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The kidney in systemic disease. Dr Saad Al Shohaib Associate professor of medicine and nephrology KAUH. The kidney in systemic disease. The kidney can be affected in different diseases including autoimmune diseases diabetes infections cardiac and liver diseases

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The kidney in systemic disease

The kidney in systemic disease

Dr Saad Al Shohaib

Associate professor of medicine

and nephrology KAUH


The kidney in systemic disease1
The kidney in systemic disease

  • The kidney can be affected in different diseases including autoimmune diseases diabetes infections cardiac and liver diseases

  • Kidney involvement usually affect mode of therapy response to therapy and outcome


Renal function in chf
Renal function in CHF

  • CHF is a common disorder and alteration in renal function affect mortality and morbidity

  • Renal impairment make treatment more difficult since the response to diuretics is decreased

  • In CHF there is Na retention in spite of extra cellular volume expantion


Case presentation
Case presentation

  • A 55 year old lady known to have CHF and CRF of unknown etiology . Her serum creatinine had been maintained in the range of 350 umol/l .Maintained on diuretics and enalapril 20 mg /day. Presented to the emergency room with progressive dyspnea and orthopnea . On examination she looked ill dyspnic and orthopnic BP 160/105 JVP raised and she had basal crackles . CXR showed pulmonary edema


Case presentation1
Case presentation

  • Lab data Na 133 K 5.3 BUN 26 mmol/l Cr 425umol /l HCO3 18 Hb 11.0 WBC 10 LFT normal ECG no new changes given 40mg of frusemide iv with no response this was repeated an hour later with no response then nephrology team was contacted for possible dialysis


Renal function in chf1
Renal function in CHF

  • There is increase in the nuerohormonal vasoconstrictors in CHF ( A2 Aldosterone and vasopressin )

  • This lead to afferent arteriolar vasoconstriction Na and K retention and water retention

  • There is increase in the hormonal vasodilators as ANP and renal prostaglandins


The kidney in chf
The kidney in CHF

  • The nuerohormonal changes lead to decrease in renal blood flow and GFR and may give a picture of pre renal azotaemia or lead to worsening of a pre existing renal impairment to the point that dialysis may be required

  • Dialysis and fluid removal in this situation may improve cardiac output and induce diuresis


The kidney in chf1
The kidney in CHF

  • Prolonged diuretic use can lead to decrease in ANP and increase in A2 and norepinephren and therefore diuretic resistance

  • In this situation a higher dose is required particularly if there is renal impairment


Hyponatremia in chf
Hyponatremia in CHF

  • In sever CHF hyponatremia may be seen due to increased vasopressin

  • Hyponatremia is an indication of severty of CHF as well as resistance to diuretics

  • A very low urine Na is a predictor of decreased response to diuretics

  • Patients with hyponatremia are more liable to get hypo tension in response to ACE inhibitors or A2 receptors antagonists


Crf and chf
CRF and CHF

  • Renal failure may co exist with CHF and make management difficult

  • In this situation a higher dose of loop diuretics is required

  • Sever renal failure of may limit the use of ACE inhibitors particularly in the presence of hyperkalemia



The kidney in liver cirrhosis
The kidney in liver cirrhosis of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • There is sever Na retention to the point that the urine may be Na free

  • Very low urine Na is a marker of disease severity

  • Very low urine Na indicate poor response to diuretics


The kidney in cirrhosis
The kidney in cirrhosis of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • There is disturbance in Na handling due increased Na reabsorption related to excess aldosterone increased renal sympathetic activity and alteration in ANP and prostaglandin

  • If Na intake continue more than loss there would be sever Na and water retention

  • Na restriction is vital in the management of ascities


Hepatorenal syndrome
Hepatorenal syndrome of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Progressive oliguric renal failure either insidious or rapid

  • Usually occur in hospitalized patients

  • May be precipitated by bleeding aggressive diuresis or abdominal paracentesis

  • Functional renal failure with very low Na

  • Should differentiated from ATN and pre renal states


Treatment of hrs
Treatment of HRS of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Search for correctable causes

  • Na and water restriction

  • Dialysis is not effective except to support candidates for transplant

  • Leveen shunt had been tried in small studies


Renal involvement in systemic vasculitis
Renal involvement in systemic vasculitis of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • The kidney is affected by many vacultidies

    Giant cell

  • Takayasu

  • Polyarteritis nodosa

  • Kawasaki

  • Microscopic arteritis

  • Wegeners

  • HSP


Vasculitis

Giant cell and takaysu of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

Medium sized ployarteritis nodosa

Small vessel vasculitis as HSP SLE and wegeners

Rarely cause significant renal disease

Main renal artery and cause ifarction

glomerulonephrits

vasculitis


Small vessel vasculitis
Small vessel vasculitis of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • In small vessel vasculitis rapidly progressive glomerulonephrits leading to ARF that may require dialysis

  • Aggressive immunosuppressive therapy using pulse steroids cyclophosophamide and possibly plasma pharesis can be useful particularly if used before creatinine exceed 5 mg /dl

  • ANCA positive disease respond better to therapy


SLE of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Common disease in Saudi Arabia

  • Renal involvement is variable from mild a symptomatic proteinuria and hematuria to ever renal impairment that may require dialysis

  • The clinical picture can change rapidly to a very aggressive disease

  • There might be a discrepancy between the clinical picture and histological findings


Case presentation2
Case presentation of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • 21 year old lady known to have SLE and lupus nephritis for the last 4 years . Biopsy was done at the time of diagnosis and showed class IV with active disease but no chronic changes . At that time her serum creatinine had been kept within normal limit as well as her clearance 24 h urine protein was 4 grams. She was treated with monthly cyclophosphamide for 6 months then every 3 months for tow years


Case presentation3
Case presentation of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Her proteinuria improved and serum Cr was normal for tow years . Follow up was lost for tow years then she came back for follow up . She was a symptomatic but serum Cr was 160 umol/l Cr clearance was 45 mls /min 24 h urine for protein 3 grams renal ultrasound was normal


Normal of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

Mesangial nephropathy

Focal proliferative

Diffuse proliferative

Steroids

Steroids

cyclophosphamide

SLE


SLE of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Class IV is treated with monthly cyclophosphmide for 6 months then every 3 months for two years

  • Azathioprine is not effective

  • In resistant nephritis cyclosporine and cellcept may be usefull

  • Repeat biopsy may be indicated to assess further immunosuppressive therapy


Case presentation4
Case presentation of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • A 48 years Egyptian male presented with mild lower limb edema for the last tow months. On examination he looked well B P 160/90and the rest of the exam was unremarkable except for mild lower limb edema . Urinalysis showed protein and red cells but no casts . 24 h urine protein was 4 grams


Case presentation5
Case presentation of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Seum Cr 85 umol/l Hb 14.2 gm LFT normal . Serum albumin 32 cholesterol 7 mmol/l ANA negative C3 normal hep C Ab positive PCR positive Genotpype 1 cryglobolin negative . .NKidney biopsy showed membranous G . N.


Case presentation6
Case presentation of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • He was treated with peg interferon for six months and proteinuria subsided to less than one gram


Glomerulonephritis with hepatitis c and b
Glomerulonephritis with hepatitis C and B of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Membranous

  • MPGN

  • Mesangial proliferative

  • Nephrotic syndrome

  • May respond to interferone


Post infectious g n
Post infectious G N of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Immune complex nephritis can follow any bacterial viral fungal or parasitic infections

  • Can follow infected shunts and endocardits

  • May complicate deep abscesses

  • Usually present 3 weeks post infection


Post infectious g n1
Post infectious G N of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Hematuria edema

  • Oliguria hypertension

  • Fever

  • Uncommonly ARF requiring dialysis


HSP of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Cutaneous vasculitis

  • Ig A deposits in the skin and kidneys

  • Transient hematuria and proteinuria occur in 50% of the cases

  • Acute proliferative glomerulonephritis with Ig A deposit may occur but would rarely require dialysis and this would indicate aggressive therapy


Rhuematoid arthritis and gout
Rhuematoid arthritis and gout of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • There is no specific renal lesion in gout and R A

  • In R A the renal lesion is usually secondary to therapy amyloid or vasculitis


Diabetic nephropathy
Diabetic nephropathy of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Common problem 30 - 40% of dialysis patients are diabetics

  • Long standing diabetes

  • Genetic predisposition hypertension poor glycemic control are important risk factors

  • Strongly associated with retinopathy


Diabetic nephropathy stages
Diabetic nephropathy stages of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Increased GFR and hyperfiltration

  • Normal GFR and mild mesangial expansion

  • Microalbumiuria

  • Overt proteinuria

  • CRF


Diabetic nephropathy diagnosis
Diabetic nephropathy diagnosis of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Clinical diagnosis

  • Long standing D M particularly in type 1

  • Proteinuria or microalbumiuria

  • Retinopathy

  • Inactive urinary sediment

  • Normal sized kidneys


Diabetic nephropathy1
Diabetic nephropathy of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides

  • Microalbumiuria is a sign of cariovscular disease and is a very important finding since interference with strict glycemic control and ACE inhibitors is important

  • Strict glycemic control can reverse glomerular changes

  • Blood pressure control is vital and the ACE inhibitor dose should be titrated to the degree of proteinuria


thank you of CHF drugs particularly NSAID ACE inhibitors and aminoglycosides


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