KIDNEY DISEASES lecture 7 - UMF IASI 2015 · 2015-02-19 · Kidney Diseases Electrophoresis In...
Transcript of KIDNEY DISEASES lecture 7 - UMF IASI 2015 · 2015-02-19 · Kidney Diseases Electrophoresis In...
Kidney Diseases
� Glomerulonephritis = nephropathies characterised by
lesions on glomerular structures – of various causes and degrees.
� Types:
� - proliferative,
� - exsudative,
� - necrotic.
� Clinical expression : nephritic syndrome = proteinuria +
hematuria + hypertension (high blood pressure)
� There is no quantitative, qualitative or etiological
correlation of lesions, between the clinical aspect and the
histological lesion; same etiological agent determines different
histological types.
Kidney Diseases
� Specific renal syndromes
� Acute nephritic syndrome – sharp debut, in healthy status characterised by:
� 1) – macroscopic hematuria
� 2) – proteinuria
� 3) – oliguria
� 4)– cilindruria
� 5) – high blood pressure
� 6) – nephritic oedema
� 7) – hyperazothermia
� 1). Massive proteinuria > 3,5 g/day
� 2). Hypoproteinemia
� 3). Oedema (increased coloidosmothic pressure).
Kidney Diseases
� Electrophoresis
� In plasma: a. hypoalbuminemia b. hypo p globulinemiac. hyper p2 globulinemia → normo pi globulinemia
� 1) lipidic hypercholesterolemia hyperlipidemia
� 2) birefringent corps
� 3. Isolated urinary abnormalities hematuria ± proteinuria
� 4. Acute or chronic onset with renal failure
� In urine:
� a. hyperalbuminemia b. hyper p globulinemia c. hypo p2 globulinemia (uria) d. hypercholesteruria e. lipiduriacylinders
Kidney Diseases
� Nonspecific syndromes and symptoms
� 1. Pulmonary acute oedema → heart failure
� 2. Coma, convulsive status
� 3. Major oedema + signs of heart failure
� 4. Symptoms of diseases that evolves with glomerularlesions Ag – antibody + plasma complement → lesions of basal membrane
Kidney Diseases
� – paraneoplasic syndromes – (Hodgkin d., bronchial carcinoma, Bronchic neoplasma)
� – purpura – sd. Hoenoch – Schonlein
� – palpitations, pallor, fever + valvulopathies –endocarditis
� – jaundice, dyspeptic syndrome – hepatitis acute, with virus B
� - infections mononucleosis, leptospirosis
� – major shivering = malaria
� – major fatigue – intoxication with Hg, Bismut
� – erithrosis on face = lupus eritematosusdiseminated.
Kidney Diseases
� Investigations
� I. Renal functions – urinary sedimentation, creatinine clearance.
� UIV +Ascendent pielograms
� II. Evolution tests:
� – plasma complement
� – ASLO
� – lymphatic cells
� – antinuclear factors,
� – fibrines degradation factors.
Differential diagnosis of hematuria
� - bladder or renal tuberculosis
� - prostatic diseases – citoscopy
haemorrhagical diathesis – haematologic
� Exams, moderate: • all mentioned situation +
� – nephritis
� – hydronephrosis
� – haemorrhagic cistitis (of mcnopausal)
� – vesical litiasis (stones) microscopic: basinetal
stones, renal infarcts, pan, renal stones
Haematuria� Intermittent – by effort, in ortostatism – benignant lesions uremia
� ascendent urinar tract infections – obstructive nephropathy:
� Stones� prostatic tumors
� intrarenal lesions
� hypotenssion – shock status, haemorrhagies, major deshidratation
� hypochloremia – major sweating treatement
� interstitial nephritis determinated by:� • septicemias (bacteriemias)
� • pneumonias
� • diabetus mellitus
� • multiple mielome
� • major hemolysis
� • Addison disease
� • intoxication with Hg
� • heart failure
� In practice: renal biopsy – is required for a precise
diagnosis. Common tests permit (allowed) a simple diagnosis:
� 1. Acute nephritic syndrome – poststreptococical GNA
� Epidemic conditions?
� 2. Nephrotic pure syndrome – which can spontaneously cess or
by treatment
� 3. Impure nephrotic syndrome – glomemlonephritis with
recidivant hematuria with Ig A; benignant evolution.
� 4. Persistant glomerulonephritis – prolonged symptoms that
requires renal biopsies, evolution continuous to renal failure
Differential diagnosis
� – common cistitis – normal renal function
� – hematuria – hematuric form of pn with renal/tbc, tumors
� – chronic glomerulonephritis – with hypertensive form of pn– proteinemia
� – nephroangiosclerosis – severe HTA – with heart failure
� – gnc – resolved with deflect – proteinuria
� – infectious syndrome – fever, shivering, asthenia
� – with acute pn
� – other infectious anexitis
� – forms with digestive manifestation of pn: pancreatitis, appendicitis, colecistitis cured
Treatment
� 1) Etiological = immunosupresive
� Cortizon – prednison 1 – 2 mg/kgc,
� azathioprine: 50 – 100 mg/day (1 – 2 mg/kg body/day), ciclophosphamide 2 mg/kgbody/day –100 mg,
� clorambucil 0,2 mg/kg body/day
� 2) Pathogenic:
� i. Antiinflammatories: indometacin 100 – 150 mg/day
� ii. Antiaggregation drugs (anticlotting)
� • Heparine – calciparine 250 u/kg body/day
� • Dipiridamol 300 – 450 mg/day
Treatment
� 3) Symptomatic – for – hypertension
renal failure – dialisis
dietetic regiment for protecting heart, kidney and brain
→ resting 10 hrs low
protein 0,5g/kgb., low salty regime 3 g/day
� 4) Preventive treatment of infections
(streptococcus → peniciline)
� Primary prevention – treatment
� Secondary – avoid all immunological
stimulation, vaccinations, serums
Acute interstitial nephritis
� Deffinition: kidney interstitial and tubular inflammation.
� Causes
� 1. Infections (bacteria, viruses, rickettsiosis)
� 2. Toxics (drugs, solvents)
� 3. Metabolic: – ↑Ca, ↓ K, ↑ uric acid
� – after burns, acute haemolysis, leukaemia
� 4. Immune – allergic : after drugs, autoimmune diseases
� 5. General diseases
� 6. Obstructive
� 7. Hereditary
� 8. Unknown (Balkan endemic nephropaty)
Acute interstitial nephritis
� Symptoms – extra urinary: – nausea, vomiting
� – diffuse abdominal pain
� – urinary: – lumbar pain → colic
� – dysuria diurnal/nocturnal
� – polakiuria
� – pain on urination
� Signs – unclear urine (with pus/blood)
� – Giordano sign – existing
� – ureteral – superior zone tenderness/medial point/inferior point
� ±palpation of kidney
� General infectious signs and symptoms:
� – fever (high = 40°C) sudden onset
� – chills
� – arthralgia
Acute interstitial nephritis
� Kydney pain:
� - bellow the costal margin post
� - costo – vertebral angle superior ureteral point
� - costo – muscular angle
� - irradiates anteriorly toward umbilicus
� - dull, aching, steady
� Colics = ureteral pain
� – origianates in costo – vertebral angle →lower
quadrant of the abdomen → the upper/ thigh and
testicle (labium ) → adductors zone
Acute interstitial nephritis
� Laboratory:
� – leukocituria ↑↑ with pyuria
� – bacteriuria
� – cilindres (of leukocytes)
� – low proteins (≤ 1g/24h)
� +syndrom of acute inflammation
� x – Ray: – inlarged kydney
� – stones
� Urography: – caliceal dilatation
� – assimetrical kidneys
Pielonephritis (PN) – interstitial
nephropaties
� Bacteriemias localised, nonspecifics, on the renal interstitial tissue (medullar) and secondary to the tubes, vessels and glomerulles.
� Infection – primary – by bloody way w > m 56% / 24%
� - secondary – by ascendent way m > w 98% / 45%.
� Frequency PN – from all renal diseases is 8 – 20 %.
� - Childhood – anatomic abnormalities
� – adults, sexual actives – neighboring infections (W)
� – old persons (obstructive uropathy – prostate) (M)
� - Diabetes mellitus
� - Pregnancy
Pielonephritis (PN) – interstitial
nephropaties� Etiopathogeny: – gram ( – ) > gram (+);
� E coli – 80 – 85%
� Proteus, Klebsiella, Enterococcus, Piocianic, Aerobacter, S. aureus after surgery, invasive instruments.
� Infective way: ascendente – most
� haematogenic – moderate
� lymphatic – minor >
� Favourising factors for infection:
� • congenital malformations – children
� • hypertrofic prostate, stones
� • renal tumors or extrinsic (genital, bowel)
� • pregnancy
Pielonephritis (PN) – interstitial
nephropaties
� 1.Dynamical troubles – of urinary tracts: neurological, diabetic neuropathy, ats, poliomielitis.
� 2. Vesico – ureteral reflux
� 3. Pregnancy – hypotonia of urinary tract – hormone induced
� 4. Invasive instrumentation
� 5. DZ – glicosuria, neurologic bladder
� 6. Metabolic troubles: gutte, nephrocalcinosis
� 7. Over medication: prednisone, opiacceas phenacetine
� 8. Physical agents – Rx
� 9. Immunological factors
Treatment
� 1. Monotherapy: antibiotics: fighting again favourising factors.
� Antiseptics drugs is divided: trimetoprim(bad rim), sulphametin – 1 g/day, cotrimoxazol – 2 g/day, norfloxacin 400 mg x/day, acid polidixic 2 – 4 g/day, pefloxacin, ciprofloxacin 1 g/day
� – nitrofurans: nitrofurantion – 300 mg/day. They are indicated in urinary primoinfection – acute pielocistitis. 7 – 10 days (or 2 days after the fever cess).
� – modern – unique bigger dose – maximal sulphamctin4 tb, negram 4 grams, norfloxacin 800 mg
� – bacteriological control after 5 days of stop treatment; also after 3 months
Treatment
� 2. Drugs indicated in resistant infections to group 1
� - Ampiciline 2 – 4 g/day, Amoxiciline 2 g/day, Tetracicline 2 – 4 g/day
� - Cephalosporines: cefaclor 1 g/day, Cheforal 2 g/day
� - G peniciljne in infections with streptococ 1 – 3 mol ul/day i.m.
� These are inducing a high urinary concentration and influence also Proteus, Klebsiella.
Treatment
� 3. Drugs for special situations – in case of resistant bacteria (piocianics proteus, klebsiella, enterobacter, stafilococ) – especially in hospital.
� - Kanamicine 2 g/day, Gentamicine 2 – 4 mg/kg/day – i.m. (ampoule of 10 mg).
� – Oxaciline, Meticiline 2 g/day – infections with stafilococ
� – Polimixim B – in infections with pseudomonas
� - Carbenicilin – pyopen
� 4. Urinary desinfectants: bacteriostatics
� – itrolropina – melenamines (3 tablets/day), blue, metilen 2 – 3 g/day
Treatment
� 5. Antibiotics – contraindicated: clorocid,
toxic, streptomicine, rifampicine
� Attention to:
� – alcalinisation or acidifiation of urine
� - degree of renal failure – which must
decrease the dose
� – creatinemia
� Recidivant acute pielonephritis – most frequent 80%.
� – ampicilline 4 g/day
� – kanamicine 2 g/day
� – gentamicine 80 mg x 4/day
� – cefalotine – i.m. 0,5 – 2 g x 4/day
� – norfloxacin 400 mg x 2/day
� Acute pregnant pielonephritis – must be treated with atbuntil cess of all syndrome
� – ampiciline 1 g/day – we have to repeat uroculture, 3 days
� – kanamicine 2 g/day after treatment
� – gentamicine
� Chronic pregnant pielonephritis atb in high doses – > 3<weeks,
� Maintenance treatment asymptomatic bacterium – in pregnancy – only after the 5th month of pregnancy – only 2 weeks.
Hyperchromic urine
� Causes
� 1. Concentrated urine: – dehydrated
� 2. Red coloured: – after specific food ingestion or drugs: aspirin, phenolphthalein, rhiboflavin
� 3. Blue coloured: – disinfectant substances
� 4. Hyperprotidic dieta for acidifying
� 5. Haematuria (with another symptom/asymptomatically)
� – microscopical (less 3 red cells/field)
� – macroscopical (red, black rad coloured)
� 6. Haemoglobinuria (intravascular haemolisis) / myoglobinuria(crash syndrome) / porphynuria
� 7. Jaundice (urinary bilirubine on conjugated jaundice)
� 8. Melaninuria
� 9. Alcaptonuria (after sunlight exposure)
Haematuria
� Causes – nephritic syndrome/chronic glomerulonephritis, cancer (renal/urinary tract), lithiasis
� – tuberculosis, renal thrombosis/ infarction, anticoagulation therapy,
� – urinary tract infection (papillary necrosis) posttraumatic,
� – haematological disorders –trombopaenia, Rendu – Osler disorder
� – systemic diseases with renal involvement (glomerular): LES, Goodpasturesyndrome