MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 1

Azotemia

Azotemia is a type of Nephrotoxicity.

Azotemia is an excess of nitrogen compounds in the blood. Uremia, or uremic syndrome, occurs when the excess of nitrogen compounds

becomes toxic to your system. Azotemia, if untreated, can lead to acute (sudden) renal failure. Renal failure is when each kidney shuts down.

Signs and symptoms of Azotemia • High serum urea level • Reduced urination • Pallor • Confusion • Fatigue • Dry mouth • Thirst • Swelling • Orthostatic blood pressure • Rapid pulse • Reduced alertness

Prevention: • Drink a lot of plain water to keep kidney function properly • Avoid taking substances or medications that can poison or damage kidney tissue • Do physical exams include blood test and urinalysis to monitor kidney and urinary tract health • Regular monitoring of blood pressure, urea, creatinine and glomerular flow rate • Eat a low-fat, low-salt diet • Exercise most days of the week

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 2

Treatment: • Renal dialysis (hemodialysis or peritoneal dialysis) • Transplantation kidney • Dietary restrictions of potassium and phosphate containing foods • Fluid restrictions • Treatment of underlying cause (hypertension,diabetes,autoimmune diseases)

Main causes BUN Creatinine BUN/Creatinine ratio

urinalysis

Prerenal azotemia

true volume depletion

advanced liver disease

congestive heart failure.

Increase significantly

Increase

More than 20

• Oliguria ( urine vol < 500 ml/d) • Anuria ( <100 ml/d) • Specific gravity > 1.015 • Normal urine sediment • Elevation of hematocrit, total

protein/albumin, calcium, bicarbonate from their baseline

Intrarenal azotemia

Drugs Chemotherapy drugs Intravenous (IV) radiocontrast dye - Non-steroidal Anti-inflammatory

Drugs Chronic (long-term) renal failure Diseases that may cause chronic

renal failure

Increase

Increase

Less than 20

• Specific gravity < 1.015 • Active urinary sediment • High urinary sodium ( > 40

mEq/L) • Low urine osmolality

Postrenal azotemia

• Intra-renal Obstruction – Acute uric acid nephropathy

• Drugs • Extra-renal Obstruction

– Renal pelvis or ureter – Bladder Urethra

Increase

Increase

More than 15

Anuria but urine output still may be present

Low than normal protein/abbumin, hematocrit, calcium, bicarbonate and uric acid.

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 3

Acute renal failure, ARF

Description

Acute renal failure is a rapid decrease in renal function over days to weeks, causing an accumulation of nitrogenous

products in the blood (azotemia).

Signs and symptoms

Bloody stools

Breath odor

Bruising easily

Changes in mental status or mood

Decreased appetite

Fatigue

Flank pain (between the ribs and hips)

Hand tremor

High blood pressure

Metallic taste in mouth

Nausea or vomiting, may last for days

Prerenal azotemia Intrarenal azotemia Postrenal azotemia

Causes

1. Low cardiac output Cardiomyopathy,cardiac tamponade, pulmonary embolism, pulmonary hypertension, positive-pressure mechanical ventilation 2. Increased renal vascular

resistance cyclosporine, hypercalcemia, anaphylaxis, anesthetics, renal artery obstruction, renal vein thrombosis, sepsis, hepatorenal syndrome

1. Acute tubular injury Ischemia Surgery, hemorrhage, arterial or venous obstruction Toxins: Aminoglycosides, amphotericin B 2. Acute glomerulonephritis Anti-GBM glomerulonephritis: Goodpasture's syndrome Immune-complex: Lupus glomerulonephritis, postinfectious glomerulonephritis, cryoglobulinemic glomerulonephritis

1. Tubular precipitation Uric acid (tumor lysis), sulfonamides, myeloma protein, myoglobin 2. Ureteral obstruction Intrinsic: Calculi, clots, sloughed renal tissue, fungus ball, edema, malignancy, congenital defects Extrinsic: Malignancy, retroperitoneal fibrosis, ureteral trauma during surgery or high impact injury

Nosebleeds Persistent hiccups Prolonged bleeding Seizures Slow, sluggish movements Swelling - generalized (fluid retention) Swelling of the ankle, foot, and leg Urination changes:

o Decrease in amount of urine o Excessive urination at night

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 4

3. Decreased efferent arteriolar

tone ACE inhibitors or angiotensin II receptor blockers 4. Low systemic vascular resistance Septic shock, liver failure, antihypertensive drugs 5. ECF volume depletion Excessive diuresis, hemorrhage, GI losses, loss of skin and mucus membranes, renal salt- and water-wasting states

3. Acute tubulointerstitial nephritis Drug reaction 4. Acute vascular nephropathy Vasculitis, malignant hypertension, thrombotic microangiopathies, scleroderma, atheroembolism 5. Infiltrative diseases Lymphoma, sarcoidosis, leukemia

3. Bladder obstruction

Mechanical: Benign prostatic

hyperplasia, prostate cancer, bladder

cancer, urethral strictures, urethral

valves, obstructed indwelling urinary

catheter

Lab diagnosis

Prerenal azotemia Intrarenal azotemia Postrenal azotemia

Hx P/E Urine sediment (usually normal,

without cellular elements or abnormal casts, unless chronic kidney disease is present)

UNa< 15 meq/L (>20 in ATN) U/Pcreat> 20 (<15 in ATN) FeNa <1% (>1% in ATN) UNa/K <1/4 BUN/creatinine >20:1 BUN/Creatinine of >20 is typical,

BUT is not specific to prerenal ARF and may also be seen:

Obstructive uropathy

BUN/Creatinine ratio: 10 – 20

Urine specific gravity: ~ 1.010

Urine Na: ~30

FeNa (%): >2-3

Urine Cr/Plasma Cr: </=20

Abnormal urine microscopy

Schistocytes in peripheral smear

Rouleaux formation suggest multiple myeloma

Myoglobin / free hemoglobin and increased serum uric acid level

Hyperkalemia

Hypercalcemia

Hyperphosphatemia

Hypernatremia

BUN/Creatinine ratio: 10 - 20

Urine specific gravity: > 1.010

Urine Na: >400 (early), ~300 (late)

FeNa (%): <1 (early), 3 (late)

Urine Cr/Plasma Cr: >40 (early), >/= 20 (late)

normal urine microscopy

Hyperkalemia

Hypercalcemia

Hyperphosphatemia

Hypernatremia

Hyperuricemia

Acidosis

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 5

Gastrointestinal bleeding

Lab diagnosis

Urinalysis:

Granular, muddy-brown casts, tubular cell cast suggest tubular necrosis

Reddish brown urine indicate presence myoglobin or hemoglobin

RBC casts indicate glomerulonephritis

WBC casts suggest pyelonephritis or acute interstitial nephritis

Uric acid crystals associated with uric acid nephropathy

Calcium oxalate crystals present in cases glycol poisoning Dipstick assay may reveal significant proteinuria as result tubular injury

Prevention

• Drink a lot of plain water to keep kidney function properly • Avoid taking substances or medications that can poison or damage kidney tissue • Do physical exams include blood test and urinalysis to monitor kidney and urinary tract health

Treatments

• Immediate treatment of pulmonary edema and hyperkalemia • Dialysis as needed to control hyperkalemia, pulmonary edema, metabolic acidosis, and uremic symptoms • Adjustment of drug regimen • Usually restriction of water, Na, and K intake, but provision of adequate protein • Possibly phosphate binders and Na polystyrene sulfonate

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 6

ARF Associated with ACE Inhibitors and Angiotensin Receptor Blockers

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 7

Example of Urinary sediment found in acute renal failure

Type of sediment Pictures

Red blood cells

Monomophic dysmorphic

Renal Tubular Epithelial Cell Cast

White blood cell cast

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 8

Uric acid crystal

Calcium Oxalate Crystals

White blood cells

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 9

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 10

Chronic renal failure, CRF

Description

Chronic kidney disease is long-standing, progressive deterioration of renal function.

Signs and symptoms

Effects and symptoms of chronic kidney disease include;

need to urinate frequently, especially at night (nocturia)

swelling of the legs and puffiness around the eyes (fluid retention)

high blood pressure

fatigue and weakness (from anemia or accumulation of waste products in the body)

loss of appetite, nausea and vomiting

itching, easy bruising, and pale skin (from anemia)

shortness of breath from fluid accumulation in the lungs

headaches, numbness in the feet or hands (peripheral neuropathy)

chest pain due to pericarditis (inflammation around the heart);

bleeding (due to poor blood clotting)

bone pain and fractures

decreased sexual interest and erectile dysfunction.

Causes

The most common causes of chronic renal failure are related to:

poorly controlled diabetes

poorly controlled high blood pressure

chronic glomerulonephritis.

Less common causes of chronic renal failure include:

polycystic kidney disease,

reflux nephropathy,

kidney stones, and

prostate disease.

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 11

Lab diagnosis

BUN: elevated

Serum creatinine: elevated

BUN/Creatinine ratio: elevated

Urine specific gravity: > 1.010

RBC count and hemoglobin low

Hypercalcemia

Hyperphosphatemia

Hypernatremia

Hyperuricemia

Acidosis

Prevention

Drink a lot of plain water to keep kidney function properly Do not smoke.

Eat meals that are low in fat and cholesterol

Get regular exercise (talk to your doctor or nurse before starting).

Take drugs to lower your cholesterol, if necessary.

Keep your blood sugar under control.

Regular monitoring of blood pressure, urea, creatinine and glomerular flow rate

Treatments

Dietary restrictions of potassium and phosphate containing foods Fluid restrictions Treatment of underlying cause (hypertension,diabetes,autoimmune diseases) Renal dialysis (hemodialysis or peritoneal dialysis)

Urinalysis:

Proteinuria

Glycosuria

Hematuria

Erythrocytes

Leukocytes

RBC, WBC casts

Uric acid crystals

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 12

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 13

End – stage kidney disease

Description

Renal failure is any acute or chronic loss of kidney function and is the term used when some kidney function remains

Signs and symptoms

Signs and symptoms mentioned in various sources for End-stage renal disease includes the 10 symptoms listed below:

Reduced urine

Total lack of urine

Nausea

Vomiting

Uremia - causing various symptoms of uremia:

Drowsiness

Confusion

Seizures

Coma

Causes

Causes of End-stage renal disease includes:

Kidney disease - obviously ESRD starts as early kidney disease.

Diabetic nephropathy -

Chronic kidney failure - ESRD is by definition the last state of chronic kidney failure

Hypertension

Glomerulonephritis

Polycystic kidney disease

Lab diagnosis

BUN: highly elevated Serum creatinine: highly elevated Hyperkalemia Hypercalcemia Hyperphosphatemia

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 14

Hyernatremia Hyperuricemia Acidosis

RBC count low

Hemoglobin count low Urinalysis:

High microalbumins

Proteinuria, glycosuria

Hematuria

Erythrocytes, leukocytes

RBC, WBC casts

Uric acid crystals

Prevention

Regular check-ups with doctor

Eat a low-fat, low-salt diet

Exercise most days of the week

Treatments

Dialysis or kidney transplantation

ACE inhibitor, angiotensin receptor blocker, or other medications for high blood pressure. is the only treatment for ESRD.

xtra calcium and vitamin D (always talk to your doctor before taking)

Special medicines called phosphate binders, to help prevent phosphorous levels from becoming too high

Treatment for anemia, such as extra iron in the diet, iron pills, special shots of a medicine called erythropoietin, and blood transfusions.

MOHD KHAIRUL AMRAN

HS221/5 MEDICAL LAB TECH UiTM 15

References: 1. Burtis CA, Ashwood ER. (1996) Tietz Fundamentals of Clinical Chemistry 4th Edition.

2. Wrong diagnosis: end – stage renal disease. Retrieved from:

3. http://www.wrongdiagnosis.com/e/end_stage_renal_disease/causes.htmOn 2 jan 2011.

4. Medline plus: end-stade kidney disease. Retrieved from :

5. http://www.nlm.nih.gov/medlineplus/ency/article/000500.htm on 02 jan 2011.

6. Health Encyclopedia - Diseases and Conditions: end – stage kidney disease. Retrieved from:

http://www.healthscout.com/ency/68/680/main.html on 02 jan 2011.

7. The merck manual online medical dictionary: chronic renal failure. Retrived from:

http://www.merckmanuals.com/home/sec11/ch143/ch143c.html on 02 jan 2011.

8. Medicine net: kidney failure. Retrieved from:

9. http://www.medicinenet.com/kidney_failure/article.htm#toccOn 03 jan 2011.

10. Global oneness: azotemia - signs and symptoms. Retrieved from:

11. http://www.experiencefestival.com/azotemia_-_signs_and_symptoms on 03 jan 2011.

12. Syed Rizwan, MD. Acute renal failure ( power point presentation )

13. Peter Fumo, MD, FACP Acute renal failure ( power point presentation )