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01-INVESTIGATIONS IN KDInvesting ckd bugando cuhas
- 1. INVESTIGATIONS IN KIDNEY DISEASE BY: DR SABRINA MMED 3 FACILLATED BY: DR RUDOVICK (MD, MMED, MSC NEPHROLOGY 6TH JUNE 2022
- 2. 2 CONTENT • INTRODUCTION AND ANATOMY • PHYSIOLOGY AND KIDNEY FUNCTION • INVESTIGATIONS IN KIDNEY DISEASE
- 3. 3 INTRODUCTION AND ANATOMY OF THE KIDNEYS Location • Posterior abdominal wall in the retroperitoneal space at T12 to L3 level • The right lies lower than the left kidney Blood supply • Renal artery • Renal vein Nerve supply • Renal nerve which is a branch of superior mesenteric ganglion • Sensory input travel to T10-11 levels of the spinal cord and sensed in the corresponding dermatome (flank pain)
- 4. 4
- 5. 5 FUNCTIONAL UNIT OF THE KIDNEY: NEPHRON
- 6. 6 FUNCTIONS OF THE KIDNEYS EXTRA CELLULAR FLUID MANTAINANCE • Electrolytes • Water • Acid-Base balance HORMONAL FUNCTION • Systemic and renal hemodynamics Renin, prostaglandins and bradykinins • RBC production: erythropoietin • Calcium, phosphorus and bone metabolism: 1,25- Dihydroxyvitamin D3 or calcitriol. EXCRETION FUNCTION
- 7. 7 IMPORTANCE OF INVESTIGATING KIDNEY DISEASE Most patients with kidney diseases are asymptomatic and only routine examination leads to suspension of kidney diseases Importance of investigating kidney diseases • Identifying the kidney dysfunction. • Diagnosing the kidney disease. • Monitoring progression of the disease and response to treatment. • Monitor changes in treatment that may impact therapy eg chemotherapy, use of amphotericin, Tenofovir etc.
- 8. 8 INVESTIGATIONS IN KIDNEY DISEASE LABORATORY IMAGING HISTOPATHOL OGY urine examination • Urine examination • Microscopy • Biochemistry • Culture and sensitivity Renal function tests • Urea • Creatinine • Electrolytes Blood biochemistry: protein, lipids and uric acid • KUB USS • CT/MRI • Angiograms • Biopsy
- 9. 9 RENAL FUNCTION EVALUATION • GFR: determines creatinine clearance • Water deprivation & vasopressin administration: urinary concertation ability • Bicarbonate and ammonium chloride loading test: urinary acidification
- 10. 10 Normal eGFR: 100 to 120 mL/min/1.73 m2 Depends on: • Age • Sex Body size
- 11. CORRELATION BETWEEN EGFR AND KIDNEY FUNCTIONS 11 The kidney adapts to loss of some nephrons by hyperfiltration of the remaining nephrons hence it requires a loss of approx. >50-75% of nephrons for a decline in eGFR (1): • Stable GFR ≠ signify stable disease: other factors must be monitored eg increase in urine sediment activity, a rise in proteinuria and worsening of HTN • Increase in GFR may mean improvement of kidney function or counterproductive increase in filtration due to hemodynamic factors 1: Finco 1989
- 12. SIGNIFICANCE OF A DECLINING eGFR 12 • Progression of the disease • Dx of a superimposed disease that is often reversible (eg AKI on CKD) • Staging of a disease
- 13. FACTORS AFFECTING GFR 13 1. VARIATION IN CREATININE PRODUCTION • Nutrition: large meat meal, vegetarians, creatinine supplements • Muscle mass: amputation (lower > upper extremities), malnutrition and muscle wasting in chronic illness, rhabdomyolysis in individuals with high muscle mass 2. VARIATION IN CREATININE SECRETION • Tubular secretion: a slight decrease GFR / early stages of KD cause proximal tubular secretion of creatinine hence masking the rise in serum creatinine (9-18 micromol/l). A stable creatinine that is normal or near normal dose not mean stable disease. • Low serum albumin eg in nephrotic syndrome or SCD: causes increase in PT creatinine secretion. • Drugs
- 14. 14 MECHANISM OF CREATININE INCREMENT DRUG DECREASED SECRETION • Trimethoprim • Cimetidine: competitively inhibit tubular secretion. Clinically used to improve the accuracy of creatinine clearance. • DTG: blocks the uptake of creatinine from blood by inhibiting the organic cation transporter, the effect is seen after 4 weeks of therapy INTERFERENCE WITH SERUM ASSAY Via alkaline picrate method • Cefoxitin • Flucytosine • Acetoacetate in DKA Via Ektachem method • Flucytosine • IVIG DRUGS THAT CAUSE INCREASE IN CREATININE
- 15. 15 CAUSES OF INCREASED BUN • High protein diet • Tissue breakdown: hemorrhage, trauma and glucocorticoid therapy CAUSES OF DECREASED BUN • Low protein diet • Liver disease 40-50% of BUN is reabsorbed in the proximal tubule. Hence in situation where there is decreased blood volume eg dehydration or massive blood loss enhances PT reabsorption of Na and water, urea is also reabsorbed causing prerenal rise in BUN. BLOOD UREA NITROGEN
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- 17. MARKERS USED TO MEASURE GFR 17 Urinary clearance • Inulin • DTPA: Diethylenetriaminepentacetate • EDTA: ethylenediaminetetraacetic acid Plasma clearance Cx = Ax ÷ Px • EDTA • Iohexol
- 18. SERUM ELECTROLYTES 18 • Electrolyte imbalance is an important complication of renal disorders • Potassium • Sodium • Phosphates • Calcium • Chloride • Magnesium • Arterial blood gases for assessment of acid-base imbalance. • PH • Bicarbonates • Hydrogen ion.
- 19. ABG… 19 ABGs are frequently used for : • Identification and monitoring of acid-base disturbances • Measurement of PaO2 and PaCO2 • Assessment of the response to therapeutic interventions (eg, insulin in patients with DKA) • Detection and quantification of the levels of abnormal hb (eg, carboxyhemoglobin and methemoglobin) • Procurement of a blood sample in an acute emergency setting when venous sampling is not feasible (most tests can be performed from an arterial sample)
- 20. 20 Absolute contraindications for ABG sampling: • An abnormal modified Allen's test • Local infection, thrombus, or distorted anatomy at the puncture site (eg, previous surgical interventions, congenital or acquired malformations, burns, aneurysm, stent, arteriovenous fistula, vascular graft) • Severe peripheral vascular disease of the artery selected for sampling • Active Raynaud's syndrome (particularly sampling at the radial site) ABG…
- 21. 21
- 22. HEMATOLOGICAL AND OTHER SUPPORTING BLOOD LAB WORKUPS 22 Complement levels eg. C3,C4 Full blood count • WBC: infection • RBC, Hb level, MCV, MCHC,RDW Anemia is a complication of CKD • Platelet count: Bleeding disorder is complication of renal disorders • ANCA • Anti-GBM • Anti Sm • ANA • Anti Double stranded DNA • Genetic Testing – ADPCKD • Serum protein electrophoresis(SPEP) • ASOT • Hormonal assay i.e. iPTH • ESR • CRP
- 23. RADIOLOGICAL ASSESSMENT OF KIDNEY DISEASES 23 Used To: • Assess Urinary Tract Obstruction • Kidney Stones • Kidney Cyst Or Mass • Kidney Size • Disorders With Characteristic Radiographic Findings, • Renal Vascular Diseases • Vesicoureteral Reflux (VUR)
- 24. RADIOLOGICAL ASSESSMENT OF KIDNEY DISEASES 24 Used To: • Assess Urinary Tract Obstruction • Kidney Stones • Kidney Cyst Or Mass • Kidney Size • Disorders With Characteristic Radiographic Findings, • Renal Vascular Diseases • Vesicoureteral Reflux (VUR)
- 25. 25 The more commonly used imaging studies include: • Ultrasonography • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Plain film of the abdomen • Renal arteriography • Renal venography • Voiding cystourethrography (VCUG) • Radionuclide studies • Retrograde or anterograde pyelography RADIOLOGICAL ASSESSMENT OF KIDNEY DISEASES
- 26. UTILITY AND LIMITATIONIS OF USS IN DX KD 26 B-mode ultrasonography: The most appropriate imaging modality for evaluation of chronic kidney disease and should be part of the initial workup USEFULLNESS • Advanced Irreversible Parenchymal Disease • Cystic Diseases • Chronic Urinary Obstruction: Less sensitive in showing obstruction if in the level of lower abdomen or pelvis because the ureter is obscured by overlying bowel. • Differentiating cystic from solid masses • Detecting size, shape, texture and echogenicity of the kidneys
- 27. 27 Doppler ultrasonography: Used to evaluate renal vascular flow in patients with possible renal artery stenosis, renal vein thrombosis, or kidney infarction. Components Direct: Examiner dependent. Sens 65-75% and spec 80-90% with negative predictive value of 70-90% Indirect/spectral analysis: Easier to perform. Tardus-parvus pattern is most specific (96%) for renal artery stenosis with a sensitivity of only 43% UTILITY AND LIMITATIONIS OF USS IN DX KD
- 28. COMPUTED TOMOGRAPHY (CT) 28 USEFULLNESS • Detecting stones/ obstruction not visualized by USS • Evaluating kidney masses • Early dx of Autosomal Dominant Polycystic kidney disease • Best imaging modality for renal vasculature ( CT angiography) USEFULLNESS OF MRI • When contrast media is contraindicated • When there is high suspension of kidney abnormality with a negative USS and CT scan • To measure kidney volume in patients with Autosomal Dominant Polycystic kidney disease for prognostic purpose.
- 29. OTHER RADIOLOGICAL IMAGING IN KIDNEY DISEASES 29 • Abdominal scan: a plain film of the abdomen can identify calcium- containing, struvite, and cystine stones but miss radiolucent uric acid stones & small radiopaque stones / stones overlying bony structures • Renal arteriography: Has an advantage that angioplasty can be performed at the same time. Useful in Dx of polyarteritis nodosa • Voiding cystourethrography: Primarily used to establish the presence and severity of vesicoureteral reflux (VUR) • Radionuclide studies: Include renal scans and radionuclide cystography. • Retrograde or anterograde pyelography
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- 31. 31
- 32. 32
- 33. KIDNEY BIOPSY 33
- 34. KIDNEY BIOPSY: CHOICE OF PROCEDURE 34 percutaneous kidney biopsy: Most preferred and less invasive. Used under uss guide or CT guide Open kidney biopsy: Considered when there is an uncorrectable bleeding diathesis, a solitary kidney or after failed attempts at percutaneous kidney biopsy. Laparoscopic kidney biopsy: An alternative to open kidney biopsy for patients who are unable or unwilling to undergo percutaneous kidney biopsy. Trans jugular kidney biopsy: Major indication for this modality is an uncorrectable clotting disorder; other indications include the requirement for combined liver or heart and kidney biopsy, morbid obesity, or a solitary kidney
- 35. KIDNEY BIOPSY 35
- 36. KIDNEY BIOPSY: POST BIOPSY OBSERVATION 36 • patient should be supine for four to six hours and then remain at bedrest overnight • Close vital signs monitoring: for signs of hemorrhage • FBP: the first generally within six hours after the procedure. • Goal BP <140/90 mmhg • Control USS: 1 hour post procedure, for detection of intraperitoneal fluid/blood collection
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- 38. REFERENCE 38 • UpToDate • Medscape • Harrison principles of internal medicine 20th edition • Brenner and Rectors, The kidney 11th edition
Editor's Notes
- Each kidney consists of 800,000 to 1,200,000 nephrons. Each nephron is an independent entity until the point at which its initial collecting tubule merges with another tubule
- In the patient with kidney disease, some or all of these functions may be diminished or entirely absent. As an example, patients with nephrogenic diabetes insipidus have a decreased urinary concentrating ability, but other functions are entirely normal. By comparison, all kidney functions may be significantly impaired in the patient with end-stage kidney disease, thereby resulting in the retention of uremic toxins, marked abnormalities in fluid and electrolyte balance, and anemia and bone disease.
- Patients with kidney disease may have obvious symptoms directly referring to kidneys eg gross hematuria, flank pain. Other may have systemic symptoms like oedema, HTN and signs of uremia
- The net effect is that patients with a true GFR as low as 60 to 80 mL/min (as measured by the clearance of a true filtration marker such as inulin or radioisotopic iothalamate or diethylenetriaminepentaacetic acid [DTPA], may still have a serum creatinine that is 88 micromol/L. However, once the serum creatinine exceeds 132 to 176 micromol/L, the secretory process is effectively saturated. After this, a stable value usually represents a stable GFR
- Allen’s test: compression of both radial and ulnar artery with clenched fist and raising the arm, then lower the arm and release ulnar artery while still compressing the radial artery, observe blood return in 10 seconds. If blood doesn’t return then it means positive Allen test.
- renal scans are the preferred imaging modality in children and infants because of the reduced radiation exposure compared with CT. Radionuclide cystograms (RNCs) are also used to detect VUR. Although VCUG provides greater anatomic detail, there is increased radiation exposure with VCUG compared with RNC. As a result, RNC is often used preferentially for follow-up imaging in patients with VUR
- Contraindications to a transjugular kidney biopsy include bilateral internal jugular vein thrombosis, allergy to contrast media, and the lack of experienced clinicians. The greater cost in time, personnel, and radiologic guidance make this procedure impractical for routine kidney biopsy but may be an option in selected circumstances when the appropriate expertise is available