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CMDT 2008
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Merten GJ et al Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial JAMA 2004 May 19;291(19):2328 34 [PMID: 15150204] Parmet S et al JAMA patient page Acute renal failure JAMA 2002 Nov 27;288(20):2634 [PMID: 12444873] Perazella MA Drug-induced renal failure: update on new medications and unique mechanisms of nephrotoxicity Am J Med Sci 2003 Jun;325(6):349 62 [PMID: 12811231] Vinen CS et al Acute glomerulonephritis Postgrad Med J 2003 Apr;79(930):206 13 [PMID: 12743337] Warnock DG Towards a definition and classification of acute kidney injury J Am Soc Nephrol 2005 Nov;16(11):3149 50 [PMID: 16207828] Weisbord S et al Radiocontrast-induced acute renal failure J Intensive Care Med 2005 Mar Apr;20(2):63 75 [PMID: 15855219]
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Clinical Findings
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A Symptoms and Signs
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Patients with acute glomerulonephritis are often hypertensive and edematous, and have an abnormal urinary sediment The edema is found first in body parts with low tissue tension, such as the periorbital and scrotal regions
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CHRONIC KIDNEY DISEASE
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ESSENTIALS OF DIAGNOSIS
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Progressive azotemia over months to years Symptoms and signs of uremia when nearing endstage disease Hypertension in the majority Isosthenuria and broad casts in urinary sediment are common Bilateral small kidneys on ultrasound are diagnostic
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B Laboratory Findings
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Dipstick and microscopic evaluation will reveal evidence of hematuria, moderate proteinuria (usually < 3 g/d), and cellular elements such as red cells, red cell casts, and white cells Red cell casts are specific for glomerulonephritis, and a detailed search is warranted Twenty-four hour urine for protein excretion and creatinine clearance quantifies the amount of proteinuria and documents the degree of renal dysfunction However, in cases of rapidly changing serum creatinine values, the urinary creatinine clearance is an unreliable marker of GFR The FENa is usually low unless renal dysfunction is marked Further tests include complement levels (C3, C4, CH50), ASO titer, anti-GBM antibody levels, ANCAs, antinuclear antibody titers, cryoglobulins, hepatitis serologies, blood cultures, renal ultrasound, and occasionally renal biopsy
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General Considerations
Chronic kidney disease affects up to 20 million Americans, or one in nine adults Most are unaware of the condition because they remain asymptomatic until the disease has significantly progressed The National Kidney Foundation s staging system helps clinicians formulate practice plans (Table 22 5) Over 70% of cases of late-stage chronic kidney disease are due to diabetes mellitus or hypertension Glomerulonephritis, cystic diseases, and other urologic diseases account for another 12%, and 15% of patients have other or unknown causes The major causes of chronic renal failure are listed in Table 22 6 Chronic kidney disease is rarely reversible and leads to a progressive decline in renal function This occurs even after an inciting event has been removed Reduction in renal mass leads to hypertrophy of the remaining nephrons with hyperfiltration The GFR in these nephrons is transiently at supranormal levels These adaptations place a burden on the remaining nephrons and lead to progressive glomerular sclerosis and interstitial fibrosis, suggesting that hyperfiltration may worsen renal function However, decreased renal mass in kidney donors is not associated with chronic renal failure
Treatment
Depending on the nature and severity of disease, treatment can consist of high-dose corticosteroids and cytotoxic agents such as cyclophosphamide Plasma exchange can be used in Goodpasture s disease as a temporizing measure until chemotherapy can take effect Treatment and prognosis for specific diseases are discussed more fully below
Cantarovich F et al High-dose furosemide for established ARF: a prospective, randomized, double-blind, placebocontrolled, multicenter trial Am J Kidney Dis 2004 Sep;44 (3):402 9 [PMID: 15332212] Esson ML et al Diagnosis and treatment of acute tubular necrosis Ann Intern Med 2002 Nov 5;137(9):744 52 [PMID: 12416948] Kodner CM et al Diagnosis and management of acute interstitial nephritis Am Fam Physician 2003 Jun 15;67(12):2527 34 [PMID: 12825841] Mehta R et al Diuretics, mortality, and nonrecovery of renal function in acute renal failure JAMA 2002 Nov 27;288(20): 2547 53 [PMID: 12444861]
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