The kidney in systemic disease

1. The kidney in systemic disease Dr Saad Al Shohaib Associate professor of medicine and nephrology KAUH

2. The kidney in systemic disease • The kidney can be affected in different diseases including autoimmune diseases diabetes infections cardiac and liver diseases • Kidney involvement usually affect mode of therapy response to therapy and outcome

3. Renal function in CHF • CHF is a common disorder and alteration in renal function affect mortality and morbidity • Renal impairment make treatment more difficult since the response to diuretics is decreased • In CHF there is Na retention in spite of extra cellular volume expantion

4. Case presentation • A 55 year old lady known to have CHF and CRF of unknown etiology . Her serum creatinine had been maintained in the range of 350 umol/l .Maintained on diuretics and enalapril 20 mg /day. Presented to the emergency room with progressive dyspnea and orthopnea . On examination she looked ill dyspnic and orthopnic BP 160/105 JVP raised and she had basal crackles . CXR showed pulmonary edema

5. Case presentation • Lab data Na 133 K 5.3 BUN 26 mmol/l Cr 425umol /l HCO3 18 Hb 11.0 WBC 10 LFT normal ECG no new changes given 40mg of frusemide iv with no response this was repeated an hour later with no response then nephrology team was contacted for possible dialysis

6. Renal function in CHF • There is increase in the nuerohormonal vasoconstrictors in CHF ( A2 Aldosterone and vasopressin ) • This lead to afferent arteriolar vasoconstriction Na and K retention and water retention • There is increase in the hormonal vasodilators as ANP and renal prostaglandins

8. The kidney in CHF • The nuerohormonal changes lead to decrease in renal blood flow and GFR and may give a picture of pre renal azotaemia or lead to worsening of a pre existing renal impairment to the point that dialysis may be required • Dialysis and fluid removal in this situation may improve cardiac output and induce diuresis

9. The kidney in CHF • Prolonged diuretic use can lead to decrease in ANP and increase in A2 and norepinephren and therefore diuretic resistance • In this situation a higher dose is required particularly if there is renal impairment

10. Hyponatremia in CHF • In sever CHF hyponatremia may be seen due to increased vasopressin • Hyponatremia is an indication of severty of CHF as well as resistance to diuretics • A very low urine Na is a predictor of decreased response to diuretics • Patients with hyponatremia are more liable to get hypo tension in response to ACE inhibitors or A2 receptors antagonists

12. CRF and CHF • Renal failure may co exist with CHF and make management difficult • In this situation a higher dose of loop diuretics is required • Sever renal failure of may limit the use of ACE inhibitors particularly in the presence of hyperkalemia

13. The kidney is very sensitive to nephrotoxic in the presence of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

14. The kidney in liver cirrhosis • There is sever Na retention to the point that the urine may be Na free • Very low urine Na is a marker of disease severity • Very low urine Na indicate poor response to diuretics

15. The kidney in cirrhosis • There is disturbance in Na handling due increased Na reabsorption related to excess aldosterone increased renal sympathetic activity and alteration in ANP and prostaglandin • If Na intake continue more than loss there would be sever Na and water retention • Na restriction is vital in the management of ascities

16. Hepatorenal syndrome • Progressive oliguric renal failure either insidious or rapid • Usually occur in hospitalized patients • May be precipitated by bleeding aggressive diuresis or abdominal paracentesis • Functional renal failure with very low Na • Should differentiated from ATN and pre renal states

18. Treatment of HRS • Search for correctable causes • Na and water restriction • Dialysis is not effective except to support candidates for transplant • Leveen shunt had been tried in small studies

19. Renal involvement in systemic vasculitis • The kidney is affected by many vacultidies Giant cell • Takayasu • Polyarteritis nodosa • Kawasaki • Microscopic arteritis • Wegeners • HSP

20. Giant cell and takaysu Medium sized ployarteritis nodosa Small vessel vasculitis as HSP SLE and wegeners Rarely cause significant renal disease Main renal artery and cause ifarction glomerulonephrits vasculitis

22. Small vessel vasculitis • In small vessel vasculitis rapidly progressive glomerulonephrits leading to ARF that may require dialysis • Aggressive immunosuppressive therapy using pulse steroids cyclophosophamide and possibly plasma pharesis can be useful particularly if used before creatinine exceed 5 mg /dl • ANCA positive disease respond better to therapy

24. SLE • Common disease in Saudi Arabia • Renal involvement is variable from mild a symptomatic proteinuria and hematuria to ever renal impairment that may require dialysis • The clinical picture can change rapidly to a very aggressive disease • There might be a discrepancy between the clinical picture and histological findings

25. Case presentation • 21 year old lady known to have SLE and lupus nephritis for the last 4 years . Biopsy was done at the time of diagnosis and showed class IV with active disease but no chronic changes . At that time her serum creatinine had been kept within normal limit as well as her clearance 24 h urine protein was 4 grams. She was treated with monthly cyclophosphamide for 6 months then every 3 months for tow years

26. Case presentation • Her proteinuria improved and serum Cr was normal for tow years . Follow up was lost for tow years then she came back for follow up . She was a symptomatic but serum Cr was 160 umol/l Cr clearance was 45 mls /min 24 h urine for protein 3 grams renal ultrasound was normal

28. Normal Mesangial nephropathy Focal proliferative Diffuse proliferative Steroids Steroids cyclophosphamide SLE

29. SLE • Class IV is treated with monthly cyclophosphmide for 6 months then every 3 months for two years • Azathioprine is not effective • In resistant nephritis cyclosporine and cellcept may be usefull • Repeat biopsy may be indicated to assess further immunosuppressive therapy

32. Case presentation • A 48 years Egyptian male presented with mild lower limb edema for the last tow months. On examination he looked well B P 160/90and the rest of the exam was unremarkable except for mild lower limb edema . Urinalysis showed protein and red cells but no casts . 24 h urine protein was 4 grams

33. Case presentation • Seum Cr 85 umol/l Hb 14.2 gm LFT normal . Serum albumin 32 cholesterol 7 mmol/l ANA negative C3 normal hep C Ab positive PCR positive Genotpype 1 cryglobolin negative . .NKidney biopsy showed membranous G . N.

34. Case presentation • He was treated with peg interferon for six months and proteinuria subsided to less than one gram

35. Glomerulonephritis with hepatitis C and B • Membranous • MPGN • Mesangial proliferative • Nephrotic syndrome • May respond to interferone

36. Post infectious G N • Immune complex nephritis can follow any bacterial viral fungal or parasitic infections • Can follow infected shunts and endocardits • May complicate deep abscesses • Usually present 3 weeks post infection

38. Post infectious G N • Hematuria edema • Oliguria hypertension • Fever • Uncommonly ARF requiring dialysis

39. HSP • Cutaneous vasculitis • Ig A deposits in the skin and kidneys • Transient hematuria and proteinuria occur in 50% of the cases • Acute proliferative glomerulonephritis with Ig A deposit may occur but would rarely require dialysis and this would indicate aggressive therapy

40. Rhuematoid arthritis and gout • There is no specific renal lesion in gout and R A • In R A the renal lesion is usually secondary to therapy amyloid or vasculitis

41. Diabetic nephropathy • Common problem 30 - 40% of dialysis patients are diabetics • Long standing diabetes • Genetic predisposition hypertension poor glycemic control are important risk factors • Strongly associated with retinopathy

42. Diabetic nephropathy stages • Increased GFR and hyperfiltration • Normal GFR and mild mesangial expansion • Microalbumiuria • Overt proteinuria • CRF

43. Diabetic nephropathy diagnosis • Clinical diagnosis • Long standing D M particularly in type 1 • Proteinuria or microalbumiuria • Retinopathy • Inactive urinary sediment • Normal sized kidneys

44. Diabetic nephropathy • Microalbumiuria is a sign of cariovscular disease and is a very important finding since interference with strict glycemic control and ACE inhibitors is important • Strict glycemic control can reverse glomerular changes • Blood pressure control is vital and the ACE inhibitor dose should be titrated to the degree of proteinuria

45. thank you