Clinical Queries: Nephrology最新文献

White coat hypertension (WCH) is fairly common and may be seen in upto 20–40% of hypertensive patients, and is increasingly common in aging populations. Despite being known for over a hundred years, awareness about the adverse effects of WCH is limited and there is still ongoing debate about the long term prognosis and appropriate management of WCH. The term is used for individuals who have BP readings that are consistently higher than normal only in the clinical setting, while the readings recorded outside, either by ambulatory monitoring or self measurement at home, are normal. Recognition of WCH is especially important to avoid over-diagnosis of hypertension or resistant hypertension as well as injudicious treatment escalation based on isolated office BP readings. The following review shall attempt to focus on these issues related to white coat hypertension.

B-cell proliferative disorders may display the pathogenic effects by increased cell numbers, increased concentration of the molecules produced by these cells or both. Most forms of renal disease associated with monoclonal gammaglobulinopathy results from deposition of monoclonal immunoglobulins or their subunits in different compartment of kidney. Renal monoclonal immunoglobulin deposition disease (MIDD) is defined by deposits of monoclonal light chain components in renal basement membrane, mesangium which often produces a nodular sclerosing glomerulopathy. Clinical features of renal MIDD include proteinuria with or without renal failure with dysproteinemias.

We describe one case of a 68 years old male presenting with swelling with heavy proteinuria and advanced azotaemia whose renal biopsy showed nodular glomerulosclerosis. The patient had features of multiple myeloma as he had bony lytic lesions, M-spike in urine electrophoresis and plasma cells in bone marrow biopsy and elevated β2 microglobulin level.

The incidence of chronic kidney disease and end stage renal disease (ESRD) is increasing in the elderly, worldwide. Hemodialysis, peritoneal dialysis and renal transplantation are different modalities of renal replacement therapy employed for elderly ESRD patients. Vascular access problems are more common in the elderly patients. The survival outcomes are similar and poor among elderly hemodialysis and peritoneal dialysis patients, although only few studies hint at higher mortality in elderly diabetic patients on peritoneal dialysis. Renal transplantation in selected patients appears to be beneficial. Dialysis refusal or withdrawal by patients is also an important issue in elderly ESRD patients.

CKD adds tremendous financial and resource burden on healthcare of any nation. Various CKD registries like USRDS gives estimate of incidence and prevalence of this illness in different countries. On similar lines CKD registry of India was initiated in 2005 and gathers information from more than 200 centres as of now. Besides this sporadic regional studies from India also give enlightening estimates of disease burden. As the term ESRD is defined by a patient receiving RRT, so it is possible to measure the incidence and prevalence of ESRD in a population quite accurately.

According to USRDS 2009 report, the annual incidence and prevalence of ESRD in the US was 354 and 1665 per million people per year. NHANES has reported the prevalence of CKD stage 1–4 to be 13.1% or 1.31 lakh/per million (1999–2004) in the US. The problems with prevalence estimates of CKD are variations in creatinine estimation methods, GFR estimation equations and accuracy of these equations especially so in elderly age group. It has remained difficult to find CKD incidence in a community because of slowly progressive disease nature requiring prolonged follow up of a large number of subjects.

Identification of factors predisposing to chronic kidney disease is important from both individual and community point of view. The motive is to help in planning effective interventions to reduce the risk of this debilitating illness. Commonly identified risk factors include increasing age, ethnicity, inheritance, congenital or acquired nephron loss, hypertension, obesity and diabetes mellitus.

Chronic kidney disease is a leading cause of morbidity and mortality worldwide. Advances in last five decades have brought forth striding changes in understanding the etiopathogenesis of the various pertinent renal disorders as well as in their management strategies. However, with increasing prevalence of diabetes and its varied complications, hypertension, infections, drug induced nephropathies, obstructive uropathies etc, chronic kidney disease is still a major health concern in our country. Skin being the largest organ of the body and eye being the window to the surroundings, their related problems assume significance. Their evaluation pertains to thorough clinical examination skills and the ease to which they can be accessed, give an opportunity for prompt diagnosis and treatment. Skin related problems like pruritus, xerosis, etc are frequent and need early intervention to reduce patient's morbidity. Ocular manifestations need a keen eye to detect the illness and an interdisciplinary approach to aggressively treat the underlying conditions in chronic kidney disease.

The kidneys maintain homeostasis in the body avoiding significant alterations in the balance of fluid electrolyte or acid–base balance until the Glomerular filtration rates (GFR) declines to below 25 ml/min due to a series of adaptive changes, both Renal and extra renal. With progressive decline in renal function these mechanisms are overwhelmed resulting in disturbances in water metabolism contributing to hyponatremia and hypernatremia. The altered regulation of sodium transport causes disturbed volume status including volume overload and depletion. The incidence of Hyperkelemia and metabolic acidosis is more frequent in Chronic Kidney Disease (CKD) with GFR below 10 ml/min. In this review article we will attempt to review the renal and extra renal adaptation mechanisms maintaining fluid, electrolyte and acid base balance in CKD along with factors which cause failure of these mechanisms. The article will also highlight the common fluid electrolyte and acid base disorders in CKD and their treatment.

Uremic myopathy is a common problem in patients on dialysis however the pathogenesis of this entity is poorly understood. The aim of this review is to discuss briefly about its epidemiology, pathogenesis and management.

Hypertension is ubiquitous in the chronic kidney disease. Impaired salt excretion leads to increased extracellular fluid volume and consequent hypertension in renal disease. It is assumed that the excess salt and water retention increases the blood flow to the tissues, which sets in motion the phenomenon of autoregulation. The tissue arterioles vasoconstrict, under the influence of various mediators to decrease the excessive blood flow. The resulting vasoconstriction increases the peripheral vascular resistance, resulting in hypertension. The kidney and central nervous system in integrated manner play role in development of hypertension in chronic kidney disease. Recently, more light has been shed on the multitude of factors and pathophysiologic mechanisms that lead to hypertension in the renal disease. The level of blood pressure is most likely determined by the level of the peripheral vascular resistance and volume status in combination. If the peripheral vascular resistance is not appropriately lowered in the face of hypervolemia, hypertension results. In this review, evidence for the different pathophysiologic mechanisms that have been postulated to explain renal hypertension is presented.

Infectious and cardiovascular (CV) complications take a huge toll on Chronic Kidney Disease and End-Stage Renal Disease patients in terms of morbidity and mortality. Infection leads to increased mortality, directly as a result of infectious disease processes and indirectly as a risk factor for cardiovascular disease. Chronic activation with hyporesponsiveness may be the most accurate description of the immune dysfunction in clinical uremia. Risk factors for infection among patients with CKD or ESRD include high burden of coexisting illnesses, malnutrition, immunosuppressive therapy, uremia and anemia. Infections in dialysis patients could be access related or non-access related. Infections in patients with chronic kidney disease & ESRD are associated with poorer outcomes compared with the general population. Preventive strategies for infection in those with CKD and ESRD are not standardized and are underutilized even in developed countries. Creation of an optimally timed arteriovenous access is the most important step for reducing the risk of infections in hemodialysis patients. Despite the evidence of decreased efficacy of various vaccines, this population should be adequately vaccinated.