UKRAINIAN MINISTRY OF PUBLIC HEALTH

VINNYTSYA NATIONAL PYROGOV MEMORIAL MEDICAL UNIVERSITY

«APPROVED»
At the methodological meeting of the
internal medicine propedeutics department
Chief of the department
___________ prof. Mostovoy Y.M.
«______»_______________ 20 __y.

Guidelines
for Third-year Students of the Medical Department

Ubgect Propedeutics of the internal medicine

Modul № 2
Enclosure module № 7
Topic Symptoms and syndromes of the renal diseases (chronic and
acute glomerulonephritis and pyelonephritis): hypertension,
eclampsia, chronic renal failure.
Course 3
Faculty Medical № 1

Vinnytsya- 2017
 1. Importance of the topic
Renal diseases usually have latent and progressing course. They gradually destroyed
kidney with developing chronic renal failure. It is very severe difficulty treated
condition that eventually results in death. Renal arterial hypertension and eclampsia is
insidious conditions which has latent symptoms and very severe and life-threatening
complication as acute and chronic renal failure. Knowledge about causes, mechanism,
symptoms and signs of the renal arterial hypertension, eclampsia, chronic renal failure
is very important for physicians of every specialty, because kidney pathology
influences on the course and treatment of majority of the human diseases.

2. Concrete aims:
─ To study features of the renal hypertension
─ To study main symptoms and signs of eclampsia
─ To study main symptoms, signs of chronic renal failure

3. Basic training level

Previous subject Obtained skill

Normal anatomy Anatomy of the kidney and urinary tract, their blood supply and
innervations
Normal physiology Kidney functions in the metabolism
Histology Ontogenesis and histological structure of the kidney and urinary
tract
Propedeutics to internal Subjective, objective and instrumental examinations of the
medicine patients with kidney disorders

4. Task for self-depending preparation to practical training

4.1. List of the main terms that should know student preparing practical training

Term Term
proteinuria Renal edema
hematuria Casturia
leukocituria Specific gravity of urine

4.2. Theoretical questions:

1. What are the causes of the renal arterial hypertension?
2. What are the clinical features of the renal arterial hypertension?
3. What is an eclampsia? Causes, pathogenesis, clinical presentation, complication.
4. Definition of the chronic renal failure, its causes.
5. Classification of the chronic renal failure.
6. Clinical symptoms and signs of affecting different systems at the patients with chronic
renal failure.
7. Instrumental and laboratory examination patient with chronic renal failure.

4.3. Practical task that should be performed during practical training

1. Revealing and assessment of the renal hypertension symptoms and signs
2. Revealing and assessment of the eclampsia symptoms and signs
3. Revealing and assessment of chronic renal failure symptoms and signs.

5. Topic content
Renal hypertension features
 All typical symptoms, signs, according to different stages, and complications of arterial
hypertension can be revealed at patient with renal diseases (see syndrome of arterial hypertension).
Causes: diabetic nephropathy, chronic glomerulonephritis, chronic interstitial nephritis;
polycystic kidneys, renovascular diseases, chronic pyelonephritis, Nephrolithiasis, hypo- or dysplasia
of kidney, renal tuberculosis, renal tumor, chronic renal failure, systemic diseases, amyloidosis.
Symptoms: frequently asymptomatic hypertension, but sometimes patients can feel typical
symptoms of the high level of blood pressure: headache, dizziness, palpitation, heart pain, nausea,
vomiting, and dyspnea.
Signs: blood pressure is high and stable, especially diastolic. Level of the high blood pressure
doesn’t decrease during night (“non-dipper” curve at the daily pressure monitoring).
Other symptoms and signs of the kidney affecting can be obtained during examination.
Eclampsia is an outburst of the tonoclonic spasms that is caused by decreased glomerular
filtration, retention of sodium and water. It results in increasing intracranial pressure, brain oedema, and
cerebral angiospasm.
Eclampsia may develop at patients with the acute or exacerbation of the chronic
glomerulonephritis, and nephropathy of pregnancy.
Before eclampsia patient feels headache, sleepiness, languor, vomiting, short-time loss of sight,
speechlessness, transitory palsy, sudden increasing blood pressure, and black-out.
Eclampsia attack begins from tonic, then clonic spasms. The consciousness is soporous. The
face is cyanotic with swelling the neck veins, and foaming at the mouth. The tongue is bit. The pupils
are wide and don’t react to light. The pulse is intense, rare. The blood pressure is increased. The body
temperature is increased too. Sometimes can be involuntary defecation and micturition. The attack
duration is 10-15 min.
Complication: hemorrhagic stroke, acute left ventricular failure, temporary disorders of sight,
speech, amnesia.
Chronic renal failure
Chronic renal failure is usually the result of a gradually progressive loss of renal function. It
occasionally results from a rapidly progressive disease of sudden onset. Few symptoms develop
until after more than 75% of glomerular filtration is lost; then, the remaining normal
parenchyma deteriorates progressively, and symptoms worsen as renal function decreases.
If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal
physiologic changes in all major organ systems.
Causes
Chronic renal failure may result from:
• chronic glomerular disease such as glomeralonephritis
• chronic infections, such as chronic pyelonephritis or tuberculosis
• congenital anomalies such as polycystic kidneys
• vascular diseases, such as renal nephrosclerosis or hypertension
• obstructive processes such as calculi
• collagen diseases such as systemic lupus erythematosus
• nephrotoxic agents such as long-term aminoglycoside therapy
• endocrine diseases such as diabetic neuropathy.
Such conditions gradually destroy the nephrons and eventually cause irreversible renal
failure. Similarly, acute renal failure that fails to respond to treatment becomes chronic renal
failure.
Classification
Chronic renal failure may progress through the following stages:
I stage – initial (glomerular filtration rate [GFR] 90 to 60 ml/minute, blood creatinin 0,176-
0,352mmol/l, blood urea < 10 mmol/l, Hb 119-135 g/l. Electrolytes are in a norm)
II stage - evident (GFR 60 to 30 ml/minute, blood creatinin 0,352-0,701 mmol/l, blood
urea 10-17 mmol/l, Hb 89-118 g/l. Na and K are decreased but Mg, Ca, Cl, P are in a norm,
polyuria, hypoisostenuria)
 III stage – severe (GFR 30 to 15 ml/minute, blood creatinin 0,701-1,055 mmol/l,
blood urea 17-25 mmol/l, Hb 66-88 g/l. Na and K are decreased or in a norm but Mg↑, Ca↓, Cl in
norm or ↓, P ↑, polyuria or pseudonormal diuresis, hypoisostenuria, subcompensated acidosis)
IV stage – terminal (GFR < 15 ml/minute, blood creatinin >1,055 mmol/l, blood urea
>25 mmol/l, Hb < 66 g/l. Na is decreased or in a norm, K is increased, Mg↑, Ca↓, Cl in a norm or
↓, P ↑, oligouria, anuria, decompensated acidosis).
Signs and symptoms
Chronic renal failure produces major changes in all body systems.
Renal and urologic changes
Initially, salt-wasting and consequent hyponatremia produce hypotension, dry mouth, and
loss of skin turgor, listlessness, fatigue, and nausea. Later, somnolence and confusion develop.
As the number of functioning nephrons decreases, so does the kidneys' capacity to excrete
sodium, resulting in salt retention and overload. Accumulation of potassium causes muscle
irritability, then muscle weakness as the potassium level continues to rise.
Fluid overload and metabolic acidosis also occur. Urine output decreases: urine is very
dilute and contains casts and crystals.
Cardiovascular changes
Renal failure leads to hypertension and arrhythmias, including life-threatening ventricular
tachycardia or fibrillation. Other effects include cardiomyopathy, uremic pericarditis, pericardial
effusion with possible cardiac tamponade, heart failure, and peripheral edema.
Respiratory changes
Pulmonary changes include reduced pulmonary macrophage activity with increased
susceptibility to infection, pulmonary edema, pleuritic pain, pleural friction rub and effusions, and
uremic pleuritis and uremic lung (or uremic pneumonitis). Dyspnea from heart failure also
occurs, as do Kussmaul's respirations as a result of acidosis.
GI changes
Inflammation and ulceration of GI mucosa cause stomatitis, gum ulceration and bleeding
and, possibly, parotitis, esophagitis, gastritis, duodenal ulcers, lesions on the small and large
bowel, uremic colitis, pancreatitis, and proctitis. Other GI symptoms include a metallic taste in the
mouth, uremic fetor (ammonia smell to breath), anorexia, nausea, and vomiting.
Cutaneous changes
Typically, the skin is pallid, yellowish bronze, dry, and scaly. Other cutaneous symptoms
include severe itching; purpura; ecchymoses; petechiae; uremic frost (most often in critically ill or
terminal patients); thin, brittle fingernails with characteristic lines; and dry, brittle hair that may change
color and fall out easily.
Neurologic changes
Restless leg syndrome, one of the first signs of peripheral neuropathy, causes pain, burning,
and itching in the legs and feet, which may be relieved by voluntarily shaking, moving, or rocking
them. Eventually, this condition progresses to paresthesia and motor nerve dysfunction (usually
bilateral foot drop) unless dialysis is initiated.
Other signs and symptoms include muscle cramping and twitching, shortened memory and
attention span, apathy, drowsiness, irritability, confusion, coma, and seizures. Electroencephalogram
changes indicate metabolic encephalopathy.
Endocrine changes
Common endocrine abnormalities include stunted growth patterns in children (even with
elevated growth hormone levels), infertility and decreased libido in both sexes, amenorrhea and
cessation of menses in women, and impotence and decreased sperm production in men. Other changes
include increased aldosterone secretion (related to increased renin production) and impaired
carbohydrate metabolism (causing increased blood glucose levels similar to those found in diabetes
mellitus).
Hematopoietic changes
 Anemia, decreased red blood cell (RBC) survival time, blood loss from dialysis and GI bleeding,
mild thrombocytopenia, and platelet defects occur. Other problems include increased bleeding and
clotting disorders, demonstrated by purpura, hemorrhage from body orifices, easy bruising,
ecchymoses, and petechiae.
Skeletal changes
Calcium-phosphorus imbalance and consequent parathyroid hormone imbalances cause
muscle and bone pain, skeletal demineralization, pathologic fractures, and calcifications in the brain,
eyes, gums, joints, myocardium, and blood vessels. Arterial calcification may produce coronary artery
disease.
Diagnosis
Clinical assessment, a history of chronic progressive debilitation, and gradual deterioration of
renal function as determined by creatinine clearance tests lead to a diagnosis of chronic renal failure.
The following laboratory findings also aid in diagnosis:
• Blood studies show elevated blood urea nitrogen, serum creatinine, and potassium levels;
decreased arterial pH and bicarbonate; and low hemoglobin (Hb) and hematocrit (HCT).
• Urine specific gravity becomes fixed at 1.010; urinalysis may show proteinuria, glycosuria,
erythrocytes, leukocytes, and casts, depending on the etiology.
• X-ray studies include kidney-ureter-bladder radiography, excretory urography,
nephrotomography, renal scan, and renal arteriography.
• Kidney biopsy allows histologic identification of underlying pathology.

6. Materials for self-control

1. What are causes of renal hypertension?
A. Diabetic nephropathy, chronic glomerulonephritis, renovascular diseases, chronic
pyelonephritis, nephrolithiasis.
B. Hypo- or dysplasia of kidney, renal tuberculosis, renal tumor, chronic renal failure,
systemic diseases.
C. Superrenal tumor, amiloidosis, leukimia, chronic hepatitis, reumatic fever, acute
uretritis.
D. A and B.
E. A and C.
2. What is a feature of the renal hypertension?
A. Severe burning heart pain.
B. Pulsatile headache.
C. Asymptomatic hypertension.
D. Nausea and vomiting, bitter taste .
E. Cough, dyspnea.
3. What is a cause of eclampsia?
A. Diabetic nephropathy.
B. Renovascular diseases.
C. Exacerbation of chronic glomerulonephritis.
D. Nephrolithiasis.
E. All mentioned above.
4. What are symptoms of pre-eclampsia?
A. Headache, sleepiness, languor, vomiting, short-time loss of sight.
B. Dyspnea, cough, oligouria.
C. Nausea, vomiting, increased blood pressure.
D. Loin pain, dysuria, headache.
E. Heart pain, dysuria, palpitation, dyspnea.
5. What are the main causes of chronic renal failure?
A. Glomeralonephritis.
B. Chronic pyelonephritis.
 C. Polycystic kidneys.
D. Renal nephrosclerosis.
E. All mentioned above.
6. Which stages does renal failure have?
A. Initial, moderate, severe, terminal.
B. Initial, severe, terminal.
C. Evident, moderate, severe.
D. Initial, evident, severe, terminal.
E. All mentioned above.
7. If level of blood creatinin is 0,384mmol/l, blood urea 15 mmol/l, Hb 100 g/l, decreased Na+
and K+ it is…
A. Severe renal failure.
B. Initial renal failure.
C. Terminal renal failure.
D. Evident renal failure.
E. Renal failure is absent.
8. If level of blood creatinin is 1,782mmol/l, blood urea 35 mmol/l, Hb 60 g/l, decreased Na+
and increased K+ it is…
A. Severe renal failure.
B. Initial renal failure.
C. Terminal renal failure.
D. Evident renal failure.
E. Renal failure is absente.
9. What specific sign may be found at patient with terminal renal failure?
A. Gum ulceration.
B. Melena, hematemesis.
C. Oligouria.
D. Uremic fetor.
E. Gum ulceration.
10. What are not causes of renal hypertension?
A. diabetic nephropathy, chronic glomerulonephritis, renovascular diseases, chronic
pyelonephritis, nephrolithiasis;
B. hypo- or dysplasia of kidney, renal tuberculosis, renal tumor, chronic renal failure,
systemic diseases;
C. superrenal tumor, amiloidosis, leukimia, chronic hepatitis, reumatic fever, acute
uretritis;
D. A and B;
E. B and C.
11. What is a feature of the renal hypertension?
A. “Non-dipper” curve at the daily pressure monitoring.
B. Shift border of the relative heart dullness to the left.
C. Weakened first sound.
D. “Night-picker” curve at the daily pressure monitoring.
E. Hypertensive retinopathy.
12. What is a cause of eclampsia?
A. Diabetic nephropathy.
B. Hypertensive nephropathy.
C. Nephropathy of pregnancy.
D. Nephrolithiasis.
E. All mentioned above
13. What symptoms characterize eclampsia?
A. Dysuria, headache, clear consciousness, hematuria.
 B. Tonic, clonic spasms, sopor, cyanotic face with swelling the neck veins, and foaming at
the mouth.
C. Wide pupils without reaction of light, intense, rare pulse, hypertension, fever,
involuntary defecation and micturition.
D. A and C.
E. B and C.
14. What are the main causes of chronic renal failure?
A. Renal calculi.
B. Systemic lupus erythematosus.
C. Aminoglycoside therapy.
D. Diabetic neuropathy.
E. All mentioned above.
15. If level of blood creatinin is 0,184mmol/l, blood urea 9,6 mmol/l, Hb 120 g/l. Electrolytes
are in a norm it is…
A. Severe renal failure.
B. Initial renal failure.
C. Terminal renal failure.
D. Evident renal failure.
E. Renal failure is absent.

16. If level of blood creatinin is 0,820mmol/l, blood urea 23 mmol/l, Hb 76 g/l, decreased Na+
and K+ it is…
A. Severe renal failure.
B. Initial renal failure.
C. Terminal renal failure.
D. Evident renal failure.
E. Renal failure is absent.
17. If level of blood creatinin is 0,084mmol/l, blood urea 7,3 mmol/l, Hb 126 g/l, normal level
of Na+ and K+ in a blood it is…
A. severe renal failure.
B. initial renal failure.
C. terminal renal failure.
D. evident renal failure.
E. renal failure is absent.
19. What respiratory syndrome may be at patient with renal failure?
A. Bronchial obstruction.
B. Emphysema .
C. Pleural effusion.
D. Lobar consolidation of the lung tissue.
E. Focal consolidation of the lung tissue.
20. What changes of skin may be developed at patient with renal failure?
A. Spots of hyper- and depigmentation
B. Pallid, yellowish bronze, dry, and scaly skin, severe itching; purpura,
ecchymoses; petechiae; uremic frost .
C. Hyperemic, swelled, shining and wet skin.
D. Diffuse, warm cyanosis, nail clubbing.
E. All mentioned above.

Situation tasks

1. The man P. 24 years old complains of face edema, headache due to arterial hypertension,
reddish color of urine. Anamnesis: 2 weeks ago patient was ill with acute tonsillitis.
 1. What is the diagnosis?
2. What are the main courses of this disease?
3. What additional methods of examination should be used?
2. The patient 30 years old during 10 years suffers from bronchoectatic disease. In last half-
year he marks occurrence of edema under eyes in the morning, reduction of the daily
dieresis. It is revealed massive proteinuria.
1. What is the syndrome in this case?
2. What are the main courses of this disease?
3. What additional methods of examination should be used?
3. Patient 28 years old complains of severe pain in loin on right side with irradiation to
inguinal region, perineal region, headache, vomiting. If patient changes position character
of pain is not changed.
1. What syndrome does this patient have?
2. What are the main courses of the disease?
3. What additional methods of examination should be used?
4. The patient 45 years old complains of attacks of nausea, vomiting. It is found urea 19,6
mmol/l and creatinine 450,0 mkmol/l in the blood. In the analysis of urine relative density is
1011. In the anamnesis: chronic glomerulonephritis.
1. What is your conclusion?
2. What are the main courses of this disease?
3. What additional methods of examination should be used?

7. Reference source
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Associate professor Viltsaniuk O.O.