Lecture -2- Approach to renal diseases Hazem.K.Al-khafajiDM.FICMS University of Al-Qadisiya College...
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Transcript of Lecture -2- Approach to renal diseases Hazem.K.Al-khafajiDM.FICMS University of Al-Qadisiya College...
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.
Thank you