Any patient with renal disease can present either as an outpatient or inpatient consultation. Some patients may be referred because of abnormal urinary findings, such as hematuria or proteinuria, or abnormal laboratory work such as an elevated serum creatinine, which may have been incidentally discovered during routine clinical evaluation or as part of initial employment requirements. Depending on the stage of renal disease, patients can present with mild edema, generalized pruritus, or more advanced signs and symptoms of uremia, such as decreased appetite, weight loss, dysgeusia, pruritus, and change in mental status. In general, the symptoms and signs of patients presenting with renal disease are nonspecific (Table 1–1) and some patients may present only with an elevation in serum creatinine.
Table 1–1.Symptoms and signs at presentation of patients with renal disease. ||Download (.pdf) Table 1–1. Symptoms and signs at presentation of patients with renal disease.
Nausea and vomiting
Shortness of breath
Urinary hesitancy, urgency, or frequency
Microscopic or gross hematuria
Frothy appearance of urine
Flank pain, mostly unilateral (may be bilateral)
Mental status changes, eg, confusion
Weight loss or gain
Lower extremity “pitting” edema
Pulmonary edema or congestion
Pleural or pericardial effusion
To narrow the differential diagnosis, it is important to determine whether the disease is acute, subacute, or chronic on presentation. There is usually an overlap in these stages, and at times, it may not be evident as to how long the disease process may have been existing. Certainly, a patient, who presents with an elevated serum creatinine that was documented to be normal a few days previously, has an acute presentation, whereas a patient, who presents with a previously elevated serum creatinine that has been rising steadily over the past several months to years, has a chronic disease. Often, acute exacerbations of chronic renal disease are common presentations.
The next step is to determine which segment or component of the renal anatomy is involved. This is subdivided into prerenal, renal (Table 1–2), or postrenal.
Table 1–2.Causes of acute renal failure. ||Download (.pdf) Table 1–2. Causes of acute renal failure.
Intravascular volume depletion
Gastrointestinal losses, eg, vomiting, diarrhea
Third spacing or redistribution of fluids, eg, burns, pancreatitis
Decreased renal perfusion
Congestive heart failure
Renal artery stenosis
Medications, eg, nonsteroidal anti-inflammatory drugs, ACE inhibitors, angiotensin receptor blockers and diuretics in the setting of volume depletion
Rapidly progressive glomerulonephritis, thrombotic thrombocytopenic purpura
Acute tubular necrosis
Exogenous: Radiocontrast nephropathy, aminoglycosides, cisplatin
Acute tubulointerstitial nephritis, eg, drugs (antibiotics), infections
Vasculitides, eg, ANCA-mediated diseases, renal artery/vein thromboses
Intrinsic: Nephrolithiasis, papillary necrosis, prostate/bladder diseases
Extrinsic: Retroperitoneal fibrosis, cervical carcinoma