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Obstructive uropathy

1. What is obstructive uropathy? Obstructive uropathy is structural or functional interference of normal urine flow anywhere along the urinary tract. Obstructive uropathy can be acute or chronic, partial, or complete, and unilateral or bilateral. 2. What is obstructive nephropathy? Long-standing obstructive uropathy may ultimately lead to kidney damage. Obstructive nephropathy is typically caused by elevated pressures in the renal pelvis and calyces due to hydronephrosis…

Nephrotic syndrome

1. What is nephrotic syndrome? Nephrotic syndrome is one of the most rigidly defined entities in clinical medicine. The term is not a specific diagnosis, but instead represents a cluster of abnormal findings. Specifically, it is comprised of four distinct elements: one physical sign, edema; and three laboratory test abnormalities, massive proteinuria, hypoalbuminemia, and hypercholesterolemia. A hypercoagulable state is an optional fifth feature, especially in adults,…

Acute glomerulonephritis and rapidly progressive glomerulonephritis

1. What is the syndrome of acute glomerulonephritis? Acute glomerulonephritis is an acute kidney injury (AKI) syndrome characterized by the sudden onset of edema and new-onset or worsening hypertension. Urinalysis demonstrates an active sediment, including abnormal proteinuria (usually >30 mg/dL or 1+ on a semiquantitative scale), hematuria, and red cell casts. Patients with acute glomerulonephritis are often azotemic (i.e., they have elevated serum blood urea nitrogen…

Contrast-induced nephropathy

1. What is contrast-induced nephropathy (CIN), and how does it occur? Iodinated contrast media can lead to a usually reversible form of non-oliguric acute kidney injury (AKI) that occurs typically 24 to 48 hours after intravenous (IV) or intra-arterial administration of contrast. CIN does not occur with oral delivery of contrast media because contrast is not absorbed through the gut. Contrast media causes AKI through two…

Rhabdomyolysis

1. What is rhabdomyolysis? Rhabdomyolysis is a condition characterized by muscle injury leading to myocyte necrosis and the release of intracellular contents into the circulation. The term is usually applied when acute kidney injury (AKI) results from the muscle injury, but AKI does not always occur, even following severe muscle injury. 2. How does rhabdomyolysis cause AKI? Rhabdomyolysis causes AKI through a combination of kidney vasoconstriction,…

Sepsis

1. How is sepsis-associated acute kidney injury (SA-AKI) defined? SA-AKI is characterized by the simultaneous presence of AKI (based on a consensus definition such as the Acute Kidney Injury Network [AKIN] or Kidney Disease Improving Global Outcomes [KDIGO] criteria; see Chapter 10 ) and the 2016 consensus criteria for sepsis (defined as life-threatening organ dysfunction caused by a dysregulated response to infection). Causes of AKI not…

Medications

Drugs covered 1. Nonsteroidal antiinflammatory drugs (NSAIDs) 2. Angiotensin-converting enzyme (ACE) and angiotensin-receptor blocker (ARB) 3. Sodium phosphate 4. Pamidronate and zoledronate 5. Proton pump inhibitors (PPIs) 6. Checkpoint inhibitors (CPI) chemotherapy 7. Antiangiogenesis drugs 8. Cisplatin 9. Braf inhibitors 10. Intravenous immune globulin (IVIG) 11. Tenofovir 12. Vancomycin + piperacillin/tazobactam 13. Ciprofloxacin 14. Topiramate 15. Crystalline nephropathy 16. Metformin 17. Bath salts 18. Dialyzability 19.…

Cardiorenal syndrome

Background 1. What does cardiorenal syndrome (CRS) mean? The term CRS has been used to define different clinical conditions in which heart and kidney dysfunction overlap. A consensus classification of CRS is outlined in Table 9.1 . Table 9.1. Classification of Cardiorenal Syndrome TYPE NAME DESCRIPTION EXAMPLE 1 Acute cardiorenal Heart failure leading to acute kidney injury (AKI) Acute coronary syndrome leading to acute heart and…

Hepatorenal syndrome

1. What is hepatorenal syndrome? The current definition of hepatorenal syndrome (HRS) updated in 2007 by the International Ascites Club (IAC) states that it is “a potentially reversible syndrome that occurs in patients with cirrhosis, ascites and liver failure, consisting of impaired kidney function, marked abnormalities in cardiovascular function, and intense over-activity of the endogenous vasoactive systems.” It can appear spontaneously or follow a precipitating event.…

Management options: Continuous renal replacement therapy

1. When should renal replacement therapy (RRT) be initiated? There are accepted urgent indications for RRT in patients with acute kidney injury (AKI) and generally include: refractory fluid overload, hyperkalemia >6 mEq/L or rapidly rising potassium levels, signs of uremia, severe metabolic acidosis, and certain alcohol and drug intoxications. Although the maintenance of serum creatinine and blood urea nitrogen (BUN) concentrations below arbitrarily set levels is…

Epidemiology, etiology, pathophysiology, and diagnosis

1. What is acute kidney injury (AKI)? AKI is a sudden decrease in kidney function occurring over a period of hours to days. The acute decrease in glomerular filtration rate (GFR) is usually manifested by the accumulation of waste products including, but not limited to, urea and creatinine in the blood (azotemia), and is sometimes accompanied by oliguria. 2. What is the difference between AKI and…

Kidney biopsy

1. What are the major clinical uses for a kidney biopsy? A kidney biopsy is performed to help establish a diagnosis and aid in the selection of an appropriate therapy when clinical and laboratory tests are unrevealing. The degree of active and chronic changes helps generate valuable information regarding the prognosis and likelihood of a treatment response. A kidney biopsy is routinely used to differentiate causes…

Kidney imaging techniques

1. List the most commonly used imaging modalities for the kidneys. Radiography (plain film, excretory urography [EU], retrograde pyelography, cystography) Ultrasonography (US) Computed tomography (CT) scan Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) Radionuclide imaging Kidney angiography 2. Describe the information that can be provided about the urinary tract on the plain abdominal radiograph. The plain abdominal radiograph, also called kidneys, ureters, bladder, can…

Measurement of glomerular filtration rate

1. What is the glomerular filtration rate (GFR)? The production of urine and the removal of waste products by the kidneys begin by filtering blood across the glomerular membrane. Blood enters the glomerulus and then can exit either through the efferent arteriole or by becoming filtrate by passing through the glomerular membrane into Bowman space and the tubules of the nephron. The GFR quantifies how fast…

Urinalysis

1. What is uroscopy? Uroscopy comes from the word “uroscopia,” meaning scientific examination of the urine. It is derived from the Greek words ouron meaning urine and skopeo meaning to behold, contemplate, examine, or inspect. Such analysis of the urine was historically termed uroscopy until the 17th century and is now called “urinalysis.” 2. What is the proper way of collecting and handling a urine specimen…

Secondary Hypertension

Definition and Prevalence of Secondary Hypertension Secondary hypertension is generally defined as hypertension associated with a specific cause and, therefore, potentially curable if that cause is removed. The use of this definition generates two separate lines of diseases. The first are considered “classic” causes of secondary hypertension, which, if diagnosed in a timely manner, can be effectively cured. Examples include acute glomerulonephritis, primary aldosteronism, renal artery…

Evaluation and Management of Hypertension

## Hypertension remains the leading cause of cardiovascular (CV) mortality and morbidity including stroke, heart disease, kidney disease, and other vascular disease. The relationship between blood pressure (BP) and CV risk is linear, continuous, and additive to other well-known risk factors including diabetes, dyslipidemia, obesity, and cigarette smoking. For individuals aged 40 to 69 years, each increment of either 20 mm Hg in systolic BP or…

Pathogenesis of Hypertension

Hypertension implies an increase in either cardiac output or, more typically, in systemic vascular resistance (SVR). Essential hypertension developing in young adults may be initiated by an increase in cardiac output, associated with signs of overactivity of the sympathetic nervous system; the blood pressure (BP) is labile, and the heart rate is increased. Later, the BP increases further because of a rise in SVR, with return…

Infectious Complications of Kidney Transplantation

Infections are among the more common complications following kidney transplantation. While advances in surgical techniques and modern induction and maintenance immunosuppression regimens have improved the outcomes of the allograft, they have also changed the risk of posttransplant infections over time. For example, lymphocyte depletion induction combined with tacrolimus-mycophenolate-based maintenance has resulted in an increase in the frequency of BK virus nephropathy. To counter the enhanced risk…

Immunosuppression in Transplantation

The central issue in organ transplantation remains the prevention of allograft rejection. Understanding the physiology of the immune response to a transplanted organ, developing targeted immunosuppressive drugs, and devising the best combinations to maintain safety and improve efficacy are key for successful graft function and long-term graft survival. Physiology of Immunorecognition The immune system evolved to discriminate self from non-self, and this response against non-self consists…