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Approach to the Patient with Renal Disease

Approach to the Patient with Renal Disease. Tarek Mohamed El Tantawy M D , MSc Nephrology – Ain Shams University Egyptian Nephrology Fellowship Trainer - MNGH HQM - Cambridge. - 1 -. Introduction. Patients with kidney disease can have a myriad of presentations.

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Approach to the Patient with Renal Disease

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  1. Approach to the Patient with Renal Disease Tarek Mohamed El Tantawy MD, MSc Nephrology – Ain Shams University Egyptian Nephrology Fellowship Trainer - MNGH HQM - Cambridge -1-

  2. Introduction • Patients with kidney disease can have a myriad of presentations. • Patients may be completely asymptomatic and have only elevated blood pressure or laboratory abnormalities such as an increase in serum creatinine, decreased glomerular filtration rate, or microscopic hematuria and proteinuria. • Alternatively, patients may present with overt signs and symptoms related to uncontrolled blood pressure, nephrotic syndrome, volume overload, changes in urination, or as part of a systemic disease. -2-

  3. Introduction • When patients present with abrupt onset signs or symptoms of systemic disease along with kidney involvement it is often relatively simple to determine when the kidney disease began and thus what may have been the etiology for the injury. • When a healthy patient (especially youngerpatient) presents with decreased GFR and active urine sediment, it is clear that they have active kidney disease and a renal biopsy will be required. -3-

  4. Introduction • However, oftentimes patients present having not seen a physician in many years, without historical laboratory studies and with an unclear duration of diabetes, or hypertension. • Such patients require a methodical approach in determining the etiology and treatment plan. This approach must be sensitive to cost, and the sensitivityand specificityof the various testing modalities. -4-

  5. Case ( I ) • A 35-year-old man presents with a 1-week history of progressive shortness of breath and an episode of hemoptysis earlier today. • For the past 2 days he has had decreased urine volume and dark colored urine. • He has no past medical history and takes no medications. • Blood pressure is 145/85 mmHg. Pulse is 110 beats per minute. Temperature is 36.8°C. Pulse oximetry is 87% on room air. • He is anxious and slightly pale. Pulmonary exam reveals bibasilar crackles. The remainder of his exam is unremarkable. • His laboratory data is notable for a hemoglobin level of 10.9 g/dL and serum creatinine of 2.7 mg/dL. His chest X-ray shows bilateral pulmonary infiltrates. • What is your approach to diagnosis and management in this patient? -5-

  6. Case ( II ) • A 55-year-old woman is referred to your office because of a serum creatinine of 2.5 mg/dL noted on routine labs 3 weeks prior. • She deniesdysuria, gross hematuria, or change in urine output. • She urinates at least two times per night. She is obese and has chronic back pain. She is not taking any prescription medications. • Blood pressure is 135/78 mmHg. Pulse is 82 beats per minute. • She has trace to 1+ edema to her mid-shin. Remainder • of her physical exam is unremarkable. • Repeat serum creatinine is 2.6 mg/dL. • Urine sediment is a bland. • What is your approach to diagnosis and management • of this patient? -6-

  7. I will focus on the approach to the patient who presents with kidney dysfunction with a focus on the key features of the history, physical exam, laboratory, and imaging that can be helpful in narrowing the differential diagnosis and determining the acuity and activity of kidney disease. -7-

  8. This information can be extremely helpful in determining the etiology of disease, guiding the diagnostic workup, and determining a treatment plan. • The information gathered using a systematic approach will provide important clinical correlation to the pathologic findings in these cases. -8-

  9. History • The first step in approaching all patients with abnormal renal function tests is a detailed history. • Patient history needs to include a detailed review of systems with a focus on the urinary system as well as on obtaining pertinent history of symptoms of systemic diseases with known renal involvement. -9-

  10. Urologic History • Has the patient had any previous urinary tract infections, previous episodes of pyelonephritis, history of vesicoureteral reflux, episodes of nephrolithiasis, or known renal cystic diseases? Each patient also needs a voiding history. • Ask the patient about changes in the color of the urine. Gross hematuria may present as tea- or cola-colored urine as is often seen in glomerular disease and nephrolithiasis. Patients with nephrotic syndrome may have foamy urine. -10-

  11. Urologic History • Patients with bladder outlet obstruction (e.g., secondary to BPH) may complain of smaller urine volumes, incomplete sensation of bladder emptying, weaker urine stream, or even dribbling at completion of voiding. • The first sign of renal disease may also be a decrease in the ability to concentrate urine, the earliest symptom of which may be new onset or increasing nocturia, sometimes noted in patients with tubulointerstitialdisease and polycystickidneydisease. -11-

  12. Volume Status • Has the patient noticed weight gain with associated lower extremity edema, orthopnea, or periorbital edema? • Conversely, is there a history of poor oral intake, emesis, diarrhea, or high output from ostomy or drains? Are there symptoms of orthostasis or syncope? -12-

  13. Systemic Diseases • The clinician should carefully assess the patient for symptoms of systemic disease processes with associated kidney involvement. • Ask the patient about any fevers, night sweats, oral ulcers, rashes, and arthralgias as these symptoms correlate with autoimmune disease and vasculitis. • The presence of dyspnea, hemoptysis, or upperrespiratorysymptoms should prompt evaluation for pulmonary-renalsyndromes. • New onset of easy bruising or petechiae may indicate thrombocytopenia from a thrombotic microangiopathy (TMA). -13-

  14. Systemic Diseases • Any history of, or risk factors for, chronic infections such as hepatitis B and C as well as HIV should be obtained. • When the renal dysfunction appears to be chronic, obtain history for chronic diseases including diabetes, hypertension, peripheralvasculardisease, tobaccoabuse, and known malignancy. • If the patient has diabetes, include in your history the duration, degree of control, and whether he or she has retinopathy and neuropathy. -14-

  15. Systemic Diseases • Detailed history of hypertension should include duration, baseline blood pressures, and medications. • If the patient has cardiovascular disease, note if any recent angiographic procedures have occurred that would place the patient at risk for contrast-induced nephropathy or atheroembolic disease. • Ask about exercise tolerance and symptoms of claudication which may be helpful in determining vascular causes of renal disease. -15-

  16. Family History • In cases of chronic renal dysfunction, family history can also be very helpful if hereditary kidney diseases such as Alport syndrome, polycystic kidney disease, or inherited interstitial kidney diseases are suspected. • In all such cases, a detailed pedigree should be obtained as well as past medical records of affected individuals. -16-

  17. Medications • Medications commonly associated with acute and chronickidneyinjury are diuretics (especially consider in the context of history of volume losses), nonsteroidalanti-inflammatorydrugs, angiotensinconverting enzyme inhibitors, angiotensin receptor blockers, highly active antiretroviral therapies, chemotherapeutic agents, calcineurin inhibitors, and lithium. • Be sure to review records from any recent hospitalizations for exposure to nephrotoxicmedications, especially aminoglycosides, vancomycin, acyclovir, and amphotericin . • Certain medications are associated with the development of interstitial nephritis such as penicillins and cephalosporins, or proton pump inhibitors. • Review the intake of over-the-counter medications, herbal medications, and supplements. Patients often do not perceive these substances as being potentially harmful and thus may not report them. -17-

  18. Physical Examination -18-

  19. Head • Careful exam of the eyes can give clues to systemic disease processes. • Ocular findings may include arteriovenous nicking in long-standing • hypertension and cotton wool spots and retinal hemorrhages in association with systemic lupus erythematosus. • Scleritis or uveitis is seen in collagen vascular diseases, vasculitis, and tubulointerstitial nephritis and uveitis syndromes. • Proptosis and orbital pseudotumor should prompt suspicion for an underlying diagnosis of granulomatosis with polyangiitis or cyroglobulinemia. • Lensrupture can be seen in Alportsyndrome. -19-

  20. Head • Oral exam findings may provide helpful clues to the presence of systemic diseases with renal involvement. Enlarged and friable “strawberry gums” are a characteristic finding in patients with granulomatosis with polyangiitis. Oralulcerations may be found in SLE and Henoch-Schönleinpurpura. • Periodontal disease is often associated with bacteremia and subsequent risk of endocarditis. • Examine the tongue for the presence of macroglossia in patients with suspected amyloidosis . -20-

  21. Cardiovascular • Assessment of volumestatus is of critical importance. • Vital signs should be taken in the supine, seated, and standing position to evaluate for the presence of orthostasis. Orthostasis, tachycardia, dry mucus membranes, and flat neck veins all lend support to a diagnosis of hypovolemia. • Hypervolemia will manifest as edema (periorbital, peripheral, or anasarca), pulmonary crackles, elevated jugular venous pressure, and cardiac gallops. • The presence of a friction rub is an indicator of uremic pericarditis or of cardiac tamponade and requires emergent attention. In the proper setting, a new murmur may be suggestive of endocarditis. • In addition to assessment of volume status, careful vascular exam should include auscultation over bilateral carotid arteries and aorta, renal, and femoral arteries for evidence of bruits • Palpate peripheralpulses and examine extremities for evidence of hypoperfusion. -21-

  22. Pulmonary • In a patient with renal disease and dyspnea, upper respiratory symptoms, or hemoptysis, prompt evaluation for pulmonary-renal syndromes should be initiated. • The most common pulmonary renal syndromes are anti-glomerular basement membrane antibody mediated, anti- neutrophil cytoplasmic antibody positive (granulomatosis with polyangiitis, microscopic polyangiitis, Churg –Strauss syndrome), and autoimmune associated (SLE). • However, even severe volume overload due to kidney failure can manifest as hemoptysis and dyspnea. The physical exam will be notable for the presence of • pulmonary crackles, rales, or ronchi. -22-

  23. Abdomen / Genitourinary • The presence of hepatomegaly will alert the clinician to potential liver disease and the possibility of associated secondary glomerular diseases including membranous nephropathy associated with hepatitis B, membranoproliferative glomerulonephritis, and cryoglobulinemia in association with hepatitis C. • Palpation of enlargedkidneys is noted in patients with polycystic kidney disease. • Pertinent genitourinary findings include a distended bladder and prostatic hypertrophy. -23-

  24. Skin / Joints • Examine the skin and joints to evaluate for systemic diseases with renal involvement. • Look for the characteristic rashes of SLE, palpable purpura as can be seen in cryoglobulinemia and HSP, petechiae as seen in TMAs, and embolic phenomenon seen in endocarditis and atheroembolic disease. • The presence of inflammatoryarthritis will also give clues to the diagnosis of underlying collagenvascular diseases. -24-

  25. Laboratory Findings • When evaluating a patient with abnormal kidney function, one of the most important initial goals is to determine if they have an acute or a chronic process and if the renal function is rapidly deteriorating or is relatively stable. • The rate of decline in kidney function, as measured by serum creat or GFR, will be an important determinant of the urgency of the workup. • A patient with rapidly progressive renal disease will likely need immediate biopsy and possibly even hospitalization to expedite evaluation, whereas a patientwithachronic course can have an evaluation carried out over many days. -25-

  26. Laboratory Findings • The only way to determine whether the renal failure is acute or chronic is to do a review of prior laboratory testing. Many times patients will be unaware of previous laboratory values or even of the significance of abnormalities. • Every effort should be made to review previous laboratory data, including serum creatinine values and urinalysis. In cases where no previous data is available, a kidneyultrasound may be helpful in sorting out an acute versus chronic process. -26-

  27. Laboratory Findings • Serum creatinine is the most widely used laboratory test for determining kidney function and estimatingGFR. • When considered alone, creatinine is an imperfect marker for estimating renal Function. • Despite limitations of this test, changes in serum creatinine (and estimated GFR) are used both in the diagnosis and management of patients with renal dysfunction. • If a patient presents with an unknown baseline or with rapidly changing renal function, a repeat creatinine level should be obtained followed by serial measurement. -27-

  28. Laboratory Findings • A freshurine specimen should be obtained for dipstick testing and microscopic examination of the sediment. • Pertinent findings on urinalysis include the presence of hematuria or proteinuria. • If proteinuria is present it should be quantified via a spot urine protein-to-creatinine ratio. While patients with tubulointerstitial disease often have proteinuria less than 1 g per 24 h and patients with glomerular disease frequently present with proteinuria greater than 2 g per 24 h, there is often significant overlap in these presentations. -28-

  29. Laboratory Findings • Microscopic exam of the urinesediment must be performed on all patients with kidney disease. • Active urinary sediment is characterized by the presence of dysmorphic red blood cells and cellular casts (granular, white blood cell , and RBC). • Active urinary sediment is indicative of acute tubulointerstitial or glomerular disorders and should prompt immediate evaluation. • In patients with evidence of active kidney disease, further laboratory testing may be useful in determining the etiology, but renal biopsy will often be required to confirm the diagnosis and potential response to treatment. -29-

  30. Laboratory Findings • Findings of chronic, slowly progressive renal dysfunction and the presence of inactive urinary sediment are consistent with chronic kidney disease. If a modifiable primary disease process is not identifiable, then therapy is aimed at slowing progression and managing sequelae of CKD. • Goals of therapy in slowing progression of kidney disease include blood pressure control, proteinuria reduction, dietary sodium and protein restriction, control of the components of metabolic syndrome, and tobacco cessation. • Once patients have reached CKD stage 3 and higher, screening for sequelae of CKD should be performed. -30-

  31. Renal Ultrasound • Renal echogenicity is a sensitive but nonspecific marker for parenchymal renal disease . • The normal cortex is hypoechoic when compared with liver or spleen. An increase in cortical echogenicity is considered to be indicative of renal disease (a proxy for fibrous tissue deposition). • Medullary echogenicity may be seen in chronic interstitial nephritis (particularly analgesic nephropathy), uric acid deposition, and nephrocalcinosis. • Urinary obstruction typically results in hydronephrosis, a dilation of the collecting system. • Ultrasound can help indicate the duration and cause of obstruction. In cases of acute obstruction, the cortex is intact, whereas chronic obstruction can lead to cortical thinning. -32-

  32. Renal Ultrasound • Renal ultrasonography when combined with clinical and laboratory findings is an extremely useful tool in the diagnosis of patients with kidney disease. Any person presenting with abnormal renal function tests should have a kidney ultrasound. • The ultrasound may actually make the diagnosis (as in polycystic kidney disease or acute obstruction) or give valuable data in regard to potential etiologies or aid in identifying the chronicity of kidney disease. • Kidney length correlates with body height and is not gender specific. In the adult, normal kidney length averages 10 –12 cm. The presence of normal sized kidneys does not exclude the possibility of chronic disease. • Normal sized kidneys can be present in patients with any type of kidney disease. Small, atrophic kidneys correlate with duration and severity of chronic disease. Smooth bilateral renal enlargement may be present in diabetes, HIV, lymphoma, amyloidosis, and renal edema (such as seen in acute glomerulonephritis or pyelonephritis). -33-

  33. Renal Ultrasound • It is important to examine the entire urinary tract when hydronephrosis is present as the location of obstruction may be suggested. • Failure to visualize the proximal ureter suggests obstruction at the ureteropelvic junction whereas a dilated ureter indicates downstream obstruction. • A large post-void bladder indicates urinary retention, whereas an empty bladder with dilation of the distal ureters suggests obstruction at the bladder Inlet . • Obstruction without ureteral dilation may also occur in retroperitonealfibrosis, cancers involving the retroperitoneum, and transplanted kidneys. • Care must be taken in interpretation of the ultrasound findings as calyceal dilation in the absence of obstruction may be seen in refluxnephropathy, papillarynecrosis, brisk diuresis, and pregnancy. -34-

  34. Cases Revisited Case 1 • Case 1 represents a rapidly progressive glomerulonephritis and highlights the importance of prompt diagnosis and treatment in a potentially life-threatening situation. The patient’s history of hemoptysis and gross hematuria alerted the clinician to the presence of a pulmonary renal syndrome. • Review of previous labs from this patient’s primary care office showed him to have a baseline serum creatinine of 0.9 mg/dL. Urine sediment was active with the presence of RBC casts. Protein-to creatinine ratio was 2. • Renal ultrasound showed normal-appearing kidneys bilaterally. Due to his acute kidney injury, active sediment, and concern for alveolar hemorrhage, the patient was directly admitted for further evaluation and treatment. • Further laboratory data was obtained which included serum for ANCA, anti- GBM antibody level, complement C3 and C4,and ANA. • A renal biopsy was performed which revealed a diffuse proliferative glomerulonephritis with linear deposition of IgG along the glomerular basement membrane. • Serum for anti-GBM antibody was positive, confirming the diagnosis of Goodpasture’s disease. -35-

  35. Cases Revisited Case 2 • Case 2 illustrates just how important meticulous history taking is. Further history was obtained which revealed that she had been taking 800 mg of ibuprofen three times daily for the past several years due to her chronic back pain. She reported taking no other over-the-counter or herbal substances. • There were no constitutional symptoms or family history of renal diseases. Her exam was unremarkable. Previous laboratory data was not available. • The urine sediment was bland. Protein excretion was 1 g via spot ratio. Renal ultrasound showed small (9 cm) bilateral kidneys with increase in cortical echogenicity. No masses, cysts, or hydronephrosis were noted. • A presumptive diagnosis of chronic tubulointerstitial disease was made and the patient was advised to discontinue her ibuprofen. • Her creatinine and proteinuria were routinely monitored and treatment focused on slowing CKD progression and management. -36-

  36. Conclusion • The patient with kidney disease may be completely asymptomatic or may present with symptoms related to kidney disease or a systemic syndrome. • Regardless of the presentation it is important to have a systematic approach to each patient which includes a detailed history, physical exam, and pertinent laboratory and renal imaging studies. • Determination of the acuity, activity, or progressive nature of the kidney disease will help guide the need for prompt or emergent evaluation and therapy. -37-

  37. Thank You -38-

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