clinical presentation of renal disease

Clinical Clinical manifestations of manifestations of

renal diseaserenal disease

Dr. Thilak Jayalath

Senior Lecturer in Medicine

Faculty of Medicine

Peradeniya

The presence of renal The presence of renal disease in a patient may be disease in a patient may be

detected because ofdetected because of

•  Presentation with a Presentation with a symptom or clinical sign symptom or clinical sign that indicates an underlying that indicates an underlying renal disorderrenal disorder

• The presence of a The presence of a systemic disease known to systemic disease known to involve the kidneyinvolve the kidney

The presence of renal The presence of renal disease in a patient may be disease in a patient may be

detected because ofdetected because of

• A family history of A family history of inherited renal diseaseinherited renal disease

• The finding of The finding of asymptomatic urinary asymptomatic urinary abnormalities or disordered abnormalities or disordered renal function testsrenal function tests

Symptoms of renal disease include

• Disturbance in the act of Disturbance in the act of micturition micturition

• Alteration in the amount Alteration in the amount and and appearance of appearance of urine urine

• Pain : renal, ureteric, Pain : renal, ureteric, vesical, and vesical, and urethral urethral

• General symptoms of renal General symptoms of renal diseasedisease

Disturbance in the act of Disturbance in the act of micturitionmicturition

FrequencyFrequency

Passing urine more often Passing urine more often than usual without increase than usual without increase in the amount of urinein the amount of urine

Disturbance in the act of micturition

Frequency

Results fromResults from

• Irritation of the bladderIrritation of the bladder

• Reduction in the capacity Reduction in the capacity of the of the bladderbladder

• Pressure from a pelvic Pressure from a pelvic tumourtumour

Disturbance in the act of micturition

Dysuria

Pain in passing urinePain in passing urine

Usually results from disease Usually results from disease of the of the

• BladderBladder

• ProstateProstate

• UrethraUrethra

Disturbance in the act of micturition

DysuriaDysuria

Pain experienced prior to , Pain experienced prior to , during, or following during, or following micturition usually in the micturition usually in the urethra or suprapubic urethra or suprapubic region region

Commonly due to infection Commonly due to infection of lower urethral tractof lower urethral tract

Disturbance in the act of micturition

Retention of urine

Occurs in

• Obstructive lesions of the urethra

• Disease of the spinal cord

• Coma

Disturbance in the act of micturition

Incontinence of urine

Seen in

• Cerebrovascular lesions

• Paraplegia

• Multiple slerosis

• Prolapsed uterus with cystocele

Disturbance in the act of micturition

Nocturia

Passing urine in the night ( commonly associated with polyuria)

Other causes• Prostatism

• Cystitis

• Bladder tumours

Disturbance in the act of micturition

Stranguary

Severe supra pubic pain associated with inability to pass urine

Seen in

• Cystitis

• Bladder tumour

Disturbance in the act of micturition

Hesitancy

Delay in initiating the urine flow

Seen in males with prostatism

Disturbance in the act of micturition

Pneumaturia

Passing of air bubbles in the urine

Most often caused by a fistula between the bladder and the colon as a result of

• Diverticular abscess

• Malignant tumour

Alteration in the amount of urine

Polyuria - over 3000 ml per day

Oliguria - less than 300 ml per day

Anuria - neglible urine output

Alteration in the amount of urine

Polyuria causes • Diabetes Mellitus

• Diabetes Insipidus

• Psychogenic polydipsia

• Chronic renal failure

• Hypokalemia

• Hypercalcemia

Alteration in the amount of urine

Oliguria

Seen in acute renal failure

Pre renal failure – Shock

Haemorrhage

Dehydration

Cardiac failure

Alteration in the amount of urine

Oliguria

Seen in acute renal failure

Intrinsic renal failure –

Acute glomerulonephritis

Acute tubular necrosis

Alteration in the amount of urine

Anuria

Must be differentiated from retention of urine

Causes include

• Infarction of a kidney or both kidneys

• Bilateral cortical necrosis

• Complete obstruction of both ureters

Alteration in the appearance of urine

Haematuria – Red or smoky brown colour

Alteration in the appearance of urine

Causes of haematuria

Painless – Urinary tract obstrution

Tuberculosis

Urogenital tumors

Glomerulonephritis

Renal cystic disease

Alteration in the appearance of urine

Causes of haematuria

Painful – Renal calculi

Urinary tract infection

Reflux nephropathy

Renal papillary necrosis

Renal infarction

Alteration in the appearance of urine

Urine become blackish or coca cola in colour

• Haemoglobinuria

• Myoglobinuria

Alteration in the appearance of urine

Frothy urine

Commonly due to proteinuria

Alteration in the appearance of urine

Proteinuria

A small amount of protein ( usually less than 100 mg ) is normally excreted in the urine daily in healthy people

Alteration in the appearance of urine

Proteinuria

50 % of proteins excreted in urine derive from plasma proteins

Remainder of proteins- postglomerular • Secretary products of distal tubular cells ( Tamm Horsfall proteins )

• From lower urinary tract ( Prostate, Urethral and semen )

Alteration in the appearance of urine

Proteinuria

Urine tests for protein best performed on fresh concentrated urine and an early morning sample is the best

Alteration in the appearance of urine

Proteinuria

Significant proteinuria

• Physiological

• Pathological

Alteration in the appearance of urine

Proteinuria

Physiological

( Proteinuria less than 1000 mg / L )

When disappears lying supine is called orthostatic proteinuria

Alteration in the appearance of urine

Proteinuria

Transient proteinuria without renal damage seen in• Cold exposure

• Vigorous exercise

• Febrile illness

• Congestive cardiac failure

Alteration in the appearance of urine

Proteinuria

Pathological proteinuria

( Proteinuria more than 1000 mg / L )

Alteration in the appearance of urine

Proteinuria

Pathological proteinuria

Commonly seen in

• Glomerular disease

• Tubular disease

Alteration in the appearance of urine

Proteinuria

Amount is very small or no proteinuria in some renal diseases

• Polycystic kidney disease

• Renal scarring

• Obstructive uropathy

Alteration in the appearance of urine

Proteinuria

Albumin - 30 mg per day excreted in healthy people

Conventional urine tests give positive tests when albumin level exceeds 300mg / day

( 200 mg / L )

Alteration in the appearance of urine

Proteinuria

Microalbuminuria ( Misnormer )

Albumin excretion rate more than normal ( 30 mg/day ) , but less than the detectable level with conventional tests ( 300 mg/ day )

30 - 300 mg /day

20 - 200 mg / L

Alteration in the appearance of urine

Proteinuria

Microalbuminuria ( Misnormer )

Seen in

• Diabetic nephropathy

• Hypertensive renal disease

Alteration in the appearance of urine

Proteinuria

Microalbuminuria ( Misnormer )

Detection needs special reagent strips

Alteration in the appearance of urine

Urine become turbid with

• Infection

• Precipitated urates

• Precipitated phosphates

Alteration in the appearance of urine

Urine colour gets darkened on standing

• Porphyria

• Alkaptonuria

Alteration in the appearance of urine

Drugs causing discolouration of urineTetracycline Yellow

Sennakoat Orange

Desferrioxamine Reddish Brown

Phenindione Pink

Nitrofurantoin Brown

Rifampicin- Red

Methylene Blue Green

Methyl Dopa Grey

Metronidazole Darkening Of urine

Pain – as a manifestation of renal disease

Burning sensation or dyscomfort over suprapubic region - Cystitis

Perineal pain or rectal pain – Prostatitis

Pain felt in the flank, hypochondrium or iliac fossa – Renal pain

Pain – as a manifestation of renal disease

Acute obstruction of ureters due to stone or blood clot – Colicky pain radiates from loin to groin and to the testicle in the male

Chronic obstruction – less severe pain and sometimes no pain

Pain – as a manifestation of renal disease

Enlarged kidneys – dull, nagging or flank pain

Acute glomerulonephritis – typically painless

General symptoms and signs of renal disease

Fever – Urinary tract infection

may be associated with renal abnormality

General symptoms and signs of renal disease

Dyspnoea - fluid overload in renal impairment

metabolic acidosis in renal

impairment

pleural effusion in nephrotic

syndrome

General symptoms and signs of renal disease

Oedema ( facial and dependent )

chronic kidney disease

nephrotic syndrome

General symptoms and signs of renal disease

Pruritus – in chronic kidney disease

Distal brown discolouration of nails - in chronic kidney disease

General symptoms and signs of renal disease

Pallor – in chronic kidney disease

Hyperpigmentation

in chronic kidney disease

Symptoms of renal disease

Symptoms of ureamia

Anorexia

Lethargy Nausea

Poor sleep Poor concentration Itching

Restless legs

EndEnd