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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #29, #42

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LEARNING OBJECTIVES

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Learning Objectives

  • Kidney disease is common and increases morbidity and mortality.

  • Signs of kidney injury include elevations of serum creatinine levels above baseline, proteinuria, and hematuria.

  • Chronic kidney disease (CKD) is most often caused by common systemic diseases, including diabetes, hypertension, and peripheral vascular occlusive disease.

  • Patients with nephrotic syndrome usually require a kidney biopsy to determine diagnosis, prognosis, and treatment options.

  • Diabetic nephropathy is a chronic progressive kidney disease that requires treatment with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blockers (ARBs) if tolerated, optimization of blood pressure and blood glucose levels, and management of comorbidities.

  • Patients with acute kidney injury (AKI) need to be evaluated for pre-, post- and intrarenal causes. Even episodes of mild AKI can increase the risk for future CKD.

  • Subacute rise in creatinine, proteinuria, and hematuria can be caused by glomerulonephritis (GN) (rapid progressive glomerulonephritis [RPGN]) and requires emergent diagnostic evaluation and treatment to prevent renal failure.

  • Acute interstitial nephritis is most often caused by medications, in particular antibiotics and proton pump inhibitors.

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Key Clinical Points

  1. In patients with CKD management of elevated blood pressure and avoidance of nephrotoxins, including nonsteroidal anti-inflammatory drugs (NSAIDs) and intravenous (IV) contrast dye, can delay progression to end-stage renal disease (ESRD).

  2. Complications of CKD include iron-deficient anemia and secondary hyperparathyroidism.

  3. Proteinuria in the absence of hematuria is a sign of intrarenal damage, is a risk factor for progression of CKD to ESRD, and requires a thorough evaluation.

  4. Hematuria can indicate glomerular disease, but can also be associated with genitourinary malignancy, cystitis, or nephrolithiasis.

  5. In patients with renovascular disease intervention is usually only indicated if conservative management failed.

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INTRODUCTION

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The kidney is a complex organ structure comprised of several different cell types that serve many functions. Therefore, kidney injury and disease can present in many different ways depending on which part of the kidney is affected, and, in turn, the kidney can be affected by a large number of different diseases. The most widely used test to detect kidney dysfunction is loss of glomerular filtration rate (GFR), which can develop acutely with loss of renal function within days or chronically over years. If renal function decreases over the course of a few weeks it is called subacute kidney injury. Damage to the renal parenchyma and ultrastructure leads to proteinuria or hematuria. In particular diseases affecting glomeruli and the renal artery can cause hypertension. Tubular cell dysfunction is responsible for abnormalities in electrolyte levels and intravascular volume.

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These pathologic findings of kidney disease are caused by a variety of kidney-specific and systemic diseases. Establishing a specific etiology of the kidney disease has important implications for management and prognosis of the disease. Systemic diseases that affect metabolism including diabetes mellitus (DM) and hypertension are well known to cause CKD. Immune-mediated diseases including lupus erythematosus ...

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