RENAL: Common Renal Conditions | S.M.

CHOK (Manchester Medical School)

Acute Kidney Injury

Acute in serum creatinine, in eGFR and urine output
Causes
Prerenal
Volume depletion
haemorrhage
severe vomiting and diarrhoea
burns
inappropriate diuresis
Hypotension
cardiogenic shock
severe sepsis
anaphylaxis
Oedematous states
cardiac failure
cirrhosis
nephrotic syndrome
Cardiovascular events
cardiac failure
arrhythmias
Renal hypoperfusion
AAA
renal artery stenosis/occlusion
hepatorenal syndrome
Medications
NSAIDS, mesalazine
ACE-i, ARB
penicillin, cephalosporins
diuretics
COX-2 inhibitors

Renal

Postrenal

Glomerular disease
nephrotic syndrome
glomerulonephritis
thrombosis
haemolytic uraemic syndrome
minimal change disease (paeds)

Tubular injury
acute tubular necrosis
nephrotoxins (aminoglycosides,
radiocontrast media, myoglobin,
cisplatin, heavy metals, light chains
in myeloma kidney)

calculus
blood clot
papillary necrosis
urethral stricture
prostatic hypertrophy or
malignancy
bladder tumour
radiation fibrosis
pelvic malignancy
retroperitoneal fibrosis

Acute interstitial nephritis

NSAIDs
infection
autoimmune diseases
Vascular disease
vasculitis
cryoglobulinaemia
polyarteritis nodosa
thrombotic microangiopathy
cholesterol emboli
renal artery stenosis
renal vein thrombosis
malignant HTPN
Eclampsia

Signs and Symptoms

CVS
-

HPTN
postural hypotension
JVP
peripheral oedema
peripheral vascular diseases
pallor
rash (petechiae, purpura)
bruising
nose bleed
pericardial rub

Renal
-

oliguria
polyuria may occur (fluid
reabsorption due to damaged
renal tubules)
anuria (acute obstruction,
glomerulonephritis, renal artery
occlusion)
gradual diminution of UO (urethral
stricture, bladder outlet
obstruction, eg BPH)

Other
-

ABDO Examn
nausea, vomiting
large painless bladder (chronic
urinary retention)
CNS Examn
deydration
confusion
RESP Examn
PE

RENAL: Common Renal Conditions | S.M.CHOK (Manchester Medical School)

Risk Assessment
Children and Young
People
-

CKD
HF
liver disease
Hx of AKI
oliguria
(<0.5ml/kg/hr)
neuro/cognitive
impairment or
disability
hypovolaemia
nephrotoxic meds
(aminoglycosides,
NSAIDs, ACEi, ARB,
diuretics)
urological
obstruction
sepsis
peads EWS
severe diarrhoea
nephritis (signs of
oedema,
haematuria)
haematological
malignancy
hypotension

Adults in Hospital
with Acute Illness

In Community
-

dehydration
(diarrhoea and
vomiting)
nephrotoxic meds
(including OTC
NSAIDs)
CKD (eGFR < 60)
neuro/cognitive
impairment or
disability

>65y/o
CKD
HF
liver disease
Hx of AKI
oliguria
(<0.5ml/kg/hr)
neuro/cognitive
impairment or
disability
hypovolaemia
nephrotoxic meds
(aminoglycosides,
NSAIDs, ACEi, ARB,
diuretics)
urological
obstruction
sepsis
peads EWS
severe diarrhoea
nephritis (signs of
oedema,
haematuria)
haematological
malignancy
hypotension

Adults having
Iodinated Contrast
-

CKD (eGFR<40)
diabetes with CKD
HF
renal transplant
>75y/o
hypovolamia
volume of
contrast agents
intra-arterial
administration of
contrast agents

Adults having
Surgery
-

emergency surgery
(sepsis or
hypovolaemia)
intraperitoneal
surgery
CKD (eGFR<60)
diabetes
HF
>65y/o
liver disease
nephrotoxic meds
(particularly
NSAIDs post-op)

Investigations
FBC, blood film
o eosinophillia: acute interstitial nephritis, cholesterol embolisation, vasculitis
o thrombocytopenia and red cell fragments: thrombotic microangiopathy
U&Es, creatinine
coagulation studies: DIC associated with sepsis
creatinine kinase, myoglobinuria :in both suggests rhabdomyolysis
CRP: inflammation
immunology: +ve ANA and anti-dsDNA in SLE
virology: Hep B, Hep C, HIV
Imaging: USS -urinary obstruction, CXR -PE, KUB Xray -renal calculi, Doppler USS -renal artery/veins
Identification (in line with (p)RIFLE, AKIN, KDIGO definitions)
serum creatinine > 26micromol/l wihtin 48hours
> 50% serum creatinine in the past 7days
urine output (<0.5ml/kg/hr) for >6rs (adults) or >8hrs (paeds)
>25% eGFR in paeds within past 7 days
urinalysis and USS (pyonephrosis or at risk of urinary obstruction) to identify cause

RENAL: Common Renal Conditions | S.M.CHOK (Manchester Medical School)

Management is mainly supportive:
stop nephrotoxic drugs, treat underlying cause
daily U+Es, monitor electrolytes (creatinine, sodium, potassium, calcium, phosphate, glucose)
identify and treat underlying cause (eg infection)
optimise fluid balance, consider loop diuretics (if fluid overload), DO NOT give dopamine
referral to urologists or nephrologists where indicated
Complications
volume overload (severe pulmonary oedema)
hyperkalaemia
metabolic acidosis
spontaneous haemorrhage (eg GI bleed)
symptoms or complications of uraemia (eg pericarditis, encephalopathy)

RENAL: Common Renal Conditions | S.M.CHOK (Manchester Medical School)

Nephrotic vs Nephritic Syndrome

Nephritic (mainly blood loss)
Definition

Causes

Post-streptococcal glomerulonephritis (PSGN)

typically affects children, 2-4wks post infection
(sore throat, otitis media, cellulitis)

haematuria
proteinuria (3.0-3.5 g/day)
urine output
HPTN
fluid retention and oedema
uraemia (including anorexia, pruritis, lethargy,
nausea, vomiting)

Non-streptococcal GN
post viral: mumps, measles, infectious
mononucleosis, malaria, schistosomiasis
Rapidly progressive GN (RPGN)
ANCE +ve vasculitis: microscopic polyangiitis,
Wegener's granulomatosis
immune complex disease 2 to: SLE, IgA
nephropathy, Henoch-Schonlein purpura
anti-GBM disease: Goodpasture
Membranoproliferative GN
autoimmune: SLE, scleroderma, Sjogren's
malignancies: leukemias, lymphoma
Haemolytic uraemic syndrome (E.coli)
Other
infective endocarditis
abdominal abscess

Mx

Manage acute derangement

fluid restriction diuretics
BP control
restriction of Na and K
dialysis if indicated
Identify underlying conditions and treat
urinalysis
immunological tests: ANA, ANCA, anti-GBM
blood culture/throat swabs (infections)
renal biopsy

Nephrotic (mainly protein loss)

proteinuria (>3.5g/day)
hypoalbuminaemia
peripheral oedema
hypercholestrolaemia/dyslipidaemia

Primary causes
minimal change glomerulonephritis (children)
focal segmental glomerulonephrtitis
membranous glomerulonephritis (adult)
Secondary causes (acronym SAD-AID-MET)
SLE
amyloidosis
DM
allergy
infections (Hep B & C, HIV, malaria, syphilis)
drugs (steroids, gold, lithium, NSAIDs etc)
malignancy
eclampsia
transplant rejection
Complications
venous thromboembolism (caused by oedema)
hypercholesterolaemia (liver synthesis
andrenal metabolism of lipoproteins)
infection (urinary loss of immunoglobulins)
renal failure (intravascular volume depletion)
malnutrition (protein loss in urine)

Treat fluid retention

restrict salt and fluid intake
loop diuretic thiazide
ACE-i ARB (BP target 125/75)
Avoid complications
prophylactic heparin
abx for infection
statin
Treat underlying cause

RENAL: Common Renal Conditions | S.M.CHOK (Manchester Medical School)

Chronic Kidney Disease

Chronic >3/12 Hx of albuminuria, in eGFR (<60ml/min)
Renal failure: eGFR < 15ml/min
Accelerated progression of CKD: >25% decrease in eGFR within 12/12
Causes

Risk Factors

CVD
HPTN
arteriopathic renal disease

Demographic
old age
African, Aficran-Caribbean, Asian origin
obesity

Renal
glomerulonepehritis
infective, obstructive and reflux nephropathies
hereditary kidney disease eg polycystic kidney
FMHx of CKD stage 5
Others
diabetes
hypercalcaemia
SLE with kidney involvement
neoplasms, myeloma

PMHx
AKI
proteinuria
CVD eg HPTN
diabetes
untreated urinary outflow tract obstruction
DHx
NSAIDs

SHx
smoking

Classifications

Stage 1
Stage 2
Stage 3a
Stage 3b
Stage 4
Stage 5

Normal
Mild
Moderate
Moderate
Severe
Renal failure

eGFR >90
eGFR - 60-89
eGFR - 45-59
eGFR - 30-44
eGFR - 16-29
eGFR <15

MUST with evidence of kidney damage:

persistent microalbuminimia
persistent proteinuria
persistent haematuria
structural abnormalities of kidney
biopsy-proven chronic glomorulonephritis

Specific symptoms only in severe CKD:

anorexia, nausea, vomiting, fatigue, weakness, pruritus, lethargy, peripheral oedema, dyspnoea, insomnia, muscle
cramps, SOB (pulmonary oedema), nocturia, polyuria, headache
hiccups, pericarditis, coma, seizures only in very severe CKD
Signs of CKD:
skin pigmentation or excoriation, pallor, HPTN, postural hypotension, peripheral oedema,
L ventricular
hypertrophy, PVD, pleural effusions, peripheral neuropathy and restless legs syndrome
Investigations
Renal Fx: gold standard - isotopic GFR,
commonly used method - eGFR withcreatinine
Biochemistry: Na,K,HCO3, hyperalbuminaemia,PO4, also check plasma glucose & cholesterol
when complications developed:alkaline phosphatase (bone disease),PTH
Haematology: Hb (normochromic normocytic anaemia)
Serology: autoantibodies eg. c-ANCA, p-ANCA, anti-GBM, Hepatitis serology and HIV
Urinalysis: proteinuria (glomerular/tubulointerstitial diseases), RBC +ve (proliferative glomerulonephritis),
WBC+nitrates (UTI), protein:creatinine ratio (PCR) or albumin:creatinine ratio (ACR) in diabetic
ECG/echo:
L ventricular hypertrophy
USS (structural abnormalities), CT (masses/cysts better than USS), MRI (if CT contraindicated, or for artery)
retrograde pyelogram: obstruction despite -ve USS findings
renal biopsy

RENAL: Common Renal Conditions | S.M.CHOK (Manchester Medical School)

Management

CVD prevention

BP control

Mineral + Bone

Phosphate

lifestyle advice
atorvastatin20mg
folic acid and Vit. B
antiplatelets
Apixaban instead of
warfarin (patients with
eGFR 30-50 with AF)

target: <140/90
ACE-i or ARB
check serum K+ before
starting, after 2/52 and
after each dose increase
DO NOT start if K+>5.0
dialysis: restrict Na diet

measure Ca, PO4, PTH,

Vit. D if eGFR<30
bisphosphanate
cole-/ergo-calciferol
dialysis: check serum Ca
adjusted for albumin lvl,
maintain 2.2-2.5mmol/L

cause 2 hyperPTH
lead to MSK pain and
abnormalities, fracture,
vascular or soft tissue
calcification
dietary advice
Ca-based PO4 binders eg
calcium acetate

Complications
Water and electrolytes:
o fluid restriction, avoid binge drinking
o restrict Na+ and PO4 intake
o loop diuretics (+ thiazide if resistance)
Hyperkalaemia
o dialysis if K>7.0mmol/L
o dietary advice: fruits, coffee, chocolate
o treat underlying causes: GI haemorrhage, tissue necrosis, acidosis
Anaemia
o renal synthesis of erythropoietin
o treat if Hb <11, stabilize between 10 and 12
o erythropoietin therapy:
eg: Epoetin alfa, darbepoetin, methoxy-polyethylene glycol-epoeitin beta
SE: HPTN, headache, flu-like symptoms, platelets, thromboembolic events, pure red cell aplasia,
hyperkalaemia, skin reactions
Acidosis
o hyperkalaemia, inhibits protein synthesis, accelerates Ca loss from bone
o PO sodium bicarbonate if eGFR<30 and serum HCO3<20mmol/L
Neurological
o peripheral neuropathy, restless leg syndrome, sleep disorder, cognitive impairment
o prevention, no specific management yet
Mineral and bone disorders
Haemodialysis

Peritoneal Dialysis

Procedures
blood drawn from AV fistula to be filtered
heparin is constantly infused
allows changing the level of serum electrolytes by
altering the levels of electrolytes in dialysate
can be at home or in hospital
Complications
access-related: infection, endocarditis, osteomyelitis,
creation of stenosis, thrombosis, aneurysm
hypotension, cardiac arrythmias, air emboli
N+V, headaches, cramps
heparin-induced thrombocytopenia
disequilibrium syndrome: restless, tremor, fits, coma
depression

Procedures
catheter in situ for dialysate infusion into peritoneum
ultrafiltration controlled by altering osmolality of
dialysate, drawing water out from blood
available as continuous ambulatory peritoneal
dialysis (CAPD) - allows high degree of independence
AVOID in intra-abdo adhesion or abdo wall stoma,
obesity, intestinal/respiratory disease, hernia
Complications
peritonitis, sclerosing peritonitis
cathether-related: infection, blockage, leaks
constipation, weight gain, fluid retention,
hyperglycaemia, malnutrition, back pain
hernias (inguinal, incisional, umbilical)
depression