PATHOPHYSIOLOGY OF KIDNEY DISEASES

Cases

Klára Bernášková, MD, Ph.D., Karolína Krátká, MD, Ph.D.

Case 1Acute pyelonephritis

Female, 29 yearsHistory + examination

• Past disease: insulin – dependent diabetes mellitus• Current complaints: She was treated for a urinary tract infection. Twelve days later, she presented with persistent flank pain.

• moderately ill-appearing woman, afebrile, BP 170/100mmHg, PR 100/min, she did not appear to be dehydrated, costo-vertebral angle tenderness on the left and left lower quadrant (abdominal) tenderness with guarding, but without rebound tenderness.

Female, 29 yearslaboratory assessment

Plazma Urinalysis

sodium 127 mmol/l 135-146 mmol/l appearance Pink/cloudy

potassium 5 mmol/l 3,8-5,5 mmol/l glucose 2 + 0

chloride 92 mmol/l 97-108 mmol/l ketones 1 + 0

bicarbonate 17 mmol/l 24-32 mmol/l protein 2 + 0

glucose 30 mmol/l 3,3-5,6 mmol/l sediment many ery, leuko

urea 16 mmol/l 2,8-8,3 mmol/l cultures negative

creatinine 140 umol/l 53-97 umol/l

leukocytes 12.109/l 4-10.109/l

neutrophils 70 % 50-60 %

bands 12 % 5 – 7 %

Female, 29 years, acute pyelonephritis, questions

• What is the probable cause of the patient´s

renal problem?• How does the urinalysis support the

diagnosis?• What do you think the decreased bicarbonate

value (normal = 24) means?• What do you think of the patient´s urea and

creatinine values?

Case 2Chronic glomerulonephritis

Female, 30 years, teacherHistory + current complaints

• Past diseases: common child diseases

appendectomy at 10

no other serious disorders

• Current complaints:

She developed ankle edema and mild swelling of the

face a week ago. During the week her edema

increased. She feels tired, she has feelings of

heaviness in the legs due to edema. Her urine

volume is low. She has no other complaints.

She feels no pain, she can breathe well.

Female, 30 years, chronic GNExamination

• BP 120/80mmHg, PR 78/min, BT 36,50C,

mild diffuse swelling of the subcutaneous

tissue in the whole body, mainly in the face.

Percussion of the chest clear, dull over the base of

the right lung (5cm). Breathing sounds vesicular,

decreased above the base of the right lung.

Symmetrical pitting edema of both legs up to the

knees. Muscles of the calf soft, unpainful.

Female, 30 years, chronic GN laboratory assessment

Blood count Urinalysis

leukocytes 5,3.109/l 4-10.109/l protein +++ -

HGB 120 g/l 140-180 g/l urinary sediment normal

HTK 35 35 – 45 proteinuria 18 g/24h 0/24h

PLT 250 140-440.109/l Creatinine clearance

2,3 ml/s 1,3-2,5 ml/s

Plazma

sodium 130 mmo/l 135-146 mmol/l

potassium 4,0 mmol/l 3,8-5,5 mmol/l

urea 6,5 mmol/l 2,8-8,3 mmol/l

creatinine 85 umol/l 35 – 100 umol/l

albumin 18 g/l 32 – 45 g/l

cholesterol 8,2 mmol/l do 5,5 mmol/l

Female, 30 years, chronic GNquestions

• What is the etiology of edema in this patient? How can you call the association of symptoms described in this patient?

• Is it possible to establish a diagnosis of the disorder with the information that you have? Try it or make some options.

• What examinations do you recommend in this case?

Female, 30 years, chronic GNquestions (2)

• What complications can occur in this patient?

• Explain pathological laboratory findings.

Case 3Cardiorenal syndrome

Male, 62 years, lawyerHistory

• Family history: Father passed away at 53 following myocardial

infarction, mother has diabetes,

brother is healthy, daughter is healthy• Past diseases: common child diseases,

medication for high blood pressure since the age

of 40, cholecystectomy at 45 because of stones,

impaired glucose tolerance discovered at the

age of 50, he goes to diabetologist regularly,

diet management• Habits: he´s been smoking for 20 years 25 cigarettes daily.

Alcohol – he drinks 2-3 glasses of wine and a glass of

whisky every day.

Male, 62 years, cardiorenal failurecurrent complaints

• He got mild pressure on the chest, sweating and

difficult breathing 2 days ago, he took some

painkiller, his symptoms improved, but did not resolve

completely. He did not feel well the following day

(yesterday), but he had no more chest pain, only mild

pressure on the chest which resolved completely

during the day.

Male, 62 years, cardiorenal failurecurrent complaints (2)

• Then he woke-up in the middle of the night,

he could not breathe, he was sweating a lot, he got

head - spinning. His breathing was better in sitting

position then in recumbent position. He called for

emergency, he was brought to the hospital and

admitted to the intensive care unit 4 hours ago.

Urinary catheter was introduced after admission.

His urine output per hour was 50ml..20ml..0ml.

Male, 62 years, cardiorenal failureexamination

• BP 80/40mmHg, PR 110-160/min irregular, BT 36,90C, patient lying with elevated head and chest, somnolent, apathic, pale, grey colour of skin, light bluish ,,marble-like´´spots at the extremities. Sweating, tachypneic, dry tongue, jugular veins filled to the angle of mandibula. Percussion of the chest clear, breathing sounds vesicular with unaccentuated inspiratory rales over half of the lung fields

Male, 62 years, cardiorenal failureexamination (2)

• Left border of the heart by percussion in the anterior axillary line. Heart sounds irregular, rapid, gallop. Abdomen above the chest level, mild distension, lower border of the liver palpable 4cm below the right costal margin, spleen not palpable, sporadic bowel sounds, ankle edema.

Male, 62 years, cardiorenal failure laboratory assessment

Blood count Blood gas analysis

leukocytes 15,3.109/l 4-10. 109/l pH 7,52 7,4

HGB 130 g/l 140-180g/l bicarbonate 24 mmol/l 22-26 mmol/l

HTK 42 39-49 pCO2 3,5 kPa 4,8-5,9 kPa

PLT 152 140- 440.109/l pO2 6,5 kPa 9,9-14,4 kPa

Plazma BE 0 -2,5-2,5 mmol

sodium 133 mmol/l 135-146 mmol/l Enzymes

potassium 4,5 mmol/l 3,8-5,5 mmol/l Troponin I highly elevated

glucose 8,2 mmol/l 3,3-5,6 mmol/l ALT 3,5 ukat/l up to 0,8 ukat/l

urea 11 mmo/l 2,8-8,3 mmol/l AST 3,4 ukat/l up to 0,6 ukat/l

creatinine 135 mmol/l 53-110 mmo/l ALP 2,0 ukat/l up to 2,7 ukat/l

cholesterol 7,5 mmol/l up to 5,5 mmol/l GMT 1,3 ukat/l up to 1,1 ukat/l

triglycerides 3,2 mmol/l up to 1,8 mmol/l

Male, 62 years, cardiorenal failure laboratory assessment (2)

• Concentration of Na in the urine 1 hour after

the admission…10 mmol/l

Male, 62 years, cardiorenal failurequestions

• What is the reason for anuria in this patient? • Which type of renal involvement plays a role?

How can you interpret the urinary sodium

concentration? • What is the underlying main disease of the patient –

reason for admission?• Can you characterize current overall patient´s

condition with some diagnostic category?• How we can restore diuresis in this patient?

–

Case 4Acute renal failure

Male, 26 years, acute renal failurecurrent complaints

• A 26 year old male was admitted to the

hospital complaining of generalized

muscle soreness. He had completed the

Boston Marathon three days prior to

admission. He has become

progressively anorectic, lethargic and

noticed a decreasing amount of urine

output over the past three days.

Male, 26 years, acute renal failurehistory

• Past medical history:

unremarkable and he was not taking any

prescription or over the counter medication.

He denied alcohol and illicit drug use.

• Family history: unremarkable for renal

disease• Allergies : none known

Male, 26 years, acute renal failureexamination

• well- developed, well – nourished male

appearing lethargic, BP 135/70, PR 84/min,

temp afebrile, weight 80 kg, extremities –

both lower extremities were tender and had

edema. Neuro – no focal deficits. He was

oriented to person, place and time, but was

somnolent and had difficulty performing

simple mathematical calculations.

Male, 26 years, acute renal failureexamination (2)

• EKG – normal sinus rhythm with peaked T

waves

Male, 26 years, acute renal failure laboratory assessment

Serum Blood gas analysis

sodium 135 mmol/l 135-146 mmol/l pH 7,35 7,4

potassium 7 mmol/l 3,8-5,5 mmol/l bicarbonate 15 mmol/l 22-26 mmol/l

chloride 101 mmol/l 95-105 mmol/l pCO2 4 kPa 4,8-5,9 kPa

urea 55 mmol/l 2,8-8,3 mmol/l pO2 13,3 kPa 9,9-14,4 kPa

creatinine 1000 umol/l 53-97 umol/l Urine

glucose 4,9 mmol/l 3,3-5,6 mmol/l Specificgravity

1015 kg/m3 1003-1030 kg/m3

calcium 2,0 mmol/l 2,0-2,75 mmol/l pH 6 4,5-7

phosphorus 2,2 mmol/l 0,7-1,75 mmol/l protein 2+ -

albumin 35 g/l 32-45 g/l blood 4+ -

ketones - -

glucose - -

osmolality 320 mosm/l 50-850 mosm/l

Male, 26 years, acute renal failurequestions

• What are the three broad categories acute renal

failure can be divided into?• Utilizing the urine and blood chemistry values, how

can one distinguish between prerenal azotemia and

acute tubular necrosis? Calculate the fractional

excretion of sodium. • Based on the information provided, what is the most

likely etiology of the patient´s renal failure?

Male, 26 years, acute renal failurequestions (2)

• What additional tests would be helpful in confirming

the diagnosis? • What EKG abnormalities are associated with

hyperkalemia?• How would you acutely manager the hyperkalemia

in this patient?• This patient has hyperkalemia, hypocalcemia and

hyperphophatemia. What factor(s) are responsible for

these derangements?

Case 5Chronic renal failure

Male, 25 years, computer specialist History

• Past diseases:

- when he was 12 he was found to have blood and

protein in his urine. He had multiple examinations,

but the reason was not clarified. At the age of 18

during his examination before compulsory military

service blood and protein in the urine were

discovered again. He underwent renal biopsy which

demonstrated chronic glomerulonephritis. Immune

– suppresive treatment was not prescribed. Regular

follow-up was recommended, be he failed to do it.

Male, 25 years, chronic renal failurecurrent complaints

• He says that he got sick 2 weeks ago, but his mother

says that he´s been unwell for several months.

He lost apetite, he was pale, tire, he lost at least 5 kg

of weight. The patient explains his weight loss by

stress, because he finished his studies and begun to

work. Two weeks ago he had a dinner in the

restaurant with his friends and there must have been

something wrong with the meals, because he got

nausea and vomited in the morning.

Male, 25 years, chronic renal failurecurrent complaints (2)

• He continued to vomit once daily for a week, but in the last few days he´s been vomiting several times a day and he got diarrhea too. Now he feels weak, he could not eat, he tried to drink at least. Since the last evening he has a severe pain on the chest, localized behind the sternum and spreading below both clavicles. The pain increases with deep breath, but he does not feel dyspneic.

Male, 25 years, chronic renal failureexamination

• BP 170/100mmHg, PR 110/min, BT 35,8OC,

asthenic, general muscle atrophy, bordeline skin

turgor. Pale grey skin, colour of a straw, white sclera,

pale coniunctiva, jugular veins filling normal, vesicular

breathing without adventitious sounds. Heart rate

regular, systolic and diastolic ,,locomotive-like´´

murmur in the precordium, 3cm above the apex.

No tenderness on the chest with palpation.

Legs without edema.

Male, 25 years, chronic renal failure laboratory assessment

Serum Blood gas analysis

sodium 135 mmol/l 135 - 146 mmol/l pH 7,11 7,4

potassium 6,2 mmol/l 3,8 - 5,5 mmol/l pCO2 3,1 kPa 4,8-5,9 kPa

urea 45 mmol/l 2,8 - 8,3 mmo/l pO2 11,2 kPa 9,9-14,4 kPa

creatinine 1450 umol/l 53 - 97 umol/l HCO3- 9,4 mmol/l 22-36 mmol/l

calcium 1,4 mmol/l 2,25 – 2,75 mmol/l BE -14,2 mmol -2,5-+2,5 mmol

phosphorus 3,8 mmol/l 0,7-1,5 mmol/l

albumin 27 g/l 32 - 45 mmol/l

cholesterol 2,3 mmol/l up to 5,2 mmol/l

glucose 4,1 mmol/l 3,5-5,5 mmol/l

CRP 9,5 mg/l up to 12 mg/l

Fe 3,5 umol/l 12-27 umol/l

PTH level 85 ng/l 10-65 ng/l

Male, 25 years, chronic renal failure laboratory assessment (2)

Blood count Urinalysis

leukocytes 10,5.109/l 4-10.109/l blood + -

HGB 54 g/l 140-180 g/l protein + -

HTK 12,4 39-49 ery 5-10 0-12

PLT 187 140-440,109/l leuko 3-5 0-20

Male, 25 years, chronic renal failurefindings

• Creatinine clearance 0,05 ml/s, proteinuria

1,6 g/24h• EKG: sinus tachycardia 110/min, elevation of the ST

segment by more than 2mm in the leads I, II, V2-V6,

depression of the P-Q segment below the level of

T-P segment in the same leads. • Sonography of the kidneys: right kidney 80mm,

cortex 7mm, left kidney 85mm, cortex 8mm, pelvis

and calyces without dilatation.

Male, 25 years, chronic renal failurequestions

• Analyse described symptoms, signs and laboratory

abnormalities, explain their relations and explain their

reason and pathogenesis.

• What is the main diagnosis of the patient –

unifying background for all abnormalities?

Male, 25 years, chronic renal failurequestions (2)

• How can you explain the fact, that the patient visited

the doctor in a very advanced stage of his disease?

Why he did not come earlier?

• Explain gastrointestinal symptoms of this patient.