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Clinical manifestations of_renal_diseasesffff - copy (2)


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Clinical manifestations of_renal_diseasesffff - copy (2)

  1. 1. Introduction and Clinical Manifestations of Renal Disease (1) Salwa Ibrahim, MD MRCP (UK) Professor of Nephrology
  2. 2. Objectives• To know basic structure and functions of the kidney• To know main symptoms of renal disease• To know how to assess kidney functions
  3. 3. Anatomy• The kidneys are retroperitonealorgans lie on either side of the spineat level of T12-L3• Normal kidneys are 11-14 cm inlength• Right kidney lies 1.5 cm lower thanthe left because of the liver
  4. 4. HistologyEach kidney contains onemillion nephrons comprising aglomerulus, PCT, Loop of Henle,distal tubule and collecting duct
  5. 5. Blood and nerve supply to the kidney• The kidneys receive 25% of the cardiac output• T10-12/L1 roots innervate the renal capsule and the ureter and pain from these structures is felt in these dermatomes
  6. 6. The Glomerulus• A glomerulus is a capillary tuft that is surrounded by Bowmans capsule• A glomerulus receives its blood supply from an afferent arteriole Unlike most other capillary beds, the glomerulus drains into an efferent arteriole• The resistance of these arterioles results in high pressure within the glomerulus, aiding the process of ultrafiltration, where fluids are forced out of the capillaries and into Bowmans capsule• A glomerulus and its surrounding Bowmans capsule constitute a renal corpuscle, the basic filtration unit of the kidney• The rate at which blood is filtered through all of the glomeruli, and thus the measure of the overall renal function, is the glomerular filtration rate (GFR).
  7. 7. The glomerular layersPodocytesGlomerular basement membraneEndothelial cells
  8. 8. Primary functions of the kidneys• Excretion of waste products e.g. urea• Maintain body water and electrolytes• Regulation of BP through renin angiotensin system• Endocrine function in erythropoiesis and vitamin D metabolism
  9. 9. The kidneys produce urine which is passesto the bladder through the uretersAs the bladder fills completely, the smoothmuscle layer (detrusor) contractsunder parasympathetic control to allowurine to pass through the urethra
  10. 10. Symptoms of renal diseaseI. Kidney (upper urinary tract symptoms): Pain and swellingII. Lower urinary tract symptoms: voiding pain (pain passing urine), frequency, urgency, hesitancyIII. Change in urine volume (polyuria, oliguria, anuria) or color (haematuria), content (proteinuria)IV. General symptoms: oedema, fatigue, nausea, vomiting, shortness of breath
  11. 11. Kidney (Upper urinary tract) symptoms
  12. 12. PainA. Renal colic• A severe sudden sustained loin pain• It often radiates to the groin• It is caused by sudden obstruction in the urinary tract usually by a calculus or a blood clot• It is often associated with nausea and vomiting
  13. 13. B.Dull ache in the loins• Usually due to stretch of the capsule of the kidney e.g. in glomerulonephritis, polycystic kidney and hydronephrosis• Lion pain with fever, rigors, pain on voiding suggest infection of the kidneys (acute pyelonephritis)• Many patients with chronic obstruction are however pain-free
  14. 14. Lower urinary tract symptoms
  15. 15. Dysuria• Pain or discomfort felt during or immediately after passing urine• It is often described as a burning sensation felt at the urethral meatus , or the suprapubic region• The most common cause is infection and /or inflammation of the bladder[cystitis]and frequency(desire to pass urine more often) is usually present
  16. 16. Voiding symptoms
  17. 17. Voiding symptoms• During storage phase• During voiding phase• After micturition• Incontinence
  18. 18. Storage symptoms Urgency• A sudden strong need to pass urine and may cause incontinence if there is no opportunity to urinate. Is due to overactivity of detrusor muscle or abnormal stretch receptor activity from the bladder Frequency• Means frequent micturition of relatively small amounts of urine
  19. 19. Causes• Cystitis, urthritis or stone bladder causing irritation of the bladder wall• Contracted bladder as occurs in Bilharziasis; the diminished capacity of the bladder leads to frequent micturition• Chronic retention of urine e.g. by enlarged prostate small amount of urine overflow from the bladder at frequent intervals• Cancer bladder• Psychogenic factors as anxiety.
  20. 20. Voiding phase symptoms Hesitancy: delay or difficulty in initiating urine flow• In men over 40, it is commonly due to bladder outlet obstruction by prostate enlargement• In women, it suggests urethral obstruction due to stenosis or uterine prolapse Poor flow: reduction in urinary stream
  21. 21. After micturition symptoms• Dribbling and incomplete emptying are caused by obstruction• Incontinence : involuntary release of urine may occurI. With the need to void (urge incontinence) caused by overactive detrusorII. or with increased intra abdominal pressure (stress incontinence) due to weakness of pelvic floor following childbirth
  22. 22. Symptoms of bladder outlet obstruction• Urgency• Frequency• Hesitancy• Poor flow• Dribbling
  23. 23. Change in urine volume
  24. 24. Polyuria Means increased volume of urine as the capacity of the bladder is limited, polyuria is associated with frequency N.B : In healthy adults urine out put will approximate to the fluid intake minus the insensible fluid losses through the skin and respiratory tract[500-800 ml/day], average 2-3 liters/dayCauses1-Diabetes mellitus (due to osmotic effect of glucose)2-Chronic renal failure especially with chronic tubulointertsitial fibrosis3-Diabetes insipidus4- Hypercalcaemia (due to impaired tubular concentrating mechanism)5- Hypokalemia (due to impaired tubular concentrating mechanism)6- Excessive fluid intake due to psychiatric disease.
  25. 25. OliguriaMeans diminished volume of urine <500 mldayCauses1- Diminished intake of fluids2- Hot weather2- Pre-renal failure3- Initial stage of acute renal failure4- Terminal stage of chronic renal failure
  26. 26. Anuria Means complete absence of urine formation so that no urine reaches the bladder and the patient has no desire to micturate Causes• lower urinary tract obstruction when bladder neck or urethral obstruction causes urinary retention• Spinal injury through neurological damage
  27. 27. Change in urine colour
  28. 28. Haematuria• Means passage of red blood cells in urine• It can beI. Macroscopic causing a reddish discoloration of the urineI. Microscopic when excess red cells are detected in urinary sediment
  29. 29. • Causes1- Prerenal e.g. Haemoragic diseases as purpuraand over dose of anticoagulants2-Renal e.g. Stones, tumours, glomerulonephritis,and renal T.B3-Ureter: stone and tumours4- Bladder : cystitis, stone and tumours5- Prostate : prostatitis, prostatic hypertrophy andtumours6- Urethra: trauma, stricture, stone and tumours
  30. 30. It should be noted that• Terminal haematuria indicates a lesion in the urethra, prostate , or bladder neck while total haematuria means the lesion is higher up• Haematuria associative with renal colic is suggestive of stone• Painless frank haematuria is suggestive of tumour• Microscopic haematuria is suggestive of a parenchymatous lesion as glomerulonephritis
  31. 31. Differential diagnosis of haematuria (causes of reddish urine)• Contamination of urine by menstrual blood• Free hemoglobin due to intravascular hemolysis• Free myoglobin in rhabdomyolysis• Drug therapy : rifampcin
  32. 32. Change in urine contents
  33. 33. Proteinuria Proteinuria is usually asymptomatic unless gross > 2-3 g/day Severe proteinuria may produce frothy urine Lowering the plasma albumin concentration, oncotic pressure Generalized oedema and nephrotic syndrome
  34. 34. Nephrotic syndrome
  35. 35. Causes of proteinuria1. Renal disease• Glomerulonephritis• Diabetes mellitus• Lupus nephritis2. Non renal disease• Fever• Severe exertion• Heart failure
  36. 36. General symptoms of chronic kidney disease
  37. 37. General symptoms of renal disease• Broadly non specific• Occur in chronic kidney disease due to retention of uremic toxins• Nausea vomiting itching disturbed consciousness• Fatigue and pallor secondary to anemia• Bony aches and muscle weakness• Shortness of breath (anemia, volume overload)
  38. 38. Uremic symptoms
  39. 39. Symptoms secondary to anemia
  40. 40. Symptoms secondary to bone disease• Bone pain• Joint pain• Bone fracture
  41. 41. Symptoms secondary to volume overload 1. Lower limb swelling 2. Pleural effusion 3. Pulmonary edema
  42. 42. Investigations
  43. 43. Renal function tests• Serum creatinine• Blood urea• Serum electrolytes• Complete blood count• Creatinine clearance• Serum calcium and phosphorus
  44. 44. Urine analysis Flat colorless hexagonal plates, which often aggregate Stix test for blood protein sugar Red cell cast Cystine crystalsFlat colorless hexagonal plates which often aggregate
  45. 45. Microscopic examination Uric acidWhite cells Phosphate crystals RBCs
  46. 46. Radiologic assessment of UT
  47. 47. Plain X-ray Abdomen Detection of calcification and radiopaque stonesUreteric stone bilateral staghorn stones Right staghorn stone
  48. 48. Intravenous Pyelogram (IVP)
  49. 49. Hydronephrosis
  50. 50. Renal ultrasonographyNo exposure to radiation and no dye is used 1. Assess renal dimensions 2. Exclude obstruction 3. Polycystic kidney Disease
  51. 51. Renal biopsy Indications1. Nephrotic syndrome2. Nephritic syndrome3. Acute renal failure4. Proteinuria, haematuria
  52. 52. Normal glomerulus
  53. 53. Membranous nephropathy
  54. 54. Necrotizing GN