Kuliah FKUMJ Ginjal Mei 2010J.Pudji Rahardjo, Sp.PD KGHJakarta

Approoach to the Patient with Renal DiseaseJ.Pudji Rahardjo, Sp.PD KGHJakarta

Clinical presentationAs an :Outpatient or inpatient :Abnormal urinary finding : hematuria or proteinuriaDuring routine clinical examinationtst or initial employment testDepending on the stage of renal desiase :Mild : edea or pruritusAdvanced symptom & signs : uremia + decreased appetite, weight loss, even alteration mental status In general the symptoms & signs tend to be nonspecific, even others only with ele vation in serum creatinine

Symptoms and signs at presentation of patients with renal diseaseEasy fatigabilityDecreased appetiteNausea and vomitingGeneralized pruritusShortness of breathSleep disturbancesUrinary hesitancy, urgency, frequencyMicroscopic or gross hematuriaProteinuiaUncontrolled hypertension

Frothy appearance of urineFlan k pain, mostly unilateralMental satus changessPallorWeight loss or gainLower extremity pitting edemaAscitesPumonary edema or congestionPleural or pericardial effusionpericarditis

Clinical presentationTo narrow the differential diagnosis :First determine whether it is acute, subacute, chronic, but it is usually overlap and at times it is not exactly clearSecond determine which segment or component of the renal anatomy is involved

Causes of Acute Renal FailurePrerenalIntravascular volume depletion Hypotension Decreased renal perfusion RenalGlomerularTubularInterstitialvascularPost renalObstructive uropathy

Assessment of Glomerular Filtration Rate (eGFR)The most common method to estimate the renal functionApproximation of the degree the renal functionNormal : 150 250L/24 hours or: 100 120 ml/min/1.73m2GFRdecreased in renal dysfunction , and used to monitor CKD and appropriate timing for RRTMethods of measurement GFR :Measured : 24 hours creatinine clearenceEstimation equation : Cockroft Gault formulaModification of Diet in Ren al Disease (MDRD) Study formula

Methods of measurement GFR24-hour urine creatinine clearence :For male :Urine creatinine X Urine volume= 20 25 mg/kg/24 hoursFor female :Urine creatinine X Urine volume= 15 20 mg/kg/24 hours

Methods of measurement GFRCockroft Gault formula :Creatinine Clearence =( 140 Age in years) X Weight (kg)

Plasma creatinine X 72

for female due to less muscle : 0.85%

Methods of measurement GFRMDRD formula GFR =175 X serum creatinineX AgeX 0.742 if femaleX 1.21 if black

Newer marker :Cystatin C is an active ongoing search, holds promise, has a constant daily production and is excreted by the kidney- 1.154- 0.203

Methods to estimate renal functionsSerum creatinineInaccurate with early or advanced stage of kidney diseaseAffected by aged, gender, muscle mass, some medication24-hour urine creatinine clearenceCumbersomeCan overestimate the true GFREstimation equationCockroft-Gault formula : highly dependent on serum creatineMDRD formula : not tested in different popul;ation (eg. The elderly and obese, or ethnicities)Radioisotopic clearenceBest measure of GFR, but invasive, uses radioisotopes, available in certain in institution

Situation in which a 24-hour urine collection is more accurate than MDRD equationGFR > 60ml/min /1.73m2Age < 18 or > 70 yearsExtreme body sizeSevere malnutritionPregnancySkeletal muscle diseaseParaplegia or quadriplegiaVegetarianRapid changing renal function

CKD Stages

GFR (ml/mn/1.73m2)DescriptionCKD Stage 190Normal kidney function, but urine findings or structural abnormalities or genetic trait point to kidney diseseCKD Stage 260 89Mildly reduced kidney function, and other findings ( as for stage 1) point to kidney disease CKD Stage 330 -59Moderately reduced kidney diseaseCKD Stage 415 29Severely reduced kidney functionCKD Stage 4< 15 (or dialysis)Very severe, or ESRD (sometimes called Establish Renal Failure)

Clinical findingsSymptoms and signs :Majority asymptomatic, incidentally discovered on routine examination (ele vated serum creatin ine or abnormal urinalysis)Symptoms positive : nonspecific

Symptoms and signs at presentation of patients with renal diseaseEasy fatigabilityDecreased appetiteNausea and vomitingGeneralized pruritusShortness of breathSleep disturbancesUrinary hesitancy, urgency, frequencyMicroscopic or gross hematuriaProteinuiaUncontrolled hypertension

Frothy appearance of urineFlan k pain, mostly unilateralMental satus changessPallorWeight loss or gainLower extremity pitting edemaAscitesPumonary edema or congestionPleural or pericardial effusionpericarditis

Clinical findingsLaboratory findings : Urrinalysis is the most important test in patient with renal diseasemust be collected by special precaution (MSU, labia majora should be cleaned, examined within 60 minutes)A dipstick examination include : SG, pH, protein, blood, glucose, ketons, bilirubin, nitrite, leukocyte esteraseMicroscopic examination : crystals, cells, casts, bacteria, fungal element

Interpretation of urinalysis findingsDipstick testing :SG : reflects the ability to concentrate urine in states of volume depletion pH : normal 4.5 8; 7.0 infection with urease-producing organism (eg. Proteous)Blood : normal 1 2 /HPF; seen in glomerulonephritides, nephrolithiasisGlucose : seen in poorly controlled DM, not reliable for diagnosis; Fanconi syn drome (proximal RTA) Protein : detects only on ly albumin , insensitive in detecting microalbuminuriaLeukocyte : pyuria Nitrite indicate the presence of microorganisms that convert urnary nitrate to nitrite

Interpretation of urinalysis findingsMicroscopiy :Casts : Hyaline nonspecific; Granular nonspecific; ATNWaxy and broad : nonspecific; advanced renal disease; Fatty NS; RBC sine qua non of GN; WBC UTI; TIN; Renal TBCrystals : Uric acid acidic urine pH; Ca-phosphat and oxalat alkaline urine; Mg-ammon- phosphat UTI by urease-producing org (Pr & Kleb); Cystine ARCystinuriaEpithelial : > 15 20 poorly cacthed urine specimenMyoglobin ;Rhabdomyolysis

Interpretation of urinalysis findingsUrinary indices :

Fractional excretion of Na (FE %) =

Urine Na X Plasma creatinine X 100

Plasma Na X Urine creatinine

Note :< 20 mEq/L : prerenal ARF, intravascular volume depletion due to fluid losses or squestration, hypotension, epsis> 40 mEq/L : ATNNa

Imaging studiesVarious Radiographic studies available :Performed either alone or in combination USG : the most common used : safe, easy todo, avoid to use radiaion or contrast that can nephrotoxic Plane film : limitation inability to detect radiolucent stoneComputed tomography (CT) : more detailed of the kidn ey structure; spiral angiography; disadvantages the use of large volume of contrastMRI : MRA with gadolinium contrast is not recommended in GFR < 30ml/mn or on RRT

Imaging studiesVarious Radiographic studies available :Radioisotpe Scanning (DMSA) is used in early detection of urinary obstruction, urine leak, vesicoureteric refluxRetrograde or Antegrade pyelography : placement of ureter stents or nephrostomy tubes, but utilize radiation and contrast media

Special test Renal biopsy : PCR Biopsy is used in situation in which evaluation of the patients history, PE, noninvasive testing, urine tests, imaging studies has failed to reveal diagnosis

Special test Renal biopsy : Indication :Unexplained persistent hematuria or proteinuria, especially associated with progression renal dysfunction,Nephrotic syndromeAcute nephritisUnexplained acute or rapidly progressive renal declineContraindication :Involving the kidneyMultiple cysts, Renal mass, single or solitary functioning kidney, active renal perirenal infection, unilateral or bilateral hydronephrosisInvolving the patientUncooperative pts, severe hypertension, intractable bleeding disorder, morbid onesity

Complications Hematuria :Gross causes red or brown urine; must be differentiate with postpartum or menstruating (should not be evaluated), medications (rifampicin, phenothiazine, phenazopyridine), intake of beets, hemoglobinuria, myoglobinuriaMicroscopic - > 2RB C/hpf, historical information is important diagnostic clues, dysmorphic suggest glomerular disorders

Complications Proteinuria Normal : 150 mg/dayProteinuria :GlomerularIncreased albumin filtration, orthostatic, exercise induced (macomolecules albumin)TubularIn tubulointerstitial disease (defected reabsorptive capacities), low-molecules - immunoglobulinOverflowEg.MM secondary overproduction of immunoglobulinOrthostatic or postural proteinuria :Increased proteinuria in upright positionBenign condition, do not progress to ESRD, majority resolve spontaneously