The approach to the patient with renal disease

Question 1

Upper urinary tract symptoms

Answer 1

• Pain: ‘loin to groin’

- Haematuria

Question 2

Lower urinary tract symptoms

Answer 2

1. Obstructive symptoms:
   - Hesitancy
   - Delay in initiating micturition
   - Poor stream
   - Incomplete voiding
   - Terminal dribbling
2. Storage symptoms
   - Frequency
   - Nocturia
   - Urgency
   - Incontinence
   - Bladder pain
   - Dysuria

Question 3

Urine abnormalities

Answer 3

1. Volume
   - Polyurea (increase) = Early CKD, osmotic diuretic or post-renal obstruction
   - Oliguria (decrease) = AKI
   - Anuria (none)
2. Colour
   - Yellow = normal
   - Pale = dilute - Xs H2O
   - Dark = concentrated/bile pigments - dehydrated
   - Pink = blood/beeturia
   - Red = blood
   - Browny red = muscle breakdown
3. Other features
   - Thick = pus (infection)
   - Frothiness = Xs protein
   - Gravel = stone fragments
   - Air = vesico-colic fistula

Question 4

Results from urine testing

Answer 4

1. Leukocytes - detects leukocyte esterase
2. Nitrite - bacteria convert nitrate into nitrite
3. Urobilinogen - suggests haemolysis
4. Protein - glomerular injury
5. pH - high with bacterial infection or renal tubular acidosis
6. Blood - glomerular vs uro-epithelium
7. Ketone - ketoacidosis
8. Bilirubin - obstructive jaundice
9. Glucose - Diabetes mellitus

Question 5

Normal function of the kidneys - A WET BED

Answer 5

A - Acid-base balance

W - Water balance
E - Electrolyte balance
T - Removal of toxins

B - Blood pressure control
E - Erythropoietin production
D - Vitamin D metabolism

Question 6

Sources of blood in urine

Answer 6

1. Uro-epithelium - cancer
2. Glomerular leakage
3. UTI
4. Bladder or kidney stone
5. Enlarged prostate

Question 7

Different techniques to look at the kidneys & ADV/DISADV

Answer 7

1. Ultrasound
   - ADV: Cheap, non-invasive, no radiation, no risk
   - DISADV: Operator dependent
2. CT scan
   - ADV: Good for detecting kidney stones
   - DISADV: Significant radiation exposure, can cause allergy with contrast, and is nephrotoxic
3. MRI
   - ADV: No radiation
   - DISADV: More expensive, takes longer
4. Angiography
   - ADV: Can see vascular anatomy, especially renal arteries and allows intervention
   - DISADV: Invasive
5. Renal biopsy:
   - ADV: Good for cancer diagnosis
   - DISADV: Invasive

Question 8

Advantages and impact of chronic dialysis on the patient

Answer 8

Advantages:

• Immediately life-saving
• MDT support
• Could be a bridge to transplantation for some
• A relief from loneliness and isolation for some on hospital haemodialysis
• For some, an opportunity for further social involvement

Impact:

• Often have multiple medical problems
• Frequent hospital admissions
• Depression and psychological illnesses common
• Heavy burden on time with dialysis, travel, clinics
• Limitation of travel (national or international)
• Restrictions on fluid intake and diet
• Employment difficulties
• Impact of home treatments on the home
• Cost to health provider