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CPD Notes: Kidney Diagnosis


When taking a history for possible renal dz, ask:
--family hx of polycystic kidneys? nephritis? calculi?
--systemic dz? lupus-->nephrosis, DM-->sclerosis, HTN-->retinopathy too
--toxic exposure? heavy metals, radiographic contrast
--drugs? esp NSAIDS, ABX, diuretics, analgesics
--Sx?
--general Sx: fever, wt loss, fatigue, rash, pruritis, sore throat
--CV Sx: dyspnea, chest pain, edema
--GI Sx: anorexia, N/V, crampy abd pain
--GU Sx: polyuria, dysuria, flank pain, hematuria, stone passage

When doing a physical exam:
--CV: BP? heart failure? pericardial rub? edema?
--GU: enlarged prostate? palpable kidney or bladder?
--neurological: peripheral neuropaty? encephalopathy (dt azotemia)? asterixis (flapping hand tremor mbdt hepatic failure, resp acidosis, uremia)?
--fundoscopic: DM? HTN?

Labs:
--UA first and repeat if abn. pyuria, bacteriuria-->UTI, sterile pyuria-->renal TB, leukocyte casts-->renal parenchyma infx, RBC casts-->glomerular cause
--urine culture, clean catch or 3-glass collection in men (urethra, bladder, prostate)(+ over 100,000 colonies), may also culture discharge (males GC and chlamydia usu)
--chem screen: BUN, creatinine, GFR
--CBC: anemia? infx? if anemic-->chronic renal failure, tumor, blood dyscrasia/clotting disorder

Imaging:
--x-ray--KUB scout film for calculi, size, shape, position
--U/S--for masses, cysts, hydronephosis, Bx aid, polycystic
--IVU = IV urography, uses injected iodine, if allergic to iodine use CT
--lots more options but out of naturopathic range: the urologist would order this stuff

Urinary Tract Symptom Triad
--frequency: UTI, preg, prolapse, foreign body, stone, excessive fluid intake, DM, food sensitivities
--urgency: UTI, urinary tenesmus
--dysuria: UTI, ZGU (gonorrhea in males)

If any of those are YES then ask:
--chills, fever? pain at T12?
--costovertebral tenderness?
--suprapubic tenderness?
--enlarged prostate?
--uterine fibroids?

Other Sx:
--nocturia
--enuresis
--incontinence: overflow, stress, urge

Polyuria
--over 2500ml/day
--ETIO: diabetes insipidus (ADH def), nephrogenic DI (dt chronic or acute renal failure), or psychogenic polydypsia

Oliguria and Anuria
--pre-renal dt CHF, shock, dehydration, MI, drugs
--renal: mneumonic VINDICATE: vascular lesion, inflammatory lesion, neoplasm, degenerative (rare), intoxication (ABX), congenital, autoimmune (common: SLE, polyarteritis nodosa, acute glomerulonephritis, amyloidosis, Wegener granulomatosis, scleroderma), trauma, endocrine
--postrenal: mneumonic MINNT: malformations, inflammation, neoplasms, neurologic (polio, MS, spine trauma), trauma (ureters, bladder, usudt instrumentation)

Hematuria
--idiopathic (aka undiagnosed) is common (10% of pop)
--over 100 causes: follow up to R/O bladder cancer (5th cancer cause of death in men, 10th in women)
--beets? menstruating? stones in kidney or bladder? kidney failure? infx?
--trauma? exercise? biking? prostate exam? BPH? (most common cause in men over 40)
--drug hx? (quinine, rifampin, phenytoin)
--sexual hx
--painless-->renal, vesical or prostatic dz
--painful-->stones, renal infarct, UTI
--blood at beginning of urination-->urethritis, cystitis
--blood at end of urination-->bladder
--blood throughout-->prostate, bladder, kidney

Edema
--4 mechanisms:
1) increased capillary pressure dt venous obstruction or arteriolar dilation, CHF
2) decreased plasma proteins dt burns, nephrosis (leakage), low intake, liver failure-->low albumin-->low oncotic pressure-->ascites
3) lymphatic obstrx dt parasites, surgery
4) increased capillary permeability dt burns, allergies
--pitting (interstitial fluid) vs nonpitting (fibrinogen coagulation)
--Sx: wt gain, ascities, rings & shoes tight, puffy face, enlarged abdomen
--ETIO of generalized edema: heart dz, liver dz, kidney dz, myxedema (hypothyroid), trichinosis, stroke, lymph

RENAL COLIC
--Sx: usu unilat severe crescendo-decrescendo pain; rivals pain of giving birth
--pain moves from back to flank to groin, w/ passage of stone
--Sx: fever/chills, N/V, mb hematuria, frequency
--ETIO: kidney stones


RENAL FAILURE

ACUTE RENAL FAILURE


ACUTE RENAL FAILURE = ARF
--increasing azotemia with or without oliguria (>500mL/day)
--ETIO from most common: 60-70% trauma, drugs, surgery/obstruction; 20-30% actue glomerulonephritis, SLE, Goodpasture's syndrome, 1-5% preg
--types: prerenal (inadequate renal perfusion), renal, postrenal (obstrx)
--LAB: chem screen shows BUN & creat on the rise
--DX: creatinine progressive daily rise is diagnostic, rises later than BUN but a better preditor of ARF, levels 5.5-6.0 poor prognosis
--Tx: dialysis or naturopathic tx depending on risk threshhold

DIALYSIS


CHRONIC RENAL FAILURE
--ETIO: glomerulonephritis, also HTN/CV dz, polycystic, chronic pyelonephritis, diabetes, SLE, congenital
--S/Sx: early: nocturia, lassitude, fatigue, brain fog
--S/Sx: intermediate: muscle twitches, cramps, convulsions, anorexia & wt loss, pruritis, N/V, stomatitis, bad taste in mouth, diarrhea
--S/Sx: GI ulcers & bleed, tissue wasting, uremic frost (bad), HTN, CHF, pericarditis
--LABS: slight to mod incr in BUN, creat, for months
--LABS: acidosis, anemia, decreased or normal sodium, decr Ca++, incr phosphorus, incr or norm K & CO2
--urine: VOLUME IS FIXED, waxy casts common

GLOMERULAR DISEASE
--proteinuria and cellular elements in urine, 6 conditions:

NEPHROTIC SYNDROME
--damage to basement membrane of glomerulus-->hyponatremia, SEVERE proteinuria, hypoalbuminemia, edema, LIPIDURIA, hyperlipidemia
--all ages and sexes, more in males when onset in childhood (age 1.5-4)
--ETIO: glomerular dz, systemic dz: DM, carcinoma, lymphoma, leukemia, SLE, HIV, amyloidosis
--Sx: FROTHY URINE, edema, anorexia, weakness, wasting, DOE, SOB
--LABS: protein excretion over 2gm/day, incr casts all kinds,
--CBC: hypoalbuminemia, hyperlipidemia, microcytic anemia
--PE: pale, moon face (periorbital edema), edema in extremities, muscle wasting, white lines in nails, orthostatic hypotension (esp in kids), adult BP mb low, high or normal




NEPHRITIC SYNDROME = ACUTE GLOMERULONEPHRITIS
--glomerular injury dt infx
--Sx: hematuria/cellular elements with slight to moderate proteinuria
--ETIO: formation of immune complexes deposited in walls of glomerulus, usudt acute post (1-6 wks, 2 average) strep infx (group A beta hemolytic), URI, pharyngitis, OM, skin infx (staph-impetigo), SBE, hep B, pneumoccocal bacteremia, mono, secondary syphillis, etc!
--Incidence: mc in kinds under three and young adults, 5% afer age 50
--Sx: oliguria, edema, hypertension, tea colored urine
--Sx: lethargy, headache, malasia, anorexia, low fever, flank pain
--LABS: UA: RBC casts are pathognomic
--LABS: mild proteinuria, WBC's, RBC's, other casts, hematuria gross in 1/3
--PE: optic fundi may be normal since HTN is rapid onset, may have retinal hemorrhages
--PROG: 80-95% for children but incr risk for HTN, 70% of adults recover in 1-2 yrs
--persistent proteinuria and microcopic hematuria may continue for years and progress to CRF

CHRONIC GRLOMERULONEPHRITIS
--assoc w/ several dz, characterized by diffuse sclerosis of glomeruli
--proteinuria, hematuria, usu HTN and insidious loss of renal fx over yrs
--ETIO: min 50% have prior acute glomerulonephritis (GN)
--Sx: mb ASx or may have uremic sx: N/V, dyspnea, pruritis, fatigue
--LABS: proteinuria, hematuria, poss RBC casts, also poss granular, hyaline and waxy casts

GOODPASTURE'S SYNDROME


GOODPASTURE'S SYNDROME
--rare, insidious
--males 9:1
--Sx: renal and lung hemorrhage (hematuria and hemoptysis), headache, malaise, anorexia
--LABS: chem: incr BUN, creat, CBC: hypo-micro anemia, UA: gross or micro hematuria, proteinuria
--PROG: very poor, usu die young (teen/20's)

IDIOPATHIC PRIMARY RENAL HEMATURIC/PROTEINURIA SYNDROME = IgA NEPHROPATHY
--ie: all the sx of renal dz but we can't tell why
--ETIO: IgA deposition on glomerular membrane (Berger's dz)
--Sx: recurrent macroscopic hematuria (90% of children) or ASx microscopic hematuria with mild proteinuria
--onset follows within 1-2 days after febrile URI
--males 6:1, child or young adult most common
--LABS: mild proteinuria (under 1 gram/day), microhematuria, infrequent RBC casts
--Serum: increased IgA
--PROG: kids mostly recover completely, 10% have renal insuff and HTN over several decades



HENOCH-SCHOENLEIN PURPURA = ANAPHYLACTOID PURPURA
--looks like idiopathic IgA nephropathy BUT extra-renal vasculitis-->skin, joint, GI involved
--common in kids up to 15 years, usu males
--self limiting (1-6 weeks)
--Hx: preceded by acute URI
--Sx: purpura symmetrically distrib on extensor sfcs of legs, arms, buttocks
--Sx: arthritis: moderate pain, little swelling, ankles, knees,hands, feet
--Sx: GI: abd pain, vomit, occult blood (R/o colits)
--Sx: kidney: 25-50% have hematuria, proteinemia, test repeatedly, transient
--LABS: mb incr ESR, positive occult blood, hematuria, proteinemia

DDX FOR RBC CASTS:
--acute glomerulonephritis
--chronic glomerulonephritis
--IgA nephropathy (aka idiopathic primary renal hematuric/proteinuric syndrome)

PROTEINURIA:
--severe 2-20gm/day in Nephrotic syndrome
--mild-moderate in Chronic Glomerulonephritis, Goodpasture's
--slight-moderate in Acute Glomerulonephritis
--mild <1gm/day in IgA Nephropathy
--transient/trace in Henoch-Schoenlein purpura

TUBULAR DISEASE

FANCONI'S SYNDROME
--congenital or acquired proximal tubule disorder
--Sx: cystinosis, glucosuria, phosphaturia, aminoaciduria, bicarbonate wasting
--six sided crystals in urine, cystine renal stones common-->chronic renal failure
--repeat kidney stone attack
--failure to resorb some to all good things

WILSON'S DZ
--familial
--copper deposition in tubules, liver, brain, eye, RBC's
--manageable if Dx'd early, Tx: zinc, ties up CU and avoid Cu in diet
--Kayser-Fleischer ring (gray-green corneal limbus) is pathognomic
--Sx: early: ASx, may present with Fanconi's syndrome
--Sx: late: tremors, mental retardation
--PROG: fatal if late dx

RENAL GLUCOSURIA
--normal or low blood glucose with persistent glucosuria
--ETIO: preg, fanconi's, congenital

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