Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Renal system history taking & urine analysis 2012


Published on

Published in: Education, Health & Medicine

Renal system history taking & urine analysis 2012

  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