PRESENTATION OF KIDNEY DISEASE Flashcards
Haematuria can be
microscopic (non-visible) or macroscopic (visible)
haematuria means
blood in the urine
proteinuria means
protein in the urine
proteinuria usually indicates that
significant kidney damage has occurred
main functions of the kidney
- excretion of nitrogenous waste and drugs
- fluid balance
- electrolyte balance
- acid base balance
- vitamin D metabolism/ phosphate excretion
- production of erythropoietin
inability to excrete nitrogenous waste causes
uraemia which causes pericarditis, encephalopathy, increased risk of infection, bleeding
disruption fo fluid balance can cause
fluid balance and oedema
disruption of electrolyte balance can cause
hyperkalaemia which can cause cardiac arrest
disruption of acid-base balance causes a
metabolic acidosis which leads to kaussmals repsiration
disorder of drug excretion causes
drug toxicity i.e. digoxin and garbapentin
the kidney is also a barrier to
the loss of proteins
disruption to this barrier causes
proteinuria causing nephrotic syndrom
history taking in renal disease
- presenting complaint but if they are asymptomatic may have to be pick up using urinalysis or reduced eGFR or biochemical screen or incidental finding using abdominal imaging or screening because of family history
presenting symptoms in an underlying disease caused by
diabetes mellitus, connective tissue disorders, vascular disease
presenting symptoms relating to loss of kidney fucntion
uraemia, anaemia, hypocalcaemia
localised presenting symptoms
loin pain, macroscopic haemturia, fever
systemic enquiry
- appetite and weight loss
- nausea and vomiting
- dyspnoea
- urinary symptoms (urinary frequency, urgency, hesitancy, polyuria, nocturia)
- joint paina/ skin or rashes
urinary frequency
is the need to urinate more often than normal
urinary urgency
sudden urge to urinate due to involuntary contraction of the bladder
polyuria
the excessive passage of urine at least 2.5 litres per day in adults
past medical history
kidney disease, diabetes mellitus, vascular disease, surgery, TB, rheumatological
family history
renal disease or hypertension
social history
smoking, alcohol or occupation
drug history
ace inhibitors, angiotensin receptor blockers, aldosterone antagonists
why are NSAIDS avoided in renal disease
because they can cause haemodynamically mediated acute kidney injury, electrolyte ad acid-base disorders, acute-interstial nephritis which may be accompanied by the nephrotic syndrome and papillary necrosis
what weird drug increases the risk of an AKI
proton pump inhibitors
what antibiotics can cause an AKI
gentamicin and vancomycin
what is used for investigations which should not be used in people with renal disease
radiological IV contrast
why is blood pressure so important in renal disease
- hypotension means the kidney are not being adequately perfused therefore, they are not adequately functioning
- hypertension is damaging to the kidneys and is the number one cause of chronic kidney disease
what is accelerated hypertension (malignant hypertension)
a medical emergency diastolic blood pressure is usually greater than 120mmHg
malignant hypertension will cause end organ decompensation
encephalopathy, cardiac failure,acute renal failure
leukonychia is a sign of
hypoalbunaemia which can be seen in nephrotic syndrome
causes of haematuria
UTIS, bladder tumour, calculi, benign prostatic hypertrophy, prostate cancer
infections causing haematuria
cystitis, tuberculosis, prostatitis, schistosomiasis
tumours causing haematuria
renal carcinoma,wilms tumour (nephroblastoma), carcinoma of the bladder, prostate cancer, urethral cancer
trauma causing haematuria
RTAS, catheter, foreign bodies
inflammation causing haematuria
glomerulonephritis, IgA vasculitis, good pastures syndrome
structural renal disease causing haematuria
calculi, simple cysts, polycystic kidney disease, congenital vascular anomalies
haematological disease causing haematuria
sickle cell disease, coagulation disorders, anti-coagulation therapy
toxins causing haematuria
sulfonadmides, cyclophosphamide, NSAIDS
differential diagnosis of red or dark urine
- myoglobinuria= presence of myoglobin in the urine caused by rhabdomyolysis
rhabdomyolysis is caused
by the breakdown of skeletal muscle fibres and myocyte cell membranes leading the release muscle content into the circulation causing multiple complications including hyperkalaemia
myocyte function under normal conditions is maintained
by adenosine-triphosphate dependant channels, which ensure effective cell ion levels and play a role in calcium flux from myocytes, damage to the mycotic membrane causes an increase in the amount of calcium in the cell which leads to apoptosis through various proteolytic enxymez, this leads to muscle necrosis and released various substances into the circulation including myoglobin, potassium, phosphate, creatinine kinaseand rate
any myoglobin within the circualtion
will be filtered by the kidneys and can lead to an acute kidney injury through direct toxicity or precipitation
causes of rhabdomyolysis
alcohol abuse, status epileptics, trauma, burns, crush injuries
urinalysis gross insepction
gross insepction= colour and turbidity
urinalysis urine dipstick
specific gravity, pH, glucose, heme, leukocyte esterase, nitrites, ketones, bilirubin, urobilingen
urine microscopy
WBC’S, RBC’S, bacteria, crystals and casts
urine colour varies with
states of hydration but can be influenced by medical condition, medications and food
red urine can be caused by
bleeding anywhere in the renal tract, rifampicin and beetroot
organe urine caused by
hyperbilirunaemia, rifampicin, excess ingestion of vitamin A or Vitamin B
brown/ black urine caused by
metronidazole or nitrofurantoin
green urine caused by
UTIS secondary to pseudomonas, methylene blue, amytryptyline
purple urine caused by
infected urinary catheters
white urine caused by
hypercalcaemia, phosphaturia, chyluria (leakage of lymphatic fluid into the urine most commonly seen in the tropics caused by a parasitic infection called phyriasis TU
Turbidity of urine is
how clear or cloudy the urine is
turbid urine may indicate
presence a UTI ore precipitated crystals
specific gravity is
density of urine/ density of water
specific gravity various from
1.01 to 1.02 depending on renal perfusion and fluid status
specific gravity is a measure of
relative density although urine is mostly composed of water because it also contains electrolytes and urea it is more dense
as a general rule
urine osmolality = specific gravity-35 but this is inaccurate in condition where there is significant protein or glucose in the urine because they will increase urine density out of proportion to the osmolality
in normal patients specific gravity is around
1.01which implies the urine omsolairtyis the same than the omsoalirty of the serum
if specific gravity is close to 1.001 this means
that the urine is more dilute than normal and implies either excessive hydration, diabetes insidious or acute tubular necrosis
if specific gravity is close to 1.035 then this means
the urine is more concentrated than normal caused by dehydration, SIADH or caused by impaired perfusion seen in chronic heart failure, cirrhosis, glycosuria or proteinuria
specific gravity fixed at1.01 is likely to indicate
advanced kidney failure where the kidney cannot regulate urine concentration
when the kidneys are functioning normally
- they will excrete more hydrogen ions in academia resulting in a lower pH of urine
- they wille excrete less hydrogen ions in alkalaemia resulting in a higher pH of urine
low pH of urine (around 5)
caused by academia caused by hypoventilation or from excessive production of lactation ketones
pH around 7.8 of urine
caused by alkalaemia
- organisms that produces creases (proteus, klebsiella) catalyses the breakdown of urea to ammonia
glycosuria
if sever can cause an osmotic diuresis
causes of glycosuria
serum hyperglycaemia, proximal tubuarl dysfunction (e.g in fanconi syndrome)
heme
urine dipstick for heme is highly sensitive for heme but it also detects myoglobin positive in haematuria or rhabdomyolysis
protein in urine is most sensitive for
albumin: the more concentrated the urine the more sensitive the test
leukocyte esterase and nitrites used to diagnose
UTIS
what is leukocyte esterase
an enzyme released from white blood cells
nitrites detect specific presence of
enterobactirase which convert nitrates in urine to nitrites
leukocyte esterase
is only a marker for inflammation, nitrites are more specific for actual bacteria
both leukocyte esterase and nitrites
can be seen in UTIS and indwelling catheters but only leukocyte esterase is seen in recent instrumentation of the GU tract, urological malignant, chronic interstitial nephritis and interstitial cystitis
urinary cast is a
protein mould of the renal tubule
red cells stuck to a renal cast
indicates nephritis
white cells stuck to cast
are associated with infection
nephrotic syndrome
- loss of protein in the urine= protein greater than 3g/day
- causes hypoalbunaemia because albumin is lost in the urine because gaps in the podocytes allow albumin to leak
hypoalbunaeia causes decreased what?
Increased intra-vascular oncotic pressure as a result fluid moves out of the intra-vascular compartment into surrounding tissues causing oedema
due to the hypoalbunaemia
the liver compensates and increased albumin production however, this has the side affect of causing hyperlipideamea
oedema can affect the
arms ankles and eyes
