Ulrich Pinder , 1506

Syndromes of the
urinary system

2024
 Main syndromes in nephrology
1. Urinary syndrome
2. Nephritic syndrome (acute nephritis)
3. Nephrotic syndrome
4. Arterial hypertension syndrome
5. Tubulointerstitial disorder syndrome
6. Acute renal failure
7. Chronic renal failure
 Attention! Renal syndromes do not allow for
an accurate diagnosis
Paradox: any kidney syndromes can occur with almost any kidney disease, as
well as with diseases of other organs and systems (!). Therefore, all kidney
damage syndromes are clinical, i.e. represent a typical set of some
characteristics. They allow us to make an assumption about the nature of the
kidney damage and begin treatment (especially in life -threatening cases ).
But to make a correct diagnosis , a complete examination of the body is
necessary , including radioisotope research methods and a kidney biopsy,
possibly other studies, for example: immunological blood tests, blood for tumor
markers , etc.
 Etiology: secondary kidney damage
factors that cause kidney damage .
It is important to decide whether the kidney damage is independent (primary) or occurred
against the background of another disease (secondary) .
Secondary kidney damage occurs against the background of:
1. Autoimmune diseases : systemic lupus erythematosus (SLE), rheumatoid arthritis,
autoimmune thyroiditis , hemorrhagic vasculitis , etc.
2. Malignant tumors: lung cancer, breast cancer, stomach cancer, tumor diseases of the
blood, etc.
3. Other diseases : liver cirrhosis, ulcerative colitis (UC), skin disease (psoriasis), lung disease
( sarcoidosis ), etc.
4. mellitus , arterial hypertension (type of kidney damage: nephropathy)
If glomerulonephritis is suspected, it is necessary to exclude the secondary nature of kidney
damage according to points 1-3.
 Etiology: primary kidney lesions

1. Infectious agent (viruses: influenza, hepatitis B and C, HIV, bacteria: streptococcus,

enterococcus, treponema pallidum, mycobacterium tuberculosis, protozoa: malarial
plasmodium, toxoplasma, parasites: schistosome, filaria). The most common cause of
pyelonephritis is Escherichia coli, the most common provocateur of acute
glomerulonephritis is streptococcus.
2. Toxic factor (alcohol, drugs, heavy metals, mercury, etc.), including medications: NSAIDs,
antibiotics, radiocontrast agents, captopril, clopidogrel and others. The most common
cause of tubulointerstitial nephritis is NSAIDs.
3. Malignant tumors: kidney cancer
 Clinical classification of kidney diseases
1) pyelonephritis, the term emphasizes that the kidney disease is inflammatory (-nephritis)
and the pyelocaliceal system ( pielo- ) is necessarily affected. In addition to the pelvis,
pyelonephritis also affects the tubules and interstitium ( tubulointerstitial tissue of the
kidney, or the medulla of the kidney). In clinical practice, the term implies “ infectious
inflammatory disease of the kidney.” The most common infectious agent is Escherichia coli .
The disease is associated with the penetration of an infectious agent (bacteria, virus) into
the kidney tissue and the development of inflammation, which can be: acute/chronic,
serous/purulent, obstructive / non-obstructive . Obstructive pyelonephritis means the
presence of an obstruction to the flow of urine in the kidney, ureter, bladder or urethra in the
form of a stone, tissue (cancer, papilloma), congenital anomaly, compression of the duct by a
tumor from outside (for example, in elderly men, prostate adenoma).
Pyelonephritis is relatively common, especially the chronic form.
 Clinical classification of kidney diseases
2) glomerulonephritis , the term emphasizes that the kidney disease is inflammatory (-
nephritis) and the glomeruli ( glomerulo- ) are necessarily affected . The glomeruli make up
the cortex of the kidney. In clinical practice, the term implies “ immuninflammatory kidney
disease” ( NOT infectious!).
“Immunoinflammatory” disease means that the damage is associated: A) with the deposition
of immune complexes circulating in the blood in the glomerulus, B) with direct damage to the
glomerular membrane by antibodies due to the similarity in the structure of glomerular
receptors and antigen receptors (autoimmune inflammation: the immune system, through
antibodies, damages its own body tissues). Causes of glomerulonephritis: infectious agent
(usually streptococcus), toxic factor.
A significant part of glomerulonephritis is secondary (against the background of malignant
tumors, autoimmune diseases, and other diseases of the body).
Glomerulonephritis is relatively uncommon.
 The role of infection in the development of kidney
diseases using the example of streptococcus
Pyelonephritis Glomerulonephritis
streptococcus penetrates the Streptococcus (antigen) caused the
kidney tissue, the result: development of an infection, for example:
purulent inflammation of the pharyngitis, sore throat
kidney

antibodies to
the immune system streptococcus
produces antibodies damage the
glomeruli of the
kidneys
Attention! Glomerulonephritis does not develop against the background of a throat infection,
but 1-2 weeks after recovery ; this is the incubation period for damage to the kidney by
immune complexes.
 Clinical classification of kidney diseases
3) tubulointerstitial nephritis (abbreviated as TIN), synonym: interstitial nephritis, the term
indicates that the kidney disease is inflammatory ( nephritis, but! according to ICD-10:
nephropathy) and the tubules and interstitium are necessarily affected ( renal
tubulointerstitial tissue, or renal medulla). In clinical practice, the term means “ non-
infectious inflammation (damage) of the kidney.” There are acute TIN/chronic TIN. Acute
TIN is characterized by frequent development of acute renal failure (ARF) (in a kidney
biopsy - tubular necrosis), and for chronic TIN - chronic renal failure (CRF) (in a kidney
biopsy - sclerosis of tubulointerstitial tissue).
In clinical practice, this is a rare diagnosis that can be assumed after the development of
acute renal failure (“renal failure” = anuria) while taking a drug. In practice, to establish a
diagnosis, an examination by a nephrologist and kidney biopsy.
 Clinical classification of kidney diseases
4. Nephropathy , the term emphasizes that the kidney disease is non-inflammatory (-
pathy ) . With nephropathies, all structures of the kidneys are affected and, as a result,
renal sclerosis is formed. The term is used for chronic diseases in the body associated
with kidney damage: hypertensive nephropathy, diabetic nephropathy.
5. Urolithiasis (UCD)
6. Kidney amyloidosis
7. Cystic kidney disease
8. Kidney development abnormalities
9. Hereditary kidney diseases
 Urinary syndrome
• The main signs of the syndrome : asymptomatic proteinuria + hematuria + leukocyturia +
cylindruria . All of these signs are not necessary in one patient.
• Clinical picture : no complaints, pathology is detected in urine tests, often as an accidental
finding
• Etiology. Urinary syndrome may be a sign of:
- kidney diseases
- non-renal disease or functional condition (for example: bladder disease, pneumonia,
hyperthermia, significant physical activity, etc.)
• To establish the causes of urinary syndrome, a complete examination of the urinary system
is required (hemogram, LBC,URINE TEST , urine according to Nechiparenko, ultrasound of
the urinary tract and kidneys, CT scan of the urinary tract and kidneys, etc.)

11
 Features of hematuria and proteinuria in
urinary syndrome
From a clinical point of view, there are two types of hematuria : microhematuria (a small
number of red blood cells in the urine, and the urine is a normal color) and gross hematuria (a
large number of red blood cells in the urine, and the urine is red). Microhematuria is
considered within the framework of urinary syndrome .
In the case of gross hematuria, there is a complaint about the red color of urine, the diagnosis
at the initial visit is “Gross hematuria of unknown etiology”, it is necessary to exclude:
glomerulonephritis, malignant tumors of the kidney and bladder.
From a clinical point of view, there are two types of proteinuria : latent (weak (up to 1g/l per
day) and moderate proteinuria (1-3g/l per day) and nephrotic syndrome (severe proteinuria, i.e.
more than 3g/l per day) Latent proteinuria is considered within the framework of urinary
syndrome .
In the case of nephrotic syndrome, there is a complaint of edematous syndrome and anasarca
and effusion in the cavity (hydrothorax, ascites), the diagnosis at initial treatment is “Nephrotic
syndrome of unknown etiology”, it is necessary to exclude: glomerulonephritis and other kidney
diseases, cancer
 Nephritic syndrome (acute nephritis)
• Signs of the syndrome : changes in urine and blood tests + arterial hypertension + edema
syndrome. All signs are not necessary in one patient. But! necessarily hematuria (up to
gross hematuria) - 100% of cases, almost all have edema and arterial hypertension (up to
90% of cases)

• Clinical picture : arterial hypertension of any severity, up to severe degrees and life-
threatening complications (hypertensive encephalopathy, AHF in the form of pulmonary
edema), edema syndrome of any severity, up to anasarca and edema of the cavities (with
the development of nephrotic syndrome). In case of gross hematuria - red urine.

• Diseases : glomerulonephritis
 Signs of acute nephritis
clinical picture lab-instrument diagnostics

1. Arterial hypertension 1. In urine:

(increased blood pressure, Proteinuria
headache, nausea, Hematuria
vomiting) Cylindruria
2. Edema syndrome (swelling Red blood cells
of the face, in severe cases Leukocytes
anasarca + swelling of the 2. In blood:
cavities and internal BAC: increased levels of creatinine , urea
organs) Hemogram: anemia, increased ESR,
3. Possible gross hematuria possible leukocytosis
 Nephrotic syndrome
• Signs of the syndrome : edematous syndrome of anasarca level + edema of cavities and
internal organs, proteinuria more than 3 g/l per day, oliguria , casts.
• The cause of edematous syndrome is hypoalbuminemia (decrease in the level of
albumin in the blood plasma) due to the loss of protein in the urine. In the LHC, the
level of total protein drops (less than 50 g/l, normal 65-85 g/l) and the level of albumin
(normal 40-50 g/l). Blood plasma proteins are necessary to retain fluid in the vascular
bed, the pressure they create is called oncotic , and the edema that develops when the
level of protein in the plasma drops is hypooncotic .
• Other signs of nephrotic syndrome: increased cholesterol levels (more than 6.5
mmol/l) and fibrinogen, arterial hypertension (may be absent).
• Nephrotic syndrome may be associated with nephritic syndrome.
• Diseases : glomerulonephritis , renal amyloidosis, secondary kidney damage
 Tubulointerstitial syndrome violations
(renal tubular dysfunction, tubulopathies )
• Syndrome of damage to tubules (brain tissue). Tubular function: reabsorption of a number
of substances (glucose, electrolytes, organic substances) and concentration of urine
• Signs of the syndrome: polyuria + in the urine: decreased density of urine + salts (urates,
oxalates) + glucosuria (in the absence of diabetes mellitus, this form is called: renal
diabetes insipidus) + proteinuria (mild, moderate) + microelements (phosphorus, calcium).
It is not necessary to have all the signs.
• Diseases: primary tubulopathies - hereditary diseases (pediatric practice), secondary
tubulopathies - against the background of other kidney diseases (for example: urolithiasis,
diabetic nephropathy, tubulointerstitial nephritis).
• In childhood, tubulopathy is accompanied by damage to the musculoskeletal system due to
loss of salts (calcium, phosphorus) - rickets-like conditions and osteoporosis (see clinical
example on the next slide), in adulthood - osteoporosis.
 Clinical case of Fanconi syndrome ( Fanconi Bickel Syndrome )
American Journal of Clinical Medical Research ( AJCMR ), 2014

Patient, male , 17 years old. On examination: height 126 cm,

An autosomal recessive
disease associated with loss
of phosphorus, glucose,
amino acids, bicarbonates
in the urine
weight 23 kg, multiple deformities of the musculoskeletal
system, rachitic rosary, Harrison's groove , multiple facial
stigmas, partial absence of teeth. Intelligence is normal.
History of developmental delay, bone fracture, recurrent
respiratory infections.
Differential diagnosis : consequences of severe rickets.
http://pubs.sciepub.com/ajcmr/2/4/1/​
 Arterial hypertension syndrome
Suspicion of arterial hypertension of renal origin may be:
1. Children and young people
2. High blood pressure numbers (grade 3 hypertension: SBP more than 180 mm Hg, DBP
more than 110 mm Hg)
3. High levels of DBP: 120-130-140 or more mmHg.
4. Frequent hypertensive crises and complications during crises: from the eyes - acute
retinopathy (decreased vision up to blindness), acute hypertensive encephalopathy (=
cerebral edema, synonym: eclampsia), AHF (pulmonary edema)

This course of hypertension with high blood pressure numbers, crises and complications is
called malignant and is life-threatening .

Causes: any kidney disease, but more often: glomerulonephritis , renal vascular pathology
(thrombosis, stenosis)
 Acute renal failure
• Signs : lack of urine (anuria) + impaired excretory function of the kidneys (increased
creatinine , urea in the BAC) + acidosis (blood test through a gas analyzer)
• Prerenal acute renal failure (adrenal): shock (acute renal ischemia due to impaired blood
flow in the kidneys when SBP decreases to less than 60 mm Hg, when SBP is 50 mm Hg and
urine filtration stops, anuria develops), nephrotic syndrome, OKN
• Renal acute renal failure (renal): acute necrosis of the tubules , often of toxic origin, for
example due to taking medications, snake and insect bites, infectious diseases, taking
surrogates of alcohol, drugs, hemolysis due to transfusion of incompatible blood groups, as
well as acute glomerulonephritis, diabetic nephropathy and other kidney diseases
• Postrenal acute renal failure : violation of the patency of the upper urinary tract, for
example: bilateral obstruction of the ureters with stones.
• With acute renal failure, the bladder is empty at catheterization! (as opposed to acute
urinary retention)
 Chronic renal failure
A syndrome that develops as a result of the gradual death of nephrons against the background
of any kidney disease. The terminal stage of the syndrome is called uremia.
Signs: until uremia develops, it flows latently. Clinical signs of uremia: oliguria, weakness, high-
grade hypertension (headache, nausea, vomiting), edema syndrome, anorexia, itching of the
skin, hemorrhagic syndrome, diarrhea, neuralgia, paralysis, cough (bronchitis), pericarditis,
encephalopathy, coma, death .
Laboratory signs of chronic renal failure: impaired excretory function of the kidneys (increased
levels of urea and creatinine in the LBC), decreased creatinine clearance according to the
Rehberg test (creatinine clearance, or glomerular filtration rate (GFR) less than 30 ml/min)
Currently, along with the term chronic kidney disease, the term “Chronic kidney disease, CKD”
(National Kidney Foundation, USA) is used; the stage of the disease is determined by the level
of GFR; a total of 5 stages are distinguished (stage 5 – uremia, requires hemodialysis)
Diseases: glomerulonephritis, diabetic nephropathy, pyelonephritis, chronic tubulointerstitial
nephritis, urolithiasis, etc.
 Conclusions on syndromes in nephrology
Urinary syndrome is an accidental finding; there are no complaints in the urine; there are no
proteins or red blood cells. Any kidney disease is suspected.
Nephritic syndrome - complaints: edema, hypertension, oliguria , almost any abnormalities in
the urine, but hematuria is a must. Suspected: glomerulonephritis.
Nephrotic syndrome is a severe condition, anasarca, swelling of the cavities and organs. There
is more than 3 g/l protein in the urine 24 hours. Suspected: glomerulonephritis.
Nephritic and nephrotic syndromes can be combined.
Tubulopathies are rare, more often a pediatric practice, in adult practice - against the
background of any kidney diseases and have practically no special significance. Characterized
by polyuria and loss of various elements (phosphorus, amino acids, glucose, etc.)
AKI - anuria, is rare, a complication of almost any severe kidney disease or serious condition of
the body (shock, acute intestinal tract, toxins). Reversible condition.
CRF (or CKD) is the outcome of any kidney disease, the terminal stage is uremia (there are a lot
of manifestations, necessarily: increased creatinine + edema syndrome + hypertension +
oliguria ). In the uremia stage, hemodialysis is necessary for survival.
Thank you for your attention!