Syndromology of renal disease.

Dr. Martin Havrda

Edema:

Palpable swelling produced by expansion of the interstitial fluid volume– Generalized edema = anasarca

Example 1:

Young female broke her calf. She received a plaster fixation for 4 weeks. After 3 weeks she observed pain in the involved leg. Following the removal of the fixation, her right leg became swallen, her calf muscles became tender, she developped mild fever. Her left leg was normal.

Example 1 – diagnosis:

Localised edema of the right leg. Local reason for oedema is likely. Deep venous thrombosis. Diagnosis?

– Doppler ultrasound– Phlebography (isotope, X-ray)

Treatment?– Heparin

Localised edema – treatment:

No diuretics! Treatment depends on the cause.

Example 2:

Male with the history of MI followed by exertional dyspnea. 2 weeks ago he had a respiratory infection with cough. Since then his dyspnea worsened and he developed edema of the legs.

Example 2 – physical examination (1):

Symmetrical edema of the legs– Not tender– Normal skin colour

Hepatomegaly Distended jugular veins

Example 2 – physical examination (2):

Patient becomes dyspneic in recumbent position, prefers sitting.

Symmetrical inspiratory rales over the lung base.

Gallop Cyanosis Impaired mental status

Example 2 – physical examination (3):

Dull percussion and decreased breathing sounds over the base of the right lung.

Example 2 – diagnosis?

Heart failure.

History of heart disease. Signs of failing left heart. Signs of failing right heart. Signs of general circulatory malfunction.

Drugs promoting edema formation:

Non-steroid antiinflammatory drugs. Some antihypertensives (CCB). Some antidiabetics (pioglitazone,

rosiglitazone). Estrogens. Other drugs…

Example 3:

Male with the history of alcohole abuse complaints on growing size of his abdomen, weakness, swelling of the legs in the last week. 10 days ago he had his birhtday.

Example 3 – physical examination (1):

Large abdomen – thin extremities– Muscular atrophy

Abdomen distended, not tender, undulatory wave positive. Icterus. Hepatomegaly. Splenomegaly. Iceberg symptom. Caput medusae. Spider naevi. Palmar erythema.

Example 3 – physical examination (2):

Symmetrical swelling of the legs– Not tender– Unaltered colour of the swollen area.

Signs of hypovolemia – Collapsed jugular veins– Hypotension– Tachycardia

Dupuytren´s contracture Gynecomastia Foetor hepaticus Encephalopathy

– flapping tremor

Example 3 – diagnosis?

Liver cirrhosis.

History of liver disease or ethanol abuse. Predominating ascites. Other signs of cirrhosis. Dyspnea is uncommon (large ascites).

Example 4:

Female suddenly developed large swelling of both legs.

No pain, no considerable history, no other symptoms.

Physical examination– Symmetrical swelling, non-tender– No other remarkable abnormalities

Example 4 – diagnosis?

Edema of renal origin.

Lack of symptoms of cardiac edema and liver cirrhosis makes renal edema likely.

Edema in renal disorders - history:

No specific symptoms Symptoms of particular renal disorder Uremic symptoms may be present

– Fatigue, malaise, weight loss– Dyspepsia, vomiting, diarrhea– Dyspnea– Itching– Confusion

Edema in renal disorders – phys.exam:

Hypertension may occur Diabetic or hypertonic vascular eye abnormalities may be present Uremic foetor may be present

Eyelid edema may predominate Pericardial friction rub in advanced uremia

Check the kidneys– Flank percussion– Bimanual palpation

Check the urinary bladder– Distended?– Tenderness above the symphysis or in the ureteric points?

Edema in renal disorders – tests:

Positive urinary sediment– Hematuria– Proteinuria

Abnormalities in serum common– Low albumin– High cholesterol– High urea– High creatinine

Ultrasonography– Kidneys enlarged, reduced size, abnormal echogenity– Dilatation of the pelvis, calyces, ureter

Many other tests...

General edema and fluid overload:

Edema of a systemic origin– Symmetrical– Gravity – dependent– Mostly unpainful

Accumulation of fluid– Pleural effusion– Pericardial effusion– Ascites– Transcutaneous fluid leakage

Clinically important evaluation of edema:

Physical examination. Blood pressure

– Hypertension in renal related edema is common Body weight. X-ray

– Pleural effusion– Pulmonary congestion

Ultrasonography– Pleural effusion– Ascites– Diameter of vena cava and hepatic veins

Echocardiography CT Bioimpedance measurement Central venous pressure

General edema – reason?

Retention of dietary or intravenously administered sodium and water by the kidneys.

– Primary (renal edema)– Secondary (cardiac edema, liver cirrhosis)– Combination (impaired cardiorenal axis)

2,5-3 liters before it becomes apparent Vascular reasons

– Increased capillary leak– Increased oncotic pressure of the interstitium

Myxedema … accumulation of proteins

EDEMA IN RENAL DISEASES:

1. Nephrotic syndrome.• Proteinuria• Hypoalbuminemia• Hyperlipoproteinemia• Edema

2. Acute nephritic syndrome.• Acute poststreptococcal glomerulonephritis

3. Loss of GFR.• Abnormal Na+ excretion

Nephrotic syndrome:

1. Proteinuria > 3,5 g/24h• Reabsorption in tubules, toxic effect.

2. Hypoalbuminemia• Loss of albumin in the urine ≈ increased albumin synthesis in the

liver.3. Hyperlipoproteinemia

• Decreased catabolism of lipoproteins• Cardiovascular risk, progression of renal disease (capture of

lipoproteins by mesangial cells)4. Edema

• Primary renal Na+ retention („overflow“ theory)• Leakage of the fluid to the interstitium → hypovolemia

(„undefilling“ theory)

Complications of the nephrotic syndrome:

1. Loss of proteins in the urine• Hypoalbuminemia, catabolism, malnutrition.• Deficit of IgG → risk of infection (pneumococcal).• Loss of binders (TBG, vit.D binding glob., Ca).• Loss of antithrombin III.

2. Increased concentration of plasma macromolecules• Fibrinogen.• IgM.

Disorders causing nephrotic syndrome:

1. Idiopathic (primary) nephrotic syndrome.• Minimal change disease.• Focal and segmental glomerulosclerosis.• Membranous nephropathy.

2. Secondary nephrotic syndrome.• Diabetic nephropathy.• Myeloma kidney.• Amyloidosis.• Many other disorders…

Glomerulonephritis = nephritic syndrome

Hematuria Proteinuria Hypertension Edema Loss of GFR Mostly unpainful

Clinical classification of glomerulonephritis

Acute– Days, weeks– Renal failure– Spontaneous recovery common

Subacute = rapidly progressive– Weeks, months– Irreversible renal failure

Chronic– Months, years– Variable prognosis

Types of glomerulonephritis – examples:

Acute– Post-streptococcal

Subacute = rapidly progressive– Goodpasture´s syndrome (pulmorenal) – Wegener´s granulomatosis

Chronic– IgA nefropathy– Membranous nephropathy

Conclusions:

Localised edema General edema Types of general edema

– Cardiac– Liver cirrhosis– Renal

Nephrotic syndrome Nephritic syndrom Loss of GFR

– Other (myxedema, allergic...) Nephrotic syndrome Nephritic syndrome