The basic elements of diagnosis
- Tiredness and fatigue, headache, nauzea and vomiting, pruritus, and polyuria.
- Hypertension secondary to encephalopathy, damage to the retina, whose cardiac insufficiency.
- Anemia, azotemia, and acidosis with elevated potassium, phosphate, sulfate and calcium, and reducing the protein.
- Specific gravity of urine is low and fixed. Mild to moderate proteinuria, urine several erythrocytes, leukocytes and wide cylinders of renal insufficiency.
General considerations
Pathoanatomic images depends on the cause of kidney damage. Large scars with the reduction of j enj em kidney size, hij alinizacij on rn glomeruli and tubules and obliteration of some dilatation and hypertrophy of the other, causing a large disturbance of renal architecture. Because of the scar tissue and prolonged hypertension resulting vascular changes. There is thickening of the media, fragmentation of elastic fibers, intimal thickening and obliteration of the lumen in some areas. In diabetic nephropathy, often express the typical lesions of glomerular sclerosis in interkapilarne.Changes in the blood vessels of periarthritis or systemic lupus erythematosus are often used to set the causal diagnosis. Obstructive uropathy a classic picture of hydronephrosis, with compression and destruction renamog parenchyma. Polycystic disease, Multiple myeloma, amyloidosis, and other rare causes of renal failure can usually be identified on the basis of characteristic pathological lesions.
Clinical Features
Clinical signs and symptoms of metabolic disorders and hypertension in renal failure occur insidiously and may be unnoticed if their effects are not very pronounced.
A. Symptoms and signs: metabolic and vascular disorders accompanying renal insufficiency caused by typical symptoms and signs. Metabolic disorders caused by kidney failure to excrete the daily amount of nitrogenous waste products and excreted or retain water and electrolytes in order to maintain balance. The result of this disorder is the clinical picture of uremia with its three cardinal signs: anemia, uremia and acidosis. Uraemic patient is weak and tired. complaining of anorexia, and vomiting nauzeu. It may have diarrhea. often out of breath. Itching is a common symptom and excoriations may be in the form of purpura. Often seen sallow and waxy skin. Polyuria is due to the inability of renal tubules to absorb water. In the case of very reduced glomerular fiitracije, oliguria occurs. The ultimate manifestation of uremia are strong nauzea, diarrhea, muscle cramps, hyperpnea, itching, bloody Jenji from mucous membranes and somnolence. Large increases in blood urea uremic frost formed on the skin and fibrinous pericarditis and pleurisy.
Hypertension may become excessive, can cause headaches, seizures, and left heart failure.Retinopathy with papilloedema, haemorrhages, exudates and strong changes in the arterioles often lead to visual impairment. Encephalopathy causes convulsions. Left heart failure is often accompanied by overt pulmonary edema.
B. Laboratory findings: laboratory tests reveal the chemical and functional disorders. Urine is usually diluted, contains a small amount of protein, nekoilko erythrocytes, leukocytes and epithelial cells, a few granular and wax cylinders of which are broad caliber (wide cylinders renal insufficiency). Anemia is usually normochromic and often between hemoglobin within 6-9 gm/100 ml. Urea and creatinine levels were very elevated. Sodium concentration in serum can be easily lowered potassium levels easy to extremely elevated, and the serum calcium concentration decreased. The concentration of bicarbonate in the plasma decreases with reteneijom phosphate, sulfate, and (often) chloride.Reduction of plasma pH is due to retention of organic acids and loss of sodium and bicarbonate.Emerging acidosis helps reduce secretion of H ions in tubular damage.
Differential Diagnosis
Chronic renal failure is the signs and symptoms that are associated with functional ncsposobnošću kidney, and generated more reduction in the number and function of the nephron, but for the cause of renal damage. It is often impossible to distinguish between renal failure due to chronic glomerulonephritis, pyelonephritis, malignant hypertension, diabetic nephropathy, obstructive nephropathy and collagen diseases. The presence of large kidneys, characteristic of polycystic disease, identifies the causes of renal insuticijencije.
Treatment
If indicated, to treat hypertension and heart failure.
A. Diet and fluid intake: limit protein intake to 0.5 gm / kg per day, helping to reduce azotemia, acidosis and hyperkalemia. Diet should contain a sufficient amount of calories. Sodium should not be limited in the diet. The fluid intake should be sufficient to maintain a sufficient amount of urine excretion, but should not attempt to achieve forced diuresis. Required amount of urine may be quite high, since a large amount of salt (eg, sodium and urea) must be extracted from the reduced number of nephrons. The fluid intake should be sufficient to maintain renal function without causing excessive diuresis or edema. Caution: It is dangerous to limit fluid intake for laboratory tests, or renal function tests.
B. Compensation electrolyte:
1 In order to compensate for sodium that is lost due to renal failure, in addition to sodium in food, provide additional input jednaikih parts of NaCl and NaHCO3, 1-2 g, 2-3 times a day during meals.
2 Potassium intake must Refine. May require active measures to reduce potassium in the case of severe hyperkalemia (see discussion in Chapter Two). Indications are set based on the measurement of elevated serum potassium level.
3 Calcium lactate, 4 gm 2-3 times daily, given for mitigation hipokalcemične tetany. Sometimes required intravenous calcium gluconate.
4 Serum phosphate levels can be reduced by preventing the absorption of phosphate from the gastrointestinal tract by providing aluminum hidrkosida gel, 30 ml 3-4 times a day.
C. Blood transfusions: for the treatment of anemia may require transfusion of whole blood or washed red cells. Iron is usually neefikasno1 in the treatment of anemia, and there is no indication of any use of Cobalt.
D. General measures: nauzea and vomiting can be reduced by giving chlorpromazine, at a dose of 15-25 mg or 10-20 mg orally LM. (Or the equivalent amount of related drugs). In order to sedation, if necessary, you can use the barbiturate drugs. Treatment of hypertension may be difficult due to the limitations sodium intake as well as for giving drugs are excreted by the kidneys. Reserpine 0.25 mg 2-4 times, given orally, is relatively safe. For the treatment of seizures are given barbiturates such as pentobarbital sodium 0.25-0.5 mg LV. or LM. or amobarbital sodium 0,5-g LV. or LM. Tafeođe can give Paraldehyde which is generally well tolerated by the oral or rectal giving, at a dose of 4-15 ml.
E. Extracorporeal dialysis and kidney transplantation: the way renal failure from any cause, the subject of research of many years. Encouraging experience led to a rapid expansion of opportunities for planned repeat extracorporeal dialysis. Growing success in renal transplantation, supporting the hope of prolonging life in patients with chronic renal failure.
1 Simplified method of dialysis with an artificial kidney and harmless cannula, allowing periodic dialysis with a minimum of professional supervision in hospital centers and the patient's home.Patients with a creatinine clearance of 0-2 ml / min can be held in the life of 3-4 years, in moderate health and moderate activities, if they are done dialysis once or twice a week. Now they have clear criteria for the selection of patients. Established centers for the treatment of chronic renal insufficiency, and in general there are domestic unit, though it takes considerable experience to those who work with these machines. For long-term therapy, peritoneal dialysis is less useful than HD.
2 Kidney transplantation from human to human, it is technically possible many years ago. The success of this operation has been limited due to the rejection of foreign organs by the recipient, except in cases where the donor and recipient were identical twins. Tests of blood and leukocytes of multiple antigens, significantly improved matching recipient and donor, with encouraging reduction in the percentage of rejection. Further experience with immunosuppressive drugs and corticosteroids, are made to improve the protection of the rejection of the transplanted homologous, over an extended period of time. It is still uncertain efficacy antilimfocitarnog serum. There are good opportunities for graft acceptance by the recipient and control of the immune response to homologous kidney transplantation may become a standard procedure for the treatment of chronic renal failure.
Forecast
Prognosis depends on the degree of renal insufficiency. Intercurrent infections contribute to the bottom unfavorable outcome.
Of the authors:
Dr. Henry Brainerd, professor of medicine
Dr. Marcus A. Krupp, Professor of Medicine
Dr. Milton J. Chatton, Professor of Medicine
Dr. Sheldon Margen, professor of medicine
- Tiredness and fatigue, headache, nauzea and vomiting, pruritus, and polyuria.
- Hypertension secondary to encephalopathy, damage to the retina, whose cardiac insufficiency.
- Anemia, azotemia, and acidosis with elevated potassium, phosphate, sulfate and calcium, and reducing the protein.
- Specific gravity of urine is low and fixed. Mild to moderate proteinuria, urine several erythrocytes, leukocytes and wide cylinders of renal insufficiency.
General considerations
Pathoanatomic images depends on the cause of kidney damage. Large scars with the reduction of j enj em kidney size, hij alinizacij on rn glomeruli and tubules and obliteration of some dilatation and hypertrophy of the other, causing a large disturbance of renal architecture. Because of the scar tissue and prolonged hypertension resulting vascular changes. There is thickening of the media, fragmentation of elastic fibers, intimal thickening and obliteration of the lumen in some areas. In diabetic nephropathy, often express the typical lesions of glomerular sclerosis in interkapilarne.Changes in the blood vessels of periarthritis or systemic lupus erythematosus are often used to set the causal diagnosis. Obstructive uropathy a classic picture of hydronephrosis, with compression and destruction renamog parenchyma. Polycystic disease, Multiple myeloma, amyloidosis, and other rare causes of renal failure can usually be identified on the basis of characteristic pathological lesions.
Clinical Features
Clinical signs and symptoms of metabolic disorders and hypertension in renal failure occur insidiously and may be unnoticed if their effects are not very pronounced.
A. Symptoms and signs: metabolic and vascular disorders accompanying renal insufficiency caused by typical symptoms and signs. Metabolic disorders caused by kidney failure to excrete the daily amount of nitrogenous waste products and excreted or retain water and electrolytes in order to maintain balance. The result of this disorder is the clinical picture of uremia with its three cardinal signs: anemia, uremia and acidosis. Uraemic patient is weak and tired. complaining of anorexia, and vomiting nauzeu. It may have diarrhea. often out of breath. Itching is a common symptom and excoriations may be in the form of purpura. Often seen sallow and waxy skin. Polyuria is due to the inability of renal tubules to absorb water. In the case of very reduced glomerular fiitracije, oliguria occurs. The ultimate manifestation of uremia are strong nauzea, diarrhea, muscle cramps, hyperpnea, itching, bloody Jenji from mucous membranes and somnolence. Large increases in blood urea uremic frost formed on the skin and fibrinous pericarditis and pleurisy.
Hypertension may become excessive, can cause headaches, seizures, and left heart failure.Retinopathy with papilloedema, haemorrhages, exudates and strong changes in the arterioles often lead to visual impairment. Encephalopathy causes convulsions. Left heart failure is often accompanied by overt pulmonary edema.
B. Laboratory findings: laboratory tests reveal the chemical and functional disorders. Urine is usually diluted, contains a small amount of protein, nekoilko erythrocytes, leukocytes and epithelial cells, a few granular and wax cylinders of which are broad caliber (wide cylinders renal insufficiency). Anemia is usually normochromic and often between hemoglobin within 6-9 gm/100 ml. Urea and creatinine levels were very elevated. Sodium concentration in serum can be easily lowered potassium levels easy to extremely elevated, and the serum calcium concentration decreased. The concentration of bicarbonate in the plasma decreases with reteneijom phosphate, sulfate, and (often) chloride.Reduction of plasma pH is due to retention of organic acids and loss of sodium and bicarbonate.Emerging acidosis helps reduce secretion of H ions in tubular damage.
Differential Diagnosis
Chronic renal failure is the signs and symptoms that are associated with functional ncsposobnošću kidney, and generated more reduction in the number and function of the nephron, but for the cause of renal damage. It is often impossible to distinguish between renal failure due to chronic glomerulonephritis, pyelonephritis, malignant hypertension, diabetic nephropathy, obstructive nephropathy and collagen diseases. The presence of large kidneys, characteristic of polycystic disease, identifies the causes of renal insuticijencije.
Treatment
If indicated, to treat hypertension and heart failure.
A. Diet and fluid intake: limit protein intake to 0.5 gm / kg per day, helping to reduce azotemia, acidosis and hyperkalemia. Diet should contain a sufficient amount of calories. Sodium should not be limited in the diet. The fluid intake should be sufficient to maintain a sufficient amount of urine excretion, but should not attempt to achieve forced diuresis. Required amount of urine may be quite high, since a large amount of salt (eg, sodium and urea) must be extracted from the reduced number of nephrons. The fluid intake should be sufficient to maintain renal function without causing excessive diuresis or edema. Caution: It is dangerous to limit fluid intake for laboratory tests, or renal function tests.
B. Compensation electrolyte:
1 In order to compensate for sodium that is lost due to renal failure, in addition to sodium in food, provide additional input jednaikih parts of NaCl and NaHCO3, 1-2 g, 2-3 times a day during meals.
2 Potassium intake must Refine. May require active measures to reduce potassium in the case of severe hyperkalemia (see discussion in Chapter Two). Indications are set based on the measurement of elevated serum potassium level.
3 Calcium lactate, 4 gm 2-3 times daily, given for mitigation hipokalcemične tetany. Sometimes required intravenous calcium gluconate.
4 Serum phosphate levels can be reduced by preventing the absorption of phosphate from the gastrointestinal tract by providing aluminum hidrkosida gel, 30 ml 3-4 times a day.
C. Blood transfusions: for the treatment of anemia may require transfusion of whole blood or washed red cells. Iron is usually neefikasno1 in the treatment of anemia, and there is no indication of any use of Cobalt.
D. General measures: nauzea and vomiting can be reduced by giving chlorpromazine, at a dose of 15-25 mg or 10-20 mg orally LM. (Or the equivalent amount of related drugs). In order to sedation, if necessary, you can use the barbiturate drugs. Treatment of hypertension may be difficult due to the limitations sodium intake as well as for giving drugs are excreted by the kidneys. Reserpine 0.25 mg 2-4 times, given orally, is relatively safe. For the treatment of seizures are given barbiturates such as pentobarbital sodium 0.25-0.5 mg LV. or LM. or amobarbital sodium 0,5-g LV. or LM. Tafeođe can give Paraldehyde which is generally well tolerated by the oral or rectal giving, at a dose of 4-15 ml.
E. Extracorporeal dialysis and kidney transplantation: the way renal failure from any cause, the subject of research of many years. Encouraging experience led to a rapid expansion of opportunities for planned repeat extracorporeal dialysis. Growing success in renal transplantation, supporting the hope of prolonging life in patients with chronic renal failure.
1 Simplified method of dialysis with an artificial kidney and harmless cannula, allowing periodic dialysis with a minimum of professional supervision in hospital centers and the patient's home.Patients with a creatinine clearance of 0-2 ml / min can be held in the life of 3-4 years, in moderate health and moderate activities, if they are done dialysis once or twice a week. Now they have clear criteria for the selection of patients. Established centers for the treatment of chronic renal insufficiency, and in general there are domestic unit, though it takes considerable experience to those who work with these machines. For long-term therapy, peritoneal dialysis is less useful than HD.
2 Kidney transplantation from human to human, it is technically possible many years ago. The success of this operation has been limited due to the rejection of foreign organs by the recipient, except in cases where the donor and recipient were identical twins. Tests of blood and leukocytes of multiple antigens, significantly improved matching recipient and donor, with encouraging reduction in the percentage of rejection. Further experience with immunosuppressive drugs and corticosteroids, are made to improve the protection of the rejection of the transplanted homologous, over an extended period of time. It is still uncertain efficacy antilimfocitarnog serum. There are good opportunities for graft acceptance by the recipient and control of the immune response to homologous kidney transplantation may become a standard procedure for the treatment of chronic renal failure.
Forecast
Prognosis depends on the degree of renal insufficiency. Intercurrent infections contribute to the bottom unfavorable outcome.
Of the authors:
Dr. Henry Brainerd, professor of medicine
Dr. Marcus A. Krupp, Professor of Medicine
Dr. Milton J. Chatton, Professor of Medicine
Dr. Sheldon Margen, professor of medicine
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