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Assessment of a Patient with Renal Disease

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1 Assessment of a Patient with Renal Disease
Dr Andrew Stein Consultant in Renal and General Medicine, UHCW


3 Aims Anatomy Function Definitions History Examination Investigation
eGFR, CKD, Creatinine History Examination Investigation Likely Cases

4 Theme of Lecture: Basic Renal Principles
Assessment of a renal patient is not that complicated, need to be methodical .. History, esp DRUGS Examination, esp fluid state Careful analysis of data Exclusion of non-renal causes of symptoms Re-assess patients daily (fluid state) Some technical knowledge of dialysis/Tx etc

5 7 Renal Syndromes AKI/AKI-CKD CKD-ESKD Nephrotic Syndrome
Nephritic Syndrome Macroscopic haematuria Microscopic haematuria Hypertension

6 Anatomy

7 Surface Anatomy of Kidney

8 Nephron

9 Normal (Basics) Normal bladder size Normal urine output 300-400 mls
2L/day (urinate 8x in day, 1x/night ≈ 200 mls) Oliguria < 400 ml/day Oligo-anuria < 200ml/day Anuria = zero ml/day

10 Kidney Size 12 (10-14) x 6 x 3 cm, 150g, retroperitoneal
How does that affect palpation?

11 Kidney Palpation Normal kidneys are not usually palpable
However, in some slim women, lower pole of the right kidney can occasionally be felt during deep inspiration Large kidneys or masses can sometimes be felt

12 Function

13 Functions of Kidney Execretory (3) Metabolic/endocrine (4)
Excretion of waste products Regulation of fluid state and electrolytes Acid-base balance Metabolic/endocrine (4) Erythropoitein Renin Prostagladins Activation of vitamin D Consequences?

14 How Hard do 2 Kidneys Work?
25% cardiac output GFR 120 mls/min = ~ 170 L /day Ie blood volume passes through kidneys 35x/day

15 What is GFR? Why Measure it?
Glomerular filtration rate (GFR) is the rate (volume per unit of time) at which ultrafiltrate is formed by the glomerulus. Approximately 120 mL are formed per minute We use GFR to estimate renal function GFR α 1/creatinine, ie mathematically linked Whats wrong with creatinine? A normal creatinine concentration can occur even when the GFR has dropped by 50% So creatinine is a fairly insensitive indicator of early renal impairement Creatinine clearance and the assessment of renal function Nankivell, BJ. Aust Prescr 2001; 24: 15-7

16 CKD: GFR α 1/creatinine Why GFR? Creatinine is rel specific but not very sensitive 120 mls/min Creatinine Creat GFR/% Do Prepare Think GFR Creat <120 mcmol/L

17 Factors Affecting Serum Creatinine
GFR 60 mls/min Age Sex Race Muscle mass, useage Diet Drugs (eg?) Creat 200 GFR 15 mls/min Needs dialysis

18 Other Problems with Creatinine
Creatinine is an imperfect filtration marker, because it is secreted by the tubular cells into the tubular lumen, especially if renal function is impaired The amount excreted exceeds the amount filtered by 10-20% Fortunately this is balanced by a similar error in the chemical assay used which overestimates serum creatinine So. Above 40 mls/min, the serum creatinine is accurate and good reflection of GFR. Under this level, it tends to overestimate GFR Note: some drugs (such as cimetidine or trimethoprim) have the effect of reducing tubular secretion of creatinine. This increases the serum creatinine. These drugs are not often used now

19 Can Urea Be Used? Measuring the blood urea concentration has limitations because, as well as renal impairment, it is increased by: Increased protein metabolism (raised in catabolic states, and high protein diet) Dehydration Heart failure RVD Steroids And, conversely, patients with renal impairment can have relatively normal blood urea concentrations if they are grossly malnourished and not eating

20 What About Tubular Function?
Although glomeruli control the GFR, damage to the tubulointerstitium is also an important predictor of GFR and progression towards renal failure Renal tubules make up 95% of the renal mass, do the bulk of the metabolic work and modify the ultrafiltrate into urine They control a number of kidney functions including acid-base balance, sodium excretion, urine concentration or dilution, water balance, potassium excretion and small molecule metabolism (such as insulin clearance) Measurement of tubular function is impractical for daily clinical use, so we usually use the GFR to assess renal function

21 Definitions

22 Definitions of Normal Renal Function, Renal Impairment and Failure in AKI/CKD (Creatinine + GFR)
AKI/AKI-CKD Creat >120 mcmol/L (normal range ) RIFLE (research mainly) CKD GFR < 120 mls/min (not used in AKI) Renal impairment = CKD <60 mls/min (CKD3a) Renal failure = <15 mls/min (CKD4) Simple Definition of Renal Impairment = Creat > 120 mcmol/L (AKI, CKD, or AKI-CKD)

23 CKD, eGFR, Creatinine and Symptoms
CKD1 – creat N (<120) CKD2 – creat N (<120) CKD3a – creat N-150 CKD3b – creat CKD4 – creat >200 CKD5 – creat >400 When do symptoms start? Who to refer?

24 Another Way of Describing Renal Impairment

25 Classification of AKI: RIFLE
RIFLE (Bellomo, 2004) Creatinine R isk x baseline I injury x F ailure >3x L oss (>4 wks) E SRD (>3 mths) Later: AKIN, KDIGO, NICE (2013)

26 History

27 Presenting Complaint Asymptomatic (routine bloods)
Symptoms of fluid overload: SOB = pulmonary oedema, pulmonary oedema and pulmonary oedema Don’t forget pulmonary haemorrhage, acidosis (Kussmaul’s breathing) SOA Other: itching, nocturia, ‘uraemia’ Urinary symptoms Frothy urine (nephrotic syndrome) Macroscopic haematuria (IgA?)

28 HPC Length of symptoms Associated symptoms
Eg onset of SOA, frothy urine and red rash on face (Diagnosis ..?)

29 Urinary Symptoms (Surgical)
Ask patient to describe urination (prostate) UTIs (reflux nephropathy) Loin pain “I cannot pass urine” (anuria) Macroscopic haematuria

30 Anuria V rare Only 3 causes Obstruction Vascular catastrophe
Severe acute glomerulonephritis

31 Macroscopic Haematuria
Recurrent visible haematuria Age > 40 years, presume neoplasia Smoking UTI/stones or other urological disorders Occupational exposure to chemicals or dyes Pelvic irradiation Excessive analgesic use Cyclophosphamide

32 PMH DM (esp DM2) Stones/UTIs Prostatic disease
Autoimmune disease (SLE) Neoplasia (pelvic, myeloma) Atheroma (RVD) Previous AKI

33 SH Smoke (RVD) Alcohol (IgA)
IV drugs / sexual orientation (Hep B, Hep C, HIV) Home set-up (dialysis etc)

34 FH PCKD (first case?) Rare (eg, Alports, other hereditary nephritis, thin basement membrane disease, nail-patella syndrome, cystinuria, hyperoxaluria)

35 Drugs + Allergies DRUGS DRUGS DRUGS NSAIDs (analgesic nephropathy)
ACEi-ARB Lithium (chronic interstitial nephritis) Chemotherapy Prev drug allergies (eg .. ?)

36 Examination General Limited cardiorespiratory GI+

37 General Examination “Observation is 90% of Medicine” Prof Dan Hoyte
Walk into the room (DM?) Face (eg SCCs (Tx-related), SLE) Hands (radial/brachial fistula) Skin (excoriation) Uraemic frost = deposition of white/tan urea crystals on the skin after sweat evaporation (v rare) Pulse (sign of LVF)

38 Cardiorespiratory = Limited cardiorespiratory BP BP BP JVP JVP JVP
Auscultation (pericardial rub) Pulmonary oedema (± pleural rub) Sacral oedema Leg oedema

39 GI+ Observation (state the obvious, eg .. ) Light palpation
Deep palpation Liver Spleen Kidneys + Bladder Bruits (epigastric, femoral)

40 Technical Signs (relating to HD, PD and Tx)
Dialysis catheter AVF (radial/brachial) PD catheter Urinary catheter/nephrostomy Tx scars Tx-related problems (eg NODAT, BCC/SCC)

41 Investigation Urine Blood Radiology + invasive

42 Urine Tests

43 Urine - MSU <5 WC <25 RC No casts (esp red cell) No growth
“Mixed growth”? .. which UTIs to investigate?

44 Dipstick – Blood, WC, Glucose
Haematuria 2+ (ie microscopic) = ? 80% sensitive, 65-99% specific Need? .. Leucocytes 1+ ≠ UTI (need? ..) Nitrites - produced when bacteria reduce urinary nitrates derived from amino acid metabolism Glucose - usually appears in urine when serum glucose increases to > 10 mmol/L) and renal function is normal Useful screening test, not diagnostic

45 Microscopic Haematuria – Who to Investigate
If associated with: Stage 4 or 5 CKD Worsening CKD Significant proteinuria (PCR ≥ 50, ACR ≥ 30 mg/mmol (≥ 0.5 g/24h)) Uncontrolled BP ≥ 140/90 mmHg (3+ drugs) Or unexplained microhaematuria following urological assessment where no cause was found

46 Dipstick - Protein Detects albumin but not other proteins, such as immunoglobulin light chains (consequence? ..) Like creatinine, his test is specific(ish), but not very sensitive for the detection of proteinuria Ie, it becomes positive (1+) only when protein excretion exceeds 0.5 g/L (upto 0.2g/L is normal). This is quite a lot Hence, concept of microalbuminuria developed

47 Dipstick – Protein (Other Problems)
Semi-quantitative categories on the dipsticks should be used with caution (esp ‘proteinuria’ = albuminuria) Only a rough guide since Albumin conc varies with urine volume, ie Dilute urine underestimates degree of proteinuria Concentrated urine may show ‘3+ proteinuria’ Different products

48 Proteinuria (quantification)
Eat 80g /day Heavy proteinuria is the hallmark of glomerular disease Normal = <0.2 g/L, ie <0.4g/day, if 2L urine Or PCR <15 mg/mmol (ACR <3 mg/mmol) PCR/100 ≈ g/24h ACR 3-30 mg/mmol = microalbuminuria Dipstick specific but not very sensitive (like creatinine) Dipstick g/L g/24h PCR (ACR) 0 <0.2 <0.4g <15 (<3) Trace (ACR 30) (ACR 70) low mod nephrotic range high nephrotic v high

49 CKD/Proteinuria Classification (Again!)

50 Blood Tests

51 Blood - Biochemistry Sodium (135-145 mmol/L)
Potassium ( mmol/L) Severe hyperkalaemia > 6.4 mmol/L Urea (3-7 mmol/L) Severe level >50 mmol/L Creatinine ( mcmol/L) Severe level >400 mcmol/L

52 Hyperkalaemia

53 Blood – Bone Biochemistry
Calcium ( mmol/L) Phosphate ( mmol/L) Alk Phos ( iu/L) PTH (<4.2 pcmol/L) Renal osteodystrophy? ..

54 Blood – Haematology Hb – anaemia WC - N Platelets – thrombasthenia
MCV? .. ?EPO if HB < 100 g/L) WC - N Platelets – thrombasthenia Clotting - N

55 Blood – Immunology (‘Renal Screen’)
Immunoglobulins (A, G, M) (IgA nephropathy, myeloma) Protein electrophoresis (myeloma) Serum free light chains (myeloma) ANA and dsDNA (SLE) Complement factors (C3 and C4) (SLE) Anti-neutrophil cytoplasmic antibodies MPO and PR3 (ANCA) (vasculitis) Anti-glomerular basement membrane antibodies (AGBM) (Goodpasture’s Syndrome) Anti-streptolysin O titre (ASOT) (post-infectious glomerulonephritis) Angiotensin converting enzyme (ACE) (raised in sarcoidosis) Cryoglobulins (mesangiocapillary GN) Hep B, Hep C, HIV (GNs and safety of patients and staff, esp HD)

56 Radiology + Invasive Tests

57 Radiology – Renal Ultrasound
2 kidneys? Prepare for biopsy Obstruction (treatable) Appearance Size (chronicity) Disparity size (RVD) Scars (reflux nephropathy) Very bright (HIVAN)

58 Radiology - Other KUB (if known to have radio-opaque stones)
CT-KUB (stones) is better CT MRI (MRA/CTA) Treatments (eg nephrostomy, antegrade or retrograde)

59 Causes of CKD Small kidneys / idiopathic 30% Glomerular Disease
Primary (GN) Secondary (eg DM 20%) Renovascular Disease Atheroma Fibromuscular Dysplasia Obstructive Nephropathy Prostate (man) Pelvic cancer (woman) Tubulo-interstitial Disease Drugs eg Analgesic Nephropathy, Lithium UTI eg Reflux Nephropathy Autoimmune eg Sarcoidosis Congenital eg PCKD

60 Investigation – Specialised (Renal Biopsy)
AKI, normal sized kidneys, no obvious cause = biopsy CKD, normal sized kidneys, Proteinuria (>1g/L = 2g/24h = ‘nephrotic range’), no obvious cause Transplant dysfunction

61 Investigation – Specialised (Renal Angiogram)
Rarely performed (now always with a review to intervention) Hypertension (RVD) with poor BP control on 4 drugs ‘Flash’ pulmonary oedema AKI in single (or single effective kidney) Fibromuscular dysplasia

62 Likely Cases

63 Case One 47y year old Asian male
Presents 2 wks SOB and SOA, O/E fluid overload DM2 2 years IHD/CCF Serum albumin 40 g/L Urinary protein 0.15 g/L 1. Other information? 2. Diagnosis?

64 Case Two 35y old female Investigated for BP Creat 68 mcmol/L
FH grandfather died of kidney problem O/E large liver? 2 large kidneys? (both?) 1. Next investigation? 2. Diagnosis?

65 Case Three 23 year old female 2 weeks SOA O/E SOA Serum albumin 25 g/L
Urinary protein 4.3 g/L Creat 87 mcmol/L 1. Renal syndrome? 2. Diagnosis?

66 Case Four 67 year old Asian male PMH DM2 (20y), TURP
C/O 6 mths SOB, O/E fluid overload, R fem bruit Creat 465 mcmol/L (198 mcmol/L, 2012) Urinary protein 0.1 g/L 1. Next investigation? 2. Diagnosis?

67 Case Five 87y old male C/O tiredness ESKF (2009)
On CAPD (4 x 2L bags a day) Creat 877 mcmol/L and stable 1. Other information? 2. Diagnosis?

68 Summary Assessment of a Renal Patient is not that complicated, need to be methodical .. History, esp DRUGS Examination, esp fluid state Careful analysis of data Exclusion of non-renal causes of symptoms Re-assess patients daily (fluid state) Some technical knowledge of dialysis/Tx etc

69 Questions

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