Page 262 - Medicine and Surgery

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258 Chapter 6: Genitourinary system

Clinical features development of ARF, including hypercalcaemia and
Usuallypresentsasapainoracheinthebackorabdomen dehydration. The mechanism of development of
which may be exacerbated by drinking large amounts ‘myeloma kidney’ is via a direct toxic effect on re-
of fluid, for example it may become symptomatic for nal tubular cells and blockage of the tubules and col-
the first time in students who drink large quantities of lecting ducts by the paraprotein. In addition, patients
beer.Theremaybeapalpableloinmass.Occasionallythe may develop amyloidosis and renal tubular acidosis as
hydronephrosis is so marked that it can mimic ascites. complications of multiple myeloma. See page 490.
In some cases, it is asymptomatic and diagnosed in- Amyloidosis: This condition may be systemic or con-
cidentally when an ultrasound is performed for another fined to the kidneys and is an important cause of
reason. Congenital cases may be found on antenatal ul- glomerulardisease.Itcancauseproteinuria,nephrotic
trasound scan, or in childhood during investigation of syndrome and renal failure. See page 513.
urinary tract infections. Henoch–Sch¨ onleinpurpura(HSP):Thissystemicvas-
culitis causes a purpuric rash, abdominal pains, joint
Complications pains and a glomerulonephritis that is indistinguish-
Infectionofthedilatedsystemduetourinarystasis,renal able from IgA nephropathy. This is unsurprising, as
stones and renal failure. HSP is characterised by tissue deposition of IgA con-
taining immune complexes. See page 381.
Systemic lupus erythematosus: This multisystem con-
Investigations
nective tissue disease commonly affects the kidneys.
An IVU shows a dilated renal pelvis (often grossly) with
SLE is the great mimicker of almost every type of
normal, undilated ureters. There is delayed passage of
glomerulonephritis from minimal change disease, to
contrast, which is not overcome by administration of
membranous nephropathy, to proliferative glomeru-
diuretics. If obstruction is in doubt, further investiga-
lonephritis. See page 365.
tions as for urinary tract obstruction (see above) may be
Systemic sclerosis: This connective tissue disorder can
needed.
cause acute or chronic renal disease due to the dam-
age caused to the renal arterioles. The only treatment
Management
known to be of benefit is ACE inhibitors. See page 367.
If the PUJ obstruction is causing symptoms or renal ANCA-associated vasculitis: This includes Wegener’s
impairment, reconstruction of the renal pelvis (pyelo-
Granulomatosis and Polyarteritis Nodosa which can
plasty) can be undertaken so that the renal pelvis drains
cause rapidly progressive glomerulonephritis, with
into the ureter, by excising the narrowed segment.
acute renal failure. Early treatment with immunosup-
pression regimes such as plasmapheresis, high dose
Prognosis steroids and cyclophosphamide can improve renal
It is not possible to predict how much function will re- function. See pages 124 and 379.
coverandasmallproportionofpatientscontinuetohave
pain.
Thrombotic thrombocytopenic
purpura – haemolytic uraemic
The kidney in sytemic disease syndrome
Hypertension: See page 73. Definition

Diabetes mellitus: This is a common cause of renal Haemolytic uraemic syndrome (HUS) and thrombotic

disease and accounts for a large number of patients thrombocytopenicpurpura(TTP)areprobablytwosep-
whoneed dialysis. See page 451. arateentities,buthavesuchsimilarclinicalpresentations
Multiple myeloma: Many patients with multiple and findings that they are usefully considered together.

myeloma will develop renal complications such as When acute renal failure is predominant it is called
proteinuria, acute or chronic renal failure and amy- HUS, and when neurological problems are predominant
loidosis. There are several contributing factors to the it is called TTP. Often both ends of the spectrum are