clinical presentation of renal disease
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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
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