Lecture -2- Approach to renal diseases Hazem.K.Al-khafajiDM.FICMS University of Al-Qadisiya College of medicine Department of medicine

Diagnosis   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 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: 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

Color Normal = pale yellow due to a pigment called urochrome. Color is associated with solute concentration. Increased solutes = darker urine; Decreased solutes = colorless urine, like water. Odor Normal = slightly aromatic when freshly voided. Bacteria = ammonia odor offensive, 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 Symptoms Prostatic 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 history genitourinary system renal stones urinary tract obstruction gynecological operations caesarian section general surgery

Family History  prostate cancer  Stones( cystine)  Renal tumors (some types)  Polycystic kidney(autosomal dominant).  Alports syndrome ( X-linked dominant)

Drugs history Nephrotoxic drugs Aminoglycasides cephalosporines NSAIDs Analgesics ((Phenacetin)) Anti TB Drugs history Nephrotoxic drugs Aminoglycasides cephalosporines NSAIDs Analgesics ((Phenacetin)) Anti TB

Social history Smoking 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 tendency Hypertension 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 Glucose Bilirubin Ketones Specific Gravity Blood pH Protein Urobilinogen Nitrite Leukocyte Esterase

1. Color Normal = pale yellow due to a pigment called urochrome. 2. Transparency Normal = clear Abnormal = cloudy, which may be caused by bacteria, blood, cells, crystals, etc. 3. pH:acidic Normal pH = 4.5 to 5.4 High protein diet = acid urine Vegetarian diet = alkaline urine 4. Specific gravity Normal = to Low Specific Gravity may be due to: 1. Excess fluid intake 2. Use of diuretics 3. Diabetes insipidus 4. Chronic renal failure

5. Protein: a. proteins are NOT supposed to be in the urine b. prevention of proteins into the urine is done by glomerular membrane 6. Bilirubin: NOT supposed to be in the urine 7. Urobilinogen: Grade this from 1 – 5 (5 being the highest) a. with high RBC destruction 8. 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 UTI 8. Leukocyte esterase: enzyme + for this enzyme then probably a UTI 9. Casts: different material clumped together inside of the renal tubule. a. As a general rule if a cast is present, then pathology is going on b. Exception to the above rule is if you see a hyaline cast, which is a normal finding c. Clumped cells come from the kidney d. Casts can be RBC or WBC casts 10- Crystals.

Abnormal Constituents of Urine Glycosuria = glucose( normally nil because of renal threshold Which is mg/dl Hematuria = 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 urine White 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  TYPES OF PROTEINURIA  Glomerular proteinuria(mostly albumin)  Glomerular proteinuria(mostly albumin)  Tubular proteinuria(low molecular weight as ß2- microglobulin, immunoglobulin light chains)  Tubular proteinuria(low molecular weight as ß2- microglobulin, immunoglobulin light chains)  Overflow proteinuria  Overflow proteinuria Proteinuria

 24 hrs urine for protein  Nephrotic range proteinuria — Urinary protein excretion greater than 50 mg/kg per day=1gm/m 2 /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 VUR Ultrasound – 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 kidneys Magnetic 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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