How kidney patients are presented

Abnormal laboratory studies (e.g., elevated blood urea nitrogen [BUN] and serum
creatinine, decreased estimated glomerular filtration rate, or abnormal serum electrolyte
values)
n Asymptomatic urinary abnormalities (e.g., gross or microscopic hematuria, proteinuria,
microalbuminuria)
n Changes in urinary frequency or problems with urination (e.g., polyuria, nocturia, urgency)
n New-onset hypertension
n Worsening edema in dependent areas
n Nonspecific symptomatologies (e.g., nausea, vomiting, malaise)
n At times symptoms can be specific (e.g., ipsilateral flank pain in those with obstructing
nephrolithiasis)
n Incidental discovery of anatomic renal abnormalities on routine imaging studies
(e.g., horseshoe kidney, congenitally absent or ptotic kidney, asymmetric kidneys,
angiomyolipoma, renal mass, polycystic kidneys)

Case Review Stone in Young Age

18 year male with history of recurrent calcium oxalate stone presented with

Nausea, vomiting and pruritis.

On examination : He had pale conjuctiva, trace limb edema and normal prssures.

Lab shows:

Urea 70 mg/dl.  S . Creatinine 5.1 mg/dl.

Hco3 18 ;  Ca 8.2;  Po4 7.0;

Ultrasound shows normal size kidney with multiple concretions bilatteally and

No obstruction seen.

24 hours urinary protein excretion 350mg.

Q: what is the aetiology of renal failure and what is the treatment?

Answere: 

The likely diagnosis is Hyperoxalurea.

High urine out put should be maintained. Avoid oxalate rich foods.

Some patients with primary hyperoxalurea respond to high dose pyridoxine.

Oral citrated may be of benefit. Once renal failure develops , patients with Primary hyperoxalurea

Should be advised of liver and kidney both transplantaion.

 

Paraquat Poisoning

Paraquate , a highly toxic herbecide which was once used alot in USA.

Its use declined when found dangerous to the worker who use it to the plants.

Now it has been restricted to commercial sell.

Breathing in paraquat may cause lung damage.It causes damage to whole body

when it touches to esophagus, stomach, intestine.

It also damage to liver, kidney. If swallowed , death occurs rapidly.

Chronic exposure causes lung fibrosis-- called paraquat lung.

Symptoms

• Burns in throat
• Coma
• difficulty in breathing
• Nosebleed
• Seizures
• Shock
• Sore throat
• Stomach pain
• Vomiting
  
  
  There is no specific treatment for Paraquat poisoning. The goal is to relieve symptoms and treat complications (supportive care).
  Remove all contaminated clothing.
  If the chemical touched your skin, wash the area with soap and water for 15 minutes, without scrubbing hard, so as not to cause abrasions which will allow greater absorption of the toxin.
  If there has been contamination of the eyes, flush them with water for 15 minutes.
  If you have swallowed Paraquat, you should receive activated charcoal as quickly as possible. Sicker patients may need a procedure called hemoperfusion, which filters the blood through charcoal to try to remove Paraquat from the lungs.
  
  
  
  
  Complication:
  • Acute respiratory distress syndrome
  • Holes in the esophagus
  • Inflammation of the area between the lungs 
  • Kidney failure
  • Scarring of the lungs (pulmonary fibrosis)
    
  
  
  
  

CASE REVIEW

42 year male with Chronic myeloid Leukemia developed acute renal failure 2 days

After start of Chemothrapy. There was no history given for hypotension episode.

Physical examination revealed generalized wasting , and lymphadenopathy,splenomegally.

Urine out put was near to 400 ml in 24 hour.

Lab revealed:

S. creatinine 5.2 mg/dl.

Urea 80mg/dl.

S. K 5.2, Hco3 18, s.ca 1.5 mmole/l

Po4 13.4:  Uric acid 19 mg/dl

His fraction excretion of sodium was 3%. And urine analysis shows mudy brown cast and

Epithelial cells.

Q. What is the diagnosis and How will u manage it?

Answere: 

This is case of acute uric acid nephropathy secondary to Tumor lysis syndrome.

Acutely rise of uric acid cause renal failure due to precipitation of uric acid within

The tubules as there was massive cell necrosis following chemotherapy. This diagnosis

Is favoured biochemically by high potassium and high phosphorus and decreased calcium.

Management starts by hydration, alkalinization of urine followd by allopurinol therapy.

New drug Rasburicase can also be given to reduce already massive load of uric acid.

 

Case Discussion

In May 2002, a 59-year-old male was admitted to our hospital because of extreme fatigue during the last week and elevated levels of urea and S-creatinine on biochemical tests. His past history included mild proteinuria since 5 years (last measurement 1,35 gr/day), cardiomyopathy since 7 years (he received verapamil treatment), chronic obstructive pulmonary disease (on inhalation therapy) since 5 years and partial deafness with tinnitus since 10 years. His family history was positive for renal disease: his mother had suffered from cardiomyopathy, deafness and chronic kidney disease (CKD) of unknown origin. On admission he did not report abnormalities of diuresis or fever.
Physical examination was regular except for reddish macular-papular skin lesions in the abdomen (which were reported since the age of 30 years) and blood pressure of 160/80 mmHg.

Laboratory examinations showed serum creatinine of 4,4 mg/dl (please provide SI units), BUN of 80.9 mg/ (please provide SI units),and moderate anaemia. In the urinary sediment 20-25 RBC/hmf (please explain) were found. 24-hour urinary protein excretion was 800 mg. A renal ultrasound revealed small, shrunken kidneys and a cardiac echo a thickening of the interventricular septum of 1,99 cm and a left ventricular outflow gradient of 67 mmHg. Ophthalmologic examination revealed tortuosity and ''sausage-like'' anomalies of the conjunctival and retinal vessels.

What is the diagnosis?

Answere:

Fabry disease . This diagnosis should be considered because of the symptoms and signs of cardiomyopathy, skin lesions, ocular abnormalities and family history of renal disease.

The clinical diagnosis of Fabry disease must be confirmed by assay of a-galactosidase activity in leukocytes or plasma and/or detection of GL3 deposition in tissue biopsies .
In our case a renal biopsy could not be performed. CT scan and MRI are no diagnostic tools for this case.

Since 2001, enzyme replacement therapy (ERT) is the only specific treatment for Fabry disease.Immunosuppressive drugs (corticosteroids and cyclosporine) have no effect on the disease. Gene therapy is a potential option for treatment of Fabry disease but is currently on development [3].Anticonvulsant drugs are used as symptomatic therapy of neuropathic pain due to Fabry disease .

COMMENTS

Fabry disease is an X-linked lysosomal storage disorder caused by deficient or absent activity of the lysosomal enzyme α-galactosidase A. Insufficient activity of this enzyme causes the accumulation of glycosphingolipids with terminal α-galactosidic linkages, particularly globotriaosylceramide (GL-3), in various tissues and cell types . This process causes damage to endothelial, perithelial and smooth-muscle cells of the vascular system, glomerular and tubular cells of the kidney, myocardial cells and valvular fibrocytes, epithelial cells of the cornea and ganglion cells of the dorsal root and autonomic nervous system, as well as cortical and brain-stem structures. Therefore, the disease presents as a multi-system disorder, clinical features being typical but highly variable in affected individuals. Renal disease is one of the major causes of morbidity and mortality in Fabry patients. In classically affected males, the first renal manifestations can be observed as proteinuria, hematuria and lipiduria. In our patient, except for hematuria and proteinuria, Fabry disease was suspected also because of skin lesions and cardiac involvement. Even though ERT was started when the patient was on dialysis, there was a clinical improvement in his cardiac and renal function. Some studies refer to a more important clinical benefit for transplanted patients with Fabry disease . Different treatment approaches are currently on development. One of them implies the use of the active-site-specific chaperone 1-deoxygalactonojirimycin that acts facilitating folding of mutant GLA in the endoplasmic reticulum and increasing its lysosomal residual activity. Reduction of Gb3 deposits has been shown in lymphoblasts from Fabry patients with missense mutations and transgenic mouse model expressing a missense mutation GLA. Gene therapy has been also developed as a potential option for treatment of Fabry disease/