Kidney & Its Common Diseases Neuro Workgroup SIG 12 June 2008 Suhaila Mohamed Usuludin Content • Kidneys & Functions • Kidney Failure/ESRD – Risk factors – Symptoms – Treatment • Hemodialysis • Peritoneal Dialysis • Common Kidney Diseases • In the wards… The Kidneys • A pair of bean-shaped organs located at the posterior wall of the abdomen • Dimensions – 11 cm long, 6 cm wide and 3 cm thick – weighs about 160g The Kidneys • Made up of functioning units called nephrons Nephron Tubules Glomerulus The Kidneys Functions • Removal of waste and excess water from body Functions • Normal kidneys release several hormones – Renin (regulates blood pressure) – Erythropoietin (stimulates production of red blood cells) – Activated form of Vitamin D (maintain normal bone structure) Kidney Failure or End-stage Renal Disease (ESRD) • Occurs when the kidneys do not function properly or sufficiently, resulting in the accumulation of waste products and toxic materials – may cause permanent and irreversible damage to body cells, tissues and organs – kidneys that function <20% of required capacity • need renal replacement therapy Risk Factors • • • • • Chronic diseases Inflammatory diseases Blockage of urinary collecting system Chronic infections Rare genetic disorders Symptoms • • • • • • • • • Decreased urination Blood in the urine Nausea and vomiting Swollen hands and ankles Puffiness around the eyes Itching Sleep disturbances High blood pressure Loss of appetite Treatment of Kidney Failure Blood creatinine rises to 900 µmol/ L • Dialysis – Hemodialysis – Peritoneal Dialysis • Transplant – the best means of treatment Hemodialysis • A process by which excess waste products and water are removed from the blood • Requires an access to the patient's blood stream and the use of a haemodialysis machine Hemodialysis • Vascular Access – arterio-venous (AV) fistula – AV graft Hemodialysis • AV grafts Hemodialysis • 3 times a week (on alternate days) for 3 to 5 or more hours each visit Hemodialysis • “Washout Syndrome” – feels weak, tremulous, extreme fatigue – syndrome may begin toward the end of treatment or minutes following the treatment – may last 30 minutes or 12-14 hours in a dissipating form Hemodialysis • Advantages – Staff performs treatment in the dialysis centre – Three treatments per week in the dialysis centre – Permanent internal access required – Regular contact with people in the centre Hemodialysis • Disadvantages – Requires travel to a dialysis centre – Fixed treatment schedule – Two needle sticks for each treatment; tie onto a machine and cannot move about during treatment – Diet and fluid intake restriction Peritoneal Dialysis • Dialysis solution flow into the peritoneal (abdominal) cavity through a catheter • Petrionuem acts as a filter Peritoneal Dialysis • 2 forms – CAPD (Continuous Ambulatory Peritoneal Dialysis) • 4 exchanges during the day, 45 min each – APD (Automated Peritoneal Dialysis) • exchanges are performed by the machine during the night while the patient is asleep Peritoneal Dialysis • Advantages – Patient's involvement in self-care – Control over schedule – Less diet & fluid restriction – More steady physical condition as it provides slow, continuous therapy – Most similar to original kidneys. Can be done in the night as in automated peritoneal dialysis – Provide less severe cardiovascular instabilities in patients with underlying heart disease Peritoneal Dialysis • Disadvantages – Four exchanges per day – Permanent external catheter – Change of body image – Some risks of infection – If on automated peritoneal dialysis, one will be tie onto a machine in the night – Storage space is needed for supplies Kidney Transplant • A kidney from either a living related or a brain dead person is removed and surgically placed into the kidney failure patient. • Not all kidney failure patients are fit to undergo transplantation. – Medication to suppress their immunity given for the transplant may worsen their general health Kidney Transplant • Advantages – Absence of need for frequent dialysis treatment – Better quality of life – Better health – Reduced medical cost after first year – No diet and fluid intake restriction – Provide less severe cardiovascular instabilities in patients with underlying heart disease Kidney Transplant • Disadvantages – Need for frequent physician visits – Pain, discomfort of surgery – Risk of transplant rejection – Prone to infections – On lifelong medications Common Kidney Diseases Polycystic Kidney Disease Hypertensive Nephrosclerosis Glomerulonephritis / Glomerulosclerosis Urinary Tract Infection (UTI) Kidney Stones Diabetic Kidney Disease Analgesic nephropathy Polycystic Kidney Disease • Genetically acquired • 2 forms - dominant and recessive • In the dominant PKD form, one parent has the disease and passes it to the child. The chance of passing the gene to the offspring is 50%. • Cysts are abnormal pouches containing fluid. Eventually the cysts replace normal kidney tissue -> suffers ESRD Polycystic Kidney Disease Signs and Symptoms • Dull pain at the side of the abdomen and back • Blood in the urine • Frequent urine tract infection • High blood pressure (often before cysts appear) • Upper abdominal discomfort (liver and pancreatic cysts) Polycystic Kidney Disease Treatment • Blood pressure - controlled and treated • Kidney failure - supportive therapy until endstage is reached when dialysis or transplantation is then required • Urine tract infection - treatment with antibiotics • Pain - analgesics are used. Alternatively, surgery to shrink or resect the cysts. Hypertensive Nephrosclerosis • Poorly controlled high blood pressure (hypertension) can lead to kidney failure – Thickening of blood vessels Hypertensive Nephrosclerosis Signs and Symptoms • Headache • Giddiness (sometimes related to posture) • Neck discomfort • Easily tired • Nauseous and/or vomiting • Protein in urine Hypertensive Nephrosclerosis Treatment • Medications to control blood pressure (antihypertensive) • Lowering of dietary salt (2g/day) • Exercise regularly Glomerulonephritis / Glomerulosclerosis • Glomerulonephritis - An inflammatory condition that affects predominantly the glomeruli. • Causes – IgA nephropathy – Streptococcus bacteria – Autoimmune • Glomerulosclerosis - scarring of the glomeruli Glomerulonephritis / Glomerulosclerosis Signs and Symptoms • Blood or protein in urine • Frothy urine (signifying protein in urine) • Dark or pink-coloured urine • Leg swelling • Systemic disease like diabetes or autoimmune disease will have systemic manifestations, e.g. weight loss, arthritis, or skin rash Glomerulonephritis / Glomerulosclerosis Treatment Specific • Suppression of inflammation may be achieved by certain medications (eg steroids). General • Medications to decrease excretion of urinary protein • Control of blood pressure • Dietary modifications Urinary Tract Infection (UTI) • Disease of the urinary tract – Infection occurs when microorganisms attach themselves to the urethra and begins to multiply. • May lead to infection of the kidneys (pyelonephritis) and cause permanent kidney damage, if left untreated. • Women are especially prone to get urinary tract infection. Urinary Tract Infection (UTI) • Conditions that increases risk of UTI – Diabetes – Situations where a urine catheter is needed – Abnormalities of the urinary tract – Obstructed urine flow (large prostate or stone) – Being pregnant Urinary Tract Infection (UTI) Signs and Symptoms • Painful urination (burning sensation) • Hot and foul smelling urine • Blood in urine • Fever (sometimes with chills) • Painful lower abdomen • Increased urgency/frequency of wanting to pass urine • Nausea and/or vomiting Urinary Tract Infection (UTI) Treatment • Appropriate antibiotics • Drink plenty of water Kidney Stones • Start as salt/chemical crystals that precipitate out from urine • Occurs when substance in urine that prevents crystalisation are ineffective Kidney Stones • Various forms of kidney stones - the most common is calcium in combination with either phosphate or oxalate • More common in – Males – 20-40 yo Kidney Stones Signs and Symptoms • Extreme pain at the site where the stone is causing the irritation • Blood in the urine (abrasion along the urinary tract as the stone travels) • Painful and/or difficult urination • Unable to pass urine if the stone is large enough to obstruct the outlet completely Kidney Stones Treatment • With plenty of water, most stones can pass through if small • Pain-killers (as prescribed by the doctor) • Some medications may help 'breakdown' larger stone • Shockwave therapy (F-SWL) to break the stone • Surgical intervention - cystoscopy or open surgery Diabetic Kidney Disease • Common in chronic and poorly controlled diabetics • Diabetes damages blood vessels in the kidneys • Occurs in both types of diabetes • Occurrence of high blood pressure in diabetics is a strong predictor for diabetic nephropathy • Most common cause of ESRD in many developed countries Diabetic Kidney Disease Signs and Symptoms • Frothy urine (signifying protein in urine) • Leg swelling (worse after walking/standing) • High blood pressure • Itching • Nausea and/or vomiting • Losing weight • Lethargy • Increased need to urinate at night Diabetic Kidney Disease Treatment • Good control of diabetes • Good control of blood pressure (aiming for < 130/85 or lower in younger patients) • Medications to decrease protein excretion and preserve the function of kidneys • Lower protein diet • Treat any urine tract infection (which is common in diabetics) Analgesic Nephropathy • Chronic kidney disease that occurs when there is a long period of painkiller/s ingestion (usually years) • Associated with conditions which require constant need for painkiller medications • May lead to ESRD Analgesic Nephropathy Signs and Symptoms • Blood in the urine • Protein in the urine • Signs and symptoms related to kidney failure such as nausea, vomiting, lethargy, swelling, and poor appetite. Analgesic Nephropathy Treatment • Avoid long-term consumption of analgesics • Those already with kidney disease of other kinds should certainly refrain from harmful analgesics as much as possible. In the wards… • Look out for… – Vital signs • BP • Temp • HR – Catheterisation? – Dialysis • When? • Eventful? – Other electrolyte values • • • • • Na K Creatinine Urea Etc – Blood count – Hb References Kidney Dialysis Foundation (2007). Normal Kidney Functions. Health Guide [Online]. Available: http://www.kdf.org.sg/health.php (2008, June 01). National Kidney Foundation (2007). Common Kidney Diseases. Education [Online]. Available: http://www.nkfs.org/index.php (2008, June 01).