1. Syndromology of renal disease.
Dr. Martin Havrda

2. Edema:
Palpable swelling produced by expansion of the interstitial fluid volume
Generalized edema = anasarca

3. Example 1:
Young female broke her calf. She received a plaster fixation for 4 weeks. After 3 weeks she observed pain in the involved leg. Following the removal of the fixation, her right leg became swallen, her calf muscles became tender, she developped mild fever. Her left leg was normal.

4. Example 1 – diagnosis: Localised edema of the right leg.
Local reason for oedema is likely.
Deep venous thrombosis.
Diagnosis?
Doppler ultrasound
Phlebography (isotope, X-ray)
Treatment?
Heparin

5. Localised edema – treatment:
No diuretics!
Treatment depends on the cause.

6. Example 2:
Male with the history of MI followed by exertional dyspnea. 2 weeks ago he had a respiratory infection with cough. Since then his dyspnea worsened and he developed edema of the legs.

7. Example 2 – physical examination (1):
Symmetrical edema of the legs
Not tender
Normal skin colour
Hepatomegaly
Distended jugular veins

8. Example 2 – physical examination (2):
Patient becomes dyspneic in recumbent position, prefers sitting.
Symmetrical inspiratory rales over the lung base.
Gallop
Cyanosis
Impaired mental status

9. Example 2 – physical examination (3):
Dull percussion and decreased breathing sounds over the base of the right lung.

12. Example 2 – diagnosis? Heart failure. History of heart disease.
Signs of failing left heart.
Signs of failing right heart.
Signs of general circulatory malfunction.

13. Drugs promoting edema formation:
Non-steroid antiinflammatory drugs.
Some antihypertensives (CCB).
Some antidiabetics (pioglitazone, rosiglitazone).
Estrogens.
Other drugs…

14. Example 3:
Male with the history of alcohole abuse complaints on growing size of his abdomen, weakness, swelling of the legs in the last week. 10 days ago he had his birhtday.

15. Example 3 – physical examination (1):
Large abdomen – thin extremities
Muscular atrophy
Abdomen distended, not tender, undulatory wave positive.
Icterus.
Hepatomegaly.
Splenomegaly.
Iceberg symptom.
Caput medusae.
Spider naevi.
Palmar erythema.

16. Example 3 – physical examination (2):
Symmetrical swelling of the legs
Not tender
Unaltered colour of the swollen area.
Signs of hypovolemia
Collapsed jugular veins
Hypotension
Tachycardia
Dupuytren´s contracture
Gynecomastia
Foetor hepaticus
Encephalopathy
flapping tremor

17. Example 3 – diagnosis? Liver cirrhosis.
History of liver disease or ethanol abuse.
Predominating ascites.
Other signs of cirrhosis.
Dyspnea is uncommon (large ascites).

18. Example 4: Female suddenly developed large swelling of both legs.
No pain, no considerable history, no other symptoms.
Physical examination
Symmetrical swelling, non-tender
No other remarkable abnormalities

19. Example 4 – diagnosis? Edema of renal origin.
Lack of symptoms of cardiac edema and liver cirrhosis makes renal edema likely.

20. Edema in renal disorders - history:
No specific symptoms
Symptoms of particular renal disorder
Uremic symptoms may be present
Fatigue, malaise, weight loss
Dyspepsia, vomiting, diarrhea
Dyspnea
Itching
Confusion

21. Edema in renal disorders – phys.exam:
Hypertension may occur
Diabetic or hypertonic vascular eye abnormalities may be present
Uremic foetor may be present
Eyelid edema may predominate
Pericardial friction rub in advanced uremia
Check the kidneys
Flank percussion
Bimanual palpation
Check the urinary bladder
Distended?
Tenderness above the symphysis or in the ureteric points?

22. Edema in renal disorders – tests:
Positive urinary sediment
Hematuria
Proteinuria
Abnormalities in serum common
Low albumin
High cholesterol
High urea
High creatinine
Ultrasonography
Kidneys enlarged, reduced size, abnormal echogenity
Dilatation of the pelvis, calyces, ureter
Many other tests...

23. General edema and fluid overload:
Edema of a systemic origin
Symmetrical
Gravity – dependent
Mostly unpainful
Accumulation of fluid
Pleural effusion
Pericardial effusion
Ascites
Transcutaneous fluid leakage

24. Clinically important evaluation of edema:
Physical examination.
Blood pressure
Hypertension in renal related edema is common
Body weight.
X-ray
Pleural effusion
Pulmonary congestion
Ultrasonography
Ascites
Diameter of vena cava and hepatic veins
Echocardiography CT
Bioimpedance measurement
Central venous pressure

25. General edema – reason?
Retention of dietary or intravenously administered sodium and water by the kidneys.
Primary (renal edema)
Secondary (cardiac edema, liver cirrhosis)
Combination (impaired cardiorenal axis)
2,5-3 liters before it becomes apparent
Vascular reasons
Increased capillary leak
Increased oncotic pressure of the interstitium
Myxedema … accumulation of proteins

26. EDEMA IN RENAL DISEASES:
Nephrotic syndrome.
Proteinuria
Hypoalbuminemia
Hyperlipoproteinemia
Edema
Acute nephritic syndrome.
Acute poststreptococcal glomerulonephritis
Loss of GFR.
Abnormal Na+ excretion

27. Nephrotic syndrome: Proteinuria > 3,5 g/24h Hypoalbuminemia
Reabsorption in tubules, toxic effect.
Hypoalbuminemia
Loss of albumin in the urine ≈ increased albumin synthesis in the liver.
Hyperlipoproteinemia
Decreased catabolism of lipoproteins
Cardiovascular risk, progression of renal disease (capture of lipoproteins by mesangial cells)
Edema
Primary renal Na+ retention („overflow“ theory)
Leakage of the fluid to the interstitium → hypovolemia („undefilling“ theory)

28. Complications of the nephrotic syndrome:
Loss of proteins in the urine
Hypoalbuminemia, catabolism, malnutrition.
Deficit of IgG → risk of infection (pneumococcal).
Loss of binders (TBG, vit.D binding glob., Ca).
Loss of antithrombin III.
Increased concentration of plasma macromolecules
Fibrinogen.
IgM.

29. Disorders causing nephrotic syndrome:
Idiopathic (primary) nephrotic syndrome.
Minimal change disease.
Focal and segmental glomerulosclerosis.
Membranous nephropathy.
Secondary nephrotic syndrome.
Diabetic nephropathy.
Myeloma kidney.
Amyloidosis.
Many other disorders…

30. Glomerulonephritis = nephritic syndrome
Hematuria
Proteinuria
Hypertension
Edema
Loss of GFR
Mostly unpainful

31. Clinical classification of glomerulonephritis
Acute
Days, weeks
Renal failure
Spontaneous recovery common
Subacute = rapidly progressive
Weeks, months
Irreversible renal failure
Chronic
Months, years
Variable prognosis

32. Types of glomerulonephritis – examples:
Acute
Post-streptococcal
Subacute = rapidly progressive
Goodpasture´s syndrome (pulmorenal)
Wegener´s granulomatosis
Chronic
IgA nefropathy
Membranous nephropathy

33. Conclusions: Nephritic syndrome Localised edema General edema
Types of general edema
Cardiac
Liver cirrhosis
Renal
Nephrotic syndrome
Nephritic syndrom
Loss of GFR
Other (myxedema, allergic...)
Nephritic syndrome