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Renal diseases (AKI (Symptoms (Paroxysmal nocturnal dyspnoea, Pulmonary…
Renal diseases
AKI
Risk factors
Advanced age
Underlying renal failure
Malignant HTN
DM
Aetiology/pathophysiology
Intrinsic
Acute tubular necrosis, Glomerular nephritis
Failure due to direct injury to renal parenchyma
Post-renal
Mechanical obstruction of urinary outflow tract e.g. calculi, tumour, prostate hyperplasia
Failure due to obstruction of urinary outflow
Pre-renal
Reduced renal perfusion e.g. hypovolaemia, sepsis
Failure due to impaired renal perfusion with an appropriate renal response
Symptoms
Paroxysmal nocturnal dyspnoea
Pulmonary oedema
Orthopnoea
Hypotension
Dizziness
Tachycardia
Vomiting
Orthostatic hypotension
Reduced urine production
Hypertension
Peripheral oedema
Epidemiology
The most common cause is acute tubular necrosis due to ischaemia followed by contrast nephropathy.
Not many patients require renal replacement therapy
Investigations and diagnosis
Urinalysis/urine culture
FBC
VBG (metabolic acidosis)
Bladder catheterisation (post-renal)
Fluid challenge (pre-renal)
Metabolic profile
Renal ultrasound
CXR/ECG (pulmonary oedema and some arrhythmias in hyperkalaemia
Definition
Acute decline in GFR from baseline with/without oliguria/anuria
Impaired clearance, altered acid/base and electrolyte regulation and impaired volume regulation.
Management
Pre-renal
Volume expansion (Crystalloid) and/or RBC transfusion
Intrinsic
Treat underlying condition-cease nephrotoxic agents
Post-renal/obstructive
Bladder catheterisation
Relief of obstruction
CKD
Definition
Pathological abnormality e.g. haematuria, proteinuria or a reduction in GFR to <60ml/min for 3 or more months.
Epidemiology
Often undetected until latter stages, with people who have had an AKI at highest risk.
Aetiology
Diabetes Mellitus most common cause followed by HTN.
Pathophysiology
A cascade of events:
Inflammation, fibrosis and Glomerular scarring as a result of increased permeability of glomerulus.
In response to renal injury- hypertrophy of glomerulus as kidney attempts to adapt to nephron loss to maintain constant GFR.
Investigations and diagnosis
Symptoms
Oedema
Weight gain
Nausea and/or vomiting
Fatigue
Pruritus
Risk factors
Over 50 years, male, black or Hispanic ethnicity, FHx, smoking, obesity, DM, HTN, autoimmune disorders
Anorexia
Serum creatinine
Increases as disease progresses
More than 97micromol/L in men
More than 105micromol/L in women
Urinalysis
Urine microalbumin
Risk factor for development of CKD
eGFR - using Cockcroft-Gault equation
Management
Stage 3-4
ACEi or ARB or CCB + stating +-ezetimibe
Additional antihypertensive
Possible renal replacement therapy
Stage 5
Dialysis
Kidney transplant
Stage 1-2
ACEi or CCB + statin
Additional antihypertensive treatment
Classification
Stage 3a: moderate decrease in GFR, 45-59ml/min
Stage 3b: moderate decrease in GFR, 30-44ml/min
Stage 2: mild decrease in GFR, 60-89ml/min
Stage 4: severe decrease in GFR, 15-29ml/min
Stage 1: normal or increased GFR, 90 or more ml/min
Stage 5: end stage kidney failure, GFR - less than 15 ml/min