Functions of the Kidney Maintain electrolyte, acid-base balance “clear” the blood of toxins Make...
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Transcript of Functions of the Kidney Maintain electrolyte, acid-base balance “clear” the blood of toxins Make...
Functions of the Kidney
• Maintain electrolyte, acid-base balance
• “clear” the blood of toxins
• Make EPO, active Vitamin D
• gluconeogenesis, hormone metabolism
Kidney disorders
• Hyponatremia• Hypokalemia• Metabolic Alkalosis
– chloride responsive
– chloride unresponsive
• Metabolic Acidosis– anion gap
– non-anion gap
• Hypernatremia• Hyperkalemia• Calcium• Phosphate• Magnesium
Renal Failure
• A growing epidemic
• 350,000 on renal replacement therapy
• 80-90,000 new every year
• Over one million thought to be in pipeline
Creatinine
• Normal 0.8-1.2mg/dl; lower in pregnancy and cirrhosis and chronically ill/aged, higher in muscleheads, pts taking creatine and in rhabdo.
• Cephalosporins/ketosis change assay to increase creat, cimetidine and trimethoprim block secretion to increase
BUN
• Normal 5-10mg/dl
• Increased with GFR, heavy GI bleed, TPN, hypercatabolic states (steroids, sepsis) and prerenal volume depletion-( >20x creat), such as CHF, cirrhosis, nephrosis, sepsis and salt depletion.
• When >100mg/dl, often associated with uremia
Severe Lesions Moderate lesions
Bladder CancerRenal cell CancerProstate cancerObstructing stoneLymphomaTranitional cell cancerMetastatic disease
Renal disease
Aortic aneurysm
StonesUTIRefluxInterstitial cystitisBladder diverticulumRadiation cystitisPapillary NecrosisRenal diseaseAV fistulaBPHProstatitisUrethral stricture
Proteinuria
• Microalbuminuria-dip (-), 30-300 mg/day of albuminuria. Seen in diabetes, vascular dz
• Dip(+) urine, 300mg-2 g seen in glomerular and tubular disease
• Dip (+) urine, > 2g/day, glomerular disease
• Dip (-) urine, still can be overflow protein from myeloma, use SSA or UPEP
Hypertension
• Defined as resting, repeated BP > 140/90
• Risk parallels severity of increased BP and other risks for vasc. Dx-male, AA, smoking, diabetes, cholesterol, age
• Treat mild BP with diet, weight loss, exercise
• Move onto drugs when above fails
• Approx 5% of pts have secondary causes, more when BP severely elevated
HTN- secondary causes
• Truncal obesity- Cushing’s
• Labile HTN - Pheo
• Bruits- Renal artery stenosis
• Decreased fem pulses- Coarctation
• Abdominal/flank mass- Polycystic kidneys
• Increased creat/edema- Renal disease
• Hypercalcemia- Hyperparathyrodism
• Hypokalemia- Hyperaldosteronism/licorice/ Liddle’s syndrome
HTN- Rx
• Diabetics, renal disease with proteinuria, Cardiac injury- ACE inhibitors
• Must watch for reversible hyperkalemia, renal insufficiency, cough, angioedema
• Think bilateral renal artery stenosis when acute renal failure occurs.
• Do not use ACEi or ARBs in pregnancy
Glomerular disease
• Hematuria, proteinuria or both
• RBC casts, especially when proliferative
• Nephritis: hematuria, hypertension, renal insufficiency and edema
• Nephrosis; proteinuria (nephrotic>3.5g/d) with edema, hypoalbuminemia and hypercholesterolemia
• Idiopathic or part of systemic disease
Chronic renal failure
• Diabetes
• HTN
• Glomerular disease (IgA, membranous, FSGS)
• PCKD
• SLE
• Interstitial disease
• Heriditary/ Congenital
PKD
• Autosomal dominant (1 in 800)
• > 2 cysts/kidney by age 30
• Large cysts with chance of infection/hemorrhage, assoc with berry aneurysm, diverticulosis, floppy valves, other organ cysts (liver/panc/ovarian)
• Treat infection with Cipro
• NO Rx for disease yet
Interstitial disease
• Reflux nephropathy with pyelo
• NSAIDS/TYLENOL/Pb/heavy metals
• SLE/Sjogren’s/Sarcoid/TB
• Chinese herbs
• Usually mild HTN, mild proteinuria, pyuria– hypercalcemia for granulomatous disease
Chronic renal failure
• Clearance- if inadequate, dialysis/transplant
• Anemia- normochromic,normocytic treated with EPO and iron
• Bones- high phos and low Vit D cause low Ca++, high PTH--Rx with PO4 binders and Vit D
• Access- potential for steal/infection/high output heart failure
Stalling ESRD
• Blood pressure control
• ACE inhibitors/ ESRD
• Low salt, low protein diet
• ? Treatment of underlying disease
• Preventing toxicities
Treating anemia
• Improves energy, sexual function, mentation, quality of life and possibly reduces LVH, angina, death
• Effective treatment with iron, EPO, NESP
• Careful to screen for other causes of anemia
Protecting the bones
• Limit phosphate intake
• Phosphate binders– Calcium or Renagel
• Vitamin D
• Monitor labs
Protect the heart??
• Exercise
• Healthy diet
• NO SMOKING, Limited EtOH
• ? Lipid management
• ?Aspirin
Dialysis
• Start for low clearance, esp if poor nutrition
• Outcome marker is albumin
• Hemodialysis most common, initial comp is dysequilibrium from rapid decrease of osmolality. Chronic complications of hypotension and cramping, arrythmia
• Death from heart disease, infection, cancer, access failure, discontinuation
Peritoneal dialysis
• Must do large volume, frequent exchanges for adequacy
• Less anemia and high blood pressure
• Peritonitis less common but still well represented. Usually Staph (70-80%) or E. coli (15-20%). Rarely fungal
• Treat with appropriate antibiotic IP, pull catheter if fungal or fails RX
Transplant
• Highly effective- 90 % 1 year success
• LRD>CAD
• Problems are immunosuppression, rejection
• Infections are early bacterial (post-op), viral after 1 month (CMV), PCP in first year;prophylaxis effective
• Technical problems;obstruction and renal artery stenosis have usual sequelae/RX