By:
Maryam Hami MD,
Associate Prof. of Nephrology
Mashhad University of Medical sciences(MUMS)
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Pain:
Kidney pain
Ureteral pain
Bladder pain
Dysuria
Other symptoms other than pain may
accompany voiding:
Urgency
Frequency
Hesitency
Incontinence
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Kidney pain is produced by sudden distention
of the renal capsule and is typically dull, and
steady
Ureteral pain is a severe colicky pain that often
originates in the CVA and radiates around the
trunk
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Bladder disorders
may cause suprapubic
pain
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refers to painful urination
Difficult urination is also sometimes described
as dysuria
It is one of a constellation of irritative bladder
symptoms, which includes urinary frequency
and haematuria
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This is typically described to be a burning or
stinging sensation. It is most often a result of
urinary tract infection
STD
bladder stones
bladder tumours
prostate disorders
anticholinergic drugs
Urgency:
Is an unusually intense and immediate desire to void. It
can be associated with infection, old age
 Frequency:
urination at short intervals without increase in daily
volume or urinary output, due to reduced bladder
capacity. It can be associated with infection, bladder
neck problems
 Hesitency:
difficulty in beginning the flow of urine; associated
with BPH in men and narrowing of the urethral
opening and may be caused by emotional stress
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Incontinence:
is any involuntary leakage of urine.
Common etiology are:
1. Polyuria
2. Prostate disorders (BPH and cancers)
3. Caffeine and Cola
4. Brain disorders (MS, spinal cord injuries,
Parkinson disease, stroke)
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Stress incontinence,
is due essentially to insufficient strength of the
pelvic floor muscles.
 Urge incontinence
is involuntary loss of urine occurring for no
apparent reason while suddenly feeling the
need to urinate.
 Overflow incontinence:
Sometimes people find that they cannot stop their
bladders from constantly dribbling, or
continuing to dribble for some time after they
have passed urine.
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Oliguria:
is the low output of urine ,It is clinically classified
as an output below 400 ml/day
 The decreased output of urine may be a sign of
dehydration ,renal failure ,hypovolemic shock ,
multiple organ dysfunction syndrome ,or
urinary obstruction/urinary retention.
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Anuria:
absence of urine, clinically classified as below
100ml/day
 Anuria can be caused by
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total urinary tract obstruction
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total renal artery or vein occlusion
3. Shock
4. Cortical necrosis
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severe ATN
6. Rapidly progressive glomerulonephritis
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Polyuria:
urine>3 L/d
Polyuria results from two potential mechanisms:
nonabsorbable solutes diuresis
water diuresis (DI)
If the urine volume is >3 L/d and urine
osmolality is >300 mosmol/L, then a solute
diuresis is clearly present and a search for the
responsible solute(s) is mandatory
WE PREPARE URINE SAMPLE
BY CENTRIFUGATION
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Urine supernatant:
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Urine Sediment:
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Urine Dipstick
Glucose
Bilirubin
Ketones
Specific Gravity
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocyte Esterase
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Glucosuria
Negative
Trace (100 mg/dL)
+ (250 mg/dL)
++ (500 mg/dL)
+++ (1000 mg/dL)
++++ (2000+ mg/dL)
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Bilirrubinuria
Negative
+ (weak)
++ (moderate)
+++ (strong)
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Urobilinogenuria
0.2 mg/dL
1 mg/dL
2 mg/dL
4 mg/dL
8 mg/dL
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Normal red blood cell excretion in the urine is
up to 2 million RBCs per day.
Hematuria is defined as two to five RBCs per
high-power field (HPF) and can be detected by
dipstick.
Common causes of isolated hematuria include:
Stones
Neoplasms
Tuberculosis
Trauma
Prostatitis
A single urinalysis with hematuria is common
and can result from menstruation, viral
illness, allergy, exercise, mild trauma
 persistent or significant hematuria:
1. three RBCs/HPF on three urinalyses
2. single urinalysis with >100 RBCs
3. gross hematuria
identified significant renal or urologic lesions in
9.1%
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Hematuria with dysmorphic RBCs, RBC casts,
and protein excretion >500 mg/d is virtually
diagnostic of glomerulonephritis.
RBC casts form as RBCs that enter the tubule
fluid become trapped in a cylindrical mold of
gelled Tamm-Horsfall protein
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Pyuria
refers to urine which
contains pus. Defined
as the presence of 4 or
more neutrophils per
high power field
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a cast formed from gelled protein precipitated
in the renal tubules and molded to the tubular
lumen; pieces of these casts break off and are
washed out with the urine.
Types named for their constituent material
include epithelial, granular, hyaline, cellular
and waxy casts.
WBC CAST
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Infection
tubulointerstitial
processes such
as interstitial
nephritis,
systemic lupus
erythematosus,
and transplant
rejection.
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Crystalluria indicates that the urine is
supersaturated with the compounds that
comprise the crystals, e.g. ammonium,
magnesium and phosphate for struvite.
Crystals can be seen in the urine of clinically
healthy animals or in animals with no evidence
of urinary disease (such as obstruction and/or
urolithiasis).
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means the presence of an excess of serum proteins in
the urine
The dipstick measurement detects mostly albumin
and gives false-positive results when
pH > 7.0
urine is very concentrated
contaminated with blood.
A very dilute urine may obscure significant
proteinuria on dipstick examination
proteinuria that is not predominantly albumin will be
missed.
Protein
% of Total
Albumin
30%
Tamm-Horsfall
50%
Immunoglobulins
12%
Secretory IgA
3%
Other
5%
TOTAL
100%
Daily Maximum
30 mg
40 mg
14 mg
6 mg
10 mg
150 mg
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Common Causes of Benign Proteinuria
Dehydration
Emotional stress
Fever
Heat injury
Inflammatory process Intense activity
Most acute illnesses
Orthostatic (postural) disorder
Cause
Daily protein excretion
Mild glomerulopathies
Tubular proteinuria
Overflow proteinuria
0.15 to 2.0 g
Usually glomerular
2.0 to 4.0 g
Always glomerular
>4.0 g
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Nephrotic syndrome classically presents with
heavy proteinuria (>3.5 g/d), minimal
hematuria, hypoalbuminemia,
hypercholesterolemia, edema, lipiduria and
hypertension
Acute nephritic syndromes classically present
with hypertension, hematuria, red blood cell
casts, pyuria, and mild to moderate (1-2 g/d)
proteinuria, a fall in GFR .
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If glomerular inflammation develops slowly,
the serum creatinine will rise gradually over
many weeks, is sometimes called rapidly
progressive glomerulonephritis (RPGN);
The histopathologic term crescentic
glomerulonephritis is the pathologic equivalent
of the clinical presentation of RPGN.
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Azotemia is a medical condition
characterized by abnormally high levels of
nitrogen-containing compounds, such as
urea, creatinine, various body waste
compounds, and other nitrogen-rich
compounds in the blood.
It is largely related to insufficient filtering of
blood by the kidneys
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Uremia
is a term used to loosely describe the
symptoms accompanying kidney failure.
Early symptoms include anorexia and lethargy,
and late symptoms can include decreased
mental acuity and coma. Other symptoms
include fatigue, nausea, vomiting, bone pain,
itch, shortness of breath, and seizures.
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Size of the kidneys
Past history of azotemia
Broad cast on U/A
Peripheral neuropathy
Renal Osteodysthrophy
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Upper UTI:
Pyelonephritis
Perinephric abcess
Prostitis
Lower UTI:
Cystitis
urethritis
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the presence of bacteria in the urinary tract,
usually accompanied by white blood cells and
inflammatory cytokines in the urine.
However, ABU occurs in the absence of
symptoms in the urinary tract and does not
usually require treatment.
SBP-mmHg
DBP-mmHg
Normal
<120
Prehypertens 120-139
ion
And <80
Or 80-89
Stage 1
140-159
Stage 2
≥160
Isolated
≥140
systolic HTN
Or 90-99
≥100
And <90
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Renal stone: A hard mass that is formed in
urinary tract.
Nephrocalcinosis: The persence of calcium
deposits in the kidneys.
Risk factors: hypercalciuria, hyperuricosuria,
hypocitraturia, hyperoxaluria
Kidney stone (calculi)
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Plain film imaging (Radiography)
Plain film of the abdomen (KUB)
Urography
Ultrasonography
Computed tomography
Magnetic resonance imaging
Radionuclide imaging
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The kidneys-ureters-bladder (KUB) is often the
first imaging study performed to visualize the
abdomen and urinary tract
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The film is taken with the patient supine and should
include the entire abdomen from the base of the
sternum to the pubic symphisis
Can show bony abnormalities, calcification and large
soft tissue masses
Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana Press Inc.
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IVU/ intravenous pyelogram is the classic
modality of imaging the entire urethelial tract
from pyelocalyceal system trhough the ureters
and bladder
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Excellent for indentifying small urethelial lesions as
well as the severity of obstruction from calculi
Provides anatomical and qualitative functional
information about the kidneys
Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana Press Inc.
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Can be used to evaluate for abnormal anatomy
and function of the lower urinary tract in both
children and adults
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Similar to the cystogram, instillation of contrast
media into the bladder through a urethral cahteter is
also employed
After full distention of the bladder, the patient is
instructed to void either after removing the catheter
or around the catheter
Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana Press Inc.
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In T1-weighted images (emphasizing the difference in
T1 relaxation times between different tissues), watercontaining structures are dark. T1-weighted images
do not show good contrast between normal and
abnormal tissues. However, they do demonstrate
excellent anatomic detail.
T2-weighted images emphasize the difference in T2
relaxation times between different tissues. Because
water is bright in these images, T2-weighted images
provide excellent contrast between normal and
abnormal tissues, although with less anatomic detail
than T1-weighted images
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Study of choice for the general imaging of the
kidney and ureter
used to create cross-sectional images of structures
in the body. In this procedure, x-rays are taken
from many different angles and processed through
a computer to produce a three-dimensional (3-D)
image
Uptake of contrast by renal parenchyma during
nephrogram phase provides rough estimate of
kidney function
Useful when renal or ureteral malginancy is
suspected
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uses the radiation released by radionuclides
(called nuclear decay) to produce images
A radionuclide, usually technetium-99m, is
combined with different stable, metabolically
active compounds to form a radiopharmaceutical
that localizes to a particular anatomic or diseased
structure (target tissue).
tracer goes to the target organ and can then be
imaged with a gamma camera, which takes
pictures of the radiation photons emitted by the
radioactive tracer