Heres some systemic disorders than can affect the kidneys:
DM - Diabetic Vascular disease
Hypertension, HF, atheroemboli & atherosclerosis
Infections - Post infective GN, infective endocarditis, sepsis
Inflammatory - SLE, Wegener’s
Drug Treatments e.g. Aminoglycosides and ACE inhibitors, penicillamine or gold, NSAIDS or contrast
Review the NKF DOQI staging of chronic kidney disease?
National Kidney Foundation Dialysis Outcome Quality Initiative.
1 - Kidney damage but GFR >90
2 - Kidney damage, GFR 60-89
3 - Moderate impairement, GFR 30-59
4 - Severe Impairment - GFR 15-29
5 - Advanced impairment (probably on dialysis) - GFR <15
When a patient presents with impaired renal function or abnormal urinalysis, what symptoms might suggest a systemic disease?
Fever - Malaise - Weight Loss
Arthralgia or Myalgia (incl joint swelling)
Vasculitic Rash - Scleroderma- Splinter haemorrhages
Breathlessness - Haemoptysis - Crepitations
Hypertension - Murmur
Epistaxis - Scleritis/uveitis - nasal cartilage deformity - retinal vasculitis - hypertensive retinopathy
Stroke or encephalopathy
What blood tests might suggest a systemic disorder?
An elevated CRP
How does diabetic nephropathy progess?
1) Silent subclinical phase in which GFR may increase due to hyperfiltration
2) Microalbuminuria phase in which 20-200ug/d reaches the urine
3) Clinical Nephropathy phase in which proteinuria exceeds 0.5g/d & GFR starts to fall
4) Renal Failure where GFR is very low and proteinuria is very high or eventually falls off to 0 as the kidneys fail completely
How does type of DM affect
Types 1 & 2 are equally at risk
DM is the commenest cause of ESRF
How does infective endocarditis lead to kidney disease?
Immune complex formation in response to endocarditis. Complexes become trapped in the glomeruli –> Glomerulonephritis +/- small vessel vasculitis
You may see:
- Abnormal U&Es
- Haematuria & Red cell casts (nephritic syndrome)
- Reduced complement
How do we handle glomerulonephritis from infective endocarditis?
IF the underlying infection is treated the kidneys should recover
What is wegener’s Granulomatosis?
A multi-system granulomatous inflammatory disorder, specifically vasculitic.
- Resp tract
How might wegener’s present? (assuming kidneys are involved)
Generally in men in their 40s-60s:
Focal Necrotising Glomerulonephritis in kidneys +:
Epistaxis/nasal defomity/sinusitis/deafness/cough/dyspnoea/haemoptysis/haemorrhage of the respiratory tract.
Arthralgia & Myalgia
Slceritis in the eyes
Pericarditis in the heart
SYstemic signs including fever, weight loss and a vasculitis skin rash
How would we diagnose Wegener’s?
Urinalysis - confirm nephritic syndrome RFTS - Raised U&Es + Creatinine Inflammatory so a raised CRP Raised ALKP & low albumin Many cases have a +ve C-anca
Chest CT for visible granuomas
Anaemia, thrombocytosis and leucocytosis
A renal biopy
What is myeloma?
A monoclonal proliferation of plasma cells –> Excess immunoglobulins & Light chains
Quite common in the elderly
What features would make you think myeloma?
Renal Disease along with:
- Markedly elevated ESR
- Weight loss
- Back pain/cord compression
If you suspect myeloma how would you confirm?
Bone marrow aspirate looking for >10% clonal plasma cells.
Serum paraprotein +/- immunoparesis
Urinary Bence-jones protein (BJP)
Skeletal survey for lytic lesions
What test would confirm endocarditis?