Introduction to nephrology for dentist students 2015 Judit Nagy

INTRODUCTION TO NEPHROLOGY Topic of nephrology: not-operable („non- surgical”) diseases of the kidneys and urinary tract What to do at a patient suspect for a nephrological disease? What to do at a patient suspect for a nephrological disease? - Diagnosis - Diagnosis - Treatment - Treatment - Follow-up - Follow-up

A) DIAGNOSIS 1. ANAMNESIS 2. PHYSICAL EXAMINATION 3. LAB TESTS serological and urine examinations serological and urine examinations 4. SPECIAL IMAGING TESTS 5. HISTOLOGICAL EXAMINATION OF RENAL BIOPSY RENAL BIOPSY

ad 1. ANAMNESIS (case history, interview) (case history, interview) most of them are painless, symptomless diseases! most of them are painless, symptomless diseases! A) present symptoms and signs A) present symptoms and signs B) past medical history B) past medical history C) patient’s enviroment, nephrological C) patient’s enviroment, nephrological risk factors risk factors D) familiar history D) familiar history E) general questions E) general questions

ad 1. ANAMNESIS A) Present symptoms and signs a) General symptoms and signs a) General symptoms and signs - oedema - oedema - hypertension - hypertension - signs of uraemia - signs of uraemia b) Signs and symptoms in connection with urination and urine b) Signs and symptoms in connection with urination and urine

a) General symptoms and signs oedema - local, symmetrical localisation = periorbital occurence: acut glomerulonephritis etc diff. diagnosis from oedema in dentical diseases diff. diagnosis from oedema in dentical diseases

- generalised, symmetrical - generalised, symmetrical moving with the position of the body moving with the position of the body localisation: localisation: upright position – in low extremities upright position – in low extremities supine position – in sacral area supine position – in sacral area occurence: nephrotic syndrome occurence: nephrotic syndrome chronic renal failure chronic renal failure diff. diagnosis: oedema in cardiac failure diff. diagnosis: oedema in cardiac failure

ad 1. ANAMNESIS A) Present symptoms and signs a) General symptoms and signs a) General symptoms and signs - oedema - oedema - hypertension - hypertension - signs of uraemia - signs of uraemia b) Signs and symptoms in connection with urination and urine b) Signs and symptoms in connection with urination and urine

- hypertension symptome: - headache at the nape symptome: - headache at the napeoccurrence: in acut glomerulonephritis in chronic glomerulonephritis etc. - general signs and symptoms of uraemia neusea, vomiting weight loss itchingpale uraemic breath

A) Present signs and symptoms (cont) b) Signs and symptoms in connection with urination, urine and the kidney - Colour of urine - Colour of urine  normal: from colorless to deep yellow  red or brown-black (acidification of hemoglobin pigment?) macrohaematuria!?

- Quantity of urine  oliguria: 24 hr. urinary output: 50 – 400 ml  oliguria: 24 hr. urinary output: 50 – 400 ml  anuria: 24 hr. urinary output: 0 – 50 ml  anuria: 24 hr. urinary output: 0 – 50 ml but ! - amount of drinked fluid!? but ! - amount of drinked fluid!? - outside temperature!? - outside temperature!? - warm – more perspiration! - warm – more perspiration! fluid loss! fluid loss! vomiting and diarrhoea! vomiting and diarrhoea! - Dysuria (difficult urination) - Dysuria (difficult urination) prostatic hypertrophy?! prostatic hypertrophy?!

- (b) Signs and symptoms in connection with kidney, urination and urine (cont.) - Pain  in either the back or the abdomen  in either the back or the abdomen  most commonly represents inflammation  most commonly represents inflammation or obstruction or obstruction 1. kidney pain in inflammation 1. kidney pain in inflammation occurs in acut pyelonephritis occurs in acut pyelonephritis - localized at or below the costal margin posteriorly posteriorly - may radiate anteriorly toward the umbilicus umbilicus

2. renal and ureteral colic caused by sudden obstruction of a ureter by caused by sudden obstruction of a ureter by stone or blood clots stone or blood clots - sudden in onset - sudden in onset - severe and colicky in nature - localized to the costovertebral angle - radiates to the labium or testicle 3. painful and frequent urination burning sensation at urination in urethra burning sensation at urination in urethra occurs in acute cystitis occurs in acute cystitis

ad 1. ANAMNESIS ( case history, interview) ( case history, interview) painless, symptomless diseases! A ) present symptoms and signs A ) present symptoms and signs B) past medical history B) past medical history C) patient’s enviroment, nephrological C) patient’s enviroment, nephrological risk factors risk factors D) familiar history D) familiar history E) general questions E) general questions

B) Past medical history - Results of blood pressure? urine analysis? renal function (se creatinine, eGFR) examinations?  at routine checkups at work, in the army, during a pregnancy, at work, in the army, during a pregnancy, at licence or blood donor examinations at licence or blood donor examinations  in the records of previous hospital attendances attendances date of the last normal results is important! date of the last normal results is important!

B) Past medical history (cont.) Nephrologic history - previous nephrological examinations laboratory tests and imaging - previous nephrological examinations laboratory tests and imaging (to avoid unnecessary repeat) (to avoid unnecessary repeat) Urologic history - nephrolithiasis ? - prostate enlargement ?

ad 1. ANAMNESIS (case history, interview) (case history, interview) painless, symptomless diseases! A) present symptoms and signs A) present symptoms and signs B) past medical history B) past medical history C) patient’s enviroment, nephrological C) patient’s enviroment, nephrological risk factors risk factors D) familiar history D) familiar history E) general questions E) general questions

C) Patient’s enviroment and nephrological risk factors - profession (exposition to gasoline…) - medications (nephrotoxic drugs: analgesics, antibiotics, gold …) - smoking (active, passive) - all components of the metabolic sy.

ad 1. ANAMNESIS (case history, interview) (case history, interview) painless, symptomless diseases! A) present symptoms and signs A) present symptoms and signs B) past medical history B) past medical history C) patient’s enviroment, nephrological C) patient’s enviroment, nephrological risk factors risk factors D) familiar history D) familiar history E) general questions E) general questions

D) Familiar history - hereditary diseases e. g. polycystic kidney disease - hypertension - obesity IN THE FAMILY - diabetes mellitus E) General questions - weight loss or weight gain (oedema? ) - nausea and vomiting (uraemia ) etc.

A) DIAGNOSIS 1. ANAMNESIS 2. PHYSICAL EXAMINATION 3. LAB TESTS 4. SPECIAL IMAGING TESTS 5. HISTOLOGICAL EXAMINATION OF RENAL BIOPSY RENAL BIOPSY

2) PHYSICAL EXAMINATION a) Inspection b) Palpation c) „Percussion” d) Auscultation

a) Inspection oedemasymmetrical ? localisation ? signs of cardiac failure ? purpura on lower extremities (Henoch- Schönlein sy?) Schönlein sy?) butterfly-like rash on the face (SLE?) etc. etc.

2) PHYSICAL EXAMINATION a) Inspection b) Palpation c) „Percussion” d) Auscultation

b) Palpation bimanual „slipped” palpation of kidneys (the examiner’s right hand palpate the kidney which is pushed forward by the left hand and after deep breathes, the right hand slip closer and closer to the left one) normally: kidneys are not plapable

2) PHYSICAL EXAMINATION a) Inspection b) Palpation c) „Percussion” d) Auscultation

c) „Percussion” blow of the back at the level of the kidneys on both side withyour fists ! question: sensitivity d) Auscultation d) Auscultation question: bruits above renal arteries (renal artery stenosis on one side or on both sides?)

A) DIAGNOSIS 1. ANAMNESIS 2. PHYSICAL EXAMINATION 3. LAB TESTS serological and urine examinations serological and urine examinations 4. SPECIAL IMAGING TESTS 5. HISTOLOGICAL EXAMINATION OF RENAL BIOPSY RENAL BIOPSY

34 StageDescription GFR ml/min Prevalence in US 1. Kidney damage with normal or elevated GFR > 90 5,9 (3,3%) 2. Kidney damage with mild decrease of GFR ,3 (3,0%) 3.Moderate decrease of GFR ,6 (4,3%) 4.Severe decrease of GFR ,4 (0,2%) 5.End stage renal failure< 15 0,3 (0,2%) Total11% Stages of chronic kidney disease