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Renal Impairment

Renal impairment encompasses both acute and chronic renal failure, which may develop as a result of numerous disorders. The clinical presentation ranges from asymptomatic to life-threatening shock, depending on the severity of impairment. The diagnosis rests on the ability of the physician to recognize clinical features and conduct a thorough laboratory workup, while the determination of the glomerular filtration rate is the cornerstone in determining the degree of renal failure.


Presentation

A myriad of disorders may cause the inability of the kidneys to perform their respective function, and the term renal impairment encompasses two major disorders - acute and chronic kidney failure:

Jaundice
  • Abstract Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal recessive condition characterized by intermittent episodes of pruritus and jaundice that may last days to months.[ncbi.nlm.nih.gov]
Nocturia
  • At first, patients may be completely asymptomatic, but signs such as alterations in urinary habits (nocturia), generalized weakness, and fatigue eventually ensue.[symptoma.com]
  • Symptoms of ESRD include: 1 nocturia malaise anorexia/nausea/vomiting pruritus restless legs dyspnoea Patients with acute renal failure from glomerulonephritis caused by viral infection and immune reaction can present with proteinuria and “nephritic sediment[myhivclinic.org]
  • Nocturia is often noted, principally due to failure to concentrate the urine. Lassitude, fatigue, anorexia, and decreased mental acuity often are the earliest manifestations of uremia.[merckmanuals.com]
  • Symptoms associated with kidney disease, such as: decreased attentiveness, nausea, vomiting, anorexia, weight change, dyspnea, orthopnea, leg swelling, fatigue, muscle cramps, restless legs, peripheral neuropathy, pruritus, urinary urgency or frequency, nocturia[hiv.va.gov]

Workup

Renal impairment, both in the form of acute and chronic renal failure, could be severely harmful and even life-threatening for the patient in the absence of an early diagnosis [1]. For this reason, physicians must obtain a thorough patient history and determine the presence of underlying disorders that may induce renal impairment, whereas a complete physical examination assesses the signs and symptoms and determine the next steps in workup [2]. In fact, the clinical examination can lead to a prompt diagnosis in some cases, examples being prostate hypertrophy and cervical cancer, where the physician might be able to palpate the masses during rectal and vaginal examinations, respectively [1]. As soon as a presumptive diagnosis is made, a meticulous laboratory workup needs to be performed. A complete blood count (CBC), kidney function tests (urea and creatinine), urinalysis, serum glucose levels, complete coagulation panel, serum electrolytes (sodium, potassium, bicarbonate, calcium, and phosphate), inflammatory parameters (erythrocyte sedimentation rate, C-reactive protein), liver transaminases, and in most severe patients, arterial blood gasses must be included [1] [2] [5]. Imaging studies are equally important in determining the cause of kidney failure, with abdominal ultrasonography being the gold standard for evaluation of kidney anatomy and structure [1] [5]. To assess the degree of kidney failure, determination of GFR using creatinine and specific calculations is vital in establishing the severity of renal impairment [1] [5].

Abnormal Renal Function
  • renal function has been shown to be an independent predictor of mortality in people living with HIV (PLWHIV). 6 The higher prevalence of RI in HIV-infected patients has been demonstrated in a study in which RI prevalence was higher in women, older patients[myhivclinic.org]
  • Both have low urine concentrations and are not indicated in the treatment of UTI in patients with normal or abnormal renal function. In contrast, ciprofloxacin and levofloxacin achieve high urine concentrations with oral or parenteral therapy.[cjasn.asnjournals.org]
  • Background There is a high prevalence (30%) of abnormal renal function among patients with HIV disease. CKD is increasingly a cause of morbidity among people with HIV infection.[hiv.va.gov]

Treatment

  • The primary end point was a sustained virologic response 12 weeks after the end of treatment.[ncbi.nlm.nih.gov]
  • Although the patient required long-term teicoplanin treatment, a further decline in renal function was not observed, and blood culture remained negative after the start of treatment.[ncbi.nlm.nih.gov]
  • Treatment is often ineffective and symptoms, particularly pruritus, can be severe.[ncbi.nlm.nih.gov]
  • The patient presented with acute confusion, muscle cramps and myoclonic jerks 5 weeks after treatment.[ncbi.nlm.nih.gov]
  • The safety and efficacy of treatment remains a clinical challenge in these patients. This review focuses on the current state of knowledge and treatment regimens in patients with decompensated cirrhosis and severe renal impairment.[ncbi.nlm.nih.gov]

Prognosis

  • As renal dysfunction may impact the clinical management of multiple myeloma and is associated with poor prognosis, the preservation of renal function is critical, warranting non-nephrotoxic alternatives where possible in managing this population. 2017[ncbi.nlm.nih.gov]
  • Results Serum sCD25 levels were significantly increased in SLE patients compared to those in HCs ( p KEYWORDS: SLE; Serum soluble CD25; lupus nephritis; prognosis prediction[ncbi.nlm.nih.gov]
  • Abstract Renal insufficiency is associated with the prognosis of acute ischemic stroke (AIS) and homocysteine (Hcy) levels. This study investigated the association between plasma Hcy levels and renal insufficiency in patients with AIS.[ncbi.nlm.nih.gov]
  • Abstract Renal impairment (RI) is one of the hallmarks of multiple myeloma (MM) and carries a poor prognosis. Microvesicles (MVs) are membrane vesicles and play an important role in disease progression.[ncbi.nlm.nih.gov]
  • Whether circulatory dysfunction and subsequent renal impairment contribute to the poor prognosis for these patients is unknown.[nejm.org]

Etiology

  • The etiology is presumed to be multifactorial, in which hemodynamic effects and a direct effect of thyroid hormone on the kidney play an important role.[ncbi.nlm.nih.gov]
  • Antimicrobial treatment of UTI requires adequate serum, renal, parenchymal, and urine concentrations of drugs with antibacterial activity versus the etiologic organism.[cjasn.asnjournals.org]
  • PAIN Pain is extremely common in end-stage renal disease and can result from renal and nonrenal etiologies.[aafp.org]
  • Incidence and etiology of acute renal failure among ambulatory HIV-infected patients. Kidney Int. 2005 Apr;67(4):1526-31. Gupta SK, Eustace JA, Winston JA, et al.[hiv.va.gov]
  • Etiology and in vitro susceptibility to fluconazole. Med Clin 2002 ; 118 : 580 –582 10 Safdar A, Chaturvedi V, Koll BS, Larone DH, Perlin DS, Armstrong D.[academic.oup.com]

Epidemiology

  • […] consequences of renal cyclooxygenase-2 (COX-2) inhibition, the reported cases should draw the attention of doctors and patients to the importance of recognizing any possible signs of renal impairment during nimesulide therapy, although only extensive epidemiological[ncbi.nlm.nih.gov]
  • Trends in renal impairment over 26 months were defined using Cockcroft-Gault (CG), simplified Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations.[ncbi.nlm.nih.gov]
  • This study aimed to assess whether individuals with significant renal impairment assessed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, but not by CG, more often develop CIN following PCI than those without renal impairment[ncbi.nlm.nih.gov]
  • Recent epidemiological studies, identifying a high prevalence of thyroid dysfunction amongst patients with renal impairment, lend a new importance to the phenomenon of reversible hypothyroidism-induced renal impairment.[academic.oup.com]
  • Translocated intestinal bacteria cause spontaneous bacterial peritonitis in cirrhotic rats: molecular epidemiologic evidence. J Hepatol 1998 ;28: 307 - 313 10. Navasa M, Follo A, Filella X, et al.[nejm.org]
Sex distribution
Age distribution

Pathophysiology

  • Several studies have described the pathophysiology of diminished renal function in hypothyroidism. Few studies or case reports have shown total amelioration of renal impairment as seen in our patient.[ncbi.nlm.nih.gov]
  • Mechanistic understanding of altered renal secretion in renal impairment is one area that may benefit from such models, despite knowledge gaps in renal pathophysiology.[ncbi.nlm.nih.gov]
  • Whilst the pathophysiology of impaired renal function in hypothyroidism is multifactorial, the reduction in GFR due to the lower cardiac output and renal blood flow is likely to be the predominant mechanism [ 3 ].[academic.oup.com]
  • […] kidney disease (CKD), caused directly or indirectly by HIV and/or due to drug-related effects. 1 ARF may be associated with antiretroviral therapy (ART), or treatment for HIV- associated opportunistic infections. 1 CKD disease can be caused by multiple pathophysiological[myhivclinic.org]

Prevention

  • Recognition of this unusual finding, and features distinguishing it from other causes of high CSF signal intensity, such as subarachnoid haemorrhage and protein in the CSF, are emphasised to help prevent diagnostic errors.[ncbi.nlm.nih.gov]
  • Its incidence can be reduced if preventive measures are instituted. This report presents a case of acute renal impairment following use of radiocontrast media.[ncbi.nlm.nih.gov]
  • KEYWORDS: Atrium fibrillation; glomerular filtration rate; prevention; renal impairment; stroke[ncbi.nlm.nih.gov]
  • […] antagonist oral anticoagulants (NOACs), also referred to as direct oral anticoagulants (DOACs), dabigatran, apixaban, edoxaban, and rivaroxaban, have emerged as effective alternatives to vitamin K antagonists (VKAs) across several indications, including the prevention[ncbi.nlm.nih.gov]
  • BACKGROUND: Among multiple causes, diabetic nephropathy (DN) is the major underlying renal disease that leads to end-stage renal disease (ESRD), and early diagnosis can effectively prevent or delay the progression to ESRD.[ncbi.nlm.nih.gov]

References

Article

  1. Fry AC, Farrington K. Management of acute renal failure. Postgrad Med J. 2006;82(964):106-116.
  2. Hilton R. Acute renal failure. BMJ : British Medical Journal. 2006;333(7572):786-790.
  3. Schrier RW, Wang W, Poole B, Mitra A. Acute renal failure: definitions, diagnosis, pathogenesis, and therapy. J Clin Invest. 2004;114(1):5-14.
  4. Parmar MS. Chronic renal disease. BMJ. 2002;325(7355):85-90.
  5. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  6. Murtagh FE, Addington-Hall J, Higginson IJ. The prevalence of symptoms in end-stage renal disease: a systematic review. Adv Chronic Kidney Dis. 2007;14(1):82-99.

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Last updated: 2018-06-22 08:01