THE RENAL SYSTEM

SIGNS AND SYMPTOMS

HISTORY TAKING = IMPORTANT ROLEHISTORY TAKING = IMPORTANT ROLE PRIOR HISTORY PAST MEDICAL HISTORY

ACUTE INFECTIONS CHRONIC INFECTIONS TOXIC SUBSTANCES SECUNDARY TO OTHER DISEASES

PAST MEDICAL HISTORYPAST MEDICAL HISTORY ACUTE INFECTIONS

(Especially HEMOLITIC STREPTOCOCCUS) TONSILITTIS; SCARLET FEVER POSTSTREPTOCOCCAL SYNDROME;

• CHRONIC INFECTIONS TUBERCULOSIS AMILOYDOSIS(secondary) Viral infections

PAST MEDICAL HISTORYPAST MEDICAL HISTORYTOXICS

– DRUGS: Aminoglycosides, lithium, ciclosporin and tacrolimus, Heavy metals non-steroidal anti-inflammatory drugs

– DIETARY: Calcium-rich food.

MECANICAL– RENAL EMBOLISM or THROMBOSIS;

SECUNDARY TO OTHER DISEASES– Hypertension, Diabetes, PARATHYROIDS diseases

FAMILY HISTORYFAMILY HISTORY

DMHTN

POLYCYSTIC KIDNEY DISEASE

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

I. RENAL PAIN

II. DIURESIS disturbances

III. URINE ABNORMALITIES

IV. RENAL EDEMA

V. GENERAL MANIFESTATIONS

RENAL PAINRENAL PAIN

RENAL COLIC CHRONIC LOIN PAIN

RENAL COLICRENAL COLIC1. ONSET: SUDDEN

TRIGGERS: VIBRATIONS, PHYSICAL ACTIVITY, RAPID WALKING PHYSICAL ACTIVITY, RAPID WALKING

2. LOCATION: RENAL ANGLE (usually UNILATERALLY);

3. RADIATION: LOINS→FLANKS→FOSSAS→GROINS→GENITALIA;

4. INTENSITY and DURATION: SEVERE, SUSTAINED

5. AGRAVATED by: PALPATION, COUGH, SNEEZING

6. AMELIORATED by: HEAT

7. ASSOCIATED with: RESTLENESS, PALOR, COLD SWEATING NAUSEA, VOMITINGS TACHYCARDIA, ANGINAL PAIN, ILEUS, MICTURITION disturbances

RENAL COLICRENAL COLIC

RENAL COLICRENAL COLICCAUSES:CAUSES:

KIDNEY STONES PAPILLARY NECROSIS

DIURESISDIURESIS DISTURBANCES DISTURBANCES POLYURIA OLIGURIA ANURIA NOCTURIA

EXAMINATION OF EXAMINATION OF THE URINETHE URINE

HAEMATURIA

PYURIA

PROTEINURIA

EXAMINATION OF EXAMINATION OF THE URINETHE URINE

Macroscopic Biochemical Microscopic Microbiological

CLARITYSpecific Gravity

RBCs, WBCsCULTURES

SENSITIVES

COLOR pH BACTERIA

ODOUR BLOOD CASTS NITRITES

VOLUME PROTEIN CRYSTALS

HAEMATURIAHAEMATURIA The presence of red blood cells in the urine due to bleeding from the kidneys or urinary tract

CAN BE:CAN BE:

MICROSCOPIC (1000–1mil. erythrocytes/ml/min)

MACROSCOPIC ( >1mil. erythrocytes/ml/min)

Color of the haematuria: Color of the haematuria: RED or BROWN

CAN LEAD to CLOTS and HAEMATIC DEPOSITS

HAEMATURIAHAEMATURIACAUSESCAUSES PRERENAL: HEMORRHAGIC conditions: coagulopathies

thrombopathies, vasculopathies

RENAL: glomerulonephrites, interstitial nephrites, tuberculosis, tumors, traumas, renal stones, polycystic kidney disease

hypertensive nephrosclerosis, acute tubular necrosis,

renal ischaemia (renovascular disease)schistosomiasis, urinary tract infectionreflux nephropathy and renal scarring

POSTRENAL: URETER: stones, tumor, inflammation,

vascular malformation, traumas BLADDER: tumor, stones, inflammation, polyp, foreign objects

URETHRO-PROSTATIC: tumor, stones, inflammationstrictures, foreign

objects, malformation

HAEMATURIAHAEMATURIA

3 CUPS TEST:3 CUPS TEST:

INITIAL → URETHRA,

PROSTATE

TERMINAL → BLADDER

TOTAL → KIDNEYS and URETER

HAEMATURIAHAEMATURIADIFFERENTIAL

CONCENTRATED urine – increased specific gravity

CONJUGATED BILIRUBIN

RED-BROWN – normalized when heated → URATES – drugs: L-Dopa

RED – DRUGS (rifampicin, metronidazol) – FOOD: beetroot, blackberries

PYURIAPYURIA

PRESENCE OF PUS CELL IN THE URINE

CAN BE:CAN BE: MICROSCOPIC = LEUCOCYTURIA LEUCOCYTURIA MACROSCOPIC

- changes in urine aspect:

LOSS of LUSTRE, TRANSPARENCY,

MUCUS FRAGMENTS, PUS DEPOSITS

- changes in odor of the urine

PYURIAPYURIACAUSESCAUSES PRERENAL: septicemia,

hematogenous dissemination of other systemic infections

RENAL: tuberculosis, infected kidney stones, tumors, malformations,

POSTRENAL: STONES NEOPLASMS MALFORMATION CYSTITIS INVASIVE UROLOGICAL MANEUVERS BENIGN HYPERTROPHY/CANCER PROSTATE

PYURIAPYURIA

DIFFERENTIALDIFFERENTIAL CLOUDY urines

URATES, PHOSPHATES

Clarifies when HEATED/ACID adding

CHYLURIA

URETHRITIS

VAGINITIS

PROTEINURIAPROTEINURIA

PRESENCE OF PROTEINS IN THE URINEPRESENCE OF PROTEINS IN THE URINE

QUANTITY MICROALBUMINURIA 30-300 mg/day MEDIUM 300mg – 3.5 g/day HIGH > 3.5 g/day

PROTEINURIAPROTEINURIA

CAUSESCAUSES PRERENAL (normal glomerular filter)

High protein levels in the blood (transfusions)

Plasma cell dyscrazias

RENAL abnormal glomerular permeability,

decreased tubular reabsorbtion, tubular secretion

GLOMERULOPATHIES, TUBULOPATHIES

POSTRENAL

Massive epithelial desquamations + leucocyturia

PROTEINURIAPROTEINURIA

URINE PROTEIN ELECTROPHORESIS (UPEP)URINE PROTEIN ELECTROPHORESIS (UPEP)

1. GLOMERULAR SELECTIVE

NONSELECTIVE

2. TUBULAR

3. ABNORMAL PROTEINS

GLOMERULAR PROTEINURIAGLOMERULAR PROTEINURIA

A. SELECTIVE

mostly ALBUMIN GLOMERULOPATHIES with potential reversible evolution

B. NONSELECTIVE

ALL PLASMA PROTEINS

SEVERE, IRREVERSIBLE GLOMERULOPATHIES

TUBULAR PROTEINURIATUBULAR PROTEINURIA

UPEPUPEP →

– TAMM-HORSFALL

– 2 MICROGLOBULIN

CAUSESCAUSES TUBULAR INJURY of any cause CHRONIC KIDNEY FAILURE PYELONEPHRITIS

HYPERTENSION

ABNORMAL PROTEINURIAABNORMAL PROTEINURIA

EXCESS OF LIGHT CHAINS

CAUSES:CAUSES:

MULTIPLE MYELOMA

ESSENTIAL MACROGLOBULINEMIA

AMYLOIDOSIS

LYMPHOMAS

““PHYSIOLOGICAL” PROTEINURIAPHYSIOLOGICAL” PROTEINURIA

Only ALBUMIN

Of transient character

CAUSES:CAUSES: FEVER CHILLS EXERCISE EXTENDED ORTHOSTATISM INTERMITTENT PROTEINURIA CONGESTIVE HEART FAILURE

GENERAL MANIFESTATIONSGENERAL MANIFESTATIONS

FEVER

SKIN and APPENDAGES OF SKIN

RESPIRATORY changes DYSPNEA,

CARDIOVASCULAR changes URAEMIC PERICARDITIS RHYTHM and CONDUCTION abnormalities

MYOCARDIAL CONTRACTION changes

HYPOTENSION

GENERAL MANIFESTATIONSGENERAL MANIFESTATIONS

GASTROINTESTINAL NAUSEA, VOMITINGS

ALTERED BOWELL HABIT

NEUROLOGICAL SOMNOLENCE, RESTLENESS, COMA

SENSORIAL or MOTOR abnormalities

PERIPHERAL NEUROPATHY

RENAL SYSTEM PHYSICAL EXAMINATIONRENAL SYSTEM PHYSICAL EXAMINATION

GENERAL PHYSICAL EXAMINATION

SKIN and SKIN APPENDAGES:

PALLOR, LEMON-YELLOW COMPLEXION, DRY SKIN

ITCHING, SCRATCH MARKS

“UREMIC FROST”

UREMIDES

“BROWN LINE” PIGMENTATION OF NAILS

RENAL EDEMA

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATIONLOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

I. INSPECTION

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATIONLOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

I. INSPECTION

LOMBAR REGIONSLOMBAR REGIONS

ABNORMAL BULGING/RETRACTION; SKIN CHANGESABNORMAL BULGING/RETRACTION; SKIN CHANGES• BULGING + INFLAMMATION: PERINEPHRITIC ABCESSBULGING + INFLAMMATION: PERINEPHRITIC ABCESS• VERTEBRAL MUSCLES CONTRACTURE: renal colicVERTEBRAL MUSCLES CONTRACTURE: renal colic

ABDOMENABDOMENBULGING OF THE FLANKSBULGING OF THE FLANKS THIN patients, CHILDRENTHIN patients, CHILDREN

• UNI or BILATERALUNI or BILATERAL• In:In: KIDNEY CYSTS, TUMORS KIDNEY CYSTS, TUMORS

HYPOGASTRIC BULGINGHYPOGASTRIC BULGING• BLADDER DISTENTIONBLADDER DISTENTION

GENITALIAGENITALIA

KIDNEYS PALPATIONKIDNEYS PALPATION

RIGHTRIGHT LEFTLEFT

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATIONLOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

II. KIDNEY PALPATION(C) ONE HAND(C) ONE HAND

place your left thumb in the right hypocondrium/ right thumb place your left thumb in the right hypocondrium/ right thumb in the left hypocondriumin the left hypocondrium the other four fingers are placed in the costovertebral anglethe other four fingers are placed in the costovertebral angle try to catch the kidney between thumb and fingers and palpate it try to catch the kidney between thumb and fingers and palpate it with your thumbwith your thumb in CHILDREN, VERY SLENDER PATIENTSin CHILDREN, VERY SLENDER PATIENTS

LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATIONLOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION

II. KIDNEY PALPATION1.1. ENLARGED: ENLARGED:

unilaterally: unilaterally: PTOSIS, COMPENSATORY HYPERTROPHY, PTOSIS, COMPENSATORY HYPERTROPHY,

NEOPLASM, CYSTSNEOPLASM, CYSTS

bilaterally: bilaterally: POLYCYSTIC KIDNEY ISEASE (PKD)POLYCYSTIC KIDNEY ISEASE (PKD)uni or bilateralLY: uni or bilateralLY: HYDRONEPHROSIS, PYONEPHROSISHYDRONEPHROSIS, PYONEPHROSIS