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Renal disease Dr David MAKANJUOLA Renal unit St. Helier hospital.

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Presentation on theme: "Renal disease Dr David MAKANJUOLA Renal unit St. Helier hospital."— Presentation transcript:

1 Renal disease Dr David MAKANJUOLA Renal unit St. Helier hospital

2 Case history 22 year old Afro-Caribbean male Microscopic haematuria noted on registration with new GP. No proteinuria Normal creatinine (90µmol/l) Blood pressure 120/70mmHg No haematuria on dipstick testing at subsequent review in GP surgery.

3 Haematuria Management should include Check serum creatinine in all patients Check for proteinuria in all patients (quantitate protein/creatinine ratio if positive) Visible (macroscopic) haematuria Invisible (microscopic) haematuria without proteinuria, GFR>60ml/min/1.73m 2 Microscopic haematuria with prot/creat ratio >50mg/mmol

4 Schematic representation of the major causes of haematuria in relation to the age at which they usually occur (horizontal axis), transience or persistence (vertical axis), and frequency (blue implies more frequent). Major causes of haematuria by age and duration From Up To Date

5 Haematuria Management should include Check serum creatinine in all patients Check for proteinuria in all patients (quantitate protein/creatinine ratio if positive) Visible (macroscopic) haematuria Invisible (microscopic) haematuria without proteinuria, GFR>60ml/min/1.73m 2 Microscopic haematuria with prot/creat ratio >50mg/mmol Usually fast track Urology referral for imaging and cystoscopy, unless strong pointers to acute renal disease Refer to nephrology if urological investigations negative Age >40, usually refer to Urology (recommended age may vary locally) Age 40 with negative urological investigations, manage as Stage 1/2 CKD manage as Stage 1/2 CKD Refer to nephrology Lower levels of proteinuria, manage as Stage 1/2 CKDmanage as Stage 1/2 CKD

6 Haematuria Management should include Check serum creatinine in all patients Check for proteinuria in all patients (quantitate protein/creatinine ratio if positive) Visible (macroscopic) haematuria Invisible (microscopic) haematuria without proteinuria, GFR>60ml/min/1.73m 2 Microscopic haematuria with prot/creat ratio >50mg/mmol Usually fast track Urology referral for imaging and cystoscopy, unless strong pointers to acute renal disease Refer to nephrology if urological investigations negative Age >40, usually refer to Urology (recommended age may vary locally) Age 40 with negative urological investigations, manage as Stage 1/2 CKD manage as Stage 1/2 CKD Refer to nephrology Lower levels of proteinuria, manage as Stage 1/2 CKDmanage as Stage 1/2 CKD Microscopic haematuria with GFR>60ml/min/1.73m2 (+/-prot/creat ratio >50mg/mmol) Refer to renal team.

7 Case history Plan - manage as stage 1/2 CKD. Poor attender at surgery. Develops flu-like illness with abdominal pain. Gives history of intermittent flank pains, but no dysuria or history of renal stones.

8 Case history Haematuria on dipstick testing on this occasion, but also, protein 1+, nitrites and leucocytes +ve. BP 150/110mmHg MSU sent. Form given for blood tests. Commenced on Trimethoprim

9 Case history Blood tests while on antibiotics show the following: Hb 15Urea 6.5 WBC 13.5Creatinine 135 Platelets 225Potassium 5.3 CRP 68 MSU – WCC > 100, RBC + Coliforms, sens to Trimethoprim, Amoxycillin

10 UREA (variable %) CREATININE (~10-15%) A digression……… Trimethoprim inhibits the secretion of creatinine into the tubules and can reversibly increase the serum creatinine up to %.

11 Another digression………

12 Tubular cell Tubular lumen NaKATPase Blood ENaC Na+ 3 Na+ 2 K+ Na+ Mineralocorticoid receptor

13 Tubular cell Tubular lumen NaKATPase Blood ENaC Na+ 3 Na+ 2 K+ Na+ Mineralocorticoid receptor

14 Tubular cell Tubular lumen NaKATPase Blood ENaC Na+ 3 Na+ 2 K+ K+ Na+ Mineralocorticoid receptor

15 Tubular cell Tubular lumen NaKATPase Blood Aldosterone ENaC Na+ 3 Na+ 2 K+ Na+ Mineralocorticoid receptor Aldosterone

16 Tubular cell Tubular lumen NaKATPase Blood Aldosterone ENaC Na+ 3 Na+ 2 K+ Na+ Mineralocorticoid receptor Aldosterone

17 Tubular cell Tubular lumen NaKATPase Blood Aldosterone ENaC Na+ K+ Na+ 3 Na+ 2 K+ Na+ K+ Aldosterone Mineralocorticoid receptor Hypertension Hypokalaemia

18 Tubular cell Tubular lumen NaKATPase Blood Aldosterone ENaC Na+ K+ Na+ 3 Na+ 2 K+ Na+ K+ Aldosterone Mineralocorticoid receptor

19 Tubular cell Tubular lumen NaKATPase Blood Aldosterone ENaC Na+ K+ Na+ 3 Na+ 2 K+ Na+ ENaC Na+ K+ Aldosterone Mineralocorticoid receptor Lower BP Hyperkalaemia

20 Tubular cell Tubular lumen NaKATPase Blood Aldosterone ENaC Na+ K+ Na+ 3 Na+ 2 K+ Na+ K+ Aldosterone Mineralocorticoid receptor Hypertension Hypokalaemia

21 Tubular cell Tubular lumen NaKATPase Blood Aldosterone ENaC Amiloride Na+ K+ Na+ 3 Na+ 2 K+ Mineralocorticoid receptor Aldosterone

22 Tubular cell Tubular lumen NaKATPase Blood Aldosterone ENaC Amiloride Na+ K+ Na+ 3 Na+ 2 K+ Mineralocorticoid receptor Aldosterone Triamterene and Trimethoprim also work in a similar fashion

23 Case history Blood tests repeated 1 week after the course of antibiotics show the following: Hb 15Urea 6.5 WBC 6.5Creatinine 150 Platelets 225Potassium 5.3 CRP 5 Urine dipstick – blood 2+

24 Acute Kidney Injury (AKI) Acute kidney injury is defined when one of the following criteria is met: Serum creatinine rises by ≥ 26µmol/L within 48 hours or

25 Acute Kidney Injury (AKI) Acute kidney injury is defined when one of the following criteria is met: Serum creatinine rises by ≥ 26µmol/L within 48 hours or Serum creatinine rises ≥ 1.5 fold from the known reference value*, or The rise in serum creatinine of ≥ 1.5 is presumed to have occurred within one week or

26 Acute Kidney Injury (AKI) Acute kidney injury is defined when one of the following criteria is met: Serum creatinine rises by ≥ 26µmol/L within 48 hours or Serum creatinine rises ≥ 1.5 fold from the reference value, which is known or The rise in serum creatinine of ≥ 1.5 is presumed to have occurred within one week or Urine output is 6 consecutive hours

27 Acute Kidney Injury (AKI) The reference serum creatinine should be the lowest creatinine value recorded within 3 months of the event. If a reference serum creatinine value is not available within 3 months and AKI is suspected, repeat the serum creatinine within 24 hours. A reference serum creatinine value can be estimated from the nadir serum creatinine value if the patient recovers from AKI.

28 AKI - classification StageSerum creatinine (SCr) criteriaUrine output criteria 1increase of ≥ 26 μmol/L within 48h or increase of ≥1.5 to 1.9 X reference SCr 6 consecutive hrs

29 AKI - classification StageSerum creatinine (SCr) criteriaUrine output criteria 1increase of ≥ 26 μmol/L within 48h or increase of ≥1.5 to 1.9 X reference SCr 6 consecutive hrs 2increase of ≥ 2 to 2.9 X reference SCr 12 h

30 AKI - classification StageSerum creatinine (SCr) criteriaUrine output criteria 1increase ≥ 26 μmol/L within 48h or increase ≥1.5 to 1.9 X reference SCr 6 consecutive hrs 2increase of ≥ 2 to 2.9 X reference SCr 12 h 3 increase of ≥3 X reference SCr or increase of ≥354 μmol/L or commenced on renal replacement therapy (RRT) irrespective of stage 24 h or anuria for 12 hrs

31 Possible outcomes from AKI Cerda, J. et al. Clin J Am Soc Nephrol 2008;3:

32 Case history Auto-immune screen –ve Hb electrophoresis normal Vasculitis screen –ve Abdominal ultrasound scan shows multiple cysts in both kidneys, as well as some cysts in the liver. Family history – no known FH of CKD, but his father died in his 40s of a stroke.

33 Polycystic kidneys

34 Epidemiology Genetics Clinical features Diagnosis Treatment

35 Polycystic kidneys - Epidemiology Common – occurs in 1 in every 400-1,000 live births. Family history - can be negative in up to 25% of cases: – New mutation – Adopted individual – Affected parent died without PKD being noted

36 Polycystic kidneys - Genetics Autosomal recessive PKD Predominantly a disease of childhood. Much less common than autosomal dominant PKD.

37 Polycystic kidneys - Genetics Autosomal dominant (adult) PKD PKD 1 – abnormality on chromosome 16 PKD 2 – abnormality on chromosome 4 In PKD 2, development of cysts and also, of ESRD tends to occur later in life and has a less severe phenotype than PKD1.

38 Polycystic kidneys - Clinical features (Renal) Haematuria – macro and microscopic. Proteinuria – usually <1g/day (PCR 100mg/mmol) Hypertension Renal stones in up to 20% (50%urate stones) Flank and abdominal pains Renal cancers – – often bilateral, and frequently present with a fever. – diagnosis difficult.

39 Polycystic kidneys - Clinical features (Extra-renal) Cerebral aneurysms Routine screening is recommended only for high-risk patients, such as those with: – a previous rupture – a positive family history of an intra-cerebral bleed or intracranial aneurysm – warning symptoms – a high-risk occupation in which loss of consciousness would place the patient or others at extreme risk and – prior to surgery that is likely to be associated with hemodynamic instability with hypertension

40 Polycystic kidneys - Clinical features (Extra-renal) Hepatic cysts Pancreatic cysts Diverticular disease Epididymal cysts Herniae Cardiac disease – – Mitral valve prolapse – Aortic regurgitation

41 Polycystic kidneys - Diagnosis Ultrasonography Best not to do it in people under the age of 18: Possibility of false negative scan especially with PKD2 Adverse consequences – emotional, career, insurance, etc. outweigh benefits of early diagnosis, especially as there is no curative treatment.

42 Polycystic kidneys - Diagnosis Ultrasonographic criteria: Positive family History of PKD AgeCriteria 15-39At least 3 unilateral or bilateral cysts 40-59At least 2 cysts in each kidney >60At least 4 cysts in each kidney

43 Polycystic kidneys - Diagnosis Ultrasonographic criteria: Negative family Hx of PKD – difficult. Suspect it if there are > 10 cysts in each kidney, especially if the kidneys are large, and/or there are also liver cysts.

44 Polycystic kidneys - Treatment Hypertension Statins Vasopressin receptor antagonists mTOR inhibitors e.g Sirolimus, Everolimus Caffeine restriction Dialysis and Transplantation

45 REFERENCES UpToDate


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