ABY

 

The presence of certain symptoms or signs may suggest an underlying diagnosis

●-Systemic symptoms and findings, such as fever, arthralgias, and pulmonary lesions, are suggestive of a systemic disease such as vasculitis or lupus.

●-Livedo reticularis and distal microemboli suggest atheroembolic disease

●-Unilateral flank pain is most consistent with obstruction, renal infarction, or infection. 

 Hypertension, hematuria with red cell casts, and a rapidly rising serum creatinine concentration are almost certainly due to acute glomerulonephritis or renal vasculitis.

Edema, heavy proteinuria, and little or no hematuria are indicative of a nonproliferative (nephrotic) glomerular disease such as diabetic glomerulosclerosis, membranous nephropathy, focal segmental glomerulosclerosis, or minimal change disease.

For most patients with mild injury, we follow a stepwise approach that begins with assessment of volume status and the exclusion of drugs that are nephrotoxins or cause prerenal azotemia . Common examples of such agents are nonsteroidal antiinflammatory agents (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and diuretics. We repeat the serum creatinine in one to two weeks. If new systemic symptoms or substantial blood pressure changes are present, more rapid evaluation is warranted.

If, on repeat testing, the creatinine remains elevated, we perform laboratory and radiographic tests as described below. 

For patients who have moderate or severe injury, we initiate the laboratory and radiographic evaluation immediately

Initial testing should include a reagent strip urinalysis (dipstick) with automated urine microscopy, the quantification of urine protein or albumin (by random [or "spot"] protein-to-creatinine ratio or albumin-to-creatinine ratio), and a kidney ultrasound. Some clinicians also send a serum and urine protein electrophoresis (SPEP and UPEP) at the time of the initial evaluation and, if these are abnormal, a serum free light chain assay.

Among all patients who are considered at higher risk for multiple myeloma based on key clinical features, we obtain a SPEP and UPEP, with immunofixation, and a serum light chain assay at the time of the initial evaluation. Patients who are considered at higher risk for myeloma include all patients who are >40 years of age who have a documented increase in the serum creatinine within three to six months and no other obvious cause for increased creatinine, such as NSAID use. 

İdrar : 

●-Patients who have a urinalysis and/or albumin-to-creatinine ratio that suggests a glomerular or interstitial lesion should be further evaluated based upon the specific finding on urinalysis or based upon determination of abnormal proteinuria. Among patients with evidence of glomerular bleeding (ie, red blood cell [RBC] casts or dysmorphic RBCs), it is important to perform an expedient evaluation, even if this requires an inpatient work-up. Some glomerular diseases may be rapidly progressive, and timely serology and biopsy evaluations followed by appropriate immunosuppression can drastically improve morbidity associated with them.

●-Patients with granular casts and renal tubular epithelial cells should be evaluated for acute tubular necrosis (ATN).

●- Patients with sterile pyuria should be evaluated for interstitial nephritis. 

●-Patients who have normal kidney imaging (no obstruction or other apparent intrinsic process such as polycystic kidney disease [PKD]), minimal proteinuria, and benign urinalysis and microscopy should be evaluated with a SPEP and UPEP, if this has not yet been performed.

Among patients who have mild injury, the serum creatinine may be repeated in one to two weeks