Uraemia

Published on 05/05/2015 by admin

Filed under Internal Medicine

Last modified 05/05/2015

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228 Uraemia

Instruction

Would you like to ask this uraemic patient some questions and perform a relevant examination?

Salient features

History

• Loss of appetite, anorexia, nausea, vomiting and hiccups

• Fatigue, malaise, loss of energy

• Polyuria, nocturia, dysuria, haematuria, difficulty in passing urine

• Swelling of the face and feet

• Shortness of breath (from secondary left ventricular failure)

• Itching

• Restless legs (overwhelming need to frequently alter position of legs)

• Paraesthesia from either hypocalcaemia (associated tetany) or peripheral neuropathy

• Bone pain (from metabolic bone disease)

• Drug history, in particular NSAIDs, tetracycline

• History of diabetes, hypertension, recurrent urinary tract infections

• Family history of renal disease, in particular polycystic kidneys

• Tell the examiner that you would like to take a history for impotence in men and ameonorrhoea in women.

Examination

• Pallor (from anaemia)

• Comment on short stature (indicates uraemia from childhood)

• Examine the nails (for Lindsay’s ‘half-and-half’ nails where the proximal portion is whitish while the distal portion is brownish red; the lunula is usually obscured)

• Comment on the lemon tinge of the skin, the pallor and scratch marks. Rarely, there may be ‘uraemic frost’: increased photosensitive skin pigmentation

• Examine the arms for asterixis (flapping tremor), haemodialysis fistula

• Comment on the vascular shunts, if any

• Comment on hyperventilation of Kussmaul’s respiration secondary to metabolic acidosis

• Examine the abdomen for palpable kidneys (hydronephrosis, polycystic kidneys) and palpable bladder

• Check for pitting leg oedema

• Tell the examiner that you would like to proceed as follows:

• Check the BP (hypertension, hypotension)
• Look for pericardial friction rub
• Look for evidence of peripheral neuropathy (glove and stocking sensory loss)
• Do a rectal and vaginal examination if urinary obstruction is suspected
• Examine the urine for sugar, albumin, specific gravity, microscopy
• Examine the retina in diabetics.

Diagnosis

This patient has chronic renal failure (aetiology) caused by diabetes mellitus (aetiology), and is currently requiring dialysis, as evidenced by the arteriovenous fistula in the arm (functional status). Be prepared to determine which stage of chronic kidney disease the patient is at if asked (see below).

Questions

How would you investigate a patient with renal failure?

• Urine: glucose, microscopy, specific gravity, creatinine clearance, 24-hour urinary protein, urine electrophoresis

• Blood: FBC, ESR

• Serum: urea, electrolytes, creatinine, protein, calcium phosphate, uric acid

• Ultrasonography of the abdomen for kidneys, bladder

• Special investigations: pyelography, protein electrophoresis, complement components, autoantibody screening, serum cryoglobulins, kidney biopsy.

What do you understand by the term azotaemia?

Azotaemia indicates a raised level of urea and creatinine without symptoms (glomerular filtration rate (GFR) about 20–35% of normal).

What do you understand by the term uraemia?

Uraemia implies a deterioration of renal function associated with symptoms (GFR <20% of normal).

Note: Chronic renal insufficiency is defined by a serum creatinine concentration of 15–30 mg/l (133–265 µmol/l); chronic renal failure is >30 mg/l.

What is the classification of chronic kidney disease?

Chronic kidney disease (CKD) is classified based on clinical parameters and the GFR.

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