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THE RENAL SYSTEM
SIGNS AND SYMPTOMS
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HISTORY TAKING = IMPORTANT ROLEHISTORY TAKING = IMPORTANT ROLE PRIOR HISTORY PAST MEDICAL HISTORY
ACUTE INFECTIONS CHRONIC INFECTIONS TOXIC SUBSTANCES SECUNDARY TO OTHER DISEASES
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PAST MEDICAL HISTORYPAST MEDICAL HISTORY ACUTE INFECTIONS
(Especially HEMOLITIC STREPTOCOCCUS) TONSILITTIS; SCARLET FEVER POSTSTREPTOCOCCAL SYNDROME;
• CHRONIC INFECTIONS TUBERCULOSIS AMILOYDOSIS(secondary) Viral infections
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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
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FAMILY HISTORYFAMILY HISTORY
DMHTN
POLYCYSTIC KIDNEY DISEASE
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SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS
I. RENAL PAIN
II. DIURESIS disturbances
III. URINE ABNORMALITIES
IV. RENAL EDEMA
V. GENERAL MANIFESTATIONS
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RENAL PAINRENAL PAIN
RENAL COLIC CHRONIC LOIN PAIN
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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
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RENAL COLICRENAL COLIC
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RENAL COLICRENAL COLICCAUSES:CAUSES:
KIDNEY STONES PAPILLARY NECROSIS
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DIURESISDIURESIS DISTURBANCES DISTURBANCES POLYURIA OLIGURIA ANURIA NOCTURIA
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EXAMINATION OF EXAMINATION OF THE URINETHE URINE
HAEMATURIA
PYURIA
PROTEINURIA
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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
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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
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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
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HAEMATURIAHAEMATURIA
3 CUPS TEST:3 CUPS TEST:
INITIAL → URETHRA,
PROSTATE
TERMINAL → BLADDER
TOTAL → KIDNEYS and URETER
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HAEMATURIAHAEMATURIADIFFERENTIAL
CONCENTRATED urine – increased specific gravity
CONJUGATED BILIRUBIN
RED-BROWN – normalized when heated → URATES – drugs: L-Dopa
RED – DRUGS (rifampicin, metronidazol) – FOOD: beetroot, blackberries
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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
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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
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PYURIAPYURIA
DIFFERENTIALDIFFERENTIAL CLOUDY urines
URATES, PHOSPHATES
Clarifies when HEATED/ACID adding
CHYLURIA
URETHRITIS
VAGINITIS
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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
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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
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PROTEINURIAPROTEINURIA
URINE PROTEIN ELECTROPHORESIS (UPEP)URINE PROTEIN ELECTROPHORESIS (UPEP)
1. GLOMERULAR SELECTIVE
NONSELECTIVE
2. TUBULAR
3. ABNORMAL PROTEINS
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GLOMERULAR PROTEINURIAGLOMERULAR PROTEINURIA
A. SELECTIVE
mostly ALBUMIN GLOMERULOPATHIES with potential reversible evolution
B. NONSELECTIVE
ALL PLASMA PROTEINS
SEVERE, IRREVERSIBLE GLOMERULOPATHIES
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TUBULAR PROTEINURIATUBULAR PROTEINURIA
UPEPUPEP →
– TAMM-HORSFALL
– 2 MICROGLOBULIN
CAUSESCAUSES TUBULAR INJURY of any cause CHRONIC KIDNEY FAILURE PYELONEPHRITIS
HYPERTENSION
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ABNORMAL PROTEINURIAABNORMAL PROTEINURIA
EXCESS OF LIGHT CHAINS
CAUSES:CAUSES:
MULTIPLE MYELOMA
ESSENTIAL MACROGLOBULINEMIA
AMYLOIDOSIS
LYMPHOMAS
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““PHYSIOLOGICAL” PROTEINURIAPHYSIOLOGICAL” PROTEINURIA
Only ALBUMIN
Of transient character
CAUSES:CAUSES: FEVER CHILLS EXERCISE EXTENDED ORTHOSTATISM INTERMITTENT PROTEINURIA CONGESTIVE HEART FAILURE
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GENERAL MANIFESTATIONSGENERAL MANIFESTATIONS
FEVER
SKIN and APPENDAGES OF SKIN
RESPIRATORY changes DYSPNEA,
CARDIOVASCULAR changes URAEMIC PERICARDITIS RHYTHM and CONDUCTION abnormalities
MYOCARDIAL CONTRACTION changes
HYPOTENSION
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GENERAL MANIFESTATIONSGENERAL MANIFESTATIONS
GASTROINTESTINAL NAUSEA, VOMITINGS
ALTERED BOWELL HABIT
NEUROLOGICAL SOMNOLENCE, RESTLENESS, COMA
SENSORIAL or MOTOR abnormalities
PERIPHERAL NEUROPATHY
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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
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LOMBAR REGION, ABDOMEN and GENITALIA EXAMINATIONLOMBAR REGION, ABDOMEN and GENITALIA EXAMINATION
I. INSPECTION
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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
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KIDNEYS PALPATIONKIDNEYS PALPATION
RIGHTRIGHT LEFTLEFT
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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
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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