Interstitial Nephropathy – Top USMLE Diseases

The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. The kidneys also play a major role in homeostatic processes, including electrolyte concentration, blood pressure, and acid–base regulation. Grossly, they consist of an outer cortex and inner medulla. Microscopic functional units known as nephrons filter the blood through a structure called the glomerulus, and this filtrate is then modified and concentrated as it moves through a complex tubular system. The renal arteries supply the kidneys via a central opening, known as the renal hilum, on its medial side; large renal veins empty directly into the vena cava.

Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH), which only accounts for a small fraction of all cases of hypertension. Renovascular hypertension can be associated with abdominal bruits, renal insufficiency, or progressive renal atrophy. Diagnosis is by clinical presentation followed by imaging studies, including duplex ultrasonography, magnetic resonance angiography (MRA), computed tomography angiography (CTA), and sometimes catheter-based angiography. Revascularization is usually reserved for cases in which medical therapy has failed.

Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Regardless of the etiology, progression of renal impairment is common and can ultimately lead to end-stage renal disease and the need for renal replacement therapy (e.g., transplantation or dialysis). The management of CKD includes treating the underlying etiology, aggressive risk factor modification, and addressing complications such as fluid overload and electrolyte imbalances.

Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Uremia refers specifically to the constellation of symptoms that occur with severe renal dysfunction. The etiologies of AKI are classified as prerenal, intrinsic renal, or post-renal, and there is a varied clinical presentation depending on the severity of kidney dysfunction. Acute kidney injury is diagnosed initially by a change in serum creatinine levels, and then the etiology is determined by clinical history, lab testing, imaging, and possibly kidney biopsy. The management of AKI depends on the etiology; however, attention to the individual's volume status and serum electrolytes is always important. If management is unsuccessful and AKI progresses to CKD, then renal replacement therapy with dialysis or kidney transplantation is necessary.

The kidneys, solid organs located in the lower back, are extremely important in regulating homeostasis through their role in maintaining blood volume, electrolyte balance, acid–base equilibrium, blood-pressure regulation, and removal of metabolic waste from the blood. Evaluation of renal function and early detection of kidney dysfunction is of primary importance. Tests of renal function are useful in identifying the presence of renal disease, monitoring the response of kidneys to treatment, and determining the progression of renal disease.