0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
330 Chronic Kidney Disease■Voiding cystourethrogram
■Renal Biopsy:
➣Useful when kidneys normal size to make specific diagnosis –
e.g., SLE, glomerulonephritis. When kidneys small (e.g.,≤9cm)
usual finding is end-stage kidney – i.e. global glomerulosclerosis
+tubulointerstitial nephritisdifferential diagnosis
■Chronic kidney disease(CKD) symptoms mimicked by systemic
diseases, cancer, wasting illnesses, depression, hypothyroidism,
chronic heart failure, chronic liver disease. Elevated BUN and crea-
tinine point to kidney, adrenocortical insufficiency.Causes of Chronic Kidney Disease
■Systemic disease: Diagnosis usually established by history, exam,
sonogram and specific laboratory tests: diabetes mellitus, hyperten-
sion, systemic lupus erythematosus, Sjogren’s syndrome, systemic
necrotizing vasculitides, atheroembolic renal disease, myeloma,
light chain deposition disease, amyloidosis, genetic disease – e.g.,
polycystic disease, tuberous sclerosis, cystinosis, Fabry’s disease,
sickle cell disease, heart failure, cirrhosis
■Primary renal and urinary tract disease: Specific glomerular dis-
ease usually requires renal biopsy; obstructive uropathy by sono-
gram or CT scan (e.g., retroperitoneal fibrosis), vesicoureteral reflux
(detected by voiding cystourethrogram), prostate disease, recurrent
UTI or voiding dysfunction (Hx, exam, voiding study)management
What to Do First
■Assess cardiovascular and volume status by physical exam and CXR,
and determine if dialysis is indicated because of:
■a) hypertension and/or pulmonary edema; b) hyperkalemia; c)
pericarditis; d) metabolic acidosis; e) altered MSGeneral Measures
■Dialysis not indicated:
➣Restore volume status with conservative measures (e.g., diuretics
in patient with volume overload).
➣Treat hypertension (present in >90% of cases).
Target blood pressure <130/80 mmHg with (in order):
ACE inhibitor/angiotensin II receptor blocker +thiazide
(serum creatinine ≤1.8 mg/dl) or loop diuretic (serum