NEPHROLOGY

Introduction
• Diseases of the kidney and urinary system
• Often clinically silent detected on tests
• Manifestation of diseases
– Lower urinary tract symptoms
• Dysuria,frequency,urgency in urinary tract infection
• Impaired urine flow,hesitancy,dribbling of
urine,incomplete emptying in bladder outlow
obstruction
• Urinary retention,incontinence/enuresis in sphincter or
bladder wall dysfunction
• Upper urinar tract symptoms
– Loin/renal angle pain and tenderness-renal
infection,infartcion or obstruction
– Severe loin pain –acute ureter obstruction
• Reduced urine volume-anuria and oliguria
• Polyuria/nocturia-failure to concentrate urine eg
eg CKD,DI others like DM with hyperglcemea,DI
• Abnormalities of urine constituents-protein,blood
• Physical examination-bimanual palpation
– Enlarged kidneys-
polycystic,tumor,hydronephrosis,cyst,amyloidosis.
others compensatory hypertrophy of single
kidney,myeloma kidney,diabetic nephropathy
– Shrunken kidneys-Chronic kidney disease
– Renal angle tenderness in pyelonephritis
– Renal bruit-renal artery stenosis
– Distended bladder in urinary obstruction
– Enlarged prostate on digital rectal examination
 Function of the kidneys

• Regulation of blood fluid volume and

composition through ultrafiltration by nephrons
• Excretion of metabolic breakdown products e.g
creatinine,ammonia,urea,uric acid etc
• Endocrine function
– Production of erythropoetin
– Vitamin D metabolism-hydroxlation of 25
hydroxycholecalciferol to 1,25 dihydrocholecalciferol
– Renin production by juxtaglomerular apparatus in
response to changes in blood volume and pressure
Anatomy and physiology
 Investigation
• Functional test
• Glomerular filtration rate-
– measure of renal excretory function.measures rate at
which fluid passes into the nephrons after filtration
– Serum creatinine commonly used
– Estimated glomerular filtration rate using set formulas
e.g
• MDRD
• Cockroft and gault
• Urinalysis-dipstick to check proteins,blood,
– Microscopy-red blood cells,crstals
 imaging
• Ultrasound
– Size,position,dilatation of collecting systems
etc,tumors,cyst of kidnes
– Other organs-prostate,bladder
– Renal doppler-velocity of renal artery
• CT SCAN-characterises masses,renal stones etc
• MRI-excellent image resolution of tumors etc
• Radionucloetides studies e.g DTPA checks renal
perfusion,DMSA checks renal function,size,shape
• Renal biopsy-under ultrasound guidance
– Nephrotic syndrome in adults or opne that is
unresponsive to treatment in children
– unexplained acute renal failure
– CKD with normal kidney size
– isolated hematuria or proteinuria
– Staging of nephropathy in SLE
 Renal disease and common
manifestation
• Pre renal conditions
– Loss of renal function e.g in shock,sepsis,dehdration
• Intrarenal
– Glomerular disease-
hematuria,proteinuria,edema,hypertension,loss of
renal function.acute and chronic glomerulonephritis
– Interstitial disease-as above include interstitial
nephritis,
– Renal vasculature-loss of function and hypertension
– Tubular disease-loss of
function,hematuria,polyuria,electrolyte and acid base
abnormalities eg acute tubular necrosis
• Post renal
– Ureter-hematuria,loin pain,loss of function.eg
renal stones
– Bladder-hematuria,acute retention.bladder
tumors,cystitis
– Prostate-obstructive symptoms.eg BPH,ca
prostate etc
– Uurethra-hematuria, urinary
retention.stricture,urethritis etc
 Urinary tract infection
• Commoner in females
• Presentation
– Frequency,urgency,dysuria,suprapubic pain,strangury,hematuria
cloudy urine
– Systemic symptoms e.g fever,vomiting uncommon unless
pyelonephritis sets in
– Pyelonephritis-fever,vomiting,rigors,loin
pain,hypotention,guarding
• Investigations
– Dipstick-nitites,leucocytes esterase positive
– Microscopy-white blood cells,organism
– Urine culture
– Blood count,urea,creatinine,blood culture if systemic unwell
 Urinary tract infection
• Typical organism
– E.Coli,proteus,psedomonnas,staphylococcus
epidermidis spp,streptococci in communit
– Klebsiella,E.coli,streptococci in hospital
• Management
– uncomplicated UTI/cystitis-
amoxicillin,nitrofurantoin,ciprofloxacin for 3 days in
women and 10 in men
– Pyelonephritis/complicated UTI
• Amoxicillin-clavulionic acid,ciprofloxacin are first choice
• Second choice-cefuroxime or gentamycin for 7-14 days
• Prostatitis-ciproflaxicin for 28 days
 Recurrent or persistent UTI
• Same organism or new organism after
treatment,look for predisposing factors
– Obstruction-stones,tumor,prostate,anomalies e g
pelvi-ureteric unction reflux
– Systemic –diabetes mellitus,immunosuppressant
drugs
– Catheterisation
• Use prophlaxis antibiotics eg nitrofurantoin
50mg at night,,coamoxyclav 250mg nocte