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MOHD KHAIRUL AMRAN 1 HS221/5 MEDICAL LAB TECH UiTM

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 2 HS221/5 MEDICAL LAB TECH UiTM

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 true volume depletion advanced liver disease congestive heart failure. BUN Creatinine BUN/Creatinine ratio urinalysis 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 Specific gravity < 1.015 Active urinary sediment High urinary sodium ( > 40 mEq/L) Low urine osmolality

Prerenal azotemia

Increase significantly

Increase

More than 20

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

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 3 HS221/5 MEDICAL LAB TECH UiTM 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

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

Prerenal azotemia
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

Intrarenal azotemia
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

Postrenal azotemia
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

Causes

MOHD KHAIRUL AMRAN 4 HS221/5 MEDICAL LAB TECH UiTM

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 waterwasting 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

Prerenal 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

Intrarenal azotemia
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

Postrenal azotemia
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

Lab diagnosis

MOHD KHAIRUL AMRAN 5 HS221/5 MEDICAL LAB TECH UiTM Gastrointestinal bleeding 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 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 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

Lab diagnosis

Prevention

Treatments

MOHD KHAIRUL AMRAN 6 HS221/5 MEDICAL LAB TECH UiTM

ARF Associated with ACE Inhibitors and Angiotensin Receptor Blockers

MOHD KHAIRUL AMRAN 7 HS221/5 MEDICAL LAB TECH UiTM

Example of Urinary sediment found in acute renal failure


Type of sediment Monomophic Pictures dysmorphic

Red blood cells

Renal Tubular Epithelial Cell Cast

White blood cell cast

MOHD KHAIRUL AMRAN 8 HS221/5 MEDICAL LAB TECH UiTM

Uric acid crystal

Calcium Oxalate Crystals

White blood cells

MOHD KHAIRUL AMRAN 9 HS221/5 MEDICAL LAB TECH UiTM

MOHD KHAIRUL AMRAN 10 HS221/5 MEDICAL LAB TECH UiTM Chronic renal failure, CRF Description Chronic kidney disease is long-standing, progressive deterioration of renal function. 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.

Signs and symptoms

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 11 HS221/5 MEDICAL LAB TECH UiTM

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

Urinalysis: Proteinuria Glycosuria Hematuria Erythrocytes Leukocytes RBC, WBC casts Uric acid crystals

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)

MOHD KHAIRUL AMRAN 12 HS221/5 MEDICAL LAB TECH UiTM

MOHD KHAIRUL AMRAN 13 HS221/5 MEDICAL LAB TECH UiTM 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 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

Signs and symptoms

Causes of End-stage renal disease includes: Causes 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 14 HS221/5 MEDICAL LAB TECH UiTM


Hyernatremia Hyperuricemia Acidosis RBC count low Hemoglobin count low

Urinalysis: High microalbumins Proteinuria, glycosuria Hematuria Erythrocytes, leukocytes RBC, WBC casts Uric acid crystals Regular check-ups with doctor Eat a low-fat, low-salt diet Exercise most days of the week 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.

Prevention

Treatments

MOHD KHAIRUL AMRAN 15 HS221/5 MEDICAL LAB TECH UiTM

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 )