Nephrolog

*Use of loop diuretics should be limited to the management of patients with volume
overload and not for AKI or oliguria per se.

* It is not necessary to wait until severe uremia develops to initiate dialytic support; renal
replacement therapy should be used as a supportive therapy in the presence of progressive
azotemia and oliguria, rather than a rescue therapy for late manifestation of AKI.

*It is well established that individuals with CKD have a 10- to 20-fold increased risk for
cardiac death compared to age-matched and gender-matched controls without CKD.

*The weight loss drug orlistat rarely may cause acute kidney injury and nephrolithiasis
because its use may lead to intestinal malabsorption and enteric hyperoxaluria.

*. The antiseizure and migraine drug topiramate is a carbonic anhydrase inhibitor that is
associated with proximal renal tubular acidosis and calcium phosphate stone formation.

*The natural history of the primary nephrotic syndrome depends on the underlying cause.
Thus, patients with minimal change nephrotic syndrome (MCNS) have an excellent
long-term prognosis, in contrast to those with primary focal segmental glomerulosclerosis
(FSGS), in whom nearly 50% will progress to end-stage renal disease (ESRD) over 5 to
10 years of follow-up, and 25% to 30% of these patients may experience recurrent
disease in a kidney transplant.




 

Ponticelli regimen in idiopathic nephrotic syndrome

• Various studies have demonstrated that treatment with methyl prednisolone and chlorambucil could increase the chance of remission of idiopathic nephrotic syndrome (INS) of varied histology in patients who do not respond to the conventional treatment. This study was done to assess the safety and efficacy of methyl prednisolone and chlorambucil regimen in patients with various types of glomerulonephritides which were resistant to the usual conventional immunosuppressive drugs. Thirty nine patients were treated between June 1998 and December 2003 with Ponticelli regimen for six months. Twenty three patients (58.98%) were men and 16 (41.02%) were women. Mean age at the onset of NS was 23.59 ± 1.28 (range 10-51) years. Four patients (10.2%) had minimal change disease (MCD), six patients (15.4%) had membranoproliferative glomerulonephritis (MPGN), two (5.1%) had IgA nephropathy, and 18 patients (46.1%) had focal segmental glomerulosclerosis (FSGS). Eleven patients were excluded from the final analysis. Of the remaining 28 patients, mean baseline proteinuria was 3.31 ± 3.09 g/day. Mean baseline plasma albumin was 2.84 ± 1.002 g/dl and mean baseline serum creatinine was 0.87 ± 0.42 mg/dl. At the end of six months of treatment, mean proteinuria was 1.02 ± 0.85 g/day. Mean plasma albumin was 3.69 ± 0.78 g/day, and mean serum creatinine was 0.85 ± 0.26 mg/dl. Mean followup was 13.21 ± 7.7 times in 18.92 ± 12.58 months. At the end of six months of treatment, seven patients (25%) achieved complete remission (CR), 10 patients (35.71%) partial remission (PR), and 11 patients (39.3%) did not show any response to the therapy. Most of the patients in responder group had FSGS (64.70%), whereas in nonresponder group patients had MPGN and mesangioproliferative glomerulonephritis (MesPGN). Out of 13 FSGS cases five (38.46%) achieved CR, six (46.15%) PR, and only two (15.38%) failed to respond. The incidence of side effects was 39.3%. Responders had more side effects than nonresponders (47 vs 27.3%). Methyl prednisolone and chlorambucil therapy (Ponticelli regimen) is safe and efficacious in achieving remission in significant number of INS patients other than membranous nephropathy, without any serious side effect on short term followup. However, a longer followup is required to demonstrate the sustained efficacy and long-term side effect of this regimen.
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• Membranous nephropathy

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• Primary/idiopathic

• 85% of MGN cases are classified as primary membranous glomerulonephritis -- that is to say, the cause of the disease is idiopathic (of unknown origin or cause). This can also be referred to as idiopathic membranous nephropathy. One study has identified antibodies to an M-type phospholipase A₂ receptor in 70% (26 of 37) cases evaluated.^[4]

•  Secondary

• autoimmu
  • The remainder is secondary due to:
  ne conditions (e.g., systemic lupus erythematosus)
• infections (e.g., syphilis, malaria, hepatitis B)
• drugs (e.g., captopril, NSAIDs, gold, mercury, penicillamine, probenecid).
• inorganic salts
• tumors, frequently solid tumors of the lung and colon; hematological malignancies such as chronic lymphocytic leukemia are less common

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• Treatment

• Treatment of secondary membranous nephropathy is guided by the treatment of the original disease. For treatment of idiopathic membranous nephropathy, the treatment options include immunosuppressive drugs and non-specific anti-proteinuric measures.

•  Immunosuppressive therapy

• Corticosteroids: They have been tried with mixed results, with one study showing prevention of progression to renal failure without improvement in proteinuria.
• Chlorambucil
• Cyclosporine
• Tacrolimus
• Cyclophosphamide
• Mycophenolate mofeti  

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• Natural history

• About a third of patients have spontaneous remission, another third progress to require dialysis and the last third continue to have proteinuria, without progression of renal failure.
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ABGs

Ph                 7.69
PCo2            23
pO2              151
sO2              99%
HCO2          29

This ABGs belongs to a young male, dialysis-dependent for 1 year complained
Difficulty in breathing. He was just been dialyzed with an ultrafiltrate of 3 liters.
On examination, he was tachypenic.   his blood pressure was 150/90.

The chest was clear on auscultation as well as on an x-ray chest
ABGs performed, shown above.
What does this blood gases show?
How will u manage?






Impression:    Acute respiratory alkalosis with metabolic alkalosis
 
When ABGs were being drawn, the patient attended to pain, His rapid respiratory effort subsided.
In a couple of hours, he was alright and went home.




 Hyperventilation (ie increased alveolar ventilation) is the mechanism responsible for the lowered arterial pCO2 in ALL cases of respiratory alkalosis.

 Respiratory Alkalosis:

Respiratory alkalosis results from hyperventilation which is manifested by excess elimination of CO₂ from the blood and a rise in the blood pH. Examples of specific causes are listed below:

Central Causes (direct action via respiratory centre)

Head Injury Stroke Anxiety-hyperventilation syndrome (psychogenic) Other 'supra-tentorial' causes (pain, fear, stress, voluntary) Various drugs (eg analeptics, propanidid, salicylate intoxication) Various endogenous compounds (eg progesterone during pregnancy, cytokines during sepsis, toxins in patients with chronic liver disease)

2. Hypoxaemia (act via peripheral chemoreceptors)

Respiratory stimulation via peripheral chemoreceptors

3. Pulmonary Causes (act via intrapulmonary receptors)

Pulmonary Embolism Pneumonia Asthma Pulmonary oedema (all types)

4. Iatrogenic (act directly on ventilation)

Excessive controlled ventilation

 Signs and Symptoms of Respiratory Alkalosis
Neurological
light-headedness
numbness and tingling
confusion
inability to concentrate
blurred vision
Cardiovascular
dysrhythmias
palpitations
diaphoresis
Miscellaneous
dry mouth
tetanic spasms of the arms and
legs

CLINICAL APPLICATION:
Treatment of respiratory alkalosis centers on resolving the underlying problem.
Patients presenting with respiratory alkalosis have dramatically increased work of
breathing and must be monitored closely for respiratory muscle fatigue. When the
respiratory muscles become exhausted, acute respiratory failure may ensue




Metabolic Alkalosis


 

Metabolic alkalosis results from elevation of serum bicarbonate. Examples of specific causes:

• Volume contraction (vomiting, overdiuresis, ascites)
• Hypokalemia
• Alkali ingestion (bicarbonate)
• Excess gluco- or mineralocorticoids
• Bartter’s syndrome

Some causes of combined respiratory alkalosis with metabolic alkalois

Physiological:   Pregnancy
In CCF when patient is tackypenic and he is being given diuretic.
In CLD:  often seen when patient has vomiting too.
In Sepsis.

NEPHROTIC SYNDROM. cont

Algorithm for proteinurea


 

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 Secondary causes of nephrotic syndrome
• Diabetes mellitus
• Neoplasia
• Drugs
• gold
• antimicrobials
• NSAIDs
• penicillamine
• captopril
• tamoxifen
• lithium
• Infections
• HIV
• hepatitis B and C
• mycoplasma
• syphilis
• malaria
• schistosomiasis
• fi lariasis
• toxoplasmosis
• Systemic lupus erythematosus (SLE)
• Amyloid
• Miscellaneous

Complications of nephrotic syndrome
• Thromboembolism:
• DVT +/– pulmonary embolism;
• renal vein;
• arterial (rare).
• Infection:
• cellulitis;
• bacterial peritonitis (rare);
• bacterial infections, e.g. pneumonia;
• viral infections in the immunocompromised.
• Hyperlipidaemia;
• Malnutrition;
• Acute renal failure.