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Approach to the Patient with Renal Disease

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Approach to the Patient with Renal Disease

  1. 1. Patrick Carter MPAS, PA-C<br />Clinical Medicine I<br />February 21, 2011<br />Approach to the Patient with Renal Disease<br />
  2. 2. Objectives<br />Define the following terms:<br />Anuria<br />Oliguria<br />Polyuria<br />Hematuria<br />Proteinuria<br />Pyuria <br />Dysuria<br />Frequency<br />Hesitancy<br />Renal colic<br />Briefly describe the anatomy and physiology of the renal system<br />Review the tools commonly used to detect renal disease including:<br />Significant historical features<br />Significant physical exam findings<br />Lab abnormalities <br />
  3. 3. Objectives<br />Define uremic syndrome<br />Review the following organ systems and their manifestations of uremia:<br />GI<br />Neurologic<br />Cardiopulmonary<br />Hematologic<br />Metabolic<br />Differentiate urine findings associated with kidney diseases including:<br />Casts<br />Pyuria<br />Hematuria<br />Proteinuria<br />
  4. 4. Objectives<br />Review the role of GFR in ability of the kidney to function<br />Define azotemia<br />Calculate a creatinine clearance on a patient.<br />Differentiate between acute and chronic renal failure including:<br />Causes<br />Laboratory findings<br />Differentiate between nephritic and nephrotic syndrome based upon lab and physical findings.<br />
  5. 5. Detection of Renal Disease <br />Patients with renal disease may or may not have symptoms <br />Symptoms of renal disease when they do occur are typically non-specific <br />The patient with renal disease may be presenting with acute or chronic disease<br />A high index of suspicion is required<br />
  6. 6. Definitions<br />Anuria – absence of urine production (<50ml/day)<br />Oliguria – decreased urine production (<400ml/day)<br />Polyuria – increased urine production (>2.5L/day)<br />Gross Hematuria – patient able to visualize blood<br />Microscopic Hematuria – blood determined by lab<br />Proteinuria - > 150mg protein / day<br />Pyuria - WBC in the urine<br />Dysuria – Pain or discomfort with urination<br />Frequency – Need to urinate more frequently than usual<br />Hesitancy – difficulty in initiating urination<br />Renal colic – intermittent pain radiating from flack to groin ( in excess of child bearing)<br />
  7. 7. Detection of Renal Disease Tools of Detection<br />History and physical <br />Urinalysis <br />Estimates of GFR, Cr Clearance<br /> BUN/Creatinine<br />Blood chemistries <br />Renal ultrasonography<br />
  8. 8. Tools of Detection: H & P<br />History<br />Changes in urination<br />Abdominal/Flank pain<br />Uremic symptoms<br />Use of NSAIDS<br />Family history of renal disease, stones or dialysis<br />Edema<br />Dyspnea<br />Confusion/Delerium<br />Physical<br />High blood pressure<br />Jugular venous distention<br />Rales<br />Pericardial rub<br />Edema<br />Renal Bruits<br />Prostate Exam<br />Abdominal pain<br />
  9. 9. Uremic Syndrome<br />The constellation of findings observed in advanced renal failure<br />Etiology of many manifestations is unknown but some symptoms appear to correlate with the accumulation of nitrogenous waste products<br />Earliest manifestations include anorexia, pruritus, fatigue, difficulty with memory and concentration<br />Advanced stages of renal failure associated with involvement of multiple organ systems<br />
  10. 10. Uremic Syndrome<br />GI manifestations of uremia<br />Anorexia, nausea<br />Weight loss<br />Uremic gastritis<br />GI bleeding<br />Arteriovenous malformations (AVMs)<br />
  11. 11. Uremic Syndrome<br />Neurologic manifestations of uremia<br />Difficulty with concentration, memory<br />Confusion<br />Drowsiness<br />Myoclonus<br />Tremors<br />Peripheral neuropathy, mononeuropathy<br />Seizures, coma<br />
  12. 12. Uremic Syndrome<br />Cardiopulmonary manifestations of uremia<br />Volume overload<br />Hypertension<br />Jugular venous distention<br />Edema<br />Pericarditis<br />Chest pain<br />Pericardial rub<br />Pericardial tamponade<br />
  13. 13. Uremic Syndrome<br />Hematologic manifestations of uremia<br />Anemia<br />Fatigue<br />Pallor<br />High output failure<br />Platelet dysfunction<br />Bleeding tendency - GI, CNS, post-operative<br />Prolonged bleeding time<br />
  14. 14. Uremic Syndrome<br />Metabolic manifestations of uremia<br />Metabolic acidosis - abdominal pain, weakness, Kussmaul respirations<br />Hyperkalemia - muscle weakness, cardiac arrhythmias<br />Hypocalcemia - tetany, perioral numbness<br />Hyperphosphatemia/hyperparathyroidism - itching, bone pain<br />Hyperuricemia - gout<br />Hypermagnesemia - reduced DTRs, arrhythmias<br />
  15. 15. Tools of Detection<br />Urinalysis<br />Important to use mid-stream, clean catch urine that is < 1 hour old<br />Urine dipstick for specific gravity, pH, protein, glucose, hemoglobin<br />Urine sediment after centrifuge evaluated for presence of cells, crystals, casts<br />
  16. 16. Tools of Detection<br />Urinalysis for proteinuria<br />Dipstick gives a semi-quantitative analysis<br />Presence of significant proteinuria is highly suggestive of presence of renal disease<br />24 hour urine collection more accurate<br /><150 mg/24 hours is normal<br />150 mg-3.5 gm/day non-nephrotic range<br />>3.5 gm/day nephrotic<br />
  17. 17. Proteinuria<br />Greater than 150mg/day<br />3 Classifications<br />Glomerular<br />Increased filtration of albumin across the glomerular capillary wall<br />Diabetic Nephropathy, Preeclampsia, IgA nephropathy<br />Benign exercise or orthostatic proteinuria<br />Tubular<br />Defective reabsorptive capacities in the proximal tubules<br />Hypertensive nephrosclerosis, Fanconia, NSAIDs, Sickle Cell<br />Overflow<br />Overabundance of immunoglobulin light chains secondary to overproduction.<br />Multiple myeloma, Amyloidosis<br />
  18. 18. Proteinuria<br />Note of Caution:<br />In order for the dipstick to light up it takes 300-500 mg/day of proteinuria<br />Better to obtain 24 hour urine collection for protein<br />Microalbumin is being utilized as a screening mechanism for diabetic patients with diabetic nephropathy in the office setting<br />
  19. 19. Tools of Detection<br />Urinalysis for hematuria<br />Dipstick is semi-quantitative analysis<br />Urine sediment abnormal if >2 RBCs per high power field<br />Presence of hematuria may or may not be secondary to renal disease<br />Dysmorphic RBCs suggest glomerular disease<br />
  20. 20. Hematuria<br />Need to determine if Gross Hematuria is actually blood<br />Contaminated (Menstruation, Hemorrhoids, Post-partum)<br />Red Beet consumption in certain genetically disposed pts<br />Medications (rifampin, pyridium)<br />Dipstick cannot differentiate between RBC, Myoglobin, or Hemoglobin<br />Rhabdo, etc.<br />History is the insight to the diagnosis<br />Burning on urination, flank pain, family history, after exercise, asymptomatic elderly or with risk factors for malignancy<br />
  21. 21. Tools of Detection<br />Urinalysis for pyuria<br />Implies either infection or inflammation of the kidney or urinary tract<br />Most cases are not related to renal disease but rather represent urinary collecting system disease<br />
  22. 22. Tools of Detection<br />Urinalysis for casts<br />WBC casts - inflammation of the kidney<br />RBC casts - glomerular inflammation<br />Granular casts - non-specific but classically associated with acute tubular necrosis<br />Broad/waxy casts - chronic renal disease<br />
  23. 23. Casts<br />
  24. 24. Estimation of GFR<br />GFR = volume of plasma filtered in a given period of time, typically expressed ml/min<br />GFR is an indirect estimate of functional renal mass<br />Can determine presence of renal insufficiency and follow progression<br />May be normal in many renal diseases<br />eGFR = 186 x Serum Creatinine-1.154 x Age-0.203 x<br /> [1.212 if Black] x [0.742 if Female]<br />Or Just use a GFR calculator<br />
  25. 25. BUN and Serum Creatinine<br />Indirect estimates of renal function due to the fact they are renally excreted<br />BUN is end-product of protein metabolism<br />Creatinine is breakdown product of muscle creatine<br />Azotemia - abnormal elevation of BUN and creatinine<br />May be influenced by factors other than renal clearance<br />Protein intake for BUN<br />Muscle mass for creatinine<br />BUN/Cr ratio is helpful in determing Pre-renal azotemia<br />
  26. 26. Creatinine Clearance<br />The amount of creatinine cleared from the plasma in a given time<br />Creatinine clearance overestimates GFR because it is secreted and freely filtered<br />Urinary Cr (mg/dl) x urine vol (ml/d) Plasma creatinine (mg/dl) x 1440 min/d<br />Normal is 100-140 ml/min (10-15% lower in females)<br />Or just use a Cr Cl calculator<br />
  27. 27. The Renal Syndromes<br />Renal Failure<br />Acute<br />Chronic<br />Rapidly Progressive<br />Nephrotic Syndrome<br />Nephritic Syndrome<br />Asymptomatic urinary abnormalities<br />Hematuria<br />Proteinuria<br />Hematuria and proteinuria<br />
  28. 28. The Renal Syndromes<br />Allows narrowing of differential diagnosis<br />Can help direct work-up and treatment<br />Each syndrome associated with multiple diseases<br />One disease may be associated with multiple syndromes (Lupus nephritis, IgA nephropathy)<br />Individuals may simultaneously have more than one syndrome<br />
  29. 29. The Renal Failure Syndromes<br />Differentiation depends on the rate of progression of renal failure<br />Acute - hours to days<br />Rapidly progressive - weeks to few months<br />Chronic - months to years<br />Uremia may be common to all forms<br />
  30. 30. Acute vs. Chronic Renal Failure<br />Acute<br />Baseline Cr normal<br />Baseline UA normal<br />Normal kidney size<br />PTH normal<br />No broad casts<br />Oliguria possible<br />Chronic<br />Baseline Cr abnormal<br />Baseline UA abnormal<br />Reduced kidney size<br />PTH elevated<br />Broad, waxy casts<br />Normal urine output<br />PTH is elevated secondarily due to low calcium levels secondary to chronic renal disease<br />
  31. 31. Acute Renal Failure<br />Common Causes<br />Acute Tubular Necrosis (ATN)<br />Prerenal azotemia<br />Acute interstitial nephritis<br />Acute glomerulonephritis<br />Urinary tract obstruction<br />
  32. 32. Chronic Renal Failure<br />Common Causes<br />Diabetic nephropathy<br />Hypertensive nephrosclerosis<br />Chronic glomerulonephritis<br />Chronic tubulointerstitial disease<br />Inherited diseases<br />Ischemic nephropathy<br />
  33. 33. Rapidly Progressive RenalFailure<br />Most common cause is rapidly progressive glomerulonephritis with the pathologic lesion of necrotizing and crescentic GN.<br />Common causes of rapidly progressive glomerulonephritis include vasculitic disorders (microscopic polyangiitis, Wegener’s disease, cryoglobulinemia), infection associated glomerulonephritis, anti-GBM disease<br />May also be seen in HIV nephropathy, collapsing FSGS, some IgA nephropathy, some lupus nephritis, and others<br />
  34. 34. Nephrotic Syndrome<br />Proteinuria > 3.0 to 3.5 gm/day<br />Hypoalbuminemia<br />Edema<br />Hyperlipidemia<br />Lipiduria (oval fat bodies)<br />
  35. 35. Nephrotic Syndrome<br />Other manifestations<br />Hypercoagulable state<br />Ascites<br />Pleural effusions<br />Infections secondary to altered immune response<br />
  36. 36. Nephrotic Syndrome<br />Common causes<br />Minimal Change Disease<br />Focal Segmental Glomerulonephritis<br />Membranous Nephropathy<br />Membranoproliferative glomerulonephritis<br />Diabetic nephropathy<br />IgA nephropathy<br />Lupus nephritis<br />
  37. 37. Acute Nephritic Syndrome<br />Renal failure, acute<br />Intravascular volume expansion<br />Hypertension<br />Edema<br />Active urine sediment<br />Dysmorphic RBCs<br />RBC casts<br />Proteinuria<br />
  38. 38. Acute Nephritic Syndrome<br />Common causes<br />Post-strep GN<br />IgA nephropathy<br />Vasculitis<br />Lupus Nephritis<br />Rapidly Progressive Glomerulonephritis<br />
  39. 39. Asymptomatic UrinaryAbnormalities<br />Hematuria<br />Gross<br />Microscopic<br />Proteinuria<br />Hematuria and Proteinuria<br />
  40. 40. Asymptomatic UrinaryAbnormalities<br />Isolated Hematuria<br />Defined as presence of > 2 RBCs per hpf in the absence of renal insufficiency, proteinuria, or pyuria<br />Most cases are of urinary collecting system origin or extraurinary<br />Dysmorphic RBCs highly suggestive of a renal source and likely glomerular source<br />
  41. 41. Asymptomatic UrinaryAbnormalities<br />Common causes of isolated hematuria<br />UTI<br />Vaginal bleeding<br />Tumors<br />Bladder<br />Ureter<br />Kidney<br />Nephrolithiasis<br />Sickle cell disease or trait<br />Glomerular disease<br />
  42. 42. Isolated Proteinuria<br />>250 mg/24 hours urinary protein in the absence of hematuria, renal failure, or manifestations of nephrotic syndrome<br />Common Causes<br />Glomerular disease<br />Inherited diseases of the kidney eg. PCKD<br />Tubulointerstitial disease<br />Vascular disease<br />
  43. 43. Asymptomatic Hematuria with Proteinuria<br />This combination is more suggestive of a renal disease than hematuria alone<br />Differential diagnosis is similar to that for proteinuria alone<br />
  44. 44. Conclusions<br />Detection is relatively easy as long as the index of suspicion is high<br />Once renal disease is detected it should be categorized into one or more renal syndromes<br />Further diagnostic approach and work-up is then guided by the approach to the various syndromes which is determined by the differential diagnosis and treatment potential<br />
  45. 45. Any Questions?<br />