PACES Approaches Ep11:Renal Approaches
The content discusses various approaches in managing acute kidney injury, including pre-renal causes, renal conditions, post-renal obstruction, infective, inflammatory, neoplastic, endocrine, and drug-related factors. It covers complications such as uremia, fluid overload, electrolyte disturbances, and anemia. The investigations involved, including basic tests and detailed work-ups, are also outlined.
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Presentation Transcript
PACES Approaches Ep11: Renal Approaches
Approaches Acute Kidney Injury Haematuria Urinary Frequency
Acute Kidney Injury Pre-Renal Hypotension, sepsis, diuretics, cardio-renal/hepato-renal Renal artery stenosis ACEi, ARB Renal Glomerular Refer to GN section Vascular Vasculitis, HUS/TTP, IE, scleroderma renal crisis Tubulointerstitial ATN: Sepsis, drugs (iodinated contrast, aminoglycosides) AIN: Drugs (penicillin, NSAIDS), infections, CTD (SLE, sjogren s) Other insults: Urate nephropathy (tumour lysis, gout), drugs (acyclovir, chemo), rhabdo Post-Renal (Obstruction): Stones, malignancy, BPH, infection Usually bilateral obstruction or unilateral obstruction in single functioning kidney
Acute Kidney Injury Infective: HUS/TTP, IgA nephropathy (synpharyngitic), post infective GN, infective endocarditis Inflammatory: SLE, Vasculitis, Pulmonary-Renal syndromes, Scleroderma, Sjogren s Neoplastic: Cancers a/w membranous glomerulopathy, myeloma, tumour lysis syndrome, urological malignancies Endocrine: DKA/HHS Metabolic: Urate nephropathy, pigment (rhabdomyolysis), phosphate nephropathy Drugs: NSAIDs, antibiotics, contrast, chemotherapy Congenital: - Systemic: Cardio-renal, hepato-renal, pulmonary-renal syndromes
Complications Uremia: Lethargy, confusion, gastritis, bruising, gastritis Fluid overload: Orthopnea, PND, pedal edema, reduction in urine output Electrolyte disturbances Anemia
Investigations Basic: U/E/Cr, FBC (eosinophilia for AIN, thrombocytopenia for HUS/TTP, SLE), LFT (hepatorenal), CK (rhabodo) UFEME, urine PCR US KUB (CT KUB if concerned about calculi), PVRU/bladder scan GN work up: ANCA, ANA, Hep B/C, HIV, myeloma screen Thorough drug history Renal biopsy
Haematuria Mimics: Beet root, medication (rifampicin), pigment (myoglobinuria), obstructive jaundice, menses Coagulopathy: Connective tissue, platelets, coagulation Urological (pelvi-caleceal, bladder, ureter, urethra, prostate): Malignancy, stones, infection, hemorrhagic cystitis, APKD Glomerular Refer to Nephritic Syndrome section
Glomerulonephritis Nephritic Syndrome - Haematuria/Cast, AKI, hypertension Autoimmune: SLE Pulmonary Renal Syndrome: Goodpasture, Wegener s Infective: Hep B/C, HIV, IgA Nephropathy Nephrotic Syndrome Proteinuria, hypoalbuminuria, hypotension, hyperlipidemia, a/w clotting tendencies DM Infective: Hep B/C, HIV Autoimmune: SLE Malignancy: A/w membranous nephropathy, myeloma
Urinary Frequency Lower Urinary Tract Symptoms (Frequency, incontinence, nocturia, hesitancy, terminal dribbling, double voiding) Urological (check for haematuria too): BPH, stones, UTI (dysuria), bladder/urothelial cancer Neurological: Spinal cord, autonomic dysfunction, Parkinson s disease, congenital disorders (spinocerebellar ataxia, spina bifida) Drugs: Anticholinergics Polyuria (>3L per day) Polydipsia: Mouth dryness (Sjogren s, anticholinergic medications), Psychogenic Diabetes mellitus (other causes of solute diuresis) Diabetes insipidus Nephrogenic: Hypercalcemia (MEN, sarcoid, malignancy), Lithium Cranial (important to screen other pituitary symptoms): Trauma, ICH, surgery, neoplasm, vascular event Drugs: Diuretics
DI Work Up Key principles: Osomotic diuresis urine osm higher (>600), urine in polydipsia driven polyuria is appropriately dilute (<300), urine in DI driven polyuria is inappropriately dilute (<300) Water Deprivation Test/Hypertonic Saline Test (DI vs polydipsia): Urine would become concentrated in polydipsia but not DI (remains <600mOsm/kg at 8- hour mark) DDAVP Challenge: Nephrogenic: No response to DDAVP Cranial: Responds to DDAVP (urine becomes concentrated) - >600 mOsm/kg; hence can treat with intranasal desmopressin
