Kidney function deterioration

CKD development and progression is insidious. Patients with stage 1 or 2 CKD usually do not have symptoms or metabolic derangements seen with stages 3 to 5, such as anemia, secondary hyperparathyroidism, cardiovascular disease, malnutrition, and fluid and electrolyte abnormalities that are more common as kidney function deteriorates. 

Patients with hypertension may develop damage to either the renal tissue (parenchyma) or the renal arteries. Chronic kidney disease presents initially as microalbuminuria (30-299 mg albumin in a 24-hour urine collection) that can progress to macroalbuminuria and overt kidney failure. The rate of kidney function deterioration is accelerated when both hypertension and diabetes are present. Once patients have an estimated glomerular filtration rate (GFR) of less than 60 mL/m per minute or macroalbuminuria, they have chronic kidney disease, and the risk of cardiovascular disease and progression to severe chronic kidney disease increases. Strict BP control to a goal of less than 130/80 mm Hg can slow the decline in kidney function. This strict control often requires two or more antihypertensive agents. 

Signs and symptoms associated with CKD become more prevalent in Stages 3,4, and 5. Anemia, abnormalities of calcium and phosphorus metabolism (and therefore secondary hyperparathyroidism), malnutrition, and fluid and electrolyte abnormalities become more common as kidney function deteriorates (see Chap. 44). 

Hyperphosphatemia is common in patients with end-stage renal disease (ESRD), since a large fraction (60-70%) of dietary phosphorus is absorbed and normally excreted by the kidneys, and as kidney function deteriorates, less phosphorus is exereted by the kidneys (Emmett 2004). Dietary restrictions have insuffieient effect. The condition may have serious consequences. Hyperphosphatemia stimulates parathyroid hormone and suppresses vitamin D3 production, and thus induces hyperparathyroid bone disease. In addition, it leads to myocardial and vascular calcification and cardiac microcirculatory abnormalities, which results in cardiac causes of death. Phosphate levels henee should be eontrolled early in the... 

Cugini D, Azzollini N, Gagliardini E, et al. Inhibition of the chemokine receptor CXCR2 prevents kidney graft function deterioration due to ischemia/reperfusion. Kidney Int 2005 67 1753-1761. 

In a 23-year-old woman, a kidney allograft recipient with recurrent lymphoceles treated with povidone-iodine irrigations (50 ml of a 1% solution bd for 6 days), a metabolic acidosis occurred and renal function deteriorated. After a few days, despite suspension of irrigation, the patient developed oliguria, and dialysis was needed. A renal biopsy showed acute tubular necrosis. 

Mr AC s renal function is reduced, as can be observed from the high serum urea and creatinine levels and low EDTA clearance. Each of the three drugs used in the BEP regimen are renally excreted. In particular the excretion of cisplatin is largely dependant on the kidneys and deterioration in renal function is directly related to the development of acute toxicity (e.g. nephrotoxicity, ototoxicity). 

DEF has been reported to cause extensive alterations in morphological features of erythrocyte and nuclear membranes and affected the permeability properties of rat liver mitochondrial membrane. A reduction in the activity of cytochrome-c-oxidase and NAD. H-oxidase has also been observed. Content of both DNA and RNA decreased in tissues studied within 1 month of DEF intoxication and was usually restored within 3 months. Histological study showed development of necrodystrophy in liver tissue and of fibroplastic glomerulonephritis in kidney. The deteriorating effect of DEF on cellular genome functions... 

Examination of the urine is often the first step in the assessment of a patient suspected of having, or confirmed to have, deterioration in kidney function. In the laboratory, urine is examined visually, chemically, and microscopically. New instrumental techniques are also being used to examine urine. 

ARF arises from a variety of problems affecting the kidneys and/or their circulation. It usually presents as a sudden deterioration of renal function indicated by rapidly rising scrum urea and creatinine concentrations. As acute renal failure is common in the severely ill, sequential monitoring of kidney function is important for early detection in this group of patients. 

For drugs that are primarily cleared by liver, there is a misconception that hepatic drug disposition will be unaffected by renal disease. Accumulating evidence has shown that deterioration of kidney function significantly reduces nonrenal clearance and alters the pharmacokinetics of some drugs that are predominantly metabolized or eliminated by liver through modulation... 

The renal system nephropathy and gradual deterioration of kidney functions. 

To produce surgical anaesthesia, it has been seen that a plasma thiopental concentration of 39-42 pg/mL is necessary [78]. The average dose required for induction is essentially independent of age in patients between 20 and 60 years [59]. A reduction in dose may be required for patients over the age of 60 with severely deteriorated hepatic function, with moderately affected kidney function [59], or those heavily premedicated with narcotics and other central depressants [61]. 

Severe consequences following the consumption of certain herbal products have been reported. As an example a recent case study described a group of women in Brussels who developed rapid deterioration in their kidney function after taking herbal weight-loss products containing the herb Aristolochia fangchi A recent review of adverse events associated with the herb ephedra Ephedra sinica) found that 31% of analyzed cases, including deaths and permanent disability, were definitely or probably related to the use of ephedra. ... 

Any attempt to separate obstructed from non-obstructed kidneys as distinct entities is artificial and unrealistic (Jones et al. 2004 Peters 1995). All hydronephrotic systems have some impairment of renal drainage, and we need to develop sensitive measures to detect early renal functional deterioration. The ultimate goal of the management of obstruction is the preservation of renal function. Currently, there is no imaging modality that can accurately assess the degree of obstruction and... 

Table 8 5 shows that each of the four common s-block ions is abundant not only in seawater but also in body fluids, where these ions play essential biochemical roles. Sodium is the most abundant cation in fluids that are outside of cells, and proper functioning of body cells requires that sodium concentrations be maintained within a narrow range. One of the main functions of the kidneys is to control the excretion of sodium. Whereas sodium cations are abundant in the fluids outside of cells, potassium cations are the most abundant ions in the fluids inside cells. The difference in ion concentration across cell walls is responsible for the generation of nerve impulses that drive muscle contraction. If the difference in potassium ion concentration across cell walls deteriorates, muscular activity, including the regular muscle contractions of the heart, can be seriously disrupted. 

It is contended that the renal slice technique measures primarily basolateral uptake of substrates or nephrotoxins, based on histological evidence of collapsed tubular lumens. This results in the inaccessibility of brush-border surfaces for reabsorptive transport (Burg and Orloff, 1969 Cohen and Kamm, 1976). This observation limits the ability of this model to accurately reflect reactions to nephrotoxins that occur as the result of brush-border accumulation of an injurious agent. Ultrastructurally, a number of alterations, particularly in the plasma membrane and mitochondrial compartments, have been shown to occur over a 2-h incubation period (Martel-Pelletier et al., 1977). This deterioration in morphology is very likely a consequence of the insufficient diffusion of oxygen, metabolic substrates, and waste products in the innermost regions of the kidney slice (Cohen and Kamm, 1976). Such factors also limit the use of slices in studying renal metabolism and transport functions. 

Each kidney has a large functional reserve such that each organ can, if necessary, do the work of two and individuals with only one kidney can live normally. The diagnosis of renal disease is often delayed because a significant amount of tissue deterioration usually occurs before there are clinical or biochemical signs of dysfunction. 

To what extent are the effects of age separable from those of deterioration in specific organ function (especially kidney and liver) ... 

Vestibular reactions like dizziness, vertigo, nausea and vomiting are particular for minocycline. Especially in pregnant women and when given in high doses hepatotoxicity has been described. Also patients with preexisting liver disease are susceptible. In patients with kidney disease renal function can further deteriorate. 

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