• MODULE NAME: RENAL MODULE

• DEPARTMENT: WEST MEDICAL WARD

• DATE: 12-08-2020
• TIME: 08:45 AM – 09:30 AM
• PRESENTER NAME: DR. A
 SYMPTOMS AND
INVESTIGATIONS IN KIDNEY
DISEASE

DR ADIL IQBAL FCPS

PROF OF MEDICINE
UNIT IV KEMU
Case #1
• The patient is a 41 year-old male who has a longstanding history of
hypertension and diabetes and presents with a complaint of pruritis,
lethargy, lower extremity edema, nausea and emesis. He denies any
other medical illnesses.
• Q what does the symptoms suggest to you?
Laboratory Data
Sodium  133  136-146 mmol/L 
Potassium  6.2  3.5-5.3 mmol/L 

BUN  170  7-22 mg/dl 

Creatinine  16.0  0.7-1.5 mg/dl 

Calcium  7.2  8.9-10.3 mg/dl 

Phosphorus  10.5  2.6-6.4 mg/dl
Alkaline
306  30-110 IU/L
Phosphatase 

Hemoglobin  8.6  14-17 gm/dl

Hematocrit  27.4  40-54 %
Mean cell volume  88  85-95 FL
If your kidneys stop working suddenly (ARF), you may
notice one or more of the following symptoms:

• Abdominal (belly) pain

• Back pain
• Diarrhea
• Fever
• Nosebleeds
• Rash
• Vomiting
What causes Acute kidney
disease (ARF or AKI)?
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You may notice one or more of the following symptoms if your
kidneys are beginning to fail (CRF or CKD):

• Itching
• Muscle cramps
• Nausea and vomiting
• Not feeling hungry
• Swelling in your feet and ankles
• Too much urine (pee) or not enough urine
• Trouble catching your breath
• Trouble sleeping
What causes chronic kidney
disease (CKD)?
• Diabetes mellitus
• High blood pressure (hypertension)
• Obstructive uropathy
• Glomerulonephritis
• Drugs
• Pyelonephritis
• Having a family member with kidney disease 
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Renal Function Tests

• Waste like urea, creatinine and uric acid,

• regulation of extracellular fluid volume,
• serum osmolality and electrolyte concentrations,
• production of hormones like
❖erythropoietin  
❖1,25 dihydroxyvitamin D
❖renin.
Specimen Collection

• for serum creatinine and blood urea nitrogen (BUN)   levels, a random
blood sample
• timed urine collections such as the 24-hour urine creatinine
clearance, (5 to 8-hour timed collection is preferable to a 24-hour
collection.)
• Collection of early morning midstream urine for urine analysis
Investigations

• Examination of the urine

• Blood and quantitative tests
• Imaging techniques
• Transcutaneous renal biopsy
Examination of the urine
• urine characteristics to aid in disease diagnosis
• physical observation, color and clarity straw colored, darker color, Red urine
• chemical, and microscopic analysis.
• Physical observation involves assessing, dehydration hematuria or
porphyria or represent the dietary intake of food like beets.
• Cloudy urine may be seen in the presence of pyuria due to urinary tract
infection.
• Specific gravity is an indicator of renal concentrating ability may be
measured using refractometry or chemically by use of urine dipstick. The
physiologic range for specific gravity is 1.003 to 1.030 
Urine dipstick 
• Dipstick uses dry chemistry methods to detect for the presence of
protein,
⮚ glucose,
⮚blood,
⮚ketones,
⮚ bilirubin,
⮚urobilinogen,
⮚ nitrite, and leukocyte esterase. 
Microscopic analysis of urine
• The microscopic analysis involves wet-prep analysis of urine to assess
in the presence of
⮚cells,
⮚casts,
⮚crystals,
⮚micro-organisms.
Urine Analysis
• Albuminuria and Proteinuria
• urine albumin 30 to 300 mg per day.
•  Microalbumin up to 30 mg/day
•  Normal urine protein up to 150 mg per day
•  Albuminuria for 3 or more months is indicative of chronic kidney
disease. 
• Frank proteinuria is defined as greater than 300 mg per day of
protein.
Tests of Tubular Function

• The renal tubules play an important role in reabsorption of

electrolytes, water, glucose
• Maintaining acid-base balance,
• Electrolytes, sodium, potassium, chloride, magnesium, phosphate
can be measured in urine.
Blood and quantitative tests

• S/Urea
• S/ creatinine
• S/E
• S/Ca
• S /PO4
Urea may be decreased in starvation, low-protein diet, and severe liver
disease.
Serum creatinine is a more accurate assessment of renal function than
urea; however, urea is increased earlier in renal disease.
Cystatin C

• Cystatin C is a low-molecular-weight protein which functions as a

protease inhibitor produced by all nucleated cells in the body.
• It is formed at a constant rate and freely filtered by the kidneys.
• Serum levels of cystatin C are inversely correlated with the glomerular
filtration rate (GFR)
Clinical Significance

• Creatinine
• Serum creatinine is elevated when there is a significant reduction in the
glomerular filtration rate or when urine elimination is obstructed. 
About 50%  of kidney function must be lost before a rise in serum
creatinine can be detected. Thus serum creatinine is a late marker of
acute kidney injury.
• BUN
• Serum urea/BUN is increased acute and chronic renal disease.
• eGFR equations are used to determine the presence of renal disease,
stage of CKD and to monitor response to treatment.
• Creatinine clearance is then calculated using the equation:
• C = (U x V) / P
• C = clearance, U = urinary concentration, V = urinary flow rate
(volume/time i-e ml/min), and P = plasma concentration
Improving Global Outcomes (KDIGO) stages of chronic kidney disease
(CKD):

• Stage 1 GFR greater than 90 ml/min/1.73 m  

• Stage 2 GFR-between 60 to 89 ml/min/1.73 m
• Stage 3a  GFR 45 to 59 ml/min/1.73 m
• Stage 3b GFR 30 to 44 ml/min/1.73 m
• Stage 4 GFR of 15 to 29 ml/min/1.73 m
• Stage 5-GFR less than 15 ml/min/1.73 m (end-stage renal disease)
Imaging techniques

• Plain X-ray
• Ultrasonography
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
Computed tomography (CT)

• Characterize renal masses

• Stage renal tumours
• Detect ‘lucent’ calculi
• Evaluate the retroperitoneum for tumours, retroperitoneal fibrosis
(periaortitis) and other causes of ureteric obstruction
• Assess severe renal trauma
• Visualize the renal arteries and veins by CT angiography
MRI is used

• To characterize renal masses as an alternative to CT

• To stage renal, prostate and bladder cancer
• To demonstrate the renal arteries by magnetic resonance
angiography
• For adrenals assessment
Urography
• Excretion urography (IVU or intravenous pyelography)
• Antegrade pyelography involves percutaneous puncture of a
pelvicalyceal system
• Retrograde pyelography
• Micturating cystourethrography (MCU)
Aortography or renal arteriography

• Conventional or digital subtraction angiography (DSA) is used. The

latter allows the use of smaller doses of contrast
• via a central venous catheter (venous DSA)
• via a fine transfemoral arterial catheter (arterial DSA).
Renal scintigraphy

• Renal scintigraphy using a gamma camera is divided into:

• Dynamic studies in which the function of the kidney is examined
serially over a period of time, most often using a radiopharmaceutical
excreted by glomerular filtration
• Static studies involving imaging of tracer that is taken up and retained
by the renal tubule.
Renal biopsy
Renal biopsy
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