Kidney Diseases

DR. ADORATA COMAN

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