Renal disorders

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  • This chapter includes contents: Label a diagram of the urinary system, distinguish between acute and chronic renal failure, outline the pathophysiology of renal failure, identify the signs and symptoms of renal failure, describe the process of hemodialysis and peritoneal dialysis, describe the signs and symptoms and care of emergent conditions associated with dialysis

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  • Miscellaneous Metabolic disorders—ketoacidosis, acute renal failure, eclampsia, acute poisoning Drugs—lithium Other—metastatic carcinoma, acute hemorrhage or hemolysis Abnormal Neutrophil Function Inherited and acquired abnormalities of phagocyte function are listed in Table 61-3. The resulting diseases are best considered in terms of the functional defects of adherence, chemotaxis, and microbicidal activity. The distinguishing features of the important inherited disorders of phagocyte function are shown in Table 61-4.

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  • After a diabetes-related LEA has been reported to be as low as 28% to 31% (169, 170). Persons with renal failure or more proximal levels of amputation have a poor prognosis and higher mortality rate. Those who undergo a diabetesrelated amputation have a 40% to 50 % chance of undergoing a contralateral amputation within 2 years (36, 171, 172). ASSESSMENT OF THE DIABETIC FOOT (Pathway 1) The pedal manifestations of diabetes are well documented and potentially limb-threatening when left untreated.

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  • Posterior Ischemic Optic Neuropathy This is an infrequent cause of acute visual loss, induced by the combination of severe anemia and hypotension. Cases have been reported after major blood loss during surgery, exsanguinating trauma, gastrointestinal bleeding, and renal dialysis. The fundus usually appears normal, although optic disc swelling develops if the process extends far enough anteriorly. Vision can be salvaged in some patients by prompt blood transfusion and reversal of hypotension. Optic Neuritis This is a common inflammatory disease of the optic nerve.

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  • Preeclampsia: Treatment Preeclampsia resolves within a few weeks after delivery. For pregnant women with preeclampsia prior to 37 weeks' gestation, delivery reduces the mother's morbidity but exposes the fetus to the risk of premature delivery. The management of preeclampsia is challenging because it requires the clinician to balance the health of both mother and fetus simultaneously and to make management decisions that afford both the best opportunities for infant survival.

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  • Diabetes Mellitus in Pregnancy: Treatment Pregnancy complicated by diabetes mellitus is associated with higher maternal and perinatal morbidity and mortality rates. Preconception counseling and treatment are important for the diabetic patient contemplating pregnancy and can reduce the risk of congenital malformations and improve pregnancy outcome. Folate supplementation reduces the incidence of fetal neural tube defects, which occur with greater frequency in fetuses of diabetic mothers.

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  • Physiology of Circadian Rhythmicity The sleep-wake cycle is the most evident of the many 24-h rhythms in humans. Prominent daily variations also occur in endocrine, thermoregulatory, cardiac, pulmonary, renal, gastrointestinal, and neurobehavioral functions. At the molecular level, endogenous circadian rhythmicity is driven by self-sustaining transcriptional/translational feedback loops (Fig. 28-2). In evaluating a daily variation in humans, it is important to distinguish between those rhythmic components passively evoked by periodic environmental or behavioral changes (e.g.

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  • Gestational Hypertension This is the development of elevated blood pressure during pregnancy or in the first 24 h post partum in the absence of preexisting chronic hypertension and other signs of preeclampsia. Uncomplicated gestational hypertension that does not progress to preeclampsia has not been associated with adverse pregnancy outcome or adverse long-term prognosis. Renal Disease (See also Chaps. 272 and 280) Normal pregnancy is characterized by an increase in glomerular filtration rate and creatinine clearance.

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  • Thrombotic Thrombocytopenic Purpura TTP and HUS were previously considered overlap syndromes. However, in the past few years the pathophysiology of inherited and idiopathic TTP has become better understood and clearly differs from HUS. TTP was first described in 1924 by Eli Moschcowitz and characterized by a pentad of findings that include microangiopathic hemolytic anemia, thrombocytopenia, renal failure, neurologic findings, and fever. The full-blown syndrome is less commonly seen now, probably due to earlier diagnosis.

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  • Hemolytic Uremic Syndrome HUS is a syndrome characterized by acute renal failure, microangiopathic hemolytic anemia, and thrombocytopenia. It is seen predominantly in children and in most cases is preceded by an episode of diarrhea, often hemorrhagic in nature. Escherichia coli O157:H7 is the most frequent, although not only, etiologic serotype. HUS not associated with diarrhea (termed DHUS) is more heterogeneous in presentation and course.

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  • T HE DECISION to devote this issue to Renal Nuclear Medicine was largely stimulated by a planning committee meeting of the Radionuclides in Nephrourology group in London a little more than a year ago. At that meeting, a progress report was delivered on the consensus reports that would be presented at the Radionuclides in Nephrourology Meeting to be held in Copenhagen in May of 1998.

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  • Therapeutic immunosuppression has very broad applications in clinical medicine, ranging from prevention and treatment of organ and bone marrow transplant rejection, management of various autoimmune disorders (e.g., rheumatoid arthritis), skin diseases, allergies and asthma. Whereas traditionally only a small repertoire of immunosuppressive agents was available for clinical use, recent discoveries have significantly increased the number of approved agents, resulting in numerous trials to further evaluate their potential.

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  • None of the newer evidence altered the priority given to metformin cited in the previous guideline. Although the specific cardioprotective effects of metformin suggested by the UKPDS study were open to challenge from some of the very recent studies, this was not on the basis of strong outcome data. Large observational studies from Canada and Scotland111,112 appeared to support the widespread advantage of metformin over sulfonylureas, but the A Diabetes Outcome Progression Trial (ADOPT) study did not.

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  • The past several decades have seen dramatic advances in understanding the etiopathogenesis of glomerulonephritis. The science of renal disease has progressed steadily from a discipline focused largely on whole organ physiology, through successive eras of cell and molecular biology, several omics (proteomics, genomics) and now into molecular mapping and personalized medicine.

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  • The majority of Cambodia children do not receive appropriate first line treatment for diarrhea. Of children under five who had diarrhea in the two weeks preceding the DHS survey, just 21% were given ORS, 36% received recommended fluids (ORS and/ or homemade rehydration fluids) and just over half received increased fluids of any kind. Many children received inappropriate treatments: 63.1% were treated with pills or syrups (CDHS, 2005). Of those who went to private sector providers, 42% were given antibiotics and 25% were given an injection.

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  • Estrogen (ES-truh-jin): A type of hormone made by the body that helps develop and maintain female sex characteristics and the growth of long bones. Estrogens can also be made in the laboratory. They may be used as a type of birth control and to treat symptoms of menopause, menstrual disorders, osteoporosis, and other conditions. Fallopian tube (fuh-LOH-pee-in): A slender tube through which eggs pass from an ovary to the uterus. In the female reproductive tract, there is one ovary and one fallopian tube on each side of the uterus.

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  • This woman has a combination of hemolytic anemia with fragmented RBCs on peripheral smear; thrombocytopenia; fever; neurologic symptoms; and renal dysfunction -- a classic pentad of symptoms that characterizes thrombotic thrombocytopenic purpura (TTP). Approximately 90% of patients will respond to plasmapheresis. Patient should be emergently treated with largevolume plasmapheresis. Sixty to 80 mL/kg of plasma should be removed and replaced with fresh-frozen plasma. Treatment should be continued daily until the patient is in complete remission.

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  • Decreased aldosterone synthesis may be due to primary adrenal insufficiency (Addison's disease) or congenital adrenal enzyme deficiency (Chap. 336). Heparin (including low-molecular-weight heparin) inhibits production of aldosterone by the cells of the zona glomerulosa and can lead to severe hyperkalemia in a subset of patients with underlying renal disease, diabetes mellitus, or those receiving K+-sparing diuretics, ACE inhibitors, or NSAIDs.

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  • Several metabolic disorders are associated with blister formation, including diabetes mellitus, renal failure, and porphyria. Local hypoxia secondary to decreased cutaneous blood flow can also produce blisters, which explains the presence of bullae over pressure points in comatose patients (coma bullae). In diabetes mellitus, tense bullae with clear viscous fluid arise on normal skin. The lesions can be as large as 6 cm in diameter and are located on the distal extremities. There are several types of porphyria, but the most common form with cutaneous findings is PCT.

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  • Efficacy of SNS in Different Disease States Efficacy studies have shown that malnourished patients undergoing major thoracoabdominal surgery benefit from SNS. Critical illness requiring ICU care including major burns, major trauma, severe sepsis, closed head injury, and severe pancreatitis [positive CT scan and Acute Physiology and Chronic Health Evaluation II (APACHE II) 10] all benefit by early SNS, as indicated by reduced mortality and morbidity. In critical illness, initiation of SNS within 24 h of injury or ICU admission is associated with a ~50% reduction in mortality.

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