Altered Renal Function

Clinical features 1-Loin pain 2-Renal ureteric pain 3-Dysurea, oliguria, polyuria, anuria,Nocturia,Frequency,Urinary incontinence 4-Dribbing of urine 5-Hematuria 6-Retension of urine 7-Fever and rigor

Investigations 1-Urine analysis 2-Ultrasound 3-IVP 4-Renal arteriograph 5-MRI 6-Renal biopsy

Overview of Kidney Diseases

Classified by site or cause of disease Organization by site: Prerenal Intrarenal (Renal) Postrenal

Prerenal disease
Results from inadequate blood flow to the kidney
Decreased intravascular volume Lesions in the renal arteries Hypotension

Systemic disorders that decrease urine output Creatinine clearance? Plasma creatine? BUN?

Renal diseases
Result from direct damage to nephron Glomerular disorders Tubulointerstitial disorders disorders of the medullary tubules and interstitial cells

Postrenal diseases
Commonly due to urinary tract obstruction
Kidney stones Tumors of bladder, ureters or prostate gland

Obstructive Disorders
Interference with urine flow at any point Anatomic or functional Impedes flow proximal to blockage Dilates urinary system Increases risk for infection Compromises renal function Anatomic changes are called obstructive uropathy
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Causes of obstruction
Congenital malformations Stones Abdominal tumor Tumor of urinary system or prostate Severe pelvic organ prolapse in women

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Urinary Tract infections

Bacteria most common cause Can also be due to viruses, fungi or parasites Classified by location in system or by complicating factors

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 Cystitis inflammation of the bladder

Urinary frequency Dysuria painful or difficult urination Urgency Lower abdominal, lower back or suprapubic pain

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Incidence
Young adult women 0.2/month Lifetime risk in women 50% Young adult men prevalence < 1% High risk groups:
Premature infants Sexually active women Women using a diaphragm or spermicide Diabetics HIV or immunosuppressive disorders Obstruction of lower urinary tract
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Treatment
Antibiotics Drink normal amounts of water, but avoid bladder irritants, such as caffeine

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Acute pyelonephritis
Inflammation is usually focal, affecting pelvis, calyces, and medulla but glomeruli not usually involved. Kidney is infiltrated with wbcs pyuria Healing involves scarring and atrophy of affected tubules

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Acute pyelonephritis
Clinical manifestations:
Acute onset Fever or chills Flank or groin pain Frequency and dysuria

May be difficult to distinguish from cystitis look for white cell casts Treatment:
Microorganism specific antibiotics
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Chronic Pyelonephritis
Manifestations are often minimal Hypertension Frequency and Dysuria Flank pain

Diagnosis
Urine analysis Intravenous pyelography, ultrasound

Treatment
Relieve obstruction antibiotics
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Glomerulonephritis
Caused by a number of factors, most commonly abnormal immune response
Infection Toxins Vascular diseases Systemic diseases (diabetes mellitus)

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Acute Glomerulonephritis
Symptoms occur 10-21 days after infection
Hematuria Proteinuria Decreased GFR, oliguria Hypertension Edema around eyes, feet and ankles Ascites or pleural effusion

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Nephrotic Syndrome
Defined as excretion of 3.5 or more grams of protein / day Also see hypoalbuminemia, edema, hyperlipidemia Decrease in vitamin D

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Nephrotic Syndrome
Treatment:
Diet normal protein, low-fat, salt restricted Diuretics Protein supplements

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Renal Failure
Acute renal failure abrupt decrease in renal function
Increase in BUN and creatinine Usually oliguria (output < 30 ml/hour or 400 ml/day) Most cases are reversible if diagnosed and treated early Prerenal most common cause failure to restore blood volume or pressure and oxygen can lead to acute tubular necrosis or acute cortical necrosis
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Acute Renal Failure

Intrarenal acute renal failure
Usually due to acute tubular necrosis Usually caused by ischemia most often after surgery (40 -50 %) Also sepsis, burns, obstetrical complications, antibiotics, radiocontrast media, other toxic substances

Whatever the cause, get decreased GFR and oliguria

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Acute Renal Failure

Postrenal acute renal failure Usually due to urinary tract obstruction that affects both kidneys Characterized by several hours of anuria with flank pain, followed by polyuria

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Acute Renal Failure

Clinical symptoms of ARF are divided into three stages: Stage1 Oliguria: urine vol.about 25 % of normal to anuria can last 1-3 weeks BUN, plasma creatinine K+ (hyperkalemia) and electrolyte imbalance fluid retention and edema congestive heart failure
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Stage 2 Diuresis: 3-4 L/day of urine Stage 3 Recovery May take 3-12 months for plasma creatinine to return to normal About 30 % never regain normal kidney function.

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Acute Renal Failure

Treatment
Prevention if possible Maintain individuals life until renal function is recovered Correct fluid and electrolyte imbalances Treat infections Maintain nutrition and cardiac function Remember drugs and/or medications are not excreted!

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Chronic Renal Failure

Progressive and irreversible loss of nephrons Slow development (years) Alterations in salt and water balance not apparent until renal function is less than 25% of normal. Common causes:
Chronic glomerulonephritis Chronic pyelonephritis
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Chronic Renal Failure

Clinical manifestations are often described using the term uremia symptoms due to accumulation of toxins in plasma.
hypertension Anorexia Nausea Vomiting Diarrhea Weight loss Pruritis (itching) Edema Anemia Neurologic changes

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Chronic Renal Failure

Diagnosis is by increased BUN and serum creatinine; imaging will show small kidneys, and can be confirmed by biopsy Management includes:
Diet control restrict proteins, potassium Evaluate fluid and sodium levels Treat with erythropoietin as needed.

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