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URAEMIA (Renal Failure)
This is a toxic condition which may arise in disease of the kidneys. It occurs most commonly in Bright's disease, either the acute or chronic form, but may be met with whenever there has beon considerable damage to the kidneys as in amyloid disease, stone in the kidneys after prolonged obstruction to the passage of urine, renal tuberculosis or congenital cystic kidney.
Theories of Causation.
There have been various explanations as to the cause of the symptoms of uraemia over the decades. One was that they are the result of the accumulation in the blood of the waste products, especially urea, which are normally exereted in the urine. This accumulation almost invariably takes place, but experimentally it has not been found that the injection of these substances into the blood leads to a condition like uraemia. Thus the accumulation of urea itself is due to kidney failure to excrete the substance itself, it is only a symptom of kidney failure. Also when there is sudden complete suppression of urine so that none at all is passed, a condition called anuria (q.v.), the patient, if unrelieved, dies in a short time with symptoms that are different from those of toxic uraemia.
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The generally accepted view is that the failure of the kidneys to excrete the waste materials, which consequently circulate continuously in the blood, leads to a disturbance of the normal chemical processes of the body and causes the production of other poisonous substances, which are responsible for the symptoms. The balance of evidence is in favour of this latter theory. Renal failure is almost always found in chronic infection of the kidneys, as in Bright’s disease, pyelonephritis, glomerulonephritis, etc.; or from some toxic effect exerted upon the kidneys directly, as in turpentine, gasoline, etc.
Uraemia may be either acute or chronic. In addition, the condition of anuria (q.v.) is sometimes called latent uraemia. The symptoms are due to the action of the poisons on the nervous system and are manifested either in the brain, the respiratory system or the digestive system.
Headache is a very common early symptom of the first mentioned type. It is usually at the back part of the head, and may extend down the neck. This may be followed by drowsiness and delirium, sometimes even by acute mania. In other cases there may be delusions, or more commonly convulsions, which are very similar in type to those occurring in epilepsy but akin to liver flap. However the condition may start, it almost always ends in coma, and sometimes the coma develops very rapidly with fow warning symptoms, and may be mistaken for cerebral haemorrhage, alcoholism, diabetic coma, etc.
In the respiratory type, shortness of breath is an important symptom. It may be present continuously, but more commonly comes on in attacks at night time, so that the patient has to sit up in bed, fighting for breath just as in asthma. In the last mentioned type there may be persistent vomiting. If this occurs early, and is not accompanied by other symptoms, it may cause considerable confusion in diagnosis by being mistaken for gastritis or dyspepsia. Nausea and diarrhoea are commonly present.
Other symptoms that may arise are numbness of the fingers, cramps in the muscles, persistent insomnia and transient blindness or deafness.
Characteristic Signs.
On examination the patients are usually thin and wasted, with dry, harsh skin. In a few cases, owing to exeretion of large quantitics of urea in the sweat due to renal suppression, a white cry stalline deposit occurs on the skin, a condition known as uridosis. The tongue is thickly furred, and the breath is offensive, and may have a distinctly urinous odour. This is sometimes described as fish breath, the odor of dead fish, characteristic of the build up of urea and ammonia in the blood, volatilizing itself through the lung.
The temperature is usually subnormal, although sometimes there is mild fever. The heart is frequently enlarged and the blood pressure high. Haemorrhages or oedema in the retina of the eye are often present, and are very important aids to diagnosis in difficult cases. The amount of urea in the blood is nearly always above the normal. One of the most constant of all the signs associated with uraemia is a reduction of the percentage of urea in the urine, thus it is of low specific gravity, and if, in a suspicious case, the urine is found to have a normal amount of urea the case is almost certainly not one of uraemia. A marked increase in the amount of urea in the cerebrospinal fluid is generally characteristic.
Uraemia is always a very serious if not fatal condition. The most favourable cases are those which arise as a complication of acute nephritis. In the chronic conditions so much kidney tissue has already been permanently destroyed that ovon if temporary recovery can be secured the end is certainly drawing near.
There are two methods.
1. Volhard's test, also called Volhard-Fahr test
Karl Theodor Fahr Franz Volhard
a test for renal function, also called the dilution test, Albarran’s test: the patient drinks 1500
ml of water on an empty stomach; if the patient was not dehydrated beforehand and the kidneys
are normal, this fluid urine will be excreted by the end
of 4 hours, with specific gravity of the urine being dropping from 1.001 to 1.004.
Dilution test: Collect 8 AM urine, discard. Give 1.5 l. before breakfast. Collect urine from 8:30 to noon. Normally the water is voided within 4 hours. After 1 1/2 litres of water the specific gravity should fall to <1.003.
Albarran's test
a test for renal insufficiency wherein the drinking of large quantities of water will cause a proportionate increase in the volume of urine if the kidneys aresound, but not if the epithelium of the secreting tubules is damaged. Syn: polyuria test.
2. Concentration test: Specific gravity of urine should reach 1.025 after fluids are withheld for 24 hours. Pt. with a solid diet, no liquids for one day. Empty bladder at 8 AM, discard; collect urine in 3 hr. intervals throughout the day and night. Normally the voidings drop rapidly in amount and kidneys should be able to concentrate to over 1.030 or over. This test is not as convenient clinically.
In treating a case of uraemia, an attempt is made to remove the toxic substances by alternative routes to the kidneys. There are three ways of doing this. Purgation helps to remove them by the bowel, sweating removes them by the skin and bleeding removes them directly. All these methods may be used. The best purgatives to use are the salines, such as magnesium (Epsom salts) or sodium sulphate, in large doses. If, however, the patient is already in coma or having convulsions and so cannot swallow medicines, a drop of croton oil may be placed on the back of the tongue.
Sweating may be brought about either by hot packs or hot-air baths, and a hypodermic injection of pilocarpine may be given just beforehand.
Bleeding or venesection is the most prompt and direct method of getting rid of the poisons. A half to one pint of blood may be withdrawn from a vein, depending upon the type and condition of the patient and then saline solution may be injected or transfusion of blood carried out., If venesection and transfusion of blood or saline cannot be done, subcutaneous or rectal injection of saline is useful in a rural emergency until dialysis can be provided.
In normal circumstances the perspiration contains traces of urea. If the amount of urea in the blood is greatly increased, more of it is excreted in tho perspiration. It sometimes happens that in chronic Mright's disease so much urea is excreted in this way that after free sweating, crystals of it are deposited on the skin when the perspiration evaporates. This gives the skin a curious frosted appearance, and the condition has been named uridrosis or urea frost.
The instrument used to measure the specific gravity of the urine is called a urinometer. It consists of three parts. The lowest part forms a small globular glass chamber containing some mercury. This part is connected by a narrow neck with a cylindrical air-containing chamber which is in turn surmounted by a hollow glass stom sealed at the top. The stem contains a graduated scale marked in equal divisious, usually from 1.000 to 1.050.
If the urinometer is placed in a tall vessel containing urine, it will float upright but partially submerged, so that the upper level of the fluid is at some point of the scale. This reading is the specific gravity. The instrument is usually graduated to give the specific gravity of a fluid at 59˚ F., which is about the ordinary room temperature, and the 1.000 mark is the reading given by distilled water.
In taking the specific gravity of urine, it is important first to allow cooling to room temperature to take place, and also to see that the instrument does not touch the walls of the containing vessel during the reading.