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The Renal System:History-Taking &Urine AnalysisClinical Skills2013
Anatomy Gross structure – 2 adult kidneys approximately150g each, lying retroperitoneally in theabdominal cavity on eithe...
Functions of the Kidney Controls volume, osmolarity and acid-base balance of plasma and EC fluid, aswell as the level of ...
Functions of the Kidney (cont) Excretes toxic metabolites and excesselectrolytes and water Maintains red cell production...
SPECTRUM OF DISEASE Congenital abnormalities Interstitial nephritis Glomerulonephritis Cystic kidney disease Renal va...
History-Taking Gathering of information Patient narrative Biomedical perspective Psychosocial perspective Context
Cardinal symptoms of diseases of theurinary tract – presenting complaint/s Abnormalities of micturition Pain presentatio...
ABNORMALITIES OFMICTURITION Dysuria Frequency and nocturia Urgency Hesitancy, decreased stream anddribbling Retention...
Dysuria Dysuria = pain / discomfort duringmicturition Often referred to as burning onmicturition Associated with cystit...
Frequency and nocturia Frequency = the need to pass smallamounts of urine frequently Due to bladder irritation – may bec...
Urgency Urgency = a sudden compelling need tourinate Caused by local irritation or inflammation
Hesitancy, decreased streamand dribbling Hesitancy = delay /difficulty in initiatingmicturition Poor stream Dribbling =...
Retention Retention of urine - due to obstructivelesions such as stricture, benignprostatic hypertrophy or BPH, tumour M...
Incontinence Incontinence is the inability to hold urine in the bladdervoluntarily Spinal cord lesions are associated wi...
PAIN PRESENTATIONS- renal, ureteric, vesical, urethral Renal angle pain - dull ache between 12thriband erector spinae mus...
ALTERATION IN URINEAPPEARANCE Change in colour egOrange -RifampicinRed -bloodBlack -malaria
ALTERATION IN AMOUNTOF URINE Polyuria Oliguria Anuria
Polyuria Passage of > 3 litres of urine per day Physiological – ingestion of large quantities offluid or substances cont...
Oliguria Passage of < 500ml of urine per day Physiological - under conditions ofwater deprivation Prerenal conditions –...
Anuria Passage of <50 mls of urine in a day Some causes:Renal infarctDissecting aneurysmComplete ureteric obstruction
Notes re Renal Failure Occurs when glomerular filtration iscompromised May also be the consequence of abnormaltubular fu...
Renal Failure (cont) Acute renal failure – suddendeterioration of renal function, usuallyreversible Chronic renal failur...
Clinical consequences of renalfailure Hypertension – renin secreted in response to impairedperfusion – activates ACE to c...
GENERAL CLINICALFEATURES OF RENALDISEASE Renal oedema Increased BP - see previous slides onrenal failure
GENERAL FEATURES (cont) Other symptoms and signs of renal failure:AnaemiaPurpura plus GIT bleedingUrogenital symptoms – p...
HISTORY-TAKING (cont) History of presenting complaint to be indetail – chronology is important,especially in chronic cond...
HISTORY-TAKING - Context Past HistoryPreceding throat or skin infection - StrepRecurrent UTIRenal stoneHT, DM, hyperurica...
HISTORY-TAKING - Context Medications(Remember to ask about OTC drugs and herbalmedications as well)SteroidsImmunosuppress...
HISTORY-TAKING - Context Family HistoryDM, hypertensionInherited forms of renal disease eg adultpolycystic kidney disease...
HISTORY-TAKING - Context Social HistoryEmployment – occupational exposureseg heavy metals such as CadmiumHome circumstanc...
Urine Volume & Composition In health, the kidneys form approx 1500-2000mls of urine/24hrs Urine is normally pale yellow ...
Urine composition vs that ofplasma Much higher levels of nitrogenous wasteproducts such as urea and ammonia Much lower c...
URINE EXAMINATION Inspection- colour and appearance (? foamy)- deposits - cloudiness of the urine may be dueto the presen...
URINE EXAMINATION Reaction- usually acidic Smell- mild smell of ammonia is normal- smell of antibiotics, foodstuffs- fis...
Chemical Analysis•Chemical reagent strips eg Combur-9“Dipstix”•Strip is dipped in urine; colour changes aremeasured after ...
Protein:Dipstix measurement is semi-quantitative + -++++Causes of proteinuria– renal disease egdiabetic nephropathy, fever...
Nitrite:– positive due to infection with bacteria thatproduce nitrite – correlates well with UTI(inaccurate results with V...
Causes of haematuria – examples:Renal causes – glomerulonephritis, renal carcinoma,analgesic nephropathy, bleeding disorde...
Microscopy – ref TalleyMSU - NB Method of collection – need a cleanuncontaminated specimen using a sterile urine jar• Micr...
Types of castsHyaline casts - < 1 per lpf, consist of Tamm-Horsfallmucoprotein secreted by renal tubules, may contain 1-2R...
Culture and SensitivityTo identify organism in infectionsTo assess sensitivity to anti-microbials
References• Past protocols• Medical Science, Jeannette Naish et alChapter 14 The Renal System• Clinical Examination, Talle...
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  1. 1. The Renal System:History-Taking &Urine AnalysisClinical Skills2013
  2. 2. Anatomy Gross structure – 2 adult kidneys approximately150g each, lying retroperitoneally in theabdominal cavity on either side of the vertebralcolumn at level of T12 – L3 Renal vasculature – renal artery and vein Urine drains via pelvis of kidney into the ureters,which cross over the pelvic brim to drain intothe bladder (NB pelvi-ureteric and vesico-ureteric junctions – note VUR associated with acongenital defect) Bladder, trigone, urethra, sphincter
  3. 3. Functions of the Kidney Controls volume, osmolarity and acid-base balance of plasma and EC fluid, aswell as the level of electrolytes Recovers small molecules filtered by thenephron, such as amino acids andsugars Excretes nitrogenous waste from proteinmetabolism, mainly urea, uric acid andcreatinine
  4. 4. Functions of the Kidney (cont) Excretes toxic metabolites and excesselectrolytes and water Maintains red cell production by thesecretion of erythropoietin Maintains calcium balance by productionof the active form of Vitamin D Controls blood pressure
  5. 5. SPECTRUM OF DISEASE Congenital abnormalities Interstitial nephritis Glomerulonephritis Cystic kidney disease Renal vascular disease Nephrotic syndrome Renal failure Infections of the urinary tract Obstruction of the urinary tract Urinary tract calculi and nephrocalcinosis Malignancy of the urinary tract eg CA bladder Incontinence
  6. 6. History-Taking Gathering of information Patient narrative Biomedical perspective Psychosocial perspective Context
  7. 7. Cardinal symptoms of diseases of theurinary tract – presenting complaint/s Abnormalities of micturition Pain presentations Alteration in the appearance of urine Alteration in the amount of urine General symptoms of abnormal renal function
  8. 8. ABNORMALITIES OFMICTURITION Dysuria Frequency and nocturia Urgency Hesitancy, decreased stream anddribbling Retention Incontinence
  9. 9. Dysuria Dysuria = pain / discomfort duringmicturition Often referred to as burning onmicturition Associated with cystitis or urethritis
  10. 10. Frequency and nocturia Frequency = the need to pass smallamounts of urine frequently Due to bladder irritation – may becaused by infection, stone, tumour Nocturia = waking up to pass urine atnight (pregnancy - pressure, diabetes –associated with polyuria)
  11. 11. Urgency Urgency = a sudden compelling need tourinate Caused by local irritation or inflammation
  12. 12. Hesitancy, decreased streamand dribbling Hesitancy = delay /difficulty in initiatingmicturition Poor stream Dribbling = terminal dribbling afterpassage of urine Associated with urinary obstruction –often associated with prostatism orbladder outflow obstruction in elderlymen
  13. 13. Retention Retention of urine - due to obstructivelesions such as stricture, benignprostatic hypertrophy or BPH, tumour May be heralded by the phase ofhesitancy
  14. 14. Incontinence Incontinence is the inability to hold urine in the bladdervoluntarily Spinal cord lesions are associated with retention andoverflow neurogenic incontinence Prostatic enlargement is associated with overflowincontinence – dribbling incontinence after incompleteurination Stress incontinence – more common in women – leakageof urine after sudden increase in intra-abdominalpressure eg due to coughing or sneezing, and associatedwith bladder prolapse Urgency incontinence – associated with urgency andcaused by local irritation or inflammation
  15. 15. PAIN PRESENTATIONS- renal, ureteric, vesical, urethral Renal angle pain - dull ache between 12thriband erector spinae muscle on the side of theaffected kidney – pyelonephritis. (Refer renalangle tenderness) Renal colic – due to ureteric obstruction – asevere pain – lumbar region; radiates toabdomen, groin, testes, thigh – due to stone ortumour Ureteric colic – spasmodic, severe pain duringthe passage of a renal calculus; radiation pathof renal colic; may be associated with vomiting,sweating. Suprapubic pain from bladder / urethra isreferred to lower abdomen, perineum and glanspenis in males
  16. 16. ALTERATION IN URINEAPPEARANCE Change in colour egOrange -RifampicinRed -bloodBlack -malaria
  17. 17. ALTERATION IN AMOUNTOF URINE Polyuria Oliguria Anuria
  18. 18. Polyuria Passage of > 3 litres of urine per day Physiological – ingestion of large quantities offluid or substances containing diuretics Pathological- Chronic renal failure or CRF – associatedpolydipsia- Diabetes mellitus – associated polydipsia- Diabetes insipidus – neurohypophyseal ornephrogenic- Oedematous states – after administration ofdiuretics
  19. 19. Oliguria Passage of < 500ml of urine per day Physiological - under conditions ofwater deprivation Prerenal conditions – shock,dehydration, haemorrhage Renal – Acute renal failure or ARF
  20. 20. Anuria Passage of <50 mls of urine in a day Some causes:Renal infarctDissecting aneurysmComplete ureteric obstruction
  21. 21. Notes re Renal Failure Occurs when glomerular filtration iscompromised May also be the consequence of abnormaltubular function Prerenal – due to decreased renal perfusion eghypotension due to massive blood loss orcardiac failure Renal – due to disease of nephron, glomeruli,microvasculature (cf DM) or tubules (cf acutetubular necrosis) Postrenal – due to obstruction to outflow orrecurrent ascending infections
  22. 22. Renal Failure (cont) Acute renal failure – suddendeterioration of renal function, usuallyreversible Chronic renal failure – longstanding andprogressive impairment of renalexcretory function – may be insidious inonset
  23. 23. Clinical consequences of renalfailure Hypertension – renin secreted in response to impairedperfusion – activates ACE to convert angiotensin I – II– vasoconstriction – aldosterone secretion – sodiumand water retention (renin- angiotensin-aldosteronesystem) Anaemia – erythropoietin deficiency Hypoproteinaemia due to protein loss – wasting andmalnutrition Renal osteodystrophy from failure of hydroxylation ofVitamin D to active form (2º hyperparathyroidism) Other metabolic complications eg gout (defectiveexcretion of uric acid), endocrine and neurologicalcomplications
  24. 24. GENERAL CLINICALFEATURES OF RENALDISEASE Renal oedema Increased BP - see previous slides onrenal failure
  25. 25. GENERAL FEATURES (cont) Other symptoms and signs of renal failure:AnaemiaPurpura plus GIT bleedingUrogenital symptoms – polyuria, polydipsia etcCardiovascular symptomsGIT symptoms – anorexia, nausea & vomiting, lossof weight, ammonia smell on the breathSkeletal abnormalities – metabolic bone diseaseGrowth retardation in children and other endocrineproblems including gynaecomastia in menNeurological symptoms such as depressed cerebralfunction and convulsions in severe uraemia
  26. 26. HISTORY-TAKING (cont) History of presenting complaint to be indetail – chronology is important,especially in chronic conditions Don’t forget the systems enquiry – tocover specific relevant aspects
  27. 27. HISTORY-TAKING - Context Past HistoryPreceding throat or skin infection - StrepRecurrent UTIRenal stoneHT, DM, hyperuricaemia (gout)Childhood enuresis > 3 years of age (may beassociated with vesico-ureteric reflux and renalscarring)HIV status, TB and Hepatitis B, CPast surgery or biopsy
  28. 28. HISTORY-TAKING - Context Medications(Remember to ask about OTC drugs and herbalmedications as well)SteroidsImmunosuppressantsAntibioticsAnti-hypertensives(know which drugs to avoid eg tetracyclines,NSAIDs) Diet – protein, fluid, salt restriction
  29. 29. HISTORY-TAKING - Context Family HistoryDM, hypertensionInherited forms of renal disease eg adultpolycystic kidney disease - inherited asan autosomal dominant; Alport’sSyndrome - inherited as an X-linkedrecessive
  30. 30. HISTORY-TAKING - Context Social HistoryEmployment – occupational exposureseg heavy metals such as CadmiumHome circumstances, family supportImpact of chronic illness, dialysisSmoking and alcohol use
  31. 31. Urine Volume & Composition In health, the kidneys form approx 1500-2000mls of urine/24hrs Urine is normally pale yellow in colour(becomes paler with decrease inosmolarity when large volumes of waterare ingested, and vice versa) pH is about 6 – slightly acidic
  32. 32. Urine composition vs that ofplasma Much higher levels of nitrogenous wasteproducts such as urea and ammonia Much lower concentrations of glucose,protein and amino acids Solutes such as salts eg NaCl, KCl andNaHCO3, and urea are excreted at afairly constant rate, independent of thevolume of urine Plasma has a constant osmolaritywhereas that of urine varies widely
  33. 33. URINE EXAMINATION Inspection- colour and appearance (? foamy)- deposits - cloudiness of the urine may be dueto the presence of bacteria or crystals(phosphates - white, urates – pink) Specific gravity (1.005 – 1.035 Naish) Note SGof water is 1.000 and of plasma 1.010- Decreased SG - CRF- Increased SG - DM
  34. 34. URINE EXAMINATION Reaction- usually acidic Smell- mild smell of ammonia is normal- smell of antibiotics, foodstuffs- fishy odour associated with UTI Quantity- (N) in 24hrs = 1500 - 2000ml
  35. 35. Chemical Analysis•Chemical reagent strips eg Combur-9“Dipstix”•Strip is dipped in urine; colour changes aremeasured after a set period and comparedwith a colour chart•Analysis of pH, protein, glucose, ketones,nitrite, bilirubin, urobilinogen, blood andleucocytes•To be demonstrated in Skills Lab
  36. 36. Protein:Dipstix measurement is semi-quantitative + -++++Causes of proteinuria– renal disease egdiabetic nephropathy, fever, post-operative,CCF, orthostatic proteinuriaGlucose:Causes of glycosuria – usually diabetesmellitus, also renal glycosuria (Note falsepositive and negative results eg large dosesVit C)Ketones:Causes of ketonuria – diabetic keto-acidosis and starvation
  37. 37. Nitrite:– positive due to infection with bacteria thatproduce nitrite – correlates well with UTI(inaccurate results with Vitamin C ingestion)Pus (WBCs):Causes of pyuria (pus in the urine)Urinary tract infection UTISterile pyuria in renal tuberculosisBlood:– positive dipstix is abnormal(Causes of haematuria, haemoglobinuria, etc– see next slide)
  38. 38. Causes of haematuria – examples:Renal causes – glomerulonephritis, renal carcinoma,analgesic nephropathy, bleeding disorders, traumaUrinary tract – cystitis, calculi, tumourCauses of haemoglobinuria – examples:Intravascular haemolysis eg haemolytic anaemia, marchhaemoglobinuriaCauses of myoglobinuria – examples:Convulsions, viral myositis, toxins such as snake venom(due to muscle destruction)
  39. 39. Microscopy – ref TalleyMSU - NB Method of collection – need a cleanuncontaminated specimen using a sterile urine jar• Microscopic examination of a centrifuged specimenLook for:• RBCs – circular, without a nucleus – uniform if from theurinary tract, dysmorphic if from the glomeruli , usually 0, < 5per lpf in very concentrated urine• WBCs – lobulated nuclei < 6 per hpf – up to 10 may bepresent in very concentrated urine• Epithelial cells• Bacteria – infection or contamination• Casts - cylindrical moulds formed in the lumen of renaltubules or collecting ducts- size determined by the dimension - they indicate damageto the glomerular basement membrane or tubule
  40. 40. Types of castsHyaline casts - < 1 per lpf, consist of Tamm-Horsfallmucoprotein secreted by renal tubules, may contain 1-2RBCs or WBCsGranular casts – consist of hyaline material containingfragments of serum proteinsRed cell casts – always abnormal – indicate primaryglomerular disease, contain 10-50 RBCs – post-Streptococcal GN, SBE etcWhite cell casts – WBCs adhere to inside of cast –usually indicate bacterial pyelonephritisFatty casts – these suggest nephrotic syndrome
  41. 41. Culture and SensitivityTo identify organism in infectionsTo assess sensitivity to anti-microbials
  42. 42. References• Past protocols• Medical Science, Jeannette Naish et alChapter 14 The Renal System• Clinical Examination, Talley and o’ConnorChapter 6 The Genitourinary System• Principles and Practice of Medicine,Davidson
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