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Five-minute Practitioner February 2008

Only got five minutes? Then just read these key points on: polycystic kidney disease, nephrotic syndrome, atopic eczema and stress and CHD

Only got five minutes? Then just read these key points on: polycystic kidney disease, nephrotic syndrome, atopic eczema and stress and CHD

Polycystic kidney disease (PKD)

PKD is a common hereditary disorder. It is characterised by multiple renal cysts, slowly enlarging kidneys and a gradual decline in renal function, which results in end-stage renal disease generally by the fifth to sixth decade. A child of an affected individual has a 50% chance of inheriting the disorder.

Patients with PKD and early chronic kidney disease (CKD) can be managed in primary care in accordance with CKD guidelines.

PKD is a multisystem disorder with a variety of renal and non-renal manifestations. Hypertension precedes the onset of renal failure in most patients and is almost universally present in those with established renal failure. Left ventricular hypertrophy is commonly associated with hypertension.

Subarachnoid haemorrhage resulting from a ruptured berry aneurysm is one of the most devastating presentations of PKD and can result in death or severe disability.

Nephrotic syndrome

Nephrotic syndrome is characterised by proteinuria with peripheral oedema, hypoalbuminaemia and hypercholesterolaemia. It is a relatively uncommon condition, with an incidence of three new cases per 100,000 per year in adults.

Oedema is often first noticed around the eyes and can become severe, with lower leg and genital oedema as well as ascites and pleural and pericardial effusions. Patients frequently report that their urine is frothy.

Patients with nephrotic syndrome are at increased risk of thromboembolic events, which can result in pulmonary embolism. Anticoagulation should be undertaken in patients at risk.

GPs should assess a patient's clinical condition, identify any complications and try to determine the underlying cause. Patients will require referral to a nephrologist for further management.

Atopic eczema

Eczema accounts for around one in 30 GP consultations. Although 80% of cases of atopic eczema seen in primary care are mild, the severity of the eczema may not be directly correlated with its impact on quality of life.

At each consultation, GPs should assess the severity of the eczema and enquire about the child's quality of life.

It is important to identify and then eliminate, or treat, trigger factors as these may exacerbate the condition.

The strength of topical corticosteroid used should be based on the severity and location of the eczema.

Eczema herpeticum is a potentially life-threatening condition. GPs should begin treatment with systemic aciclovir immediately (even in the case of localised infection) and arrange same-day referral to a dermatologist.

Stress and CHD

The Whitehall II study has now provided a clear link between chronic work stress and CHD among a population of working age.

The study found that chronic work stress increased the incidence of CHD, with the strongest association in those aged under 50 years at baseline.

Work stress was also associated with low physical activity, poor diet, the metabolic syndrome (and its individual components), lower heart rate variability and a higher morning rise in cortisol.

Overall, a third of the effect of work stress on CHD risk was attributable to its effect on health behaviours and the metabolic syndrome. However, adjusting for adverse health behaviours did not change the association between work stress and low heart rate variability, suggesting a direct effect on the autonomic nervous system and neuroendocrine function, rather than indirect effects through health behaviour.

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