Beruflich Dokumente
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1
04 Nov
2014
Renal Symptoms
Alfredo Guzman, M.D.
Wag mong hanapin sa butas ng donut ang sarap
Ron Capinding
PAUNAWA
Paulo Coelho
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.
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
4.
the
that
and
and
fluid
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
Elevation of water soluble
metabolites in the blood
Not associated with symptoms
1.
2.
3.
Uremia
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
Page 1 of 6
Renal Symptoms
Nov. 4, 2013
such as:
o Glomerulonephritis
o Diabetic glomerulosclerosis
POST-RENAL AZOTEMIA
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
Oliguria
Nonoliguria
RENAL MANIFESTATIONS
CHARACTERISTICS OF IMPAIRED TUBULAR FUNCTION
Urinary sodium
>20 mmol
concentration
Usually is 40 mmol/L
Urine-to-plasma (U/P) ratio
<2
for urea
Urine-to-plasma (U/P) ratio
<20
for creatinine
Urine osmolality
<350 mmol/kg of water
Ratio of blood urea nitrogen
Not elevated
(BUN) to serum creatinine
PROTEINURIA
Normal adults may excrete up to 150 mg/d protein.
Of this, only 5 to 15 mg is albumin (<30 mg/d Harrisons 18th Ed.)
tested in pxs suspected of glomerulopathies
Massive proteinuria
Protein excretion >3.5 g/24 hrs
Nephrotic syndrome
SINGLE
NEPHRON
GFR (SNGFR)
Increased
Normal
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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%:
PRIMARY POLYDIPSIA
cause: unknown
increase fluid intake
results from habit, psychiatric disorder, neurologic lesions or
medications
NOCTURIA
Occurs during:
Solute diuresis
Dysuria
Glomerulonephritis
proteinuria
Isolated Hematuria
Urgency
Enuresis
Incontinence
Hirsutism
Virilization
Urinary
frequency
or
renal
Overflow Incontinence
The inability to control urination.
Unable to completely empty the bladder
leading to overflow, which leaks out
unexpectedly
Male-pattern hair growth
Affects approximately 10% of women of
reproductive age
FEMALES ONLY
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
Macroscopic Hematuria
Diabetes Insipidus
Central: lack ADH
idiopathic
Nephritic Syndrome
Chronic
Glomerulonephritis
(CGN)
Proteinuria 150mg-3g/d
Hematuria > 2RBCs/HPF in spun
urine
Brown or red painless hematuria
Usually coincides with intercurrent
infection
Asymptomatic
Hematuria or proteinuria in between
attacks
Oliguria
Proteinuria usually <3g/d
Edema
HPN
Abrupt onset, usually self-limiting
HPN
Renal Insufficiency
Proteinuria > 3g/d
Small kidneys
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Renal Symptoms
Nov. 4, 2013
Rapidly Progressive
Glomerulonephritis
(RPGN)
Nephrotic Syndrome
Due to phosphate
precipitation
Urine pH
Urine
Protein
and lymphatics
CHEMICAL CHARACTERISTICS
Normal Values
Comments
4.5-8 (5-6)
pH
Possible Conditions
5
Uric acid stones
7
Vegetarian diet
Systemic acidosis
8
(renal-tubular
acidosis)
7-8
Struvite stones
Negative (<150 Mostly detects albumin
mg/ 24 hrs)
Possible
pH
Conditions
Trace
1-10mg/dl
+1
15-30mg/dl
+2
40-100mg/dl
+3
150-350mg/dl
+4
> 500mg/dl
MICROALBUMINURIA
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:
1.
2.
3.
4.
5.
6.
7.
8.
COMMON CAUSES
Drug induced interstitial nephritis
(NSAIDs, rifampicin, lithium)
Infectious ( viral, bacterial , parasitic)
Malignancy (multiple myeloma, lymphoma)
Transplant rejection
Reflux Nephropathy
Obstructive Nephropathy
Metabolic (gout)
Radiation
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
Color
Specific
Gravity
Turbidity
PHYSICAL CHARACTERISTICS
Normal Values
Clinical Values
Yellow
May point to drug ingestion
(rifampicin)
1.003 - 1.030
1.000-1.005 in diabetes
insipidus
>1.030 due to contrast
dyes, glucose, mannitol
No clinical
Chyluria (milky white) due
significance
to fistula between bladder
Eosinophils
Epithelial
Cells
OTHER CELLS
Seen in allergic nephritis
Squamous
Least significant
Transitional
From pelvis to urethral lining
Renal tubular Most significant, consider
acute tubular necrosis
Hyaline Cast
Non-pathologic, seen commonly in
dehydrated patients (small urine
volume/diuretics)
Made up of Tamm-Horsfall protein
Broad Waxy Cast
Made up of both the granular and
hyaline casts and is due to urine
flow stasis in the collecting ducts or
distended renal tubules.
Extreme stasis of flow
May be seen in renal failure
Fatty Cast
Seen in patients with nephrotic
syndrome
WBC Cast
Made up of PMNs, indicative of
Pyelonephritis and acute interstitial
nephritis
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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 (%)
>85
<50
50 85
Possible Origin
of Disease
Glomerular
Tubular
Urinary tract
Granular Cast
Fine Granular Casts are derived
from disintegration of cellular casts,
from tubule cell lysosomes, protein
aggregates.
Can be seen in GN
(glomerulonephritis), PN
(pyelonephritis) and strenuous
exercise
With surrounding amorphous urates
CREATININE CLEARANCE
Creatinine Clearance
= (Urinary creatinine (mg/ml) x Urinary Volume) x 100 / Serum
creatinine (24 hr urine collection)
Widely used method to estimate GFR
Quick estimation of creatinine clearance from plasma (CockcroftGault) formula
(140 Age ) X Wt in kg
72 X Cr in mgs/dl
multiply result by 0.85 for female
SERUM CREATININE
Mainly derived from metabolism of creatine/creatine phosphokinase
from skeletal muscle cells
Produced at almost constant rate
Steady state concentration dependent on renal excretion w/c mainly
reflects of GFR
Renal mass
Renal failure
Stone disease or obstruction
Perirenal
and
pararenal
(urinoma, hematoma, abscess)
5. Transplant dysfunction
6. Cystic diseases
7. Prostate disease
Plain Film of
Abdomen
Contrast Films
spaces
disease
RADIOLOGY
Used to assess bone, soft tissue changes,
calcifications, renal location
Series of films taken at varying time after
contrast administration
Page 5 of 6
Renal Symptoms
Nov. 4, 2013
INTRAVENOUS UROGRAPHY
Fairly accurate diagnostic procedure when properly done
At 30 min
At 5 10 min
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)
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.
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