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Nephrology/Answer #4 to Dr. Falkinburg

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QUESTION: Monday, January 21, 2013, 22:17

Dear Dr. Falkinburg:

>>Dear Jorge, I need further information to answer your question.

I gladly answer your request for additional information

>> Have you had a renal ultrasound and, if so, were your kidneys large, small or normal in size?  

No. I don’t remember having any renal ultrasound study carried out on me, only ecographies (bladder, prostate AND kidney). One of the ecographies (March 2012) showed that my kidneys had the following dimensions: Left kidney= 0.1 cm, with no alterations; Right kidney= 7.7 cm with a cystic area of 3.7 cm that does not show urostasis. The following description of the kidney images was also given: the parenchyma has an adequate eco-structure; the relationship between sinus and parenchyma is well preserved. Personal note: when about 13-15 years old I remember having high fevers for 2-3 years on the row in summer, and my nephrologist suspects that they could have been renal infections (they were treated with sulphamides (no antibiotics at that time) until they disappeared) are the reason of that cystic area in my left kidney.

>> Was there any evidence of urinary obstruction found on ultrasound?  

No ultrasound study was made.

>> What is the creatinine level in your blood?

On December 17 it was 1.86 mg/100ml, and a second analysis 10 days later in a different laboratory (to discard a possible error of the first laboratory) was 1.93 mg/100ml (however, both analyses resulted in the same creatinine clearance of 42.0 and 42.3 ml/min, respectively).

>> Was your creatinine clearance calculated from a formula or was it determined after a 24 hour urine collection?

It was determined after a 24 hour urine collection.

>> What medications do you take?

(1)   100 mg of Allopurinol once/day to control uric acid (I was a gout patient many years ago).
(2)   20 mg of Omeprazol once a day to control hiatal hernia.
(3)   20 mg of Simvastatin once a day; despite I don’t have elevated cholesterol my nephrologist suggested this as a precautionary measure to reduce risk of renal tissue sclerotization.
(4)   100 mg aspirin (Prevent) once a day; this is because I had a transitory brain ischemia event (between 20-30 minutes) on September 20, 2012. Also since then my clinical doctor recommended to increase the once a day 10 mg Simvastatin I was taking, to 20 mg/day.

>> Do you know the protein level in your Urine?

If the protein level in my urine is what I think (we call it “proteinuria” in Spanish) that level has been nil in all the 24-hours urine collection studies (at least, about 25 studies in a period of approximately  18-20 years.

>> Get me this information and I will try to answer your questions. Sincerely,  Dr. Falkinburg

Thank you very much.

Sincerely,

Jorge

ANSWER: Good morning, Jorge,

An echo is the same thing as an ultrasound.

Based upon the description you gave, your kidneys seem to be on the small side. This suggests that the process in your kidneys is of a chronic nature.

Your protein excretion is normal (certainly, not increased).

This scenario is seen in a condition called nephrosclerosis. This is a chronic kidney condition that occurs in older individuals (over 60 years) and is associated with hardening of the arteries.  It often occurs in association with high blood pressure, but not always. The patients usually have evidence of hardening of the arteries in other places as you do, vis a vis, your "transitory ischemia of the brain".  This is caused by hardening of the arteries. If high blood pressure is present the process is accelerated and kidney failure can occur fairly quickly.  

Another condition that can cause a similar picture is chronic pyelonephritis.  This is usually, but not always, associated with recurrent kidney infection. Your echo description did NOT sound like a description of ch. pyelo. However, it would be prudent for you to have a urine culture performed to be sure that there is no associated infection of the urine as this could accelerate kidney failure.

The description of your kidneys on echo also mitigates against any obstruction to the flow of urine from your kidney to your bladder which can result in kidney failure with scant or absent protein excretion.

Nephrosclerosis is far and away the most likely explanation for your condition.

Regarding your question, "Do you need urodynamic studies?" I do NOT believe that you need such a procedure because of your abnormal kidney function.  If you have lower urinary tract symptoms, such as frequency of urination, straining to initiate the urinary stream, dribbling, you could make the case for quantifying your symptoms to help decide whether or not some surgical intervention could help you. Urodynamics could be helpful in that case.  I would suggest that you receive a second urology opinion to help you decide.

Hope this is of some help yo you.

Please, feel free to follow up if I have been unclear.  These are complicated issues.

Sincerely,

Dr Falkinburg



---------- FOLLOW-UP ----------

QUESTION: Tuesday, January 22, 2013, 15:11

>> Answer:    Good morning, Jorge,

Good morning Dr. Falkinburg; thank you for the quick response.

>> An echo is the same thing as an ultrasound.

OK. I am not that familiar with the medical slang.

>> Based upon the description you gave, your kidneys seem to be on the small side. This suggests that the process in your kidneys is of a chronic nature. Your protein excretion is normal (certainly, not increased). This scenario is seen in a condition called nephrosclerosis. This is a chronic kidney condition that occurs in older individuals (over 60 years) and is associated with hardening of the arteries.  It often occurs in association with high blood pressure, but not always. The patients usually have evidence of hardening of the arteries in other places as you do, vis a vis, your "transitory ischemia of the brain".  This is caused by hardening of the arteries. If high blood pressure is present the process is accelerated and kidney failure can occur fairly quickly.  

OK. Nephrosclerosis is a diagnostic I had not been given before.

>> Another condition that can cause a similar picture is chronic pyelonephritis.  This is usually, but not always, associated with recurrent kidney infection. Your echo description did NOT sound like a description of ch. pyelo. However, it would be prudent for you to have a urine culture performed to be sure that there is no associated infection of the urine as this could accelerate kidney failure.

As I mentioned I have had those episodes when a youngster that we suspect could have been pyelonephritis, but I do not think that they constitute a chronic pyelonephritis condition (I normally urinate well, no pain, no sensation of plenitude in the bladder, no fever). I had an uroculture performed last week, and it was negative.

>> The description of your kidneys on echo also mitigates against any obstruction to the flow of urine from your kidney to your bladder which can result in kidney failure with scant or absent protein excretion.

Good. At least that is a positive indicator.

>> Nephrosclerosis is far and away the most likely explanation for your condition.

Assuming that this would be the real cause of the declining performance of my kidneys: (1) is there any way to confirm this diagnosis (apart for taking a tissue sample of my kidney, which quite invasive)? (2) is there any procedure or medication that can retard a nephrosclerosis process? (my nephrologist recommended Simvastatin as a prevention against nephrosclerosis; does it make sense?.) (3) apparently you don’t believe that the other medications I am taking (100 mg/day of Allopurinol and 20 mg/day of Pantoprazol) are interacting with the nephrosclerosis process and actually jeopardizing my kidneys?

>> Regarding your question, "Do you need urodynamic studies?" I do NOT believe that you need such a procedure because of your abnormal kidney function.  If you have lower urinary tract symptoms, such as frequency of urination, straining to initiate the urinary stream, dribbling, you could make the case for quantifying your symptoms to help decide whether or not some surgical intervention could help you. Urodynamics could be helpful in that case.  I would suggest that you receive a second urology opinion to help you decide.

Actually I was only looking at the bladder as a potential factor affecting the kidneys’ functionality. If that is not so (or at least it is not really critical) then I would prefer to postpone (or even not to be exposed at all to ) the urodynamic study; the main reason being that if that study will only provide information useful for lower urinary tract symptoms, I feel that my present condition is relatively good (I do not get up at night to urinate, and urinating very frequently during the day –being retired– is not that much of a nuisance).  Anyway, I will follow your suggestion in terms of getting a second opinion from an urologist.

>> Hope this is of some help to you. Please, feel free to follow up if I have been unclear.  These are complicated issues. Sincerely, Dr Falkinburg

Yes indeed it was extremely useful. By the way one more comment and a marginal question: I have a fairly balanced diet for my condition: low in red meats (occasionally fish and chicken), and dominantly composed of vegetables and pasta: is that OK? No specific additional suggestions? Finally: the last two laboratory analyses of the creatinine clearance (CC) based upon 24 hours of urine collection (CC of around 40 ml/min) were based upon (by oversight or carelessness from my part) a fairly low liquid intake as compared with my usual intake; to give an idea: previous CC were based on between 2300-2600 ml of total urine in 24 hours; however the last two CC were based on 1950 and 1850 ml of total urine in 24 hours; I know that as CC is expressed as ml/min the total volume of urine is contemplated in the results, but I wondered if an important difference in total volume urinated of the order of 20-25% might not have influenced (downwards) the CC results.

Thank you again,

Cordially,

Jorge

ANSWER: Good morning Jorge,

The treatment for nephrosclerosis (it would be essentially the same for pyelonephritis as well) is to be sure that there is no concurrent urinary infection, keep your blood absolutely normal and, possibly, the administration of a class of medications called ace inhibitors (such as lisinopril, ramapril).  These medications are used mainly for the treatment of high blood pressure but through a complicated vascular mechanism, reduce the pressure within the little filters of the kidney making them last longer.  They work best when there is associated protein in the urine but many nephrologists use them for all chronic kidney diseases.  The only caveat is that they make the creatinine inch up a little  bit but I used them anyway until the creatinine reaches 2 - 2.5 mg% then I discontinue them.

Kidney failure has been treated by some with a low protein diet (around 40 grams per day). This is very unpalatable but has been shown to slow the evolution of kidney failure in various kidney diseases as well as improving symptoms of kidney failure.  These occur when the creatinine reaches 7 - 10mg%.

This treatment would be the same if your diagnosis were chronic pyelonephritis.

Simvastatin or any other (I'd use the cheapest) "statin" is often empirically prescribed for nearly all kidney diseases.  In addition to their lipid lowering properties, statins have certain anti-inflammatory characteristics that intuitively would be useful in treating kidney diseases.  Therefore, it is a good choice.  Neither pantaoprazol nor allopurinol are contraindicated in your case.

The urine volumes you describe should not change your creatinine clearance either for the better or for the worse. It is of paramount importance that your urine collections be accurately timed.  Do the following:

Say the collection is from 7AM to 7AM the next day.  At the beginning, at 7AM, urinate into the toilet and flush it away (this is last night's urine).  This begins the collection.  Every drop of urine produced by you, henceforth, must be saved into a container.  If you need to move your bowels, urinate first. Collect all urine produced, including the last one voided at 7+AM the following day, which ends the collection. This is a 24 hour urine.

Missing one specimen can introduce up to a 20% error in the calculation of your clearance.

I think I've convered your queries but if I've overlooked anything, follow up.

Have a great day!

Dr Falk




---------- FOLLOW-UP ----------

QUESTION: Monday, January 28, 2013, 14:24

Dear Dr. Falkinburg

Sorry for not answering earlier. I had a message ready to be sent since last Thursday (see below) but you were not on line at that moment, and afterwards I fall into bed with a strong flu. I am OK now, and I wanted to send you my last thankful message.

As maybe a last final point: I have the feeling that you do not believe that my condition might be affected seriously by the bladder problem (hypotonic bladder wall derived from a “struggle” bladder, and a fairly important urine residue in the bladder). So, even assuming that the renal arteries eco-doppler study to be done next week (see below) would confirm some degree of nephrosclerosis, my point is: do you feel that my bladder condition is an aggravating factor to a nephrosclerosis  condition? Presently my bladder physiology is not something that really bothers me (I can sleep 8-10 hours per night without interruptions), but I have a sort of obsession with it, thinking that it seriously jeopardizes my kidneys’ function. If you feel it is not that serious, probably it will help me to take it easy with it; otherwise, it might be worth keeping an attentive control of my bladder urine residues.

Thanks again,

Jorge

Thursday, January 24, 2013, 12:11

Dear Dr. Falkinburg

Thank you very much for your kind and detailed second answer in relation to my renal condition.

With respect to your suggestion of treating nephrosclerosis with the ace inhibitors, I was given one of them (called here Losartan), but as I am a person of low blood pressure (between 110-111 maximum and 80-90 minimum) this medication made me drop the blood pressure to levels of between 80-90 maximum and 50-60 minimum; my clinical doctor judged inconvenient such a low blood pressure, and my nephrologist also thought that those levels were below the recommended pressures for a good kidney filtration.

Thank you also for the detailed description of the procedure for the urine collection for the creatinine clearance analyses; I have been doing all my urine collections exactly in the way you described.

I visited my nephrologist yesterday, and she suggested a study of the upper urinary tracks; before going ahead with a urodynamic study (which she feels is not essential after four surgical interventions with a thorough “cleaning” of the sphincter/prostate tissues) she would like to have an idea of the state of my renal arteries with an eco-doppler study.

Actually I do not have any more specific questions, and I want thank you for the clear and quick responses to my consultations (in a few minutes I will complete the survey of AllExperts).

Cordially,

Jorge

Answer
Good afternoon Jorge,

Ace inhibitors as well as angiotension receptor blockers (ARB'S) have been prescribed to preserve kidney even if the BP is normal.  Certainly this has the potential of reducing the blood pressure too much.  That seems to be the case with you. Therefore, I agree that the ACE/ARB treatment
should not be prescribed in your case.

Best of luck fro you.

Dr Falk  

Nephrology

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Newell R. Falkinburg, M.D., FACP

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I am a board certified nephrologist and emeritus professor of medicine at a major medical school and past Director of Nephrology & Hypertension at a university affiliated hospital. I have expertise in all areas of clinical nephrology, dialysis, transplantation and plasmapheresis.

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