Presentation of Renal Disease Flashcards
Presentation of renal disease?
Many patient are asymptomatic and it is an incidental finding
Loin pain/urinary symptoms
Haematuria:
• Microscopic
• Painless macroscopic haematuria (typical of IgA nephropathy, looks like coca-cola)
Proteinuria
Hypertension (asymptomatic OR accelerated)
Acute kidney injury (AKI)
Chronic kidney disease (CKD)
Nephrotic syndrome
Nephritic syndrome
Functions of the kidneys and what happens when these fail?
- Excretion of urea - uraemia
- Fluid balance - fluid retention and oedema
- Electrolyte balance - hyperkalaemia and arrhythmia
- Acid-base balance - metabolic acidosis and Kussmaul’s respiration
- Vitamin D metabolism - renal bone disease (rickets/osteomalacia) and vascular claudication
- Production of erythropoietin - anaemia
- Drug excretion - drug toxicity, e.g: digoxin, gabapentin
- Barrier to loss of proteins - proteinuria and nephrotic syndrome
What does uraemia mean?
Raised urea in the blood leading to: • Pericarditis • Encephalopathy and asterixis (CO2/liver flap) • Neuropathy • Gastritis
Findings that indicate renal disease on examination and Ix in an asymptomatic patient?
Raised BP
Dipstix - microscopic haematuria and/or proteinuria
Reduced eGFR
Incidental findings on abdominal imaging, e.g: USS
Screening due to FH
Systemic features of PC in a patient with renal disease?
Related to an underlying disease, e.g:
• Diabetes mellitus
• CTD
• Vasculitis
Related to loss of kidney function, e.g: • Uraemia • Fluid retention and oedema • Anaemia • Bone pain
Local/renal features of PC in a patient with renal disease?
Loin pain
Macroscopic haematuria
UTI
Systemic enquiry in renal disease?
Reduced appetite and weight loss
N&V and dyspepsia
Dyspnoea
Urinary symptoms, e.g: • Frequency (unable to create conc. urine) • Urgency • Hesitancy • Polyuria and nocturia
Arthralgia
Skin rash (palpable, purpuric for vasculitis)
PMH of relevance in renal disease?
CKD, DM, vascular disease (if kidneys do not receive enough blood, they can become ischaemic)
Surgery
TB
Rheumatological disease, e.g: RA
FH of relevance in renal disease?
Renal disease, e.g: polycystic kidney disease
Hypertension
SH of relevance in renal disease?
Smoking, alcohol, occupation (inorganic dyes, etc), carers
DH of relevance in renal disease?
ACEIs, ARBs (good in renal disease but contraindicated with renal artery stenosis), diuretics
NSAIDs, antibiotics, PPIs
Radiology contrast
OTC/herbal remedies
Systemic examination signs in renal disease?
Related to disease: • Pyrexia • Skin rash • Heart murmurs • Consolidation • ENT symptoms • Retinopathy (DM and hypertension) • Neuropathy • Arterial bruits, e.g: femoral, are a sign of vascular disease • Rheumatoid
Related to loss of kidney function: • Pallor • Arrhythmia • Pericardial rub and lung crepitations • Raised JVP (fluid retention) and oedema • Gout
Local/renal examination signs in renal disease?
Tender loins or upper abdomen
Arterial bruits (over the kidneys)
Palpable kidneys (only in gross disease)
BP cut-off in renal disease?
Unacceptable if >140/90 mmHg
What is accelerated hypertension?
NOT INTERCHANGEABLE WITH MALIGNANT HYPERTENSION (which is assoc. with fibrinoid necrosis)
Medical emergency where the diastolic BP is >120 mmHg and these is assoc:
• Papilloedema
• End-organ decompensation
Examples of end-organ decompensation that may occur in acceleration hypertension?
Encephalopathy
Fits
Cardiac failure and acute renal failure
Other signs of renal failure/disease?
Leukonychia (proteinuria can cause hypoalbuminaemia)
Splinter haemorrhages
Vasculitis skin rash (systemic vasculitis OR acute glomerulopnephritis)
Gouty tophi (gout is more common with renal disease)
Variable macroscopic appearance of urine?
Normal is straw-coloured
Dark, conc. urine indicates dehydration
Red urine (frank haematuria) - indicates lower urinary tract pathology
Coca-cola urine - indicates upper urinary tract pathology
Urinalysis values?
Specific gravity (urine conc.)
Haematuria (Hb)
Proteinuria
pH - if alkaline, that indicates an acidosis or a UTI
Leukocyte esterase/nitrites - UTI
Methods of quantifying urine protein?
24 hour urine collecting (impractical now) - normal is <150 mg / 24 hours
Urine protein : creatinine ratio - 50 mg / mmol
Different ranges of proteinuria?
Asymptomatic Low Grade (<1 g / day) Heavy Proteinuria (1-3g / day) Nephrotic Range (>3g / day)
Uses of urine microscopy?
Can shows:
• Bacteria
• RBCs
Types of RBCs that can be seen on urine microscopy?
Isomorphic - normal, doughnut shaped RBCs; presence indicates a lower urinary tract bleed
Dysmorphic - central, white area in the RBC; presence indicates a glomerular bleed
Types of urinary casts?
Hyaline - usually benign
Red cell - always pathological and usually assoc. with nephritic syndrome
Leukocyte - infection/inflammation
Granular - indicative of chronic disease
ECG signs that may be seen with renal disease?
If severe hypertension, may have caused left ventricular hypertrophy (tall QRS complexes)
Hyperkalaemia shows peaked (tall, tented) T-waves
Stages of CKD according to the GFR?
Stage 1 - kidney damage with normal/increased GFR:
• ≥90
Stage 2 - kidney damage with mildly decreased GFR:
• 60-89
Stage 3 - moderately decreased GFR:
• 30-59
Stage 4 - severely decreased GFR:
• 15-29
Stage 5 - kidney failure:
• <15 or dialysis
Patterns of CKS?
Stable CKD has a stable GFR over a period of time
Progressive CKD shows a progressively decreasing GFR over a period of time
Define acute kidney injury?
Decline in GFR over hours/days/weeks:
• With or without oliguria (<400ml urine output/day)
• In a patient with normal/impaired baseline renal function
Creatinine pattern in AKI?
Rises and then decreases (once AKI settle), however it never returns to normal
Define AKI on CKD?
Patient who has CKD develops AKI
Define diagnostic features of nephrotic syndrome?
Proteinuria >3g/day (mostly albumin but also other globulins)
Hypoalbuminaemia
Oedema (nephrOtic syndrome) - pitting oedema on ankles, peri-orbital oedema, etc
They also develop hypercholesterolaemia due to reduced carriage; they often have NORMAL renal function (not always)
Define diagnostic features of nephritic syndrome?
AKI with: • Oliguria • Oedema/fluid retention • Hypertension • Active urinary sediment, e.g: RBCs, RBC and granular casts, proteinuria
