy metals,radiographic contrasts, drugs (analgetics,NSAID, antibiotics)
![Page 5: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/5.jpg)
Associated symptoms
• General:fever, weight loss, fatigue,skin rash,pruritus, sore throat
• Cardiovascular:dyspnea, chest pain,edema• Cardiovascular:dyspnea, chest pain,edema
• Gastrointestinal:anorexia,nausea,vomiting
• Genitourinary:polyuria,dysuria, flank pain,hematuria, passage of renal stones
![Page 6: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/6.jpg)
Physical examination
• Cardiovasc:hypertension,cardiac failure, percardial rub, edema
• Genitourinary: palpable kidneys or bladder, prostatic enlargement
• Genitourinary: palpable kidneys or bladder, prostatic enlargement
• Neurological:peripheral neuropathy, encephalopathy, asterixis
• Fundoscopic:diabetic retinopathy, hypertensive retinopathy
![Page 7: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/7.jpg)
Urinalysis/1-color
• Colorless: dilute urine( diab mell., diuretics)• Yellow: normal,riboflavin• Amber: concentrated urine,sulfasalazine• Blue-green: biliverdin, methylene blue, • Blue-green: biliverdin, methylene blue,
triamterene• Red: hemat-hemoglobin-myoglobinuria
phenolphtalein,adriamycin• Red-brown: porphyria,urobilinogen, bilirubin
metronidazole, nitrofurantoine• Brown-black: melanin, acidif.of Hbg,alkaptonuria, senna• Milky white: chyluria, pyuria
![Page 8: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/8.jpg)
Urinalysis/2 Chemical assesment
Detect protein,occult blood,glucose, ketones• Semiquantitative(estimate the degree of
urine concentration)urine concentration)• Sensitive to albumin but not to immunglob.,
tubular proteins• The finding of occult blood indicate the
presence of either red blood cells or free Hbg or myoglobin
![Page 9: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/9.jpg)
Urinalysis/3.Microscopic examination - Casts
Red blood cell GN,vasculitis
White blood cell interstitialN, pyeloN
Epithelial cell Acute tub.necrosis Epithelial cell Acute tub.necrosis interstitialN, GN
Waxy,broad Advanced renal failure
Fatty Heavy proteinuria
Hyaline Normal finding in concentrated urine
![Page 10: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/10.jpg)
Leukocyta cast in the tubulus
![Page 11: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/11.jpg)
Cast in the urin sediment
![Page 12: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/12.jpg)
Urin sediment-
CastsCasts
![Page 13: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/13.jpg)
Urinalysis/3.Microscopic exmination - Cells
Red blood cell Urinary tract infection,inflammation
White blood cell Urinary tract infection, White blood cell Urinary tract infection, inflammation
Eosinophil Drug induced interstitial nephritis
Squamous epithelial cell contaminants
![Page 14: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/14.jpg)
Urinalysis/3.MicroscopicLeukocyta
![Page 15: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/15.jpg)
Urin sediment in interstitial nephritis
![Page 16: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/16.jpg)
Urinsediment-
CellsCells
![Page 17: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/17.jpg)
Microscopic examination/3.Crystals
Uric acid Acid urine, acute uric acid nephropathy, hyperuricosuria
Calcium phosphate Alkaline urine
Calcium oxalate Acid urine, hyperoxaluria, ethylene glycol poisoning
Cystine cystinuria
Sulfur Sulfadiazine antibiotics
![Page 18: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/18.jpg)
Urin sediment-Crystals
![Page 19: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/19.jpg)
Investigation of renal function
1.Functional integrity of glom. ultrafiltr. barrier
Proteinuria• Normal excretion is < 150mg/24 hours• Highly selective proteinuria- albumin• Highly selective proteinuria- albumin• Poorly selective proteinuria-higher mol.
weight proteins• Microalbuminuria-increase in albumin
excretion, that are detectable by sensitive immunoassay( predict diabetic nephropath.)
![Page 20: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/20.jpg)
Types of proteinuriaOverflow Abnormal
plasma proteins across normal G
0,2->10grams
Mol.weight
low
<40,000
BenceJones myoglobin
Glomerular Defective > 3-5grams High G.nephritis, Glomerular Defective G.retention of norm.prot.
> 3-5grams High >68,000
G.nephritis, nephrotic sy
Tubular Defective reabsorption of norm.prot.
<2 grams Low
<40,000
Interstic.N. Heavy metal antibiotic injury
Hemodynamic
Increased filtration,decreased reabs.
<2 grams Variable
20,000-68,000
Fever,CHF. Exercise
![Page 21: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/21.jpg)
Investigation of renal function 2.The presence of urogenital inflammation
Leukocyturia• Abnormal > 5 leukocytes per high power field-
Urinary tract infectionUrinary tract infection
• Steril pyuria- tbc
• Steril pyuria+urgency,frequency-nongonococcal urethritis
• +eosinophils-acute allergic interstit.nephritis
• Leukocyta casts=parenchymal disease
![Page 22: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/22.jpg)
Investigation of renal function2.The presence of urogenital inflammation
Hematuria• Abnormal > 2 red blood cell/ high power
fieldfield
• Red blood cell casts+ proteinuria=glomerulal lesion
![Page 23: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/23.jpg)
Causes of hematuria isolated from other urine abnormalities
• Urologic -urogen., tu, renal cyst or tu nephrolithiasis or urolith(usually painful)
• Hematologic – coagulopathies, • Hematologic – coagulopathies, hemoglobinopathies,sickle trait
• Nephrologic – Glom. pathies, especially IgA nephropathy,benign essential hematuria
• Menstruation
![Page 24: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/24.jpg)
Investigation of renal function3.Glomerular filtration rate
Estimates of the mass of functional renal tissue• Creat.clearace(ml/min)=Urine creat(mg/dl) x
volume of urin/plasma creat(mg/dl)Normal range 95-105 ml/min/ 1,75sqmNormal range 95-105 ml/min/ 1,75sqm
• BUN-imperfect quantitative indicator of renal filtration.The liver synthetisized it from ammonia derived from the protein catabolism.The kidney filtered, reabsorbed and secreted it.Normal range 2-8,3 mM/l
![Page 25: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/25.jpg)
Investgation of renal function4.Tubular function
• Renal concentrating and diluting ability The total solute concentration of urine assessed by measurement of urine specific gravidity, which relates the weight of a unit volumen of urine to an equal volume of waterItis only a rough indication of urin osmolality ( higher density solute (glucose, protein, contrasts) have relative higher specific grav.to their osmolalityrelative higher specific grav.to their osmolality
• Normal max. urine osmolality 1000+/- 200mOsm= 1030 spec gravTest:stop fluid intake for 16 hours-til three consecutive urine specimen show no further increase in osmolality.Administer sc.5 U vasopressin,and measure the urine osm.
• Maxc diluting capacity 80 mOsm-1002 spec .gravTest:1200ml water p.os to a fasting patientThree hourly measureement os urin.spec. grav.
Diuretics, and glucosuria impaired the diluting, and conc. capacity
![Page 26: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/26.jpg)
Investigation of renal function5.Acidification capacity
• Urine is more acidic than body fluids because of endogenous production of nonvolatile acids
• In the presence of arterial acidosis ph<7, the urine ph should be < 5,3ph should be < 5,3
• Test for acid.capacity( susp. of distal tub.dysf):
0,1g/kg ammoniumchlorid by mouth-urinary ph must achive 5, or less
![Page 27: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/27.jpg)
Investigation of renal function6.Urinary electrolytes
• Measure the urinary excretion of solute relative to the exr. of creatinin
• The fract.excr. of Na is useful in the diff.dg. • The fract.excr. of Na is useful in the diff.dg. of acute renal failure(>20-40mEq/l)
• The fract.excr.of Ca, Ph, uric acid, amino acids for renal stones and tubular diseases
![Page 28: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/28.jpg)
Imaging studies of the urinary tract
Study Information ConsiderationPlain radiography Renal size, calculi Inexpensive
Ultrasound Size, cysts, tu art/venous flow Doppl.
Noninvasive
Scan Blood flow, tubular func.
Functional study
Iv urogram Size, shape, tu,stones, obstruction
Requiers iv conrast
CT +retroperitoneal space Requires iv contrast
Retrograde urography Ureteral obstruction Invasive
Renal arteriography Renal vasculature, tu. Invasive
Renal venography Thrombosis,. Blood sampling
Invasive
![Page 29: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/29.jpg)
Kidney tu rtg
![Page 30: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/30.jpg)
Kidney tu US
![Page 31: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/31.jpg)
Multiplex tu of kidney CT
![Page 32: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/32.jpg)
Kidney tu MR
![Page 33: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/33.jpg)
Vesicourethral reflux –iv. pyelo
![Page 34: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/34.jpg)
Stone in the urether –iv pyelo
![Page 35: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/35.jpg)
Arteriovenosus malformation-angio
![Page 36: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/36.jpg)
Indications for renal biopsy
• Presumptive presence of glom. diseaseHeavy proteinuria >3- to 5 grams/24hNephrotic syndromeAcute nephritic syndromeAcute nephritic syndrome
• Proteinuria with hematuria• Renal involv. by systemic disease• Unexplained acute renal failure• Persistent acute renal failure ( beyond 2-4weeks)• Renal transplantation- rejection, reccurence of original
disease
![Page 37: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/37.jpg)
Mebranoproliferative GN-histology
![Page 38: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/38.jpg)
Interstitial nephritis -histology
![Page 39: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/39.jpg)
Small vessel vasculitis-histology
![Page 40: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/40.jpg)
The major renal syndromes
• Nonspecific manifestations: hematuria, azotaemia, hypertonia
• Group of findings( history,physical,-• Group of findings( history,physical,-laboratory examinations) may be used to describe some more common syndromes
![Page 41: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/41.jpg)
The major renal syndromes
• Acute renal failure• The nephritic syndrome• The nephrotic syndrome• Nephritic/nephrotic syndrome• Nephritic/nephrotic syndrome• The interstitial nephritic syndrome• Renal tubule defects• Renal cystic diseases• Chr. renal failure• Asymptomatic urinary tract abnormalities
![Page 42: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/42.jpg)
Acute renal failure
Clues:anuria,oliguria,documented recent decline ( some days) in GFR
Prerenal( the underperfusion syndrome)
reduced effective volumen-circ.collapse,cong. heart failure, cirrhosis with ascites
occlusive renal art. dis.-fibrimusc. hyperplasia,artscler, embolia
vasoconstriction of ren. microvasc-acute transplant rejection cylosporin, amphotericin nephrotox.
Postrenal( urinary tract obstruction)
from renal papillae to the urethral meatus
Renal (generally evident from the findings which characterises the acute gloemrulonephritic syndrome)
![Page 43: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/43.jpg)
The nephritic syndrome(glomerular disorder)
Inflammatory and/or necrotizing lesions in the glomeruli
Clues: hypertonia, hematuria,RBC casts, azotaemia, proteinuria,edema
• Primary renal disorders: postinfectious GN, idiopathic • Primary renal disorders: postinfectious GN, idiopathic rapidly progr.GN, Goodpasture sy, hemolitic uremic sy.
• Systemic disorders: vasculitis( SLE,Wegener, Schönlein-Hennoch)
![Page 44: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/44.jpg)
The nephrotic syndrome(glomelural disorder)
Predominantly noninflammatory derangement of the glomeruly, abnormal leakiness of the glom. to albumin and other macromolecules
Clues:proteinuria greater than 3,5g/24h/1,73m2, Clues:proteinuria greater than 3,5g/24h/1,73m2, hypoalbuminaemia, hyperlipideaemia,lipiduria, edema
Primary renal disorders:idiopathic nil dis.,membranosus nephropathy, focal sclerosis
Systemic disorders:Nil dis. in Hodgkin, membranosus nephropathy in SLE, drugs, neoplasms, focal sclerosis in heroin abuse,essential cryoglob.,diabetic nephropathy.
![Page 45: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/45.jpg)
Nephritic/nephrotic syndrome(Glomerular disorder)
Clues:hematuria,massive proteinuria/azotemia,hypertension, edema
Primary renal disorders: membranoproliferative GN type I , type II, mesangioproliferative GN (IgA/IgGnephropathy)type II, mesangioproliferative GN (IgA/IgGnephropathy)
Systemic disorders : vasculitides partialy SLE, diabetic nephropathy
![Page 46: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/46.jpg)
The interstitial nephritic syndrome
The primary abnormality is damage to the tubulointerstitial system of the kidney, with secondary glomerular damage
Clues:hyporeninaemia,hypoaldosteronism,Clues:hyporeninaemia,hypoaldosteronism,
modest salt wasting, hyperkalaemia, hyperchloremic metabolic acidosis
Urinary abnormalities: hematuria,proteinuria usually but not always
![Page 47: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/47.jpg)
The interstitial nephritic syndrome
Three classes1.Chr.tubulointerstit.dis:(proteinuria, casts,azotemia)
hypertension,gout, drugs(NSAID), sickle cell
2.Acute allergic interstit. dis.(eosinophils in the urine, may 2.Acute allergic interstit. dis.(eosinophils in the urine, may be marked hematuria, proteinuria, oliguria): penicillin, NSAID
3.Acute pyelonephritis ( bacterial invasion of the kidney: fever,bacteriuria, pyuria, leukocyte casts,hematuria, mild proteinuria)
![Page 48: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/48.jpg)
Renale tubule defects
1.Prox.tub.defects:glucosuria,aminoaciduria,phosphaturia, bicarbonate wasting
2.Possible loop of Henle( reduced NaCl reabsorption—hypovolaemia- hyperaldosteron-reabsorption—hypovolaemia- hyperaldosteron-hypokalaemia)( Bartter sy)
3.Distal tub. defects:permeable to protons,cannot maintain acid urine
4.Collecting duct defect: nephrogenic diabetes insipidus
![Page 49: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/49.jpg)
Renal cystic diseases(hereditary tubular disorders)
• 1.Isolated simple cysts, or multiple :ren size normal, calyceal system only minimally distorsed
• 2.Adult polycystic kidney:positive family history( autosom
dominant),kidney enlargement, calyceal distorsion. dominant),kidney enlargement, calyceal distorsion. Hematuria, stones, hyertension, flank pain,
• 3.Microcystic kidney of medulla: children,recessive trait,high requirement for salt intake
![Page 50: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/50.jpg)
Chr. Renal failure
• Clues: azotemia for > 3 month, prolonged symptoms and signs of uremia,renal osteodystrophy,bilateral kidney size osteodystrophy,bilateral kidney size reduction, broad casts in urinary sediment.
• Other findings: hematuria, proteinuria, casts,oliguria, polyuria, edema, hypertension, electrolyt disorders
![Page 51: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/51.jpg)
Asymptomatic urinary tract abnormalities
• Isolated hematuria
• Isolated proteinuria
• Pyuria• Pyuria
![Page 52: IIIApproach to the patient with renal disease - Elitegyetemsemmelweis.hu/.../11/Approach-to-the-patient-with-renal-disease.pdf · Approach to the patient with renal disease III](https://reader033.vdocuments.site/reader033/viewer/2022052608/5a7efd9f7f8b9a72118ef1af/html5/thumbnails/52.jpg)
Summary
• Take a good history• Do a correct physical examination• Check the urin characteristics (color, specific
gravidity, protein, sugar content, sediment)gravidity, protein, sugar content, sediment)• Estimate 24h protein content, do a urine protein
ELFO• If necessary, do a urine culture• Check the GFR• Use appropriate imaging methods• If necessary, do a renal biopsy