Approach to Patient With Diseases of the Kidney and Urinary Tract FINAL

APPROACH TO PATIENT WITH DISEASES OF THE KIDNEY AND URINARY TRACT Marie Fe A. Vergara- Lim Dy, MD February 20, 2014; 1:00-3:00 PM Internal Medicine 10 KIDNEY DISEASE SYNDROMES      

Acute and Rapidly Progressive Renal Failure Acute Nephritis Chronic Renal Failure Nephrotic Syndrome Asymptomatic Urinary Abnormalities Urinary Tract Infection

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Renal Tubule Defects Hypertension Nephrolithiasis Urinary Tract Obstruction  Kidney Disease Syndromes are mostly secondary complications to other diseases.

Function of the Kidney Manifold tasks of the kidney     

Your kidney is responsible for the removal of metabolic end product such as BUN, creatinine and other toxins. toxins . The kidney also functions to balance your water that maintains electrolyte balance that balance  that is important in blood  pressure control.  Also, the kidney is the site for vitamin D activation and Calcium balance thus balance thus involves in the bone structure. It is responsible for excretion of phosphorus. It has a function to maintain normal acid balance. Excretion balance.  Excretion of hydrogen and reabsorption of bicarbonate. Last but not the least, it produces erythropoietin that is important in the formation of red blood cells.

Kidneys are able to do this function through the process of glomerular filtration in the glomerulus, tubular reabsorption and secretion. Blood is delivered in the aorta t 0 renal arteries down to afferent arterioles then enter to glomerular arteries. Glomerular capillaries will produce ultrafiltrate of plasma devoid of large molecules. Blood and other molecules will go back to main circulation through efferent arterioles. Ultrafiltrate of the plasma that is formed fo rmed will go to the glomerulus to the tubules. Inside the tubules, there will be reabsorption, secretion s ecretion of water, electrolyte and formation of urine. Once urine is formed it will  pass through the renal pelvis, down to the ureter, urinary urinary bladder and out in the urethra. Any disturbances along the way, as well as the abnormality in the anatomy of the renal vessels, glomerulus, renal tubules, tubulo-interstitium, urinary tract will result in the sign and symptoms of your kidney patients. When you combined the symptoms, you will be able to identify your renal syndromes.

1. ACUTE & RAPIDLY PROGRESSIVE RENAL FAILURE (ARF/RPRF) 

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It is the decline in glomerular filtration rate (GFR) rate (GFR) happens over days days (ARF)  (ARF) or weeks weeks (RPRF)  (RPRF) Acute Renal Failure: Failure : Maximum of 12 weeks  Reversible Chronic Renal failure: failure: >12 weeks  Progressive renal disease

CLINICAL CLUES FOR ARF/RPRF Anuria or oliguria Uremia of Uremia of recent onset  Azotemia (Increased BUN & Creatinine)  Symptoms (Abdominal pain, decreased in sensorium, pruritus, gastritis)  Alteration of sleep-wake cycle Edema Hypertension Electrolyte imbalances Urinary sediments Causes of AKI:

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Acute tubular necrosis  Urinary Obstruction  Nephrotoxins 

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Causes of RPRF:  Vasculitis  Crescentic GN  HUS  Malignant nephrosclerosis  Cryoglobulinemia

RIFLE  

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Used to evaluate ARF Risk of renal dysfunction Injury to the kidney Failure of kidney function Loss of kidney function End stage kidney disease disease (ESKD)

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Transcriber/s:RemirrNolasco& Transcriber/s:RemirrNolasco& Charles Obdianela Formatting: Jun-jun Formatting: Jun-jun Mendoza Editor: Marie Mae Pantolla

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Creatinine value and Urine output are used as a basis to classify in which the patient’s belong. Case: 42 female hypertensive. 2 months ago her serum Creatinine level was 74 (Normal level: up to 111-120). She then returned to the clinic presenting with 1 week history of diarrhea and a current serum Creatinine level of 110. 

From 74 to 110, her creatinine increased by >25% = RISK of Kidney failure HINDI PURKET NORMAL EH NORMAL – Dr. Lim Normal Urine Output: 1-2cc/kg/hour Minimal urine output that could still maintain Kidney function: 400mL Oliguria = Kidney failure accelerates

4. NEPHROTIC SYNDROME 

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Massive proteinuria alone has come to define the syndrome, since this finding connotes a serious renal disease whether or not the protein losses lead to hypoalbuminemia, lipid disturbances, or edema Hypercholesterolemia (> 200 mg/dl) Hypoalbuminemia (< 3.5 g/dl) Edema and anasarca Lipiduria Proteinuria of >3.5g/1.73 m2 surface area/ 24 hours of mainly albumin  Mnemonic: HHELP

PRIMARY NEPHROTIC SYNDROME Orthostatic or postural proteinuria (benign) Membranous glomerulonephritis Idiopathic MPGN FSGS IgA nephropathy MCD Proliferative GN

CAUSES OF NEPHROTIC SYNDROME Minimal Change Disease Idiopathic Membranous glomerulopathy Focal and Segmental Glomerulosclerosis Diabetic nephropathy    

CLINICAL FEATURES Edema, anasarca leading to dyspnea Urine contains fewer cellular elements Acute changes in GFR and urine volume are uncommon Hematuria, invariable   

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SECONDARY NEPHROTIC SYNDROME Hereditary-familial

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Autoimmune

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Infectious Drug-induced Neoplastic

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DM, Alport’s syndrome, sickle cell disease (DM: no.1 cause in the Philippines) SLE, Goodpasture’s syndrome, Wegener’s granulomatosis, PAN, RA Postinfectious GN, endocarditis, hepatitis B NSAIDs, heroin, gold, Hg Hodgkin’s disease, lymphomas, leukemia, MM

Evaluation of proteinuria Patient with (+) protein in urine, you can request for 24 hr excretion of protein and creatinine or spot check of BUN/crea ratio. Microalbuminuria: less than 300mg, you can consider early DM, essential HTN, early stage of GN. Macroalbuminuria: 300mg – 3.5 g + cast in urine can be due to myeloma associated with kidney, CHF, fever or exercise. Nephrotic range proteinuria: consider DM, amyloidosis, late stage of minimal change disease, FSGS and membranous  

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5. ASYMPTOMATIC URINARY ABNORMALITIES 

Mild hematuria, pyuria, and cast or subnephrotic proteinuria with no evidence of other nephrologic syndromes

ISOLATED HEMATURIA Is clue to:  Neoplasm (especially old patients)  Stone, infection in any part of the urinary tract  Analgesic and sickle cell nephropathies

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Transcriber/s:RemirrNolasco& Charles Obdianela Formatting: Jun-jun Mendoza Editor: Marie Mae Pantolla

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Diagnostics that must be used:  IVP  Cystoscopy  Renal arteriography Investigate before diagnosing asymptomatic urinary abnormality Nephronalhematuria  Urinary casts contains RBC or Hgb pigment indicating damage to the nephron  Vehicular accident

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Nephronalhematuria with proteinuria  Suggests a worse prognosis with high tendency to progress to chronic renal failure

ISOLATED PROTEINURIA Indicates little or no inflammatory reaction within the glomeruli (DM, amyloidosis) 

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PYURIA (LEUKOCYTURIA) Usually reflect infection and inflammation of the lower urinary tract rather than parenchymal renal disease May be present in TIN, Lupus nephritis, pyelonephritis, renal transplant rejection WBC cast establishes the kidney as the site of inflammation Causes Sterile Pyuria:  Recent bacterial urinary infection being treated with antibiotics  Glucocorticoid therapy 

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Acute febrile episodes  Cyclophosphamide administration  Pregnancy  GU trauma  Prostatitis and cystourethritis  All forms of TIN 2 weeks gap between antibiotics Urine culture: Gold standard for UTI Sterile pyuria can mean UTI TB patients: Request urine AFB in 5 different urine collections

PERSISTENT STERILE PYURIA Unusual infections  TB (common cause in the PH)  Fungi  Atypical mycobacteria  Haemophilusinfluenzae  Anaerobic or fastidious bacteria 

6. URINARY TRACT INFECTION 

Demonstration in urine of pathogenic organism 5  Bacterial colony counts >10  organisms/ml urine 2  > 10 (100) colonies/mL in symptomatic patients and urine obtained by suprapubic aspiration or bladder catheterization  Kahit 100 CFU lang, pwedenamag start ang treatment. DO NOT wait for it to  5 reach 10 CFU.

CLINICAL MANIFESTATIONS as to site of involvement  Bladder & Urethral Inflammation  Dysuria, frequency, urgency and suprapubic tenderness  Prostatitis  Frequency, dysuria, urgency with prostate that is boggy and tender  Renal Parenchymal Infection:  Flank pain, chills, fever, nausea and vomiting, hypotension from sepsis and leukocyte casts

WHO ARE AT RISK FOR UTI? Gender  Female – due to anatomic reasons (shorter urethra)  50 – 60% adult women report that they have had UTI (>2x/yr = recurrent)  Affects 1-3% of female school children  Sexual intercourse 3x a week is associated with 2.6 times greater risk of UTI  Pregnancy Abnormality in the urinary tract due to:  Enlarged prostate (>40yrs old:NPH)  Stones  Vesicoureteral reflux  Neurogenic bladder Immunocompromised state  Diabetes  Patients taking immunosuppressant Indwelling catheter 

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RECURRENT UTI Episodes of acute uncomplicated cystitis documented by urine culture occurring >2x/year in a non-pregnant woman with no known urinary tract abnormality. 

DIAGNOSTIC TEST

WBC cast SIGNS AND SYMPTOMS Upper Tract (Systemic)  Fever,chills, flank pains, CVA tenderness, nausea and vomiting Lower Tract (Localized)  Dysuria, frequency, urgency, gross hematuria or hypogastric pain 

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Urinalysis Dipstick for leukocyte esterase and nitrates Urine Gram stain and Culture with sensitivity Blood culture

ACUTE CYSTITIS YES (if with signs of vaginal discharge or irritation) YES (if no response after 3 days of antibiotic) NO

ACUTE PYELONEPHRITIS YES (pyuria>5 wbc/hpf of centrifuged urine)

YES (>10,000cfu/mL)

YES if with sepsis

There is no need for urinalysis if it fit UTI symptoms. TREAT NA AGAD. However, if patients present with vaginal discharge, Urinalysis is needed.

Transcriber/s:RemirrNolasco& Charles Obdianela Formatting: Jun-jun Mendoza Editor: Marie Mae Pantolla

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7. RENAL TUBULE DEFECTS 

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This syndrome encompasses a large number of acquired and hereditary disorders, all of which tend to affect renal tubules more than glomeruli Impairment of secretion and/or reabsorption of electrolytes and organic solutes and limit urinary concentrating and diluting ability Polyuria, nocturia, metabolic acidosis, and various disorders of the fluid and electrolyte balance

HEREDITARY ANATOMIC DEFECTS Polycystic kidney disease (PCKD), medullary cystic disease and medullary sponge kidney Hematuria, bacteriuria, flank pain, or unexplained azotemia Detected by ultrasonography of intravenous pyelography 

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PCKD = most common hereditary kidney anatomic defect

TUBULE TRANSPORT DYSFUNCTION 3 Patterns of Renal Dysfunction:  Proximal Tubular Dysfunction  RTA type II w/ or w/o Fanconi’s syndrome  Distal Tubular Dysfunction  RTA type I  Salt wasting or  Hyperkalemia  Renal Medullary Dysfunction  Decreased concentrating ability with polyuria & nocturia  RTA Type I and II are commonly found in children 

8. HYPERTENSION  

Blood pressure > 140/90 on 2 separate office visits JNC VII CLASSIFICATION

BP Classification Normal Pre-hypertension Stage 1 Stage 2

Systolic BP (mm Hg) Diastolic BP (mm Hg) 100

9. NEPHROLITHIASIS 

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Definite Diagnosis:  Passage of stone  Visualization by x-ray  Removed by surgery or cystoscopy  CT Stonogram is most useful in the diagnosis Suggestive of Diagnosis:  Renal colic  Painful hematuria  Unexplained pyuria, dysuria and frequency

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Composition of Renal Stones  Calcium  Uric Acid  Cystine  Struvite   All are radiopaque except for uric acid

stones and are visible in routine abdominal radiography. 

Stones 0.4cm in size may pass freely in the tubules. If more than that, if will be difficult to excrete it. 1 cm size of stone may need surgical removal 

10. URINARY TRACT OBSTRUCTION 

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Anuria  In adults, almost always due to obstruction of the bladder outflow  Blockage of upper urinary drainage from both kidneys or from a solitary functioning kidney Bladder Outflow Obstruction  Large bladder after voiding  Nocturia, frequency, overflow incontinence, slowing or hesitancy of micturition  Urethral stricture, tumor, stone, neurogenic causes, prostatic hypertrophy Upper Tract Obstruction

Transcriber/s:RemirrNolasco& Charles Obdianela Formatting: Jun-jun Mendoza Editor: Marie Mae Pantolla

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Few symptoms especially when obstruction is incomplete and unilateral  Normal volume of urine or even increased because of defect in the renal concentrating function 

Urinary Tract Obstruction  Urinary Stasis secondary to obstruction predisposes to recurrent urinary tract infection.  Chronic urinary obstruction predisposes to progressive loss of renal function

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Common Mechanical Causes of Urinary Tract Obstruction Ureter Bladder Outlet Congenital Ureteropelvic junction narrowing or obstruction Ureterovesical junction narrowing or obstruction and reflux Ureterocele Retrocaval ureter Acquired Intrinsic Defects Calculi Inflammation Infection Trauma Sloughed papillae Tumor Blood clots 

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Urethra

Bladder neck obstruction Ureterocele

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Posterior urethral valves Anterior urethral valves Stricture Meatal stenosis Phimosis

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Acquired Extrinsic Defects Pregnant uterus Retroperitoneal fibrosis Aortic aneurysm Uterine leiomyomata Carcinoma of uterus, prostate, bladder, colon, rectum Lymphoma Pelvic inflammatory disease, endometriosis Accidental surgical ligation 

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Benign prostatic hyperplasia Cancer of prostate Cancer of bladder Calculi Diabetic neuropathy Spinal cord disease Anticholinergic drugs Alpha adrenergic antagonsit Carcinoma of cervix, colon Trauma

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Stricture Tumor Calculi Trauma Phimosis

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Trauma

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Harrison’s principle of Internal Medicine, 18 th edition, page 2396

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SUMMARY SYNDROMES

IMPORTANT CLUES TO DIAGNOSIS

ACUTE OR RAPIDLY PROGRESSIVE RENAL FAILURE

Anuria Oliguria Documented renal decline in GFR

ACUTE NEPHRITIS

Hematuria, RBC casts Azotemia, oliguria Edema, Hypertension Azotemia for >3 months Prolonged symptoms or signs of uremia Symptoms and signs of renal osteodystrophy Kidneys reduced in size bilaterally Broad cast in urinary sediments. Proteinuria >3.5g/1.73 m2/24 hrs Hypoalbuminemia Edema Hyperlipidemia Hematuria Proteinuria Sterile pyuria, casts Bacteriuria Other infectious agent documented in the urine Pyuria, leukocyte casts Frequency, urgency Bladder tenderness, flank tenderness Electrolyte disorder Polyuria, nocturia Renal calcification Large kidneys Renal transport defects Systolic / diastolic hypertension

CHRONIC RENAL FAILURE

NEPHROTIC SYNDROME

ASYMPTOMATIC URINARY ABNORMALITIES URINARY TRACT INFECTION / PYELONEPHRITIS

RENAL TUBULE DEFECTS

HYPERTENSION

NEPHROLITHIASIS

URINARY TRACT OBSTRUCTION

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

FINDINGS THAT ARE COMMON Hypertension Hematuria Proteinuria, pyuria Casts, edema Proteinuria Pyuria Circulatory congestion Proteinuria Casts Polyuria, Nocturia Edema, hypertension Electrolyte disorders Casts Lipiduria

Hematuria Mild azotemia Mild proteinuria Fever

Hematuria Tubular proteinuria Enuresis

Proteinuria Casts Azotemia Hematuria Pyuria Frequency, urgency Hematuria Pyuria Enuresis Dysuria

KEEP CALM AND Study.

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Latest PPT / RECORDINGS + NOTES + DEVIATIONS 5-10% CREDITS Book This marks the last topic for IM Evals 5. Big thanks and special mention sa nag-volunteer na Transcriptionists (Gelo, Remirr, and Charles) at saimbanaEditors (Craig, Henry, Marie Mae). Pa comment nalangng corrections, comments and suggestions (regarding any of the topics) sa Transcription Group post para ma-inform agadangmadlang people. -Junjun

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