Non Glomerular Disorders

NON GLOMERULAR DISORDERS

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***INTERSTITIAL NEPHROPATHY:

They are group of inflammatory diseases affect renal tubules and the surrounding interstitium, associated with electrolyte abnormalities specially Hyperkalemia and metabolic acidosis, may be with renal failure, proteinuria rarely > 1gm/day while haematuria and pyuria are common

** Acute Interstitial Nephritis: 

Causes: 1. Drug related: - Antibiotic; Penicillins (( Methacillin )) - NSAID 2. Immune : Transplant rejection 3. Infections : Acute bacterial Pyelonephritis

Clinical features

*Development of acute renal insufficiency is common. *May develop fever, skin rash, arthralgia *peripheral Eosinophelia with or without eosinophiluria *Hypertension and oedema are uncommon.

Diagnosis:

GUE shows haematuria, sterile pyuria, WBC cast & eosinophiluria. Impaired renal function (( high blood urea and s. creatinine )) Renal biopsy shows tubular atrophy and interstitial infiltration by inflammatory cells



Treatment:
Withdrawal the offending drug in drug induced Short course of prednisolone 1mg/kg/day for 1-2 weeks may accelerate recovery. Dialysis some time is necessary. Treatment of the underlying cause if possible

** Chronic Interstitial Nephritis:

It is characterized by slowly progressive renal insufficiency, non nephritic range protienuria and functional tubular defect with interstitial fibrosis with atrophy and loss of renal tubules.

Causes:

1. Vesicouretral reflux 2. Drugs: Analgesic nephropathy 3. Sickle cell nephropathy

4. Toxins & heavy metals eg. Lead poisoning 5. Metabolic disorders eg. Hypokalemia, hyperuricemia 6. Hereditary diseases eg. Polycystic kidney disease 7. Malignant diseases eg. Multiple myeloma

Clinical features: 

1. Usually adult with CRF, hypertension and small size kidneys. 2. Electrolyte disturbances ((Hyperkalemia and acidosis disproportionately more severe than the degree of azotemia. 3. No evidence of active renal inflammation. 4. Urinalysis are nonspecific with no cellular casts. 5. Features related to the underlying cause.

Treatment:

1. Symptomatic 2. Correction of electrolyte disturbances 3. Dialysis may be indicated 4. Treatment of the underlying cause

*** URINARY TRACT INFECTION (( UTI ))

Risk factors:
1. Incomplete bladder emptying eg. Bladder outlet obstruction 2. Foreign bodies eg. Urethral catheter. 3. Loss of host defenses eg. DM

Aetiology:

E.coli, Proteus, Klebsiella, Psudomonus, Streptococci, Staphylococcus epideomidis.

Spectrums of presentations of UTI :

1. Asymptomatic bacteriuria;
5% of pregnant women have asymptomatic bacteruria It is increasingly common in those aged over 65 years. Treatment is indicated in infants and pregnant women but not in general population.

2. Symptomatic acute urethritis & cystitis:

Patients presented with frequency, dysuria, urgency, suprapupic pain, cloudy urine and may have unpleasant odor, Microscopical or visible haematuria Slight or absent systemic symptoms.

3. Acute Pyelonephritis:

Classic triad of; loin pain, fever and tenderness over the kidneys 30% may have dysuria Fever may be associated with rigors vomiting & hypotension

4. Acute prostatitis:

Dysuria, frequency, perineal or groin pain, difficulty in passing urine, enlarged tendor prostate

5. Septicaemia:

Investigations:
1. GUE 2. urine culture 3. renal sonography 4. blood culture 5. IVU

Treatment:

1. Cystitis: Trimethoprim 200 mg/day. For 3 days. OR Nitrofuradantin 50 mg/6hr. For 3 days. OR Norfloxacin 400 mg/12hr. For 3 days.

2. pyelonephritis:- Same treatment of cystitis but for 7 – 14 days.- Gentamycin or cephalosporin may be used 3. Prostatitis: - Trimethoprim, ciprofloxacin or norfloxacin for 4 – 6 weeks

4. Fluid intake of at least 2 Litters per day is recommended. 5. Urinary alkalizing agents may help symptomatically. 6. Personal hygiene and emptying of the bladder regularly.

*** CYSTIC KIDNEY DISEASES:

** POLYCSTIC KIDNEY DISEASE:
It is an autosomal dominant inherted disease



Clinical Features:
Usually asymptomatic until adult life. May presented with vague discomfort in loin or abdomen or with acute renal colic due to hemorrhage into a cyst.

Hypertension is common. May presented with recurrent UTI. Usually haematuria with little or no protienuria Chronic progressive gradual reduction in renal function CRF

Associated conditions:

Hepatic cyst, Berry aneurysms of the cerebral vessels, AR, MR, colonic diverticuli and abdominal hernias

Investigations:

1. family history 2. Clinical features 3. Abdominal ultrasound

Treatment: 

PKD is not a premalignant disorder. Supportive treatment Treatment of hypertension. Dialysis. Renal transplantiation.

*** TUMOURS OF THE KIDNEY  &  URINARY TRACT:

** Renal Adenocarcinoma:
The most common malignant tumour of the kidney in adult. Typical presentation: Haematuria, loin pain and renal mass. Systemic effects include: Fever, raised ESR, polycythaemia, abnormalities in plasma proteins and liver function test.


Diagnosis:
Abdominal U/S , Contrast enhanced abdominal CT scan.

Treatment:

Radical nephrectomy including the perirenal facial envelope and the epsilateral para-aortic lymph nodes. It is resistant to radiotherapy and chemotherapy but some benefit from immunotherapy using interferon and IL-2 Even when metastases are present, nephrectomy should always be considered.

** Tumours of renal pelvis, ureters and bladder:

Transitional cell carcinoma associated with exposure to chemicals and dye industries. Squamous cell carcinoma usually following chronic inflammation or irritation due to stone or Schistosomiasis. 80% presented with haematuria which is usually visible and painless.

Investigations:

1. IVU 2. U/S 3. cystoscopy & biopsy

Treatment:

1. Transuretheral resection of the tuomour 2. Intervesical chemotherapy 3. Radical cystectomy & urinary diversion