Common Renal Problems
Moderator : Dr. Abi Abraham M., Lakeshore Hospital, Kochi
The symposium covered frequent renal disorders and approach to those problems
Approach to EdemaDr. Kishore S. Dharan, MOSC Medical College, Kollencherry
Edema is defined as a palpable swelling produced by expansion of the interstitial fluid volume. The pathophysiology could be either an alteration in capillary hemodynamics that favors the movement of fluid from the vascular space into the interstitium or retention of dietary or intravenously administered sodium and water by the kidneys. The major causes of edema are Increased capillary hydraulic pressure ( as in increased plasma volume due to Na+ retention, Local venous obstruction or decreased arteriolar resistance), hypoalbuminemia, increased capillary permeability, venous insufficiency and lymphatic obstruction. Evaluation include a complete history and physical examination and investigations including Complete blood count, Urinalysis, Electrolytes, Creatinine, Blood sugar, TSH, Albumin and other tests for specific indications. Principles of therapy are reversal of the underlying disorder (if possible), dietary sodium restriction (to minimize fluid retention) and diuretic therapy. Causes of refractory edema are inadequate diuretic dose, excess sodium intake, delayed intestinal absorption of oral drug, decreased diuretic excretion into the urine, increased sodium reabsorption and NSAIDs.
Mild renal dysfunction in a diabetic Dr. Binu Upendran, Lourdes Hospital, Kochi
Diabetes mellitus is the commonest cause for chronic kidney disease. Evaluation of renal failure early in diabetes is mainly to rule out all treatable causes of renal failure .Common causes to be ruled out are Urinary Tract Infection ,drug induced renal dysfunction ,renal stone disease, Ischemic renal disease and primary glomerular disease occurring in a diabetic. Only 30-40% of diabetics go on to develop Diabetic Nephropathy. Persistent microalbumenuria predicts the occurrence of diabetic nephropathy early in a diabetic. Predictability of occurrence of diabetic nephropathy is increased if diabetic nephropathy is also present. The initial evaluation of renal dysfunction in a diabetic should include ultrasound abdomen and urine culture besides routine blood and urine examination.
Drug induced NephropathyDr. Jose Paul, Lissie Hospital, Kochi
Drug induced nephropathy is an important cause of hospital acquired acute renal failure. Kidneys are targeted because of the high blood flow, high degree of metabolism and in being a major route of elimination of drugs. Mechanisms of renal damage include acute tubular necrosis, interstitial nephritis, pigment nephropathy, tubular obstruction and thrombotic microangiopathy. The usual drugs causing nephropathy in clinical practice include NSAID’s, ACE – I, aminoglycosides and contrast media. The risk factors for aminoglycoside induced nephropathy include old age, hypovolemia, hypotension, pre existing renal impairment and concomitant use of nephrotoxins. It is imperative to measure renal functions once every 48 hours while the patient is on aminoglycosides. Loading dose of drugs remains unchanged in a patient with renal failure, while either dosing interval method or dose reduction method can be used to calculate the maintenance dose
The kidney in hypertensionD. Rajesh R., AIMS, Kochi
The kidney is often the victim in systemic hypertension ie hypertensive renal disease and is always the villain in renal parenchymal disease and renovascular hypertension. Pathogenetic factors related to the kidney especially renin angiotensin aldosterone system play a role in systemic hypertension. Hypertensive nephrosclerosis is the term used in patients with hypertension and chronic kiney disease in the absence of other causes of renal failure. Diabetic nephropathy followed by hypertensive nephrosclerosis & chronic glomerulonephritis constitute causes of renal parenchymal hypertension. Autosomal Dominant Polycystic Kidney disease can also present with hypertension. Hypertension accelerates progression of renal failure irrespective of the cause. Strict BP control with ACE inhibitors or Angiotensin receptor blockers are the main stay of treatment . ACE I therapy requires close monitoring of s.creatinine and potassium. High index of suspision is required in patients with resistant hypertension to rule out renovascular hypertension and ishemic nephropathy commonly due to atherosclerosis. Percutaneous renal angioplasty / surgical revascularisation may be required only in selected patients.