TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Alfredo Guzman, M.D.

Wag mong hanapin sa butas ng donut ang sarap Ron Capinding Paulo Coelho

Renal Symptoms

3.1 04 Nov

2014

REVIEW OF ANATOMY

GROSS ANATOMY

Bean-shaped Divided into 2 parts

o Cortex (outer portion); contains all the glomeruli o Medulla (inner portion)

*Tubules are located in both the cortex and the medulla

MICROSCOPIC ANATOMY

NEPHRON

o Basic unit of the kidney o Each nephron is composed of a tuft of capillaries called the

glomerulus Glomerulus lies between the 2 arterioles (efferent and afferent) After the glomerulus series of tubules , the length of which depends

on where the glomerulus is located

FUNCTIONS OF THE KIDNEY

1. Regulation of the composition and volume of body fluid (Obligate H2O loss = 500mL/day)

2. Aid in the control of systemic blood pressure 3. Bio-activation of vitamin D3

implication: Calcium Metabolism

o Vit D3 aids in calcium absorption D3 serum Ca level PTH Ca and PO4 Renal Osteodystrophy bone demineralization d/t

chronic renal disease

4. Regulation of red cell mass by erythropoietin production

o Renal Failure can lead to anemia d/t

erythropoietin

uremic toxins in RBC

CLINICAL MANIFESTATIONS OF RENAL DISEASES

1. Glomerular 2. Tubular 3. Interstitial 4. Vascular

FROM 2B 2016

Clinical manifestations of these disorders depends on the pathophysiology of the renal injury

Nephrologic syndromes usually consist of several elements that reflect the underlying pathologic processes

Duration and severity of the disease will affect these findings and typically include one or more of the following: o disturbances in urine volume (oliguria, anuria, polyuria) o abnormalities of urine sediment (RBCs, WBCs, casts, and

crystals) o abnormal excretion of serum proteins (proteinuria) o reduction in GFR (azotemia) o presence of hypertension and/or expanded total body fluid

volume (edema) o electrolyte abnormalities o in some syndromes, fever/pain

AZOTEMIA

elevation of water-soluble metabolites in blood

retention of nitrogenous waste products (creatinine, urea) d/t reduced GFR

results from: o reduced renal perfusion o intrinsic renal disease o postrenal processes (ureteral obstruction)

no associated symptoms

GFR

serum creatinine is the most widely used marker for GFR

directly proportional to urine creatinine excretion and inversely to serum creatinine (UCR/PCR)

Urea

not constant

reabsorbed by the tubule

Azotemia Uremia

Elevation of water soluble metabolites in the blood

Not associated with symptoms

Same as above but with associated symptoms

First Sx: Sleep disturbances

SERUM CREATINE

More reliable index of glomerular filtration rate (GFR) than urea because of the latter's lower back-diffusion from tubule lumen to peritubular blood

Mainly derived from metabolism of creatine or creatine phosphokinase from skeletal muscle cells

Produced in almost constant rate

Steady state concentration dependent on renal excretion w/c mainly reflects of GFR

APPROACH TO THE PATIENT: AZOTEMIA

decide if reduced GFR represents acute or chronic renal injury

clinical situation, history, and laboratory data helps in diagnosing

REDUCED SINGLE NEPHRON GLOMERULAR FILTRATION RATE

TUBULAR FUNCTION NORMAL

Tubular function is still intact o volume of urine should not be below the obligate urine volume

loss o ability of the kidneys to concentrate the urine is still intact o the specific gravity should be elevated o osmolarity should be high

PAUNAWA

Ang trans na ito ay hango mula sa MED Trans ng 2B and 2D 2016 at

mula sa librong Harrisons 18th ed. May ilang mga notes na kasama

ito base sa mga napagusapan sa klase.

creatine phosphokinase

SLEEP DISTURBANCES- first symptom

hindi ginagamit na marker for GFR kasi hindi constant at narereabsorb

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Renal Symptoms

Nov. 4, 2013

o urine sodium level should be low o urine acidity there is some form of acidosis

if that is not the case: there is a problem in tubular function: Acute Tubular Necrosis/ Acute Renal Failure

PRE-RENAL AZOTEMIA POST-RENAL AZOTEMIA

single nephron GFR (SNGFR)

GFR of all single nephron is reduced

Normal tubular function

Normal BUN: serum creatinine concentration is 10:1

Elevated ratio also can be produced by the following factors: o Tetracycline administration o Glucocorticoid therapy o Presence of blood in the

gastrointestinal tract o Increased protein turnover

due to trauma or burn

Applied when acute obstruction lowers single nephron GFR (SNGFR) causes azotemia

Causes backflow

Increased pressure

Compression

Renal injury

Acute incomplete obstruction of the ureter and acute glomerular injury also may reduce SNGFR and leave tubule function relatively intact

TUBULAR FUNCTION IMPAIRED

ACUTE RENAL FAILURE

Certain acute renal diseases that produce azotemia

Lower single nephron GFR (SNGFR) and damage the tubules sufficiently

Reduce or even abolish tubules reabsorptive function

Produce acute renal failure

CHARACTERISTICS OF IMPAIRED TUBULAR FUNCTION

Urinary sodium concentration

>20 mmol Usually is 40 mmol/L

Urine-to-plasma (U/P) ratio for urea

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Renal Symptoms

Nov. 4, 2013

In glomerular hematuria: RBC exposed to urine Hypo-osmotic urine Decreased osmolarity of the urine Causes the RBCs to shrink: Dysmorphic RBC Count the no. of RBC and the dysmormphic RBC

More than 85%:

Possible Glomerular Hematuria Less than 50%:

Possible tubular hematuria or hematuria outside kidneys (infection, stones, injury etc.)

From 2B 2016 trans:

female ask menstrual cycle

single urinalysis with hematuria is common and can result from: o menstruation o viral illness o allergy o exercise o mild trauma

Gross hematuria o with blood clots o usually not an intrinsic renal process o suggest a postrenal source

Persistent urinalysis o >3 RBCs/HPF on 3 urinalyses, or gross hematuria o associated with significant renal or urologic lesions in 9.1% of

cases

Isolated microscopic hematuria o can be manifested by glomerular diseases

Glomerulonephritis

Na and H2O retention HTN periorbital edema (puffiness oround the eyes) during the

morning

proteinuria

hematuria with dysmorphic RBCs, RBC casts, proteinuria >500 mg/dL (virtually diagnostic)

Total hematuria

occurs evenly throughout voiding

blood has had the opportunity to mix fully with the bladder urine

Isolated Hematuria

bleeding occurs mainly at the beginning or end of micturition

without significant proteinuria, cells, or urinary casts

prostatic or urethral origin is more likely

no significant findings

common causes of isolated hematuria o urinary tract stones o benign and malignant neoplasms of

the urinary tract o tuberculosis o trauma o prostatitis o few primary renal diseases

ABNORMALITIES OF URINE VOLUME

POLYURIA

a urine volume above 3 L/d quantification of urine volume by 24h urine collection results from 2 possible mechanisms:

o excretion of non-absorbable solutes (glucose) o excretion of water (defect in ADH prod. or renal

responsiveness) o distinguished by urine osmolality

300 mosmol/L solute diuresis

Diabetes Insipidus Central: lack ADH

idiopathic 2

o to hypothalamic conditions (posthypophysectomy, trauma,

neoplasm, inflammatory, vascular, or infectious) Nephrogenic: not receptive to the effect of hormones (receptors)

Solute Diuresis eg. Mannitol

Natriuretic Syndromes

Syndromes associated with tubule dysfunction Seen in renal tubular acidosis o May have problems with PROXIMAL TUBULES:

Distal tubule will try to compensate and is unable to compensate and reabsorb all.

(+) diuresis o May have problems with DISTAL TUBULES:

Normal functioning proximal tubule but the distal continues to excrete excess urine volume.

o May cause: Loss of Sodium Inability to reabsorb nutrients, sugar, vitamins Cannot maintain acid base balance: Metabolic Acidosis

PRIMARY POLYDIPSIA

cause: unknown increase fluid intake results from habit, psychiatric disorder, neurologic lesions or

medications

NOCTURIA

Occurs during: Reduced renal osmotic concentration High sodium excretion Solute diuresis Low bladder capacity.

More than twice Possibility: may also have polyuria

OTHER RENAL MANIFESTATIONS

Dysuria Pain or a burning sensation during urination

Urinary frequency

Voiding at frequent intervals

Due to a sense of bladder fullness because of an irritable bladder that feels full even when it is not

Urgency Exaggerated sense of needing to urinate

Due to an irritable or inflamed bladder

Enuresis

Involuntary passage of urine at night or during sleep hence the synonym bed-wetting

Bed-wetting without gross urologic abnormalities

Incontinence

Inability to retain urine in the bladder

Results from neurologic or mechanical disorders of the system that controls normal micturition

Overflow Incontinence

The inability to control urination. Unable to completely empty the bladder

leading to overflow, which leaks out unexpectedly

Hirsutism

Male-pattern hair growth Affects approximately 10% of women of

reproductive age FEMALES ONLY

Virilization

State in which androgen levels are sufficiently high

Cause the following signs and symptoms: o Deepening of the voice o Breast atrophy o Increased muscle bulk o Clitoromegaly o Increased libido

Ominous sign that suggests the possibility of an ovarian or adrenal neoplasm

CLINICAL MANIFESTATIONS OF GLOMERULAR DISEASE

Asymptomatic Proteinuria 150mg-3g/d Hematuria > 2RBCs/HPF in spun

urine

Macroscopic Hematuria Brown or red painless hematuria Usually coincides with intercurrent

infection Asymptomatic Hematuria or proteinuria in between

attacks

Nephritic Syndrome Oliguria Proteinuria usually 3g/d Small kidneys

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Renal Symptoms

Nov. 4, 2013

Rapidly Progressive Glomerulonephritis

(RPGN)

Renal failure over days or weeks Proteinuria usually 3.5g/d Increased cholesterol Decreased albumin Lipiduria

DIFFERENCE BETWEEN NEPHROTIC AND NEPHRITIC

Features Nephrotic Nephritic

Onset Insidious Abrupt

Edema ++++ ++

BP Normal Raised

JVP Normal or low Raised

Proteinuria ++++ ++

Hematuria May or may not occur +++

RBC Casts Absent Present

Albumin Low Normal / slightly decreased

edema in nephrotic syndrome is d/t massive proteinuria

TUBULOINTERSTITIAL DISEASES

Characterized by inflammatory scarring changes

Primarily involves tubules and interstitium

Relative sparing of the glomerulus and vasculature

CLINICAL PRESENTATION

As compared to glomerular causes of kidney diseases, patients with

tubular kidney disease progress in a slow progressive manner:

Slower rate of loss of renal function Less severe systemic hypertension No edema despite severe degree of renal insufficiency Impaired concentrating capacity

(nocturia, polyuria) Glycosuria w/o hyperglycemia Low grade proteinuria Electrolyte imbalance

COMMON CAUSES

1. Drug induced interstitial nephritis (NSAIDs, rifampicin, lithium)

2. Infectious ( viral, bacterial , parasitic) 3. Malignancy (multiple myeloma, lymphoma) 4. Transplant rejection 5. Reflux Nephropathy 6. Obstructive Nephropathy 7. Metabolic (gout) 8. Radiation

CLINICAL ASSESSMENT OF RENAL FUNCTION

Urinalysis

Serum creatinine

Creatinine Clearance

Ultrasound

Radiologic Exam

Electrolytes

CBC

URINALYSIS

In contrast to GFR, urinalysis tells little about the severity of renal disease but may point to a specific diagnosis.

A key feature of the assessment of any patient with renal disease 1. Physical Properties 2. Chemical Properties 3. Microscopy

PHYSICAL CHARACTERISTICS

Normal Values Clinical Values

Color Yellow May point to drug ingestion (rifampicin)

Specific Gravity

1.003 - 1.030 1.000-1.005 in diabetes insipidus

>1.030 due to contrast dyes, glucose, mannitol

Turbidity No clinical significance

Chyluria (milky white) due to fistula between bladder

Due to phosphate precipitation

and lymphatics

CHEMICAL CHARACTERISTICS

Normal Values Comments

Urine pH 4.5-8 (5-6) pH Possible Conditions

5 Uric acid stones 7 Vegetarian diet

8 Systemic acidosis (renal-tubular

acidosis) 7-8 Struvite stones

Urine Protein

Negative ( 500mg/dl

MICROALBUMINURIA

Urine albumin concentration >30ug/min or 30mg/day

Most of the urinary proteins are low molecular weight proteins like Tamm-Horsfall proteins.

ALBUMIN CREATININE RATIO

More accurate method.

Example: ratio of

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Renal Symptoms

Nov. 4, 2013

RBC Cast Seen in glomerulonephritis and

sometimes in strenuous exercises

Dysmorphic RBC

Due to longer contact with urine

Dysmorphic RBCs (%)

Possible Origin of Disease

>85 Glomerular

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Renal Symptoms

Nov. 4, 2013

INTRAVENOUS UROGRAPHY

Fairly accurate diagnostic procedure when properly done

At 30 min Maximum visualization of the renal parenchyma

At 5 10 min Collecting system, ureters, bladder

Normal IVP showing filling of ureters w/ contrast dye from the pelvis to the bladder.

Showed a delayed nephrogram due to a stone in the left mid ureter

RETROGRADE PYELOGRAPHY

Placement of catheter through urethra by cystoscopy advancing to renal pelvis

Information on possible filling defects, obstructing lesion especially length of obstruction and ureter distal to the obstruction

ANTEROGRADE PYELOGRAPHY

Contrast procedure via percutaneous renal puncture.

TAKE-HOME MESSAGES (2D 2016)

1. Pyuria or presence of pus cells in the urine does not always equate to urinary tract infection. 2. After establishing working diagnosis, we should be able to estimate the degree of renal dysfunction. 3. If the creatinine is 2mg/dl, it is best to refer the patient to a kidney specialist. 4. If with significant proteinuria despite normal creatinine levels, best to refer to a kidney specialist.

2C 2015 NOTES:

25% of cardiac output goes to the kidneys Change in sleeping pattern earliest manifestation of uremia Anorexia, nausea and vomiting more noticeable manifestations of

uremia

Uremia absolute indication for dialysis GFR is dependent on blood flow

Prerenal azotemia tubules are still intact i.e., can still concentrate sodium; maintain electrolyte and acid base balance; but GFR is decreased

Postrenal azotemia due to acute obstruction lowers single nephron GFR (SNGFR)

GI loss most common cause of hypovolemia Prostate cancer most common cause of painless hematuria Acidosis + Urine pH is basic tubule dysfunction Obligate water loss 500 cc/day Increase urine sodium of >20-40mmol/liter despite hypovolemia

acute tubular necrosis (ATN) or acute renal failure (ARF)

Prerenal azotemia fluids may still be excreted Renal failure fluids may not be excreted anymore Cause of bilateral kidney obstruction benign prostatic hyperplasia

(BPH), pregnancy

Oliguria = 3.5g/24hrs or 1.7m2/body surface area massive

proteinuria may lead to nephrotic syndrome Tamm-Horsfall proteins filtered proteins Bence-Jones proteins multiple myeloma Glomerular proteins high molecular weight proteins Hematuria consider prostate or urethral origin Isolated hematuria no proteins, casts, cells in the urine; only

hematuria is present

Central diabetes insipdius decreased ADH Nephrogenic diabetes insipidus increased ADH but the kidneys

are not responsive

Mannitol causes solute diuresis Natriuretic syndromes there is development of renal-tubular

acidosis (RTA)

Primary polydipsia (idiopathic) patient drinks a lot of water polyuria, nocturia

Nocturia in venous insufficiency due to increased preload or increased circulating blood volume

Dysuria there is burning sensation while urinating Crescent formation hallmark of rapidly progressive

glomerulonephritis (RPGN)

Reflux nephropathy there is development of recurrent UTI especially in children; due to congenital diseases

Obstructive nephropathy recurrent UTI not related to STDs Obstruction in the urethra, bladder extrarenal cause Obstruction in the tubules intrarenal cause Intrarenal obstruction usually due to gout leads to uric acid

nephropathy

Chemotherapy destroys a lot of cells will increase uric acid excretion may also obstruct the tubules (intrarenal obstruction)

Pyuria consider glomerulopathies (proliferative)