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By:

Maryam Hami MD,


Associate Prof. of Nephrology
Mashhad University of Medical
sciences(MUMS)


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Pain:
Kidney pain
Ureteral pain
Bladder pain
Dysuria
Other symptoms other than pain may
accompany voiding:
Urgency
Frequency
Hesitency
Incontinence

Kidney pain is produced by sudden


distention of the renal capsule and is
typically dull, and steady

Ureteral pain is a severe colicky pain that


often originates in the CVA and radiates
around the trunk

Bladder disorders
may cause
suprapubic pain

refers to painful urination


Difficult urination is also sometimes
described as dysuria
It is one of a constellation of irritative
bladder symptoms, which includes
urinary frequency and haematuria

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This is typically described to be a burning


or stinging sensation. It is most often a
result of
urinary tract infection
STD
bladder stones
bladder tumours
prostate disorders
anticholinergic drugs

Urgency:
Is an unusually intense and immediate desire to
void. It can be associated with infection, old age

Frequency:
urination at short intervals without increase in daily
volume or urinary output, due to reduced
bladder capacity. It can be associated with
infection, bladder neck problems
Hesitency:
difficulty in beginning the flow of urine; associated
with BPH in men and narrowing of the urethral
opening and may be caused by emotional stress

Incontinence:
is any involuntary leakage of urine.
Common etiology are:
1. Polyuria
2. Prostate disorders (BPH and cancers)
3. Caffeine and Cola
4. Brain disorders (MS, spinal cord injuries,
Parkinson disease, stroke)

Stress incontinence,
is due essentially to insufficient strength of
the pelvic floor muscles.
Urge incontinence
is involuntary loss of urine occurring for no
apparent reason while suddenly feeling
the need to urinate.
Overflow incontinence:
Sometimes people find that they cannot stop
their bladders from constantly dribbling,
or continuing to dribble for some time
after they have passed urine.

Oliguria:
is the low output of urine, It is clinically
classified as an output below 400 ml/day
The decreased output of urine may be a
sign of dehydration, renal failure,
hypovolemic shock, multiple organ
dysfunction syndrome, or urinary
obstruction/urinary retention.

Anuria:
absence of urine, clinically classified as
below 100ml/day
Anuria can be caused by
1. total urinary tract obstruction
2. total renal artery or vein occlusion
3. Shock
4. Cortical necrosis
5. severe ATN
6. Rapidly progressive glomerulonephritis

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Polyuria:
urine>3 L/d
Polyuria results from two potential
mechanisms:
nonabsorbable solutes diuresis
water diuresis (DI)
If the urine volume is >3 L/d and urine
osmolality is >300 mosmol/L, then a
solute diuresis is clearly present and a
search for the responsible solute(s) is
mandatory

WE PREPARE URINE SAMPLE


BY CENTRIFUGATION

Urine
supernatant:

Urine Sediment:

Urine Dipstick

Glucose
Bilirubin
Ketones
Specific Gravity
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocyte Esterase

Glucosuria

Negative
Trace (100 mg/dL)
)mg/dL 250+ (
)mg/dL 500++ (
)mg/dL 1000+++ (
)mg/dL+ 2000++++ (

Bilirrubinuria

Negative

)weak+ (

)moderate++ (

)strong+++ (

Urobilinogenuria

mg/dL 0.2

mg/dL 1

mg/dL 2

mg/dL 4

mg/dL 8

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Normal red blood cell excretion in the urine


is up to 2 million RBCs per day.
Hematuria is defined as two to five RBCs
per high-power field (HPF) and can be
detected by dipstick.
Common causes of isolated hematuria
include:
Stones
Neoplasms
Tuberculosis
Trauma
Prostatitis

A single urinalysis with hematuria is


common and can result from
menstruation, viral illness, allergy,
exercise, mild trauma
persistent or significant hematuria:
1. three RBCs/HPF on three urinalyses
2. single urinalysis with >100 RBCs
3. gross hematuria
identified significant renal or urologic
lesions in 9.1%

Hematuria with dysmorphic RBCs, RBC


casts, and protein excretion >500 mg/d is
virtually diagnostic of glomerulonephritis.
RBC casts form as RBCs that enter the
tubule fluid become trapped in a
cylindrical mold of gelled Tamm-Horsfall
protein

Pyuria
refers to urine
which contains pus.
Defined as the
presence of 4 or
more neutrophils
per high power
field

a cast formed from gelled protein


precipitated in the renal tubules and
molded to the tubular lumen; pieces of
these casts break off and are washed out
with the urine.

Types named for their constituent


material include epithelial, granular,
hyaline, cellular and waxy casts.

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Infection
tubulointerstiti
al processes
such as
interstitial
nephritis,
systemic lupus
erythematosus
, and
transplant
rejection.

Crystalluria indicates that the urine is


supersaturated with the compounds that
comprise the crystals, e.g. ammonium,
magnesium and phosphate for struvite.
Crystals can be seen in the urine of
clinically healthy animals or in animals
with no evidence of urinary disease (such
as obstruction and/or urolithiasis).

means the presence of an excess of serum


proteins in the urine

The dipstick measurement detects mostly


albumin and gives false-positive results when
pH > 7.0
urine is very concentrated
contaminated with blood.

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A very dilute urine may obscure significant


proteinuria on dipstick examination
proteinuria that is not predominantly albumin
will be missed.

Protein
% of Total
Maximum
Albumin
30%
Tamm-Horsfall
50%
Immunoglobulins
12%
mg
Secretory IgA
3%
mg
Other
5%
mg
TOTAL
100%

Daily
30 mg
40 mg
14
6
10
150 mg

Common Causes of Benign Proteinuria


Dehydration
Emotional stress
Fever
Heat injury
Inflammatory process Intense activity
Most acute illnesses
Orthostatic (postural) disorder

Cause

Daily protein excretion

Mild glomerulopathies
Tubular proteinuria
Overflow proteinuria

0.15 to 2.0 g

Usually glomerular

2.0 to 4.0 g

Always glomerular

>4.0 g

Nephrotic syndrome classically presents


with heavy proteinuria (>3.5 g/d),
minimal hematuria, hypoalbuminemia,
hypercholesterolemia, edema, lipiduria
and hypertension
Acute nephritic syndromes classically
present with hypertension, hematuria,
red blood cell casts, pyuria, and mild to
moderate (1-2 g/d) proteinuria, a fall in
GFR .

If glomerular inflammation develops


slowly, the serum creatinine will rise
gradually over many weeks, is
sometimes called rapidly progressive
glomerulonephritis (RPGN);
The histopathologic term crescentic
glomerulonephritis is the pathologic
equivalent of the clinical presentation of
RPGN.

Azotemia is a medical condition


characterized by abnormally high levels
of nitrogen-containing compounds, such
as urea, creatinine, various body waste
compounds, and other nitrogen-rich
compounds in the blood.
It is largely related to insufficient
filtering of blood by the kidneys

Uremia
is a term used to loosely describe the
symptoms accompanying kidney failure.
Early symptoms include anorexia and
lethargy, and late symptoms can include
decreased mental acuity and coma.
Other symptoms include fatigue, nausea,
vomiting, bone pain, itch, shortness of
breath, and seizures.

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Size of the kidneys


Past history of azotemia
Broad cast on U/A
Peripheral neuropathy
Renal Osteodysthrophy


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Upper UTI:
Pyelonephritis
Perinephric abcess
Prostitis
Lower UTI:
Cystitis
urethritis

the presence of bacteria in the urinary


tract, usually accompanied by white
blood cells and inflammatory cytokines
in the urine.

However, ABU occurs in the absence of


symptoms in the urinary tract and does
not usually require treatment.

SBP-mmHg

DBP-mmHg

Normal
<120
Prehypertens 120-139
ion

And <80
Or 80-89

Stage 1
140-159
Stage 2
160
Isolated
140
systolic HTN

Or 90-99
100
And <90

Renal stone: A hard mass that is formed


in urinary tract.
Nephrocalcinosis: The persence of
calcium deposits in the kidneys.
Risk factors: hypercalciuria,
hyperuricosuria, hypocitraturia,
hyperoxaluria

Kidney stone (calculi)

Plain film imaging (Radiography)


Plain film of the abdomen (KUB)
Urography
Ultrasonography
Computed tomography
Magnetic resonance imaging
Radionuclide imaging

The kidneys-ureters-bladder (KUB) is


often the first imaging study performed
to visualize the abdomen and urinary
tract
The film is taken with the patient supine and
should include the entire abdomen from the
base of the sternum to the pubic symphisis
Can show bony abnormalities, calcification
and large soft tissue masses

Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana

IVU/ intravenous pyelogram is the classic


modality of imaging the entire urethelial
tract from pyelocalyceal system trhough
the ureters and bladder
Excellent for indentifying small urethelial
lesions as well as the severity of obstruction
from calculi
Provides anatomical and qualitative functional
information about the kidneys

Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana

Can be used to evaluate for abnormal


anatomy and function of the lower
urinary tract in both children and adults
Similar to the cystogram, instillation of
contrast media into the bladder through a
urethral cahteter is also employed
After full distention of the bladder, the patient
is instructed to void either after removing the
catheter or around the catheter

Potts, J. (2004). Essential Urology: A Guide to Clinical Practice. Humana

In T1-weighted images (emphasizing the


difference in T1 relaxation times between
different tissues), water-containing structures are
dark. T1-weighted images do not show good
contrast between normal and abnormal tissues.
However, they do demonstrate excellent
anatomic detail.
T2-weighted images emphasize the difference in
T2 relaxation times between different tissues.
Because water is bright in these images, T2weighted images provide excellent contrast
between normal and abnormal tissues, although
with less anatomic detail than T1-weighted
images

Study of choice for the general imaging of


the kidney and ureter
used to create cross-sectional images of
structures in the body.In this procedure, xrays are taken from many different angles
and processed through a computer to
produce a three-dimensional (3-D) image
Uptake of contrast by renal parenchyma
during nephrogram phase provides rough
estimate of kidney function
Useful when renal or ureteral malginancy is
suspected

uses the radiation released by radionuclides


(called nuclear decay) to produce images
A radionuclide, usually technetium-99m, is
combined with different stable, metabolically
active compounds to form a
radiopharmaceutical that localizes to a
particular anatomic or diseased structure
(target tissue).
tracer goes to the target organ and can then
be imaged with a gamma camera, which
takes pictures of the radiation photons
emitted by the radioactive tracer