NP17 Nephrology

Acid-Base Disorders/Parenchymal Kidney Diseases

saline sensitive metabolic alkalosis (most common)

volume repletion carbonic anhydrase inhibitor (e.g. acetazolamide) to facilitate loss of
HCO3- in urine
saline resistant metabolic alkalosis
remove source of aldosterone or glucocorticoid spironolactone

Parenchymal Kidney Diseases

Vascular Diseases of the Kidney
LARGE VESSEL DISEASE
Table 8. Summary of Vascular Diseases
Large Vessel Disease

Small Vessel Disease

Acute renal artery occlusion (infarct)

Renal artery stenosis (ischemia)
Renal vein thrombosis

Hypertensive nephrosclerosis
Atheroembolic renal disease
Thrombotic microangiopathy
Scleroderma
Calcineurin inhibitor nephropathy

1. RENAL INFARCTION (ACUTE RENAL ARTERY OCCLUSION)

important, potentially reversible cause of renal failure
Etiology
abdominal trauma, surgery, embolism, vasculitis, extra-renal compression, hypercoagulable
state, aortic dissection
kidney transplant more vulnerable
Signs and Symptoms (depend on presence of collateral circulation)
fever, N/V, flank pain
leukocytosis, elevated AST, ALP
marked elevated LDH (LDH >4x upper limit of normal with minimal elevations in
AST/ALT strongly suggestive)
acute onset HTN (activation of RAAS) or sudden worsening of long-standing HTN
renal dysfunction, e.g. elevated Cr (if bilateral, or solitary functioning kidney)
Investigations
renal arteriography (more reliable but risk of atheroembolic renal disease)
contrast-enhanced CT or MR angiography, duplex Doppler studies (operator dependent)
Treatment
prompt localization of occlusion and restoration of blood flow
anticoagulation, thrombolysis, percutaneous angioplasty or clot extraction, surgical thrombectomy
medical therapy in the long-term to reduce risk (e.g. antihypertensives)
2. ISCHEMIC RENAL DISEASE (RENAL ARTERY STENOSIS)
chronic renal impairment secondary to hemodynamically significant renal artery stenosis or
microvascular disease
significant cause of ESRD: 15% in patients over 50 yr old (higher prevalence if significant
vascular disease)
usually associated with large vessel disease elsewhere
causes of renal artery stenosis
atherosclerotic plaques (90%): proximal 1/3 renal artery, usually males >55 yr, smokers
electrolytes, osmolality (gently rehydrate when needed, e.g. CHF)
fibromuscular dysplasia (10%): distal 2/3 renal artery or segmental branches, usually young
females (typical onset <30 yr) (gently rehydrate when needed, e.g. CHF)
when there is decreased RBF, GFR is dependent on angiotensin II-induced efferent arteriolar
constriction which raises the FF (GFR/RBF)
most common cause of secondary HTN ("renovascular HTN"), 1-2% of all hypertensive patients
etiology
decreased renal perfusion of one or both kidneys leads to increased renin release and
subsequent angiotensin production
increased angiotensin raises blood pressure in two ways
1. causes generalized arteriolar constriction
2. release of aldosterone increases Na+ and water retention
elevated blood pressure can in turn lead to further damage of kidneys and worsening HTN

Essential Med Notes 2015