Lecture -2-Approach to renal

diseases

Hazem.K.Al-khafaji

DM.FICMS

University of Al-Qadisiya

College of medicine

Department of medicine

Diagnosis

History

History

Physical examination Investigations

Introduction

Most diagnosis can be reached by a complete history, and a thorough physical examination

Challenges in History Communication (anxiety, language, educational

background ) Make the patient feel comfortable

calm, caring. Family member

Medical history

Renal diseases may be silent(asymptomatic) until advanced stage specially chronic renal failure or chronic kidney disease(CKD) because the patient lost 50% of renal function but the kidneys still compensating. Renal stones may be silent until it acquire significant size. Asymptomatic bacteruria specially in pregnant lady my preceded the development of severe pyelonephritis.

Silence ≠ Innocence

How common is CKD? What are other signs and symptoms of CKD?

Am J Kidney Dis 2002; 39:S1

How the patient with KD presents?

The patient may present with general complaints ( not specific to renal diseases) as:-

Anorexia , Nausea & vomiting . Fatigue, Fever , Malaise.

. But, the patient may presents with features which considered as markers of kidney ,ureter , urinary bladder , or urethra pathology. Keeps in your mind that functional abnormalities of the kidney with or without decreased GFR, manifest abnormalities in blood or urine prior to clinical abnormalities.

Pain

Can be severe urinary tract obstruction(renal colic) inflammation

Inflammation of the GU tract is most severe when it involves the parenchyma of a GU organ Pyelonephritis Prostatitis Epididymitis

Inflammation of the mucosa of a hollow viscus usually produces discomfort Cystitis Urethritis

Pain

Renal Pain Site: ipsilateral costovertebral angle just lateral to the

sacrospinalis muscle and beneath the 12th rib

Acute distention of the renal capsule

Pain Associated symptoms

Gastrointestinal symptoms Nausea Vomiting Ileus

Ureteral pain

Usually acute and secondary to obstruction

Midureter ( Rt side): referred to the right lower quadrant (McBurney's point) and simulate appendicitis

Midureter (Lt side) :referred over the left lower quadrant and resembles diverticulitis.

Scrotum in the male or the labium in the female. Lower ureteral obstruction frequently produces symptoms of

bladder irritability( frequency, urgency, and suprapubic discomfort)

Vesical Pain

Vesical pain is due

Over distention

inflammation

Urine

Volume Normal:-700-1500 ml/24 hrs( climate weather) Polyuria = excessive production of urine(more

then2L/24hrs) = earliest stages of renal failure(nocturia),diabetes mellitus or diabetes insipidus.

Oliguria: less then 500ml/24 = dehydration, glomerulonephritis or obstructive uropathy

Anuria = decreased production of urine either nil or less then 50ml/24hrs = acute cortical necrosis or obstructive uropathy.

Trace pedal edema

Medications: HCTZ 25 mg/d Insulin

ColorNormal = pale yellow due to a pigment called urochrome.Color is associated with solute concentration. Increased solutes = darker urine;Decreased solutes = colorless urine, like water.

OdorNormal = slightly aromatic when freshly voided.Bacteria = ammonia odoroffensive, drugs and diseases my also cause characteristic odor.Diabetes mellitus = urine smells "fruity" or like acetone.

Haematuria Haematuria : the presence of blood in the urine

In adults, should be regarded as a symptom of urologic malignancy until proved otherwise Is the haematuria gross or microscopic? Timing: (beginning or end of stream or during entire

stream)? Is it associated with pain? Is the patient passing clots? If the patient is passing clots, do the clots have a specific

shape?

Haematuria

Initial haematuria: usually arises from the urethra least common usually secondary to inflammation.

Total haematuria most common bladder or upper urinary tracts.

Terminal haematuria the end of micturition secondary to inflammation bladder neck or prostatic urethra. Painless terminal haematuria is the earliest feature of

schistosomiasis haematobium

Lower Urinary Tract Symptoms

Irritative Symptoms Urinary frequency Nocturia Frequency Dysuria: painful urination Incontinence

Stress Urgency

Obstructive SymptomsProstatic hypertrophy (benign or

malignant) Decreased force of urination Urinary hesitancy frequency Post void dribbling Straining

Enuresis

Urinary incontinence that occurs during sleep Mostly in children up to 5 years

Urethral Discharge

Urethral discharge is the most common symptom of venereal infection.

Fever and Chills

Usually in Pyelonephritis Prostatitis Epididymitis

Past Medical History

Systemic diseases that may affect the urinary system diabetes mellitus. Hypertension. Neurological diseases. TB Schistosomiasis History of previous urinary tract infection(UTI),

urolithiasis ( stones or calculi)

past surgical historygenitourinary system

renal stonesurinary tract obstruction

gynecological operationscaesarian sectiongeneral surgery

Family History

prostate cancer Stones( cystine) Renal tumors (some types) Polycystic kidney(autosomal dominant). Alportꞌs syndrome ( X-linked dominant)

Drugs history

Nephrotoxic drugsAminoglycasidescephalosporines

NSAIDsAnalgesics ((Phenacetin))

Anti TB

Social historySmoking and Alcohol Use

Cigarette smoking urothelial carcinoma, mostly bladder cancer Erectile dysfunction. Progression of renal failure

Chronic alcoholism impaired urinary function Sexual dysfunction. testicular atrophy, and decreased libido.

PHYSICAL EXAMINATION

General Observations visual inspection of the patient earthy colour (uremic) Cachexia

Malignancy, TB

Jaundice or pallor Gynecomastia

endocrinologic disease alcoholism hormonal therapy for prostate cancer

Skin rash(SLE) Features of bleeding

tendencyHypertension

Dyspnoea

Kidneys

Palpation of the kidneys supine position The kidney is lifted from behind with one hand in

the costovertebral angle In neonates, palpating of the flank between the

thumb anteriorly and the fingers over the costovertebral angle posteriorly

Kidneys

Auscultation : epigastrium ( 2-3cm above & lateral to umbilicus) for bruit. renal artery stenosis aneurysm. renal arteriovenous fistula.

Normally, only the lower pole of Rt.kidney may

be palpable in thin people

Abnormal Physical Examination Findings—Kidneys

The most common abnormality detected on examination of the kidneys is enlarged kidney due to polycystic kidney or hydronephrosis or a mass

In neonates and younger children, the transillumination helps to distinction between cystic and solid.

Adult polycystic kidney disease

Bladder

at least 150 ml of urine in it to be felt. Percussion is better than palpation A bimanual examination, best done under

anesthesia, is very valuable to asses bladder tumor extension

Rectal and Prostate Examination in the Male

Digital rectal examination (DRE) : every male after age

40 years Men of any age who

present for urologic evaluation

Investigations

Biochemical Tests of Renal Function

Urinalysis (G.U.E) Appearance Specific gravity and osmolality pH Glucose Protein Bilirubin Urobilinogen nitrite Urinary sediments RBC WBC Cast crystal

Urinalysis is important in screening for disease is routine test for every patient, and

not just for the investigation of renal diseases

Urinalysis comprises a range of analyses that are usually performed at the point of

care rather than in a central laboratory.

Urinalysis is one of the commonest biochemical tests performed outside the

laboratory.

Examination of a

patient's urine should

not be restricted to

biochemical tests.

Urinalysis

Chemical Analysis

Urine Dipstick

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

Specific GravitySpecific Gravity

BloodBlood

pHpH

ProteinProtein

UrobilinogenUrobilinogen

NitriteNitrite

Leukocyte EsteraseLeukocyte Esterase

1. ColorNormal = pale yellow due to a pigment called urochrome.

2. TransparencyNormal = clearAbnormal = cloudy, which may be caused by bacteria, blood, cells, crystals, etc.

3. pH:acidicNormal pH = 4.5 to 5.4High protein diet = acid urineVegetarian diet = alkaline urine4. Specific gravityNormal = 1.001 to 1.030.Low Specific Gravity may be due to:1. Excess fluid intake2. Use of diuretics3. Diabetes insipidus4. Chronic renal failure

5. Protein:a. proteins are NOT supposed to be in the urineb. prevention of proteins into the urine is done by glomerular membrane6. Bilirubin:NOT supposed to be in the urine7. Urobilinogen:Grade this from 1 – 5 (5 being the highest)a. with high RBC destruction8. Nitrates:Made by many bacteria species (with the exception of Staph & Strep)a. e.g. e. coli, proteus, If you see these in the urine, tells you that there is an infection.

b. if nitrate +, urinary tract infection is suggested (UTI)c. a – test does NOT rule out a UTI8. Leukocyte esterase: enzyme + for this enzyme then probably a UTI9. Casts: different material clumped together inside of the renal tubule.a. As a general rule if a cast is present, then pathology is going onb. Exception to the above rule is if you see a hyaline cast, which is a normal findingc. Clumped cells come from the kidneyd. Casts can be RBC or WBC casts10- Crystals.

Abnormal Constituents of UrineGlycosuria = glucose( normally nil because of renal thresholdWhich is 180-220mg/dlHematuria = Red blood cells( up to 2 cells considered normal)Pyuria = White blood cells(up to 4 cells = normal)Bacteriuria = bacteria( normal flora because distal urethra is contaminated)Ketonuria = ketones(diabetic ketoacidosis or prolonged starvation)

Red blood cell cast in urineWhite blood cell cast in

urine

Urinary casts. (A) Hyaline cast (200 X); (B) erythrocyte cast (100 X); (C) leukocyte cast (100 X); (D) granular cast (100 X)

Urinary crystals. (A) Calcium oxalate crystals; (B) uric acid crystals (C) triple phosphate crystals with amorphous phosphates ; (D) cystine crystals.

• Crystals

Normal < 150 mg/24h. TYPES OF PROTEINURIA 

Glomerular proteinuria(mostly albumin)  Tubular proteinuria(low molecular weight as ß2-

microglobulin, immunoglobulin light chains)  Overflow proteinuria 

Proteinuria

24 hrs urine for protein Nephrotic range proteinuria — Urinary protein excretion greater than 50 mg/kg

per day=1gm/m2/day = more then3.5gm Hypoalbuminemia — Serum albumin concentration less than 3 g/dL (30 g/L) Edema Hyperlipidemia

Biochemical Tests of Renal Function

Measurement of GFR Clearance tests Plasma creatinine Urea, uric acid and β2-

microglobulin

Calculations

Cockcroft-Gault Men: CrCl (mL/min) = (140 - age) x wt (kg)

S.Cr mg/dl x 72

Women: multiply by 0.85

Urea is the major nitrogen-containing metabolic product of protein

catabolism in humans,

Its elimination in the urine represents the major route for nitrogen

excretion.

More than 90% of urea is excreted through the kidneys, with

losses through the GIT and skin

Urea is filtered freely by the glomeruli

Plasma urea concentration is often used as an index of renal

glomerular function

Urea production is increased by a high protein intake and it is

decreased in patients with a low protein intake or in patients with

liver disease.

Plasma Urea

1 to 2% of muscle creatine spontaneously converts to creatinine daily and

released into body fluids at a constant rate. Endogenous creatinine produced is proportional to muscle mass, it is a

function of total muscle mass the production varies with age and sex Dietary fluctuations of creatinine intake cause only minor variation in daily

creatinine excretion of the same person. Creatinine released into body fluids at a constant rate and its plasma levels

maintained within narrow limits Creatinine clearance may be measured as an

indicator of GFR.

Creatinine

Imaging studies for kidney disease

Tests that create various pictures or images may include:Plain X-rays(KUB ) – check the size of the kidneys and look for kidney stones(calcified) IVU ,Cystogram ( is a bladder x-ray)Voiding cystourethrogram – is when the bladder is x-rayed before and after urination for VURUltrasound – Ultrasound may be used to check the size of the kidneys. Kidney stones,mass,obstruction. Computed tomography (CT) – x-rays and digital computer technology are used to create an image of the urinary tract, including the kidneysMagnetic resonance imaging (MRI) – a strong magnetic field and radio waves are used to create a three-dimensional image of the urinary tract, including the kidneys.Renal angiography. For renal artery stenosis.Radioisotopic studies

Biopsy for kidney disease Biopsies used in the investigation of kidney disease may include: Kidney biopsy – the doctor inserts a special needle into the back under local anesthesia & ultrasonography guidance to obtain a small sample of kidney tissue which examined under light microscope, electronic microscope & immunohistological study.. A kidney biopsy can confirm a diagnosis of chronic kidney disease, also assess the prognosis & decision of treatment. The most common indication is nephrotic syndrome,other indication is progressive uraemia without evident cause, isolated haematuria &/or proteinuria of renal origin. Contraindicated if the kidneys small size, bleeding tendency, uncontrolled severe hypertension, perinephric abscess & solitary kidney , But biopsy from transplanted kidney is relative contraindication. Bladder biopsy – Insert cystoscope into the bladder via the urethra. This allows the doctor to view the inside of the bladder and check for abnormalities & may take a biopsy of bladder lesion or mass.

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