Transcript 3. introduction to nephrol for dentist students

Introduction to
nephrology for dentist students
2015
Judit Nagy
INTRODUCTION TO
NEPHROLOGY
Topic of nephrology: not-operable („nonsurgical”) diseases of the kidneys and
urinary tract
What to do at a patient suspect for a
nephrological disease?
- Diagnosis
- Treatment
- Follow-up
A) DIAGNOSIS
1. ANAMNESIS
2. PHYSICAL EXAMINATION
3. LAB TESTS
serological and urine examinations
4. SPECIAL IMAGING TESTS
5. HISTOLOGICAL EXAMINATION OF
RENAL BIOPSY
ad 1. ANAMNESIS
(case history, interview)
most of them are painless, symptomless
diseases!
A) present symptoms and signs
B) past medical history
C) patient’s enviroment, nephrological
risk factors
D) familiar history
E) general questions
ad 1. ANAMNESIS
A) Present symptoms and signs
• a) General symptoms and signs
- oedema
- hypertension
- signs of uraemia
• b) Signs and symptoms in connection
with urination and urine
a) General symptoms and signs
oedema
- local, symmetrical
localisation = periorbital
occurence:
acut glomerulonephritis etc
diff. diagnosis from oedema in dentical
diseases
- generalised, symmetrical
moving with the position of the body
localisation:
upright position – in low extremities
supine position – in sacral area
occurence: nephrotic syndrome
chronic renal failure
diff. diagnosis: oedema in cardiac failure
ad 1. ANAMNESIS
A) Present symptoms and signs
• a) General symptoms and signs
- oedema
- hypertension
- signs of uraemia
• b) Signs and symptoms in connection
with urination and urine
- hypertension
symptome: - headache at the nape
occurrence:
in acut glomerulonephritis
in chronic glomerulonephritis etc.
- general signs and symptoms of uraemia
neusea, vomiting
weight loss
itching
pale
uraemic breath
A) Present signs and symptoms (cont)
b) Signs and symptoms in connection with
urination, urine and the kidney
- Colour of urine
 normal: from colorless to deep yellow
 red or brown-black
(acidification of hemoglobin pigment?)
macrohaematuria!?
- Quantity of urine
 oliguria: 24 hr. urinary output: 50 – 400 ml
 anuria: 24 hr. urinary output:
0 – 50 ml
but ! - amount of drinked fluid!?
- outside temperature!?
- warm – more perspiration!
fluid
loss!
vomiting and diarrhoea!
- Dysuria (difficult urination)
prostatic hypertrophy?!
- (b) Signs and symptoms in connection with
kidney, urination and urine (cont.)
- Pain
 in either the back or the abdomen
 most commonly represents inflammation
or obstruction
1. kidney
pain in inflammation
occurs in acut pyelonephritis
- localized at or below the costal margin
posteriorly
- may radiate anteriorly toward the
umbilicus
2. renal and ureteral colic
caused by sudden obstruction of a ureter by
stone or blood clots
- sudden in onset
- severe and colicky in nature
- localized to the costovertebral angle
- radiates to the labium or testicle
3. painful and frequent urination
burning sensation at urination in urethra
occurs in acute cystitis
ad 1. ANAMNESIS
(case history, interview)
painless, symptomless diseases!
A) present symptoms and signs
B) past medical history
C) patient’s enviroment, nephrological
risk factors
D) familiar history
E) general questions
B) Past medical history
- Results of
blood pressure? urine analysis? renal function
(se creatinine, eGFR) examinations?
 at routine checkups
at work, in the army, during a pregnancy,
at licence or blood donor examinations
 in the records of previous hospital
attendances
date of the last normal results is important!
B) Past medical history (cont.)
Nephrologic history
- previous nephrological examinations
laboratory tests and imaging
(to avoid unnecessary repeat)
Urologic history
- nephrolithiasis ?
- prostate enlargement ?
ad 1. ANAMNESIS
(case history, interview)
painless, symptomless diseases!
A) present symptoms and signs
B) past medical history
C) patient’s enviroment, nephrological
risk factors
D) familiar history
E) general questions
C) Patient’s enviroment and nephrological risk
factors
- profession (exposition to gasoline…)
- medications (nephrotoxic drugs:
analgesics, antibiotics, gold …)
- smoking (active, passive)
- all components of the metabolic sy.
ad 1. ANAMNESIS
(case history, interview)
painless, symptomless diseases!
A) present symptoms and signs
B) past medical history
C) patient’s enviroment, nephrological
risk factors
D) familiar history
E) general questions
D) Familiar history
- hereditary diseases
e. g. polycystic kidney disease
- hypertension
- obesity
IN THE FAMILY
- diabetes mellitus
E) General questions
- weight loss or weight gain (oedema? )
- nausea and vomiting (uraemia ) etc.
A) DIAGNOSIS
1. ANAMNESIS
2. PHYSICAL EXAMINATION
3. LAB TESTS
4. SPECIAL IMAGING TESTS
5. HISTOLOGICAL EXAMINATION OF
RENAL BIOPSY
2) PHYSICAL EXAMINATION
a) Inspection
b) Palpation
c) „Percussion”
d) Auscultation
a) Inspection
oedema symmetrical ? localisation ?
signs of cardiac failure ?
purpura on lower extremities (HenochSchönlein sy?)
butterfly-like rash on the face (SLE?)
etc.
2) PHYSICAL EXAMINATION
a) Inspection
b) Palpation
c) „Percussion”
d) Auscultation
b) Palpation
bimanual „slipped” palpation of kidneys
(the examiner’s right hand palpate the kidney
which is pushed forward by the left hand and
after deep breathes, the right hand slip closer
and closer to the left one)
normally: kidneys are not plapable
2) PHYSICAL EXAMINATION
a) Inspection
b) Palpation
c) „Percussion”
d) Auscultation
c) „Percussion”
blow of the back at the level of the
kidneys on both side with your fists !
question: sensitivity
d) Auscultation
question: bruits above renal arteries
(renal artery stenosis on one side or
on both sides?)
A) DIAGNOSIS
1. ANAMNESIS
2. PHYSICAL EXAMINATION
3. LAB TESTS
serological and urine examinations
4. SPECIAL IMAGING TESTS
5. HISTOLOGICAL EXAMINATION OF
RENAL BIOPSY
Stages of chronic kidney disease
Stage
Description
GFR
ml/min
Prevalence in US
1.
Kidney damage with normal or
elevated GFR
> 90
5,9
(3,3%)
2.
Kidney damage with mild
decrease of GFR
60-89
5,3
(3,0%)
3.
Moderate decrease of GFR
30-59
7,6
(4,3%)
4.
Severe decrease of GFR
15-29
0,4
(0,2%)
5.
End stage renal failure
< 15
0,3
(0,2%)
Total
11%
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