Presentation on theme: "Assessing Renal Patients"— Presentation transcript
Slide1
Assessing Renal Patients
Sharondeep
GillSlide2
Overview
Chronic Kidney Disease
History
Examination
Fistula
Cases
Clinical Topics
SummarySlide3
CKDSlide4
CKD
GFR <60 for >3 months
Renal failure: GFR<15 or need for dialysis/transplant
Causes
Hypertension
Diabetes
Glomerulonephritis
Polycystic Kidney Disease
Chronic
Obstruction
Infection - Chronic Pyelonephritis
Medications - AnalgesicsSlide5
CKD Stages
Stage 1: normal
-
eGFR
>90 ml/minute/1.73 m
2
with other evidence of chronic kidney
damage.
Stage 2: mild impairment
-
eGFR
60-89 ml/minute/1.73 m
2
with other evidence of chronic kidney damage.
Stage 3a: moderate impairment
-
eGFR
45-59 ml/minute/1.73 m
2
.
Stage 3b: moderate impairment
-
eGFR
30-44 ml/minute/1.73 m
2
.
Stage 4: severe impairment
-
eGFR
15-29 ml/minute/1.73 m
2
.
Stage 5: established renal failure (ERF)
-
eGFR
less than 15 ml/minute/1.73 m
2
or on dialysis
.
-Persistent
microalbuminuria
, proteinuria or haematuria
(after exclusion of other causes -
eg
, urological disease).
-Structural
abnormalities of the kidneys, demonstrated on ultrasound scanning or other radiological tests -
eg
, polycystic kidney disease, reflux nephropathy.
-Biopsy-proven
chronic glomerulonephritis.Slide6
HISTORYSlide7
History
Normal
Hx
+
A
norexia
, nausea, vomiting, fatigue, weakness, pruritus, lethargy, peripheral oedema, dyspnoea, insomnia, muscle cramps, pulmonary oedema,
nocturia
, polyuria and
headache.
Hiccups
, pericarditis, coma and seizures
only
in
very severe
CKD
.
PMHx
:
diabetes, hypertension, polycystic kidney disease
Dialysis
Transplant – functioning?
DHx
:
Diabetic or antihypertensive medications
Immunosuppression
Steroids
FHx
:
Polycystic kidney disease
Diabetes
HypertensionSlide8
EXAMINATIONSlide9
Examination
WIPER – wash hands, intro, patients name/dob, explain + consent, reposition
Inspection
Around the bed
Nutritional status – wasting?
Excoriations
Cushing Syndrome
Hands
Flapping tremor (uraemia)
Nails –
leukonychia
(
hypoalbuminaemia
in
nephrotic
syndrome),
koilonychia
(Fe deficiency anaemia in nephritic syndrome
Pulse
BP
Arms: AV fistula – expose both arms fully, palpate and
auscultateSlide10
Examination - Fistula
Used in haemodialysis
Surgical procedure to connect artery side to end with ligation of distal vein
Higher pressure and increased flow
Use 6-8 weeks post formation
Active: palpable thrill, audible bruit, access marks
Types: Radio-cephalic
,
Ulnar-
basilic
,
brachio
-cephalic
Implications: body image, clothing, avoid trauma, no
bp
/blood taking
Complications: infection, stenosis, thrombosis, bleeding, failure
Steal syndrome: distal tissue ischaemiaSlide11
Examination
Head & Neck
Eyes – conjunctival pallor
Mouth/tongue – gingival hypertrophy (immunosuppression)
Neck – JVP, scar (
parathroidectomy
)
Abdo
Inspection
Distension
Scars
Hockey stick/Rutherford Morrison
Previous peritoneal dialysis
Back
Palpation – LIF mass
Percussion
Auscultation (renal bruits)
Peripheral oedemaSlide12
Case 1Slide13
Mr AB Age 54Slide14
No thrill, no audible bruit
2 x small soft masses either side of umbilicus
10cm firm, non tender mass below scarSlide15
Case 2Slide16
Mr CD Age 58
No thrill, no audible bruit
Well healed scarSlide17Slide18
Case 3Slide19
Mrs EF Age 54
Thrill & bruit, puncture markSlide20
10cm firm, non tender mass below scarSlide21
Clinical Topics
Causes of CKD
Haemodialysis vs Peritoneal Dialysis
Indications for haemodialysis
Renal Transplant
Immunosuppression and its complications
Cushing Syndrome
Polycystic Kidney Disease
Hyperparathyroidism
Renal
OsteodystrophySlide22
Haemodialysis Indications
Persistent hyperkalaemia >7
mmol
Acidosis pH <7.2
Refractory pulmonary oedema
Uraemia causing pericarditis / encephalopathy
Posioning
/ overdose e.g. aspirinSlide23
Polycystic Kidney Disease
50% will get ESRF
Can
also get cysts in
liver
, pancreas, brain, and arterial blood vessels
Autosomal dominant
PKD1 mutation on
Chrom
16 (85%)
PKD2 mutation (15%)
Autosomal recessive
Tend to present younger
May need nephrectomy if severe
Associated with: mitral valve prolapse, SAHSlide24
Hyperparathyroidism
Renal
osteodystrophy
:
1.
O
steoporosis
2. Hyperparathyroidism
3.
Osteomalacia
4.
Osteosclerosis
“
pepperpot
lesions & rugger jersey spine” – sclerotic end plates and lucent central areasSlide25
Resources
Levey
AS, Coresh J (2012). Chronic Kidney Disease. Lancet 379: 165-180.
http
://
www.37med.com/uploadfile/2012/0118/20120118055854639.pdf
BTS Guidelines on Renal Transplant
http
://www.bts.org.uk/Documents/Guidelines/Active/transplantationguidelinesFINALApril08%20(2).pdf
Patient.co.uk
OHCM
