THE RENAL SYSTEM
SIGNS AND SYMPTOMS
HISTORY TAKING = IMPORTANT ROLE

PRIOR HISTORY
 PAST MEDICAL HISTORY
 ACUTE INFECTIONS
 CHRONIC INFECTIONS
 TOXIC SUBSTANCES
 SECUNDARY TO OTHER DISEASES
PAST MEDICAL HISTORY

ACUTE INFECTIONS
(Especially  HEMOLITIC STREPTOCOCCUS)



•
TONSILITTIS;
SCARLET FEVER
POSTSTREPTOCOCCAL SYNDROME;
CHRONIC INFECTIONS



TUBERCULOSIS
AMILOYDOSIS(secondary)
Viral infections
PAST MEDICAL HISTORY
 TOXICS
– 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 HISTORY

DM
 HTN
 POLYCYSTIC KIDNEY DISEASE
SIGNS AND SYMPTOMS
RENAL PAIN
II. DIURESIS disturbances
III. URINE ABNORMALITIES
IV. RENAL EDEMA
V. GENERAL MANIFESTATIONS
I.
RENAL PAIN


RENAL COLIC
CHRONIC LOIN PAIN
RENAL COLIC
1.
ONSET: SUDDEN
TRIGGERS: VIBRATIONS, 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
AMELIORATED by: HEAT
ASSOCIATED with:
6.
7.





RESTLENESS, PALOR, COLD SWEATING
NAUSEA, VOMITINGS
TACHYCARDIA, ANGINAL PAIN,
ILEUS,
MICTURITION disturbances
RENAL COLIC
RENAL COLIC
CAUSES:


KIDNEY STONES
PAPILLARY NECROSIS
DIURESIS DISTURBANCES




POLYURIA
OLIGURIA
ANURIA
NOCTURIA
EXAMINATION OF THE URINE

HAEMATURIA

PYURIA

PROTEINURIA
EXAMINATION OF THE URINE
Macroscopic
Biochemical
Microscopic
CLARITY
Specific Gravity
RBCs, WBCs
COLOR
pH
BACTERIA
ODOUR
BLOOD
CASTS
VOLUME
PROTEIN
CRYSTALS
Microbiological
CULTURES
SENSITIVES
NITRITES
HAEMATURIA

The presence of red blood cells in the urine
due to bleeding from the kidneys or urinary tract


CAN BE:
 MICROSCOPIC (1000–1mil. erythrocytes/ml/min)
 MACROSCOPIC ( >1mil. erythrocytes/ml/min)

Color of the haematuria:

RED or BROWN

CAN LEAD to CLOTS and HAEMATIC DEPOSITS
HAEMATURIA
CAUSES

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 infection
reflux nephropathy and renal scarring

POSTRENAL:
 URETER: stones, tumor, inflammation,
vascular malformation, traumas
 BLADDER: tumor, stones, inflammation, polyp, foreign objects
 URETHRO-PROSTATIC: tumor, stones, inflammation
strictures, foreign objects, malformation
HAEMATURIA

3 CUPS TEST:

INITIAL
→ URETHRA, PROSTATE

TERMINAL
→ BLADDER

TOTAL
→ KIDNEYS and URETER
HAEMATURIA
DIFFERENTIAL

CONCENTRATED urine – increased specific gravity

CONJUGATED BILIRUBIN

RED-BROWN – normalized when heated → URATES
– drugs: L-Dopa

RED – DRUGS (rifampicin, metronidazol)
– FOOD: beetroot, blackberries
PYURIA
PRESENCE OF PUS CELL IN THE URINE

CAN BE:

MICROSCOPIC = LEUCOCYTURIA
 MACROSCOPIC
- changes in urine aspect:
LOSS of LUSTRE, TRANSPARENCY,
MUCUS FRAGMENTS, PUS DEPOSITS
- changes in odor of the urine
PYURIA
CAUSES

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
PYURIA
DIFFERENTIAL

CLOUDY urines
 URATES, PHOSPHATES
 Clarifies when HEATED/ACID adding

CHYLURIA

URETHRITIS

VAGINITIS
PROTEINURIA
PRESENCE OF PROTEINS IN THE URINE

QUANTITY

MICROALBUMINURIA
30-300 mg/day
 MEDIUM
300mg – 3.5 g/day
 HIGH
> 3.5 g/day
PROTEINURIA
CAUSES

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
PROTEINURIA
URINE PROTEIN ELECTROPHORESIS (UPEP)
1.
GLOMERULAR
 SELECTIVE
 NONSELECTIVE
2.
TUBULAR
3.
ABNORMAL PROTEINS
GLOMERULAR PROTEINURIA
A.
B.
SELECTIVE

mostly ALBUMIN

GLOMERULOPATHIES with potential reversible evolution
NONSELECTIVE

ALL PLASMA PROTEINS

SEVERE, IRREVERSIBLE GLOMERULOPATHIES
TUBULAR PROTEINURIA

UPEP →
– TAMM-HORSFALL
– 2 MICROGLOBULIN

CAUSES
 TUBULAR INJURY of any cause
 CHRONIC KIDNEY FAILURE
 PYELONEPHRITIS
 HYPERTENSION
ABNORMAL PROTEINURIA

EXCESS OF LIGHT CHAINS

CAUSES:
 MULTIPLE MYELOMA
 ESSENTIAL MACROGLOBULINEMIA
 AMYLOIDOSIS
 LYMPHOMAS
“PHYSIOLOGICAL” PROTEINURIA

Only ALBUMIN

Of transient character

CAUSES:
 FEVER
 CHILLS
 EXERCISE
 EXTENDED ORTHOSTATISM
 INTERMITTENT PROTEINURIA
 CONGESTIVE HEART FAILURE
GENERAL MANIFESTATIONS

FEVER

SKIN and APPENDAGES OF SKIN

RESPIRATORY changes


DYSPNEA,
CARDIOVASCULAR changes

URAEMIC PERICARDITIS

RHYTHM and CONDUCTION abnormalities

MYOCARDIAL CONTRACTION changes

HYPOTENSION
GENERAL MANIFESTATIONS


GASTROINTESTINAL

NAUSEA, VOMITINGS

ALTERED BOWELL HABIT
NEUROLOGICAL

SOMNOLENCE, RESTLENESS, COMA

SENSORIAL or MOTOR abnormalities

PERIPHERAL NEUROPATHY
RENAL 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 EXAMINATION
I. INSPECTION
LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION
I. INSPECTION
LOMBAR REGIONS
ABNORMAL BULGING/RETRACTION; SKIN CHANGES
• BULGING + INFLAMMATION: PERINEPHRITIC ABCESS
• VERTEBRAL MUSCLES CONTRACTURE: renal colic
ABDOMEN
BULGING OF THE FLANKS
• UNI or BILATERAL
• In: KIDNEY CYSTS, TUMORS
HYPOGASTRIC BULGING
• BLADDER DISTENTION
GENITALIA
THIN patients, CHILDREN
KIDNEYS PALPATION
RIGHT
LEFT
LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION
II. KIDNEY PALPATION
(C) ONE HAND
 place your left thumb in the right hypocondrium/ right thumb
in the left hypocondrium
 the other four fingers are placed in the costovertebral angle
 try to catch the kidney between thumb and fingers and palpate it
with your thumb
 in CHILDREN, VERY SLENDER PATIENTS
LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION
II. KIDNEY PALPATION
1.
ENLARGED:
unilaterally: PTOSIS, COMPENSATORY HYPERTROPHY,
NEOPLASM, CYSTS
bilaterally: POLYCYSTIC KIDNEY ISEASE (PKD)
uni or bilateralLY: HYDRONEPHROSIS, PYONEPHROSIS