approach to renal disease.pptx bbbbbbbbbbb

Hggfffccccgy

1. APPROACH TO A PATIENT WITH RENAL DISEASE : SYMPTOMS, SIGNS AND THEIR INTERPRETATION DR ASHFAQ HUSSAIN SENIOR RESIDENT DEPARTMENT OF NEPHROLOGY PATNA MEDICAL COLLEGE

2. CONTENT CLINICAL PRESENTATION OF RENAL DISEASE KIDNEY DISEASE FOCUSED HISTORY TAKING GENERAL PHYSICAL EXAMINATION ASSESSMENT OF FLUID BALANCE ABDOMINAL EXAMINATION OTHER SYSTEM EXAMINATION

3. CLINICAL PRESENTATION OF RENAL DISEASE The patient with renal disease may come to the attention of the clinician for one of the following reasons . Asymptomatic Symptom or signs which directly or indirectly indicates underlying renal disease. Systemic disorders known to be complicated by renal involvement.

4. Referrals come from colleagues in other departments looking for renal problems associated with conditions they are treating- - primary care physicians -DM,HTN, Heart failure, IHD,chronic drug intake( lithium,NSAIDS,CNI ) - urologists- neurogenic bladder, kidney stones,retroperitoneal fibrosis . -gastroenterologists- those on 5ASA drugs for IBD which can cause interstitial nephritis . -cardiologists- atherosclerotic disease and aortic aneurysms associated with renal vascular disease -rheumatologists- patients with vasculitis suspicious of relapse. ASYMPTOMATIC

5. ABNORMAL FINDINGS IN PATIENTS AT RISK OF RENAL DISEASES- MICROSCOPIC HEMATURIA - Normal individuals excrete about 1 million RBCs per day in urine . T his equates to about 1 to 3 RBCs per high-power field (HPF). excretion of more than 3 RBC/HPF is abnormal. Asymptomatic microscopic hematuria may be detected in up to 13% of adults.

6. Asymptomatic Proteinuria Normal urine protein excretion is less than 150 mg/days. Microalbuminuria is defined as the excretion of 30 to 300 mg of albumin per day. Non-nephrotic < 3.5g/day Nephrotic - > 3.5g/day

7. ABNORMAL CONSTITUENTS OF URINE- asymptomatic bacteriuria, leucocyturia s/o asymptomatic infection or urinary tract colonization AN ABNORMAL eGFR - individuals with a reduced eGFR need nephrological assessment depending on their underlying comorbid conditions,age and the rate of change. A RAISED BP- referred if its secondary to renal disesase (reduced eGFR,hematuria,proteinuria ) INCIDENTAL ELECTROLYTE ABNORMAILTIES- hypo/hyperkalemia, hypo/hypernatremia.

8. SYMPTOMATIC URINARY DISEASE- URINARY SYMPTOMS DYSURIA -sensation of discomfort with micturition . In men- burning in penile urethra s/o urethritis but a deeper pain suggests problem in prostate or bladder. Cystitis is uncommon in men unless there is an underlying cause such as stone or outflow obstruction. In women- often associated with urinary urgency and frequency suggesting a diagnosis of cystitis, more common in sexually active females but also after menopause in estrogen deficient state. Strangury is the symptom of very painful and difficult micturition often caused by a bladder stone at the interna urethral meatus or in the urethra itself.

9. URINARY FREQUENCY, POLYURIA AND NOCTURIA POLYURIA - more than 3L/day NOCTURIA - disturbing need to wake and micturate during the sleep cycle. Most healthy subjects can last until morning because sleep is associated with ADH secretion. More urine production at night than during the day is attributed to preferential renal perfusion when the other calls on cardiac output are reduced, commonly seen in patients with CKD, CHF and nephrotic syndrome

10. ANURIA - complete absence of urine flow or urine output less than 100ml/day. D/D-acute renal vascular occlusion, catastrophic renal injury such as anti GBM disease and bilateral complete urinary obstruction or obstruction of a single kidney OLIGURIA - <400ml/24 hrs or <0.5ml/kg/hr. There are many causes but usually we get evidence of a systemic disorder with/without precipitant, for example,dehydration in a patient with heart failure . LOIN PAIN- renal colic is sudden onset severe pain coming in waves, radiating anteriorly to genitalia, a/w nausea and vomiting. Causes can be renal stones, cysts, pyelonephritis, renal infarcts, pelvi ureteric junction obstruction, and the loin pain hematuria syndrome.severe loin pain can also be due to nut cracker phenomenon when left renal vein is compressed between aorta and superior mesenteric artery .

11. Centrifuge urine Centrifuge blood MACROSCOPIC HEMATURIA

12. 1. Azotemia: reduction of GFR Renal Syndromes The renal syndromes usually consists of multiple elements that reflect the underlying pathological process. Mutually inclusive syndromes. Specific combination of these features helps identify one of the major renal syndrome. 2. Proteinuria 3.Urinary abnormalities 4.Disturbance of urinary volume 5. Electrolyte disturbances 6. Hypertension with expanded body volume (edema)

13. Renal Syndromes

14. SYSTEMIC DISORDER KNOWN TO BE COMPLICATED BY RENAL INVOLVMENT METABOLIC DISEASES AND INHERITED DISORDERS - most important is diabetes mellitus that is now the single most common cause of ESRD. Tuberous sclerosis, sickle cell disease and Anderson fabry disease are other rare disorders causing renal failure. MALIGNANCY- the most common joint malignancy kidney problem is in paraprotein disorders the effect of which range from acute cast nephropathy to deposition disorders such as AL amyloid, light and heavy chain deposition disease. C hemotherapy with agents such as cisplatin has adverse effects on kidney which can make RRT necessary.

15. INFECTION - sepsis and shock are the most common cause of AKI in hospital setting but there are community acquired infections that present with life threatening renal injury too such as falciparum malaria, E.coli, leptospira , post infectious proliferative glomerulonephritis. chronic infections leading to glomerular injury-hepatitis B, hepatitis C and bacterial endocarditis. AUTOIMMUNE INFLAMMATORY DISORDERS - SLE, HSP,systemic sclerosis. Sarcoidosis and sjogren syndrome can involve the kidney and evidence of interstitial inflammation obtained from renal biopsy provides justification for immunosuppressive treatment. EFFECTS OF DRUGS- particularly in oncology( cisplatin and iv pamidronate ),anti retroviral and anti TB drugs, high dose acyclovir and sulphonamides , and amphotericin.

16. PREGNANCY- it’s a systemic state in which the kidneys are vulnerable especially if there is an underlying renal disease. The catastrophic effects of complications such as eclampsia, HELLP syndrome and HUS almost always require nephrology input. OTHER SYSTEM FAILURE- patients with end stages of heart and liver failure are usually referred with oliguria, disproportionate plasma urea concentrations, and hyperkalemia all explained by combination of system failure and pharmacological attempts to ameliorate their condition with various diuretics, ACEIs and spironolactone.

17. KIDNEY DISEASE FOCUSED HISTORY TAKING PRESENTING COMPLAINT- can be one of the mentioned above. What concerns the patient may not always be what concerns doctor, for example-a patient with tiredness may be found to have anemia and renal impairement . HOPI - onset, duration,progression , alleviating and aggrevating factors, and associated symptoms. For eg - visible hematuria of IgA nephropathy- a disease of acute onset, painless, may follow an infection and is of short duration PAST HISTORY- chronic illness like DM, HTN, childhood illnesses like reflux nephropathy, hospitalization and pregnancy history should be enquired about.

18. DRUG HISTORY- we should enquire about long term medications, any recent changes in treatment, recent course of antibiotics and use of non prescription medications such as NSAIDS and herbal remedies. Family history- any family history of renal disease, HTN,diabetes or deafness. Most common inherited renal conditions are ADPKD and alport syndrome

19. THE PHYSICAL EXAMINATION GENERAL APPEARANCE- the patient may look unwell with pallor , skin may have scratch marks from pruritis and in severe cases there may be drowsiness or asterixis . Hiccups may occur. Breathlessness may represent fluid overload, or hyperventilation due to metabolic acidosis.

20. HANDS - pallor of palmar creases for anemia,nails for muehrckes lines ( sign of hypoalbuminemia , for nephrotic syndrome ) or half and half nails lindsays nails of CKD (proximal half white, distal half red).

21. FACE EXAMINATION RASH - underlying CTD; the butterfly rash of SLE for example. CONJUNCTIVAL PALLOR- for anemia in CKD. INFLAMED EYE WITH SCLERITIS/UVEITIS- may occur in systemic vasculitis. FUNDOSCOPY - to reveal changes of diabetic or hypertensive retinopathy GINGIVAL HYPERPLASIA- due to calcineurin inhibitors such as cyclosporine/tacrolimus.

22. DIALYSIS ACCESS- arms are to be examined for Arteriovenous fistula , they look like prominent blood vessels on the forearm or upper arm. A functioning fistula will have a readily palpable fluid thrill. a tunnelled venous access catheter may be seen exiting the anterior chest wall which can be followed under the skin entering the IJV.

23. SKIN - inspect for rashes, bruising, scratch marks and excoriations. A vasculitic rash will appear as purpura,most commonly on the legs- systemic vasculitis, HSP or cryoglobulinemia , all of which can cause AKI and CKD. A drug rash increases the likelihood of an allergic interstitial nephritis .

24. ASSESSMENT OF FLUID BALANCE GENERAL APPEARANCE- sunken eyeballs, dry mucous membranes, reduced skin turgor can be indicative of dehydration in vomiting or diarrhea. PULSE AND BP- HTN common in renal disease. BP falling on patient standing or sitting upright is indicator of hypovolaemia . JVP - may be elevated due to fluid overload, or rarely due to cardiac tamponade from uraemic pericarditis. CHEST – auscultation for features of pulmonary edema or pleural effusion and S3 in fluid overload. A pericardial rub may occur in uraemia .

25. peripheral edema- examine for sacral edema in bed bound patients and in the legs, starting at the ankles and noting the highest level at which edema can be identified(such as mid calf, knees and mid thigh) In severe cases, edema can extend into scrotum or labia. Significant edema is a hallmark of nephrotic syndrome . Sequential measurement of patients body weight, providing assessment of fluid loss or gain over short term. Physical examination should be complemented with fluid balance charts.

26. Skin pressed for atleast 15-20 seconds against a bony prominence,2-3cm above medial malleolus in legs

27. ABDOMINAL EXAMINATION INSPECTION - look for abdominal distension In flanks, operative scars( for renal transplant) in the RIF/LIF extending inferiorly to midline. Palpation - bimanual palpation(balloting technique)

28. PALPATION -ADPKD is the most common cause of palpable kidneys. When pyelonephritis is suspected,tenderness in the renal angle should be determined. PERCUSSION - assessment for ascites , and to identify an enlarged bladder(percussion over the midline from a resonant area at the umbilicus and then moving inferiorly) AUSCULTATION - bruits over epigastrium and over both renal arteries may hint towards renovascular disease.

29. OTHER SYSTEM EXAMINATION JOINTS - examine for inflammation and swelling of joints which can occur in systemic vasculitis. Presence of chronic arthritis such as RA may lead to amyloid(a cause of nephrotic syndrome) and medication used to treat arthritis such as NSAIDS can cause AKI. Areas for bony tenderness in the spine may be a feature of myeloma . Nervous system - in DM, the presence of neuropathy is common in those with CKD. Peripheral neuropathy can also occur with vasculitic diseases.

30. Thank you