Sindroame renale

8/13/2019 Sindroame renale

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Approach to the patient with renal

disease

Dr. Silvia Spnu


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Reminder

Syndrome= an association of signs and symptomswhich form together a characteristic morbid frame,

which can be observed in different diseases.

Disease= a morbid entitycharacterized usually by

at least twoof these criteria:

recognized etiologic agent!s"

identifiable group of signs and symptoms

consistent pathological alterations.


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Identification of renal disease

#enourinary signs$symptoms

%rinary or blood abnormalities identified occasionally or by screening

&bnormal renourinary imaging studies !%S, '(, etc."

First stage renal investigations (routine)

'linical e)amination: anamnesis, physical e)amination %rinalysis, *uantitative determinations !eg. proteinuria$+ h"

Serum creatinine and urea !creatinine clearance calculation"-

electrolytes- acidbase balance

maging: %S, intravenous urography

Recognizing the renal syndromes argeted renal investigations

Diagnosis of the renal disease


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Renal syndromes

Renal failure (acute! rapidly progressive! chronic) "ephritic syndrome

"ephrotic syndrome

#acroscopic hematuria

Asymptomatic urinary a$normalities %rinary tract infection

Renal tu$ule defects

&ypertension

"ephrolithiasis %rinary tract o$struction


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Acute renal failure

Definition= abrupt / of 01# !hours or days" with

consecutive azotemia

D' criteria

rapid increase of s% and s'r

oliguria !D233 ml$+h" or anuria

signs and symptoms of uremia

hyper 45emia, metabolic acidosis

*tiologyprerenal, renal, postrenal


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Rapidly progressive renal failure

Definition= progressive / of 01# in the course ofwee6swith consecutive doubling of serum

creatinine in less than 7 months.

*tiology

primary e)tracapillary !rapidly progressive" 08

and secondary 08 !vasculitis, 0oodpasturesyndrome".

other: thrombotic microangiopathies !9%S",

tubulointerstitial nephritis.


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+hronic renal failure

Definition= comple) of clinical and biochemical

abnormalities resulting from a progressive

and ireversibledamage of the nephrons.

D' criteria

/01# with consecutive azotemia documented

for 7 months

%S: decreased 6idney size

anemia

*tiologythe ma;ority of chronic nephropathies


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he structure of the glomerular capillary wall


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he role ,function of the glomerular capillary wall

Role= to assure the selective passage ofsubstances into urine.

-ermselectivity assured by all 7 components of

the barrier:

. size selectivity and,or

. electrical charge selectivity

Damage to any of the 7 components = proteinuria


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he nephritic syndrome (Acute /")

-athophysiology

Definition= the result of acute inflamationin therenal glomeruli.

acute 0 of /FR damage of the glomerularcapillary wall (/+1)

9ydrosaline retention 0lomerular macro$microscopic hematuria!dysmorphic erythrocytes, erythrocyte casts"

1acial and peripheral edema 0lomerular proteinuria


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he nephritic syndrome

D' criteria 9ematuria !glomerular"

>dema

9ypertension ?roteinuria !glomerular"

&cute / of 01#

*tiologyprimary and secondary glomerular

diseases


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Types of hematuria

nonglomerular glomerular


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Erythrocyte casts


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-roteinuria

-hysiological proteinuria up to @A3 mg$+h

globulins 5 albumin !B++3 mg$+h"

#icroal$uminuria

= urinary loss of albumin between 73733 mg$+h

pathologicalC

mar6er of early glomerular in;ury !eg. diabeticnephropathy"

mar6er of vascular endothelial dysfunction

assessment of cardiovascular ris6


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ypes of proteinuria

/lomerular

proteins with intermediate E !mostly albumin"

'ause: defective glomerular barrier

u$ular

?roteins with low E !F+microglobulin, retinol bindingprotein"normally filtered in the glomerulus and reabsorbed inthe pro)imal tubule.

'ause: tubulointerstitial nephritis!/reabsorbtion"

-rerenal (overflow proteinuria)

proteins with low E !G$H light chains" I production thatovercomes tubular reabsorbtion capacity

'ause: plasma cell dyscrasias !eg. myeloma"


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Types of proteinuria (urine protein

electrophoresis): glomerular (G), prerenal (PR)

and tubular (T)


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he nephrotic syndrome

Definition= glomerular proteinuria 7,A g$+ h J edema, hypoproteinemia,

hypoalbuminemia, hyperlipidemia.

-athogenesisdamage of the 0'E as an

electric$mechanic barrier.

*tiologyprimary and secondary glomerular

diseases.


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he nephrotic syndrome . -athophysiology

Damage of the /+1 as an electric,mechanic $arrier

glomerular proteinuria 7,Ag$+h

+onse2uences of nephrotic range proteinuria

hypoproteinemia, hypoalbuminemia, malnutrition

hydrosaline retention !edema", hypotension, acute 6idney failure thromboembolic complications !urinary loss of anticoagulant proteins:

&(, plasminogen"

hyperlipidemia, lipiduria !reactive hepatic lipoprotein synthesis"

increased ris6 for infections !urinary g losses"

deficient binding and transport of some drugs

ionic and hormonal disbalances !urinary losses of binding proteins"

increased tubular reabsorbtion of filtered proteinstubulointerstitial

to)icity


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he nephrotic syndrome . reatment

Specific treatment= treatment of the underlying glomerular disease

"on.specific treatment

reduction of proteinuriadietary protein restriction, &'>$K,

8S&D, nephrectomy

reduction of edemadietary salt restriction, diuretics, albumin,hemofiltration

in case of hypovolemia and acute 3idney failurealbumin

treatment ,prophyla'is of throm$osisfractioned heparin

reduction of hyperlipidemia 90'o& reductase inhibitors !statins"

prophyla'is of infectionsvaccines !eg. antipneumococcal vaccine"


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Differentiation $etween nephrotic syndrome

and nephritic syndrome

ypical Features "ephrotic "epritic

4nset Insidious A$rupt

*dema 5555 55

6lood pressure "ormal Raised

7ugular venouspressure

"ormal,low Raised

-roteinuria 5555 55

&ematuria #ay,may not occur 555

Red.cell casts A$sent -resent

Serum al$umin 8ow "ormal,slightly reduced


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#acroscopic hematuria

#ecurrent $ single episode

0lomerular $ non glomerular

*tiology

uropathies:stones, tumours, infections

nephropathies:g& nephropathy, thin basement

membrane nephropathy


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Asymptomatic urinary a$normalities

-roteinuria 9:!;g,


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%rinary tract infection (%I)

Def.= colonization of the urine and urinary tract tissues from

the bladder to the renal parenchima, with pathogenic

microorganisms.

*tiologynonspecific bacteria !>.coli, etc"

. tuberculosis, fungi !'andida", viruses

D' criteria isolation of the pathogenic agent from urine

symptoms and clinical signs of %(

radiological modifications


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Renal tu$ule defects

anatomic:autosomal dominant polycystic 6idney disease

!&D?4D"

functional!deficient tubular transport"

&ypertension renovascular!renal artery stenosis"

renal parenchymal!glomerular diseases"

"ephrolithiasiseliminated 6idney stones, stones removed by

urology procedures or identified by imaging !%S, i.v

urography"

%rinary tract o$structionobstacle 5 retrograde dilatation


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+lassification of the medical

nephropathies

0lomerular diseases

(ubulointerstitial diseases

Lascular diseases

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