2-Renal Failure and manifestation of Renal disease.pdf

Renal failure : Female side notes: Important: Male side notes: Important: Uro - medicine Done by Renad Alhomidi - yazeed ElShidi Female section: Notes Team Abeer Mabrouk - Albandri Alajlan Bayan Alanazi -Ghaida Almasari- Ilal alhuthail - Khawlah Alrashed - Lama Aljathalin - Nouf Alkhalifah - Rand Al...

Renal failure : Female side notes: Important: Male side notes: Important: Uro - medicine Done by Renad Alhomidi - yazeed ElShidi Female section: Notes Team Abeer Mabrouk - Albandri Alajlan Bayan Alanazi -Ghaida Almasari- Ilal alhuthail - Khawlah Alrashed - Lama Aljathalin - Nouf Alkhalifah - Rand Alanazi - Razan Alshehri - Reem Male section: — The Male Side Lecture was Covered by Dr. Abdullah AlGhamdi & is Summarized By Yazeed ElShidi, 442… In these 2 Simple Pages… DEFINITIONS AKI: hours to days AKD: is in between AKI & CKD period CKD: more than 3 months AKI CAUSES Prerenal: Any condition that leads to decreased renal perfusion (ex: Any Heart Failure- SepsiHypovolemia - Renal artery Thrombus - The 5 types of shock(Hypovolemic, Cardiogenic, Hemorrhagic, Obstructive, Septic) - Renal artery Stenosis) Renal: GD(Nephrotic or Nephritic) - Tubular Diseases - Exogenous - Ischemic ATN(AcuteTubularNeprhitis) - AIN(AcuteInterstitialNephritis… from Ex: UTI+Penicillin…) Postrenal: Anything that obstructs Ureter or Urinary Bladder How to Investigate & Confirm? Postrenal: Easiest to rule out… (US or CT-KVB(Meaning without contrast because it is contraindicated with kidney disease) (No contrast in any kidney disease… Renal + pre renal + post renal) *Hydronephrosis means back pressure of urine Prerenal could lead to renal… So How to know if patient is pre renal or renal? (check FENa (AKA Fractional excretion of sodium to check if its renal or prerenal) GD: check Urine analysis to check for protein or blood in the urine Vascular Disease: History will include Vasculitis or TPP(ThromboticThrombocytopenicPurpura)… *Most of the Patients present with asymptomatic or vague symptoms (only Oliguria +maybe fatigue, Weakness, Nausea, Loss of Appetite, Vomiting, Lowerlimb Edema) MCQs will be how to treat renal or prerenal… removing underlying causes If Postrenal… remove obstruction MCQ: patient with AKI… when to do dialysis? When there is refractory hyperkalemia(=Arrhythmia), refractory acidosis, Uremic encephalopathy(confusion) or uremic Pericarditis(pericardial rub sound), refractory pulmonary edema, Toxin injestion(methanol, ethelene glycol) *Refractory mean it is resistant to correction *methanol can lead to blindess *Most common cause of AKI: Prerenal - then Renal ATN CKD: Definition: EGFR less than 60ml/min(in General) or US Abnormality or Biopsy with kidney disease or Transplant CKD Stages 5 1- 90-120 2- 60-90 3- Type A:45-60 or Type B:30-45 4: 15-30 5: less than 15 *(FYI: stage 1 & 2 isn’t used in a healthy person… so your EGFR may be 80 and be considered normal… it is only when you have Kidney disorders where we will consider stage 1 & stage 2) MCQ Will be a px with for example with EGFR 27…, which stage? Ans: Stage 4 MCQ: Px with EGFR over 60 & -ve Biopsy -ve urinalysis & non transplant…? Ans: Normal Px MCQ: Px who is also has no biopsy findings, -ve urinalysis, non transplant… But has EGFR under 60? Ans: CKD, Stage 3 (Type A if between 45-60) *below 60 regardless is CKD Causes of CKD: AKI, Diabetes, Hypertension How to prevent CKD: control Dibetes *How to control DM? Ideal BP in DM & HTN: 130/80… Tx: ARB & ACEI & next step is SGLTI(now comes in MCQs) *MCQ: when dialysis for CKD? Ans: Either EGFR under 10 or AKI 5 Indications Sick Days medication(stopping some meds when pt presents with AKI): NSAIDS, Metformin, ACEI/ ARB Clinical scenario : 43, male, dm & htn, metformin, ARB, creatinine 2.8 (aka 280)… Check: HTN(less than 130/80) DM HBA1c(less than 7) GFR(ex: 25=stage 4) + to know if patient has CKD or AKI: check creatinine basal level… if he has Creatinine 2.8 a year ago… this is CKD, if 1 month… this is AKI) Next i will specify if its pre/renal/post… Next If he has CKD so i will stop ARB, Stop metformin If AKI: i will look for indications of dialysis… By checking: Serum K, pH, Urea(if high: auscultate for pericardial rub incase of pericarditis) Refractory Pulmonary Edema - Toxic Ingestion(includes behavior of the patient) If indead AKI i will do: US(to rule put obstruction) - Urinalysis for protein & blood - Prerenal(by checking FENa) or Renal Urine Microscopy (to differ between Glomerular - vascular - tubular - interstitial) DR. ABDULLAH SAID THE LAST QUESTION IN THE SLIDES Summarizes THE POSSIBLE EXAM QUESTION! SOLVE IT ! :) Renal failure &manifestation of Renal diseases Dr.Ihsan Nasr Eldin Elnour MD-Internal medicine RENAL Failure. Kidney Function -Detoxify blood -Increase calcium absorption Calcitriol -Stimulate RBC production Erythropoietin Regulateblood pressure and electrolyte balance renin Assessment of Renal Function Glomerular Filtration Rate (GFR) = the volume of water filtered from the plasma per unit of time. Gives a rough measure of the number of functioning nephrons. Cannot be measured directly, so we use creatinine and creatinine clearance to estimate. Pathophysiology AKI: Reductions in renalblood flow ( RBF) represent a common pathologic pathway for decreasing glomerular filtration rate (GFR). CKD: Initially, as renal tissue loses function, there are few noticeable abnormalities because the remaining tissue increases its performance (renal functional adaptation). Decreased renal function interferes with the kidneys’ ability to maintain fluid and electrolyte homeostasis. The ability to concentrate urine declines early and is followed by decreases in ability to excrete excess phosphate, acid, and potassium. When renal failure is advanced (GFR ≤ 15 mL/min/1.73 m2.) Assessment of Renal Function (cont.) Creatinine Clearance Best way to estimate GFR. GFR = (creatinine clearance) x (body surface area in m2/1.73). Ways to measure: 24-hour urine creatinine: Creatinine clearance = (Ucr x Uvol)/ plasma Cr Cockcroft-Gault Equation: (140 - age) x lean body weight [kg] CrCl (mL/min) = ——————————————— (x 0.85 if Cr [mg/dL] x 72 female). Assessment of Renal Function (cont.) Creatinine A naturally occurring amino acid predominately found in skeletal muscle. Freely filtered in the glomerulus. excreted by the kidney and readily measured in the plasma. As plasma creatinine increases, the GFR exponentially decreases. Limitations to estimate GFR:-Patients with decrease in muscle mass, liver disease, malnutrition advanced age, may have low/normal creatinine despite underlying kidney disease. 15-20% of creatinine in the bloodstream is not filtered in glomerulus, but secreted by renal tubules (giving overestimation of GFR) Medications may artificially elevate creatinine Trimethoprim (Bactrim) Cimetidine. Classifications Acute versus chronic. Pre-renal, renal, post-renal. Anuric, oliguric, polyuric. Acute Versus Chronic Acute kidney injury sudden onset rapid reduction in urine output Usually reversible Tubular cell death and regeneration Chronic Kidney Disease ( CKD) Progressive Not reversible Nephron loss 75% of function can be lost before its noticeable Major causes of Kidney Failure Pre renal Disease ************** RENAL Vascular Disease Glomerular Disease Interstitial/Tubular Disease. ******************* Obstructive Uropathy Causes of Renal failure Pre-renal = In pre-renal uraemia, there is impaired perfusion of the kidneys with blood. vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure. cardiac failure, liver dysfunction, or septic shock. Intrinsic This is most commonly due to acute renal tubular necrosis. Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins. Other causes include disease affecting the intrarenal arteries and arterioles as well as glomerular capillaries, such as a vasculitis (, accelerated hypertension, cholesterol embolism, haemolytic uraemic syndrome, thrombotic thrombocytopenic purpura (TTP), Preeclampsia and crescentic glomerulonephritis Post-renal = uraemia results from obstruction of the urinary tract at any point from the calyces to the external urethral orifice prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders neurogenic bladder bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and fungus Prerenal Disease Reduced renal perfusion due to volume depletion and/or decreased perfusion Caused by: Dehydration Volume loss (bleeding) Heart failure Shock Liver disease Renal -Vascular Disease Acute Vasculitis – Wegener’s granulomatosis Thromboembolic disease TTP/HUS Malignant hypertension Scleroderma renal crisis Chronic Benign hypertensive nephrosclerosis Intimal thickening and luminal narrowing of the large and small renal arteries and the glomerular arterioles usually due to hypertension. Most common in African Americans Treatment: Hypertension control Bilateral renal artery stenosis should be suspected in patients with acute, severe, or refractory hypertension who also have otherwise unexplained renal insufficiency Treatment: Medical therapy, surgery, stents. Glomerular Disease -RENAL Nephritis Inflammation seen on histologic exam Active sediment: Red cells, white cells, granular casts, red cell casts Variable degree of proteinuria (< 3g/day) Nephrotic No inflammation Bland sediment: No cells, fatty casts Nephrotic range proteinuria (>3.5 g/day) Nephrotic syndrome = proteinuria + hyperlipidemia + edema Glomerular Disease -- Glomerulonephritis Pos tinfectious glomerulonephritis Group A Strep Infection Rapidly progressive glomerulonephritis IgA nephropathy Membranoproliferative glomerulonephritis: infective endocarditis Systemic lupus erythematosus Hepatitis C virus Infections: CMV, Staph. Aureus, H. influenzae SLE Goodpasture syndrome (anti-GBM) Henoch-Schönlein purpura Wegener granulomatosis Polyarteritis nodosa Vasculitis (cryoglobulinemia) Glomerular Disease – Nephrotic Syndrome Minimal Change Disease NSAIDS Paraneoplastic (Hodgkin’s Lymphoma) Focal glomerulosclerosis HIV Massive Obesity NSAIDS Membranous nephropathy NSAIDS, penicillamine, gold Etanercept, infliximab SLE Hep. C, Hep. B Malignancy (usually of GI tract or lung) GVHD s/p renal transplant Mesangial proliferative glomerulonephritis Diabetic nephropathy Post-infectious glomerulonephropathy (later stages) Amyloidosis IgA nephropathy Infections: HIV, CMV, Staph. aureus, Haemophilus parainfluenza Celiac disease Chronic Liver disease Interstitial/Tubular Disease Acute: Acute Tubular Necrosis: One of the most causes of acute renal failure in hospitalized patients Causes: Hypotension, Sepsis Toxins: Aminoglycosides, Amphotericin, Cisplatin, Foscarnet, Pentamadine, IV contrast Rhabdomyolysis (heme-pigments are toxins) Urine sediment: muddy brown granular casts Acute Interstitial Nephritis: Causes: Drugs: Antibiotics, Proton-pump inhibitors, NSAIDS, allopurinol Infections: Legionella, Leptospirosis Auto-immune disorders Urine sediment: urine eosinophils (but not always present), white blood cells, red blood cells, white cell casts Cast Nephropathy – Multiple Myeloma Tubular casts – PAS-negative, and PAS-positive (Tamm-Horsefall mucoprotein) Interstitial Tubular Disease Chronic Polycystic Kidney Disease Hypercalcemia Autoimmune disorders Sarcoidosis Sjögren’s syndrome Obstructive Uropathy Obstruction of the urinary flow anywhere from the renal pelvis to the urethra. Can be acute or chronic. Most commonly caused by tumor or prostatic enlargement (hyperplasia or malignancy). Need to have bilateral obstruction in order to have renal insufficiency. Manifistations Symptoms of (AKI) Decrease urine output (70%). Edema, esp. lower extremity. Mental changes (uraemic symptoms). Heart failure. Nausea, vomiting. Pruritus. Anemia. Tachypenia Cool, pale, moist skin. Urine Output in AKI Oliguria = daily urine output < 400 mL When present in acute renal failure, associated with a mortality rate of 75% (versus 25% mortality rate in non-oliguric patients). Most deaths are associated with the underlying disease process and infectious complications Anuria No urine production Or 0-100 ml/day probably time for dialysis Assessing the patient with Acute Kidney injury History: Cancer? Recent Infections? Blood in urine? Change in urine output? Flank Pain? Recent bleeding? Dehydration? Diarrhea? Nausea? Vomiting? Blurred vision? Elevated BP at home? Elevated sugars? Assessing the patient with AKI(cont.) Family History: Cancers? Polycystic kidney disease? Meds: Any non-compliance with diabetic or hypertensive meds? Any recent antibiotic use? Any NSAID use? Assessing the patient with AKI– Physical exam Vital Signs: Elevated BP: Concern for malignant hypertension Low BP: Concern for hypotension/hypoperfusion (acute tubular necrosis) Neuro: Confusion: hypercalcemia, uremia, malignant hypertension, infection, malignancy HEENT: Dry mucus membranes: Concern for dehydration (pre-renal) Abd: Ascites: Concern for liver disease (hepatorenal syndrome), or nephrotic syndrome Ext: Edema: Concern for nephrotic syndrome Skin: Tight skin, sclerodactyly – Sclerodermal renal crisis Malar rash - Lupus Assessing the patient with acute renal failure – Laboratory analysis Fractional excretion of sodium: FENa FENa= (UrineNa+ x PlasmaCreatinine) ______________________ x 100 (PlasmaNa+ x UrineCreatinine) FENa < 1% → Prerenal FENa > 2% → Epithelial tubular injury (acute tubular necrosis), obstructive uropathy If patient receiving diuretics, can check FE of urea. Assessing the patient with AKI– Urinalysis  Hematuria  Non-glomerular:   Urinary sediment: intact red blood cells Causes:  Infection  Cancer  Obstructive Uropathy  Rhabdomyolysis   myoglobinuria; Hematuria with no RBCs Glomerular:   Urine sediment: dysmorphic red blood cells, red cell casts Causes:     Glomerulonephritis Vasculitis Atheroembolic disease TTP/HUS (thombotic microangiopathy) Assessing patient with AKI– Urinary Casts Red cell casts Glomerulonephritis Vasculitis White Cell casts Acute Interstitial nephritis Fatty casts Nephrotic syndrome, Minimal change disease Muddy Brown casts Acute tubular necrosis Assessing Patient with AKI– Urinalysis (cont.) Protein Need microscopic urinalysis to see microabluminemia Can check 24-hour urine protein collection Nephrotic syndrome - ≥ 3.5 g protein in 24 hours Albuminuria Glomerulonephritis Atheroembolic disease (TTP/HUS) Thrombotic microangiopathy Nephrotic syndrome Tubular proteinuria Tubular epithelial injury (acute tubular necrosis) Interstitial nephritis Assessing patient with AKI– Renal u/s: Look for signs of hydronephrosis as sign of obstructive uropathy. Renal Biopsy If unable to discover cause of renal disease, renal biopsy may be warranted. Renal biopsy frequently performed in patient’s with history of renal transplant with worsening renal function. Indications for Hemodialysis Refractory fluid overload. Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels. Metabolic acidosis (pH less than 7.1). Azotemia (BUN greater than 80 to 100 mg/dL [29 to 36 mmol/L]). Signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status. Severe dysnatremias (sodium concentration greater than 155 meq/L or less than 120 meq/L) Hyperthermia. Overdose with a dialyzable drug/toxin. Treatment of AKI Treat underlying cause Blood pressure Infections Stop inciting medications Nephrostomy tubes/ureteral stents if obstruction Treat scleroderma renal crisis with ACE inhibitor Hydration Diuresis (Lasix) Dialysis Renal Transplant. Chronic Kidney Disease 150–200 cases per million people = new cases each year Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S. Mortality = 20%. The current definition for CKD will be retained: GFR 65 mg/mmol or protein creatinine ratio of 100 mg/mmol. CKD Symptoms Malaise Weakness Fatigue Neuropathy CHF Anorexia Nausea Vomiting Seizure Constipation Peptic ulceration Diverticulosis Anemia Pruritus Jaundice Abnormal hemostasis Chronic Kidney Disease = A GFR of < 60 for 3 months or more. Most common causes: Diabetes Mellitus Hypertension Management: Blood pressure control! Diabetic control Smoking cessation Dietary protein restriction Phosphorus lowering drugs/ Calcium replacement Erythropoietin replacement Start when Hgb < 10 g/dL Bicarbonate therapy for acidosis Dialysis? Stages of Chronic Kidney Disease Stage Description GFR (mL/min/1.73 m2) 1 Kidney damage with normal or increased GFR ≥ 90 2 Kidney damage with mildly decreased GFR 60-89 3 Moderately decreased GFR 30-59 4 Severely decreased GFR 15-29 5 Kidney Failure < 15 Acute Problems in CKD Relating to underlying disease Relating to ESRD Dialysis related problems Problems Related to ESRD Metabolic – K/Ca. Volume overload. Anemia IRON EFICIENCY ,NORMOCHROMIC NORMOCYTIC, platelet disorder, GI bleed. HTN, pericarditis. Peripheral neuropathy, dialysis dementia. Abnormal immune function. Dialysis ½ of patients with CRF eventually require dialysis. Diffuse harmful waste out of body. Control BP. Keep safe level of chemicals in body. Dialysis is 2 types : Hemodialysis Peritoneal dialysis. Types of Access Temporary site. central venous catheter AV fistula Surgeon constructs by combining an artery and a vein 3 to 6 months to mature. AV graft Man-made tube inserted by a surgeon to connect artery and vein. 2 to 6 weeks to mature. Temporary Catheter Peritoneal Dialysis Abdominal lining filters blood Dialysis Related Problems Disequilibration Syndrome At end of early sessions Confusion, tremor, seizure Due to decrease urea concentration of blood versus brain leading to cerebral edema.. THANK YOU