Lecture -2Approach to renal
diseases
Hazem.K.Al-khafaji
DM.FICMS
University of Al-Qadisiya
College of medicine
Department of medicine
Diagnosis
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History
History
Physical examination
Investigations
Introduction
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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 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.
Am J Kidney Dis 2002; 39:S1
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
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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.
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
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Urinary frequency
Nocturia
Frequency
Dysuria: painful urination
Incontinence
 Stress
 Urgency
Obstructive Symptoms
Prostatic hypertrophy (benign or
malignant)

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Decreased force of urination
Urinary hesitancy
frequency
Post void dribbling
Straining
Enuresis

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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
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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
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prostate cancer
Stones( cystine)
Renal tumors (some types)
Polycystic kidney(autosomal dominant).
Alportꞌs syndrome ( X-linked dominant)
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


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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
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.
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 = 1.001 to 1.030.
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 180-220mg/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)
• Crystals
Urinary crystals. (A) Calcium oxalate crystals; (B) uric acid
crystals (C) triple phosphate crystals with amorphous
phosphates ; (D) cystine crystals.
Proteinuria
 Normal < 150 mg/24h.
 TYPES OF PROTEINURIA
 Glomerular proteinuria(mostly albumin)
 Tubular proteinuria(low molecular weight as ß2microglobulin, immunoglobulin light chains)
 Overflow 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)

 Women: multiply by 0.85

S.Cr mg/dl x 72
Plasma Urea
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.
Creatinine
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.
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.
Thank you