MANAGING CHRONIC RENAL INSUFFICIENCY: INITIAL EVALUATION AND SEARCH FOR A REVERSIBLE CAUSE
Once azotemia is detected, a comprehensive history and physical examination should be perpromptly detect the most readily reversible cause of renal insufficiency, a foley catheter should be placed and kidney ultrasound obtained to help exclude outlet obstruction (prostate, uterus). Sonography also will establish the presence of two kidneys, while defining kidney size and location. In hypertensive individuals, a difference in kidney size of more than 2-cm raises suspicion of unilateral renal artery stenosis.
If there is no evidence of urinary outlet obstruction, prerenal causes of azotemia such as congestive heart failure, hypovolemia, cirrhosis, nephrosis, and ischemic nephropathy should be excluded. Apcalis Oral Jelly
It should be recognized that obstructive renal insufficiency or prerenal azotemia may be superimposed upon baseline intrinsic renal insufficiency. Intrinsic renal insufficiency may be caused by “nephrotoxic” drugs such as nonsteroidal antiinflammatory drugs or “alternative medicine” products. In the evaluation of intrinsic renal insufficiency, a urinalysis is helpful in differentiating between glomerular and non-glomerular causes of renal disease. Urinalysis with microscopy will document proteinuria, detect red cell casts and exclude infection. If the patient has nephrotic range proteinuria (urinary protein>3.5 grams/day), serologic testing should be performed to identify secondary causes of nephrotic syndrome such as systemic lupus erythematosus, hepatitis В and C, human immunodeficiency virus infection (HIV), etc. A percutaneous kidney biopsy will establish histopathological diagnosis in those whom diagnosis is unknown and may be helpful in guiding therapy and should be performed in most nephrotic patients, except those with small contracted kidneys (which suggest irreversibility of renal disease) or diabetic nephropathy.
PROTECTING THE KIDNEYS AGAINST FURTHER DAMAGE
Minimal stress, harmless to healthy kidneys, may injure failing kidneys. Accordingly, conditions that impose potential risk to the kidneys such as hypovolemia, radiocontrast agents, hypotension, infection, nephrotoxic drugs (nonsteroidal antiinflammatory drugs), toxic “alternative medicines,” and dehydration must be minimized. Each prescribed drug should be checked to discern necessary dose adjustments in renal insufficiency. Aminoglycosides are dangerous; a single dose may induce further loss of residual renal function. cialis professional 20 mg
If radiocontrast media is unavoidable, plasma volume should be repleted before injection, especially if the serum creatinine level is 2.5 mg/dl (221 micromoles per liter) or over. A recent study suggests that administration of acetylcysteine before contrast use may diminish the incidence of contrast nephrotoxicity. The amount of radiocontrast media given should be reduced as much as possible without compromising the information obtained from the study.
Extreme Care During Venipuncture
Many patients require several hemodialysis vascular accesses in their lifetime. To protect arm blood vessels for future vascular access, venipuncture should be performed only when absolutely necessary and when possible, restricted to the dominant arm, or upper arm vessels of the nondominant arm.