2D2016 3.4-2 Azotemia and Urinary Abnormalities (Harrison's)

Trans 3.4-2

December 3, 2013

Harrison’s

Azotemia and Urinary Abnormalities

Believe you can and you’re halfway there. AZOTEMIA: INTRODUCTION  Renal syndromes may arise as a: o Consequence of a systemic illness or o Can occur as a primary renal disease  Nephrologic syndromes usually consist of several elements that reflect the underlying pathologic processes  The duration and severity of the disease affect those findings and typically include one or more of the following: o Reduction in glomerular filtration rate (GFR) (azotemia) o Abnormalities of urine sediment [red blood cells (RBC), white blood cells, casts, and crystals] o Abnormal excretion of serum proteins (proteinuria) o Disturbances in urine volume (oliguria, anuria, polyuria) o Presence of hypertension and/or expanded total body fluid volume (edema) o Electrolyte abnormalities o In some syndromes, fever/pain Initial Clinical And Laboratory Data Base For Defining Major Syndromes In Nephrology SYNDROMES Acute or rapidly progressive renal failure

Acute nephritis

Chronic renal failure

Nephrotic syndrome

Asymptomatic urinary abnormalities Urinary tract infection/pyelon ephritis

IMPORTANT CLUES TO DIAGNOSIS  Anuria  Oliguria  Documented recent decline in GFR  Hematuria, RBC casts  Azotemia, oliguria  Edema, hypertension  Azotemia for >3 months  Prolonged symptoms or signs of uremia  Symptoms or signs of renal osteodystrophy  Kidneys reduced in size bilaterally  Broad casts in urinary sediment  Proteinuria >3.5 g per 1.73 m2 per 24h  Hypoalbuminemia  Edema  Hyperlipidemia  Hematuria  Proteinuria (below nephrotic range)  Sterile pyuria, casts  Bacteriuria >105 colonies/ml  Other infectious agent documented in urine  Pyuria, leukocyte casts

Binsol. Calagui. Disquitado. Perez.

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COMMON FINDINGS Hypertension, hematuria Proteinuria, pyuria Casts, edema Proteinuria Pyuria Circulatory congestion

 Proteinuria  Casts  Polyuria, nocturia  Edema, hypertension  Electrolyte disorders

 Casts  Lipiduria

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Hematuria Mild azotemia Mild proteinuria Fever

Renal tubule defects

Hypertension

Nephrolithiasis

Urinary tract obstruction

 Frequency, urgency  Bladder tenderness, flank tenderness  Electrolyte disorders  Polyuria, nocturia  Renal calcification  Large kidneys  Renal transport defects  Systolic/diastolic hypertension  Previous history of stone passage or removal  Previous history of stone seen by x-ray  Renal colic  Azotemia, oliguria, anuria  Polyuria, nocturia, urinary retention  Slowing of urinary stream  Large prostate, large kidneys  Flank tenderness, full bladder after voiding

 Hematuria "Tubular" proteinuria (500 40

Binsol. Calagui. Disquitado. Perez.

3 L/d and urine osmolality is >300 mosmol/L  search for the responsible solute(s) is mandatory (glucose, mannitol, or urea) o Water diuresis: excretion of water (usually from a defect in ADH production or renal responsiveness).

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Azotemia and Urinary Abnormalities

 urine output is >3 L/d and the urine is dilute (