FACULTY OF INTERNAL

MEDICINE
NPMCN
GENERAL MEDICINE UPDATE
COURSE JAN 2022
Investigations in renal disease
DR UME OKAFOR
CONSULTANT PHYSICIAN/NEPHROLOGIST
ESUT TEACHING HOSPITAL PARKLANE ENUGU
OUTLINE
• INTRODUCTION
• URINE
• BLOOD
• IMAGING/ENDOSCOPY
• BIOPSY
INTRODUCTION
• Kidney diseases are common
• Acute or chronic
• Functional or structural
• Intrinsic or non intrinsic
• Early stages are usually asymptomatic or with few clinical features
• Thus need for investigations for
• Screening
• Diagnosis
• Staging
• Monitor treatment
Urine
• Main excretory function of the kidney
• Affected by diseases of the kidney
• Important in diagnosis of kidney diseases
• Appropriate collection
• Fresh urine
• Mid stream
• EMU
Urinalysis
• Assessment of characteristics urine.
• Physical observation

• Chemical analysis

• Microscopic examination
Physical observation
• Volume- • Appearance/colour
• The normal daily urinary output - • Normal is amber
750 – 2500mls • Dark - Concentrated
• Varaiable depending on state • Light - Dilute
of hydration. • Bloody/coke
• The daily urinary output can • Injury UGS
be measured using the 24hr • Infection
urine collection. • GN
• Turbid/cloudy urine
• Anuria - < 100ml/day • UTI
• Oliguria - <400ml/day • Chyluria
• Polyuria >2500ml/day • Dark or smoky
• Pigmenturia
• Urine frequency • Frothy urine
• Proteinuria
Chemical analysis
• Uristix/urine dipstick
• Provides qualitative analysis of different analytes in urine using
chemical analysis.
• The colour changes following interaction of the urine with the
chemical reagents impregnated on the paper of the dipstick are
compared to the color chart guide to interpret the results.
• Uses dry chemistry methods
• Can be done at point-of care.
• Many parameters tested by uristix
• 2 - 11
Analytes tested
• pH
• Normal - 4.0-8.0
• Increased – UTI, Respiratory
alkalosis, RTA, CKD, post
prandial, vomiting, vegans
• Decreased – Resp acidosis,
DKA, diarhoea
• Specific gravity
• The normal – 1.010 – 1.025.
• Increased - conc. Urine,
dehydration, shock, pre renal
AKI, ATN
• Decreased - dil. Urine, CRF, DI,
Polyuric ATN, post obst diuresis
• Protein - semiqauntitative
• Normal <30mg/dl
• Proteinuria Score
• Trace (5-20mg/dl)
• 1+ (30mg/dl/0.5g/d)
• 2+(100mg/dl/0.5 – 1g/d)
• 3+(300mg/dl/1 - 2/d)
• 4+(1000mg/dl/>2g/d)
• Physiological/Pathological
• Nephrotic range.
• Microalbuminuria/micral
• 30 – 300mg/d
Analytes tested contd
• Glucose
• Renal threshold -180mg/dl
• DM
• False positive
• Ascorbic acid
• Reduced renal threshold
• Pregnancy
• KD - FS, CKD
• Blood
• Globin part of Rbc
• Haematuria/haemoglobinuria/my
oglobinuria
• Menstrual blood
• False positives are due to
• Dehydration (raised sp gravity)
• Exercise
• False negative
• Ascorbic acid
Analytes tested contd
• Ketones • Bilirubin
• Only Acetoacetate and acetone • Conjugated jaundice
detected • Urobilinogen
• X Beta hydroxyl butyrate • Prehepatic jaundice
• Ketonuria • Haemolysis
• DKA • Nitrite
• Starvation • Converts nitrate to nitrite
• Vomiting • UTI
• Enterobacteriaceae
• Leucocyte esterase
• UTI
Microscopic examination
• Wet preparations
• Organisms

• Casts

• Crystals
Microscopic examination contd
• Organisms • White cells
• UTI • <5/Hpf
• Red cells • Inflammatory UGS
• Normal <3/Hpf • WBC cast
• UGS injury • Pyelonephritis
• Dysmorphic red cell • Epithelial cell
• GN • Dehydration
• Red cell cast • TIN
• GN • Contaminants
• Tubular injury
Microscopic examination contd
• Other cast
• Hyaline casts consist of protein
and may occur in glomerular
disease
• Fatty casts are seen in nephrotic
syndrome
• Granular cast is seen in CRF and
the recovery phase of ARF.
• Broad cast
• Waxy cast
• Crystals
• Oxalate - envelope
• Ethylene glycol poisoning
• Hyperoxaluria
• Triple phosphate – coffin lead
• UTI, alkaline urine
• Uric acid – needle shaped
• Gout
• Cystine – hexagonal
• Cystinuria
• Stones
Other urine examinations
• Urine culture and sensitivity
• Urine srerile
• Detect and diagnose UTI/STI
• Orgs
• 100,000 CFU/ml
• < in presence of symptoms and catheter urine
• Sterile pyuria/AUS
• Contamination
• Susceptibility test
• Urine cytology
• Malignancy
• Haematuria
Urine protein excretion
• Abnormal presence in the urine • Proteinuria – overt >300mg/d
• 24 hr excretion • Glomerular dis
• Random/spot excretion • GN, DN, HN, LN, SCN, NS
• ACR or PCR • Tubular dis
• IN
• Normal urine protein <150mg/d • Overflow
• Tamm Horsfall • MM, MG
• Albumin • Inflammatory
• Globulin • UTI, TUM, lithiasis
• Microalbuminuria • Physiologic
• 30 – 300mg/d • Exercise, fever, posture
• Epithelial injury
Urine tubular test
• Urinary osmolarity >750mosm • Fractional excretion of sodium –
• WDT 100x UNa xScr/UcrxSNa
• DI • <1% pre renal
• Urine acidification test – distal RTA • >2% renal
• Glsuria, Amacuria, bicaturia and • Fractional excretion of urea
phosturia – proximal RTA • <35% - pre renal
• Urine sodium • Anion gap
• <20mmol – pre renal
• Urine osmolarity
• > 500mosmol – pre renal
• < 300mosmol – renal
Blood
• Kidney receives 25% of cardiac output
• Blood contains most metabolites/chemicals including end product
metabolism
• The kidney regulates most of these substances including elimination
of waste
• The concentration of these substances are altered in kidney disease
• Thus the assessment of these substances aids in management of
patients with kidney disease.
Glomerular filtration rate (GFR)
• The rate at which substances in plasma are filtered through the
glomerulus/rate of clearance of a substance from the blood.
• Provides a useful index of overall renal function
• Normal 90-130 mL/min/ 1.73 m2 of body surface area.
• GFR can be measured or estimated.
Measured GFR
• Renal clearance of plasma
substances
• Freely filtered at the glomerulus
• Neither reabsorbed nor
secreted
• No extrarenal elimination.
• Inulin, 51 Cr-EDTA, 99 Tc-DTPA,
Iohexol, Evans blue.
• Exogenous, difficulty to assay,
not readily available and
expensive
• Endogenous substance in the
plasma at a constant rate
preferred – serum creatinine
• Timed measures of GFR – 24,
12, 8 hrs
• Limitation in timed collection of
urine
• GFR = UV/P
• U = urine co
• P = plasma co
• V = urine volume/minute
Estimated GFR
• Estimated GFR • CCG – (140 – age) x wt
• Equations 72xScr(mg/dl)
• Cockcroft and Gault If female x 0.85
• MDRD
• CKD epi – Cr/CCr
Unit – ml/min/1.73m2
• Schwatz Scr – serum creatinine(mg/dl), if
• Counahan - Barratt in umol/l convert to mg/dl by
dividing with 88.4.
• Software/medcal for most
Others – endogenous markers
• Creatinine
• Most frequently used - KF
• GFR – measured/estimated
• Stable and steady production
• Secreted in PCT –
overestimate GFR
• Late rise in KD
• Muscular size/activity
• Pregnancy
• Uric acid
• Cystatin
• Urea
• End product of protein metabolism
• Reabsorbed at LH – underestimate
GFR
• Indicates KD earlier than creatinine
• Increases in large protein meal,
catabolism, dehydration and upper
GIT bleeding
• Decreases in starvation, low protein
diet and liver disease
• Urea : creatinine ratio
• AKI, UGIBleeding
Others blood test
• Electrolyte • Iron studies
• Calcium • FBC
• Phosphate • ESR
• Magnesium • Serology
• Albumin • PSA
• Alkaline phosphatase • HbA1C
• PTH • Others
• VIT D3
Novel blood markers
• Beta2-microglobulin
• Retinol-binding protein
• NGAL (Neutrophil gelatinase-associated lipocalin),
• Kidney injury molecule 1 (KIM-1)
• L-type fatty acid-binding protein (L-FABP)
• FGF23 (Fibroblast growth factor 23)
• Beta-trace protein
Imaging
• To diagnose, monitor and treat KD
• X rays
• Ultrasound
• CT scan
• MRI
• Scintigraphy
• Endoscopy
x rays
• Radiation • Contrast
• Readily available • Allergy, arrhythmia, KD
• Plain • IVU - KUB, KFT, Stones
• Radiopaque stones
• Antegrade pyelography
• Renal calcifications
• BMD • Retrograde pyelography
• anncillary • Micturating cystourethrography
(MCU)
• Aortography or renal
arteriography/angiography
Imaging contd
• Ultrasonography • CT Scan
• No radiation • Same/better than X ray
• Available/cheap • Expensive
• Operator dependent • CTU
• Kidney size/structure • Stage renal tumour
• Bladder size, structure, content and • MRI
function
• Same as CTS
• Prostate • No radiation
• Abd/pelvic tumours • Renal tumour/vessels
• Doppler • Scintigraphy – KFT/urine flow
• RBF
• Endoscopy – KUB, masses, fibrosis
Biopsy
• Invasive procedure to obtain • Indications
kidney tissue sample • Unexplained
• Sterile procedure proteinuria/haematuria/AKI
• Adult NS
• Percutaneous • Atypical/non resp. NS in children
• Landmark • KTP – AAR/CAN
• US guided • Precautions
• Needle • Consent
• Trucut - VS • Hb 10 and above
• Automated – semi/full • Platelet >100,000
• Laparascopic • INR <2
• Withhold
• Transjugular antiplatelet/anticouagulant
• Open laparotomy • Skin infection – needle point
• Contraindication • Procedure
• Bleeding diathesis • position– prone, sitting, lt lat
• Uncoperative • Sterile/LA/?sedation
• Solitary kidney • Synchronise with resp. –
• Shrunken kidney inspiration
• Severe HBP • < 4 pass
• Morbid obesity • Modality/medium
• Skin infection • LM - Formalin/10%
• Severe azotaemia formaldehyde
• Multicystic KD • IF – NS/Michel fixative
• Horse shoe • EM - Glutaldehyde
• Personel
• Post care
• Pressure dressing • Complications
• Observe - 12 – 24hrs - supine • Pain
• Check VS – • Bleeding
• 5min x 1hr • Haematoma - perinephric
• 30mins x 2 hrs • Infection
• 1hr x 4hrs
• 2hrly • Perforation bowel
• Liberal fluid • AVF
• All urine – observe • AKI
• Colour • Nephrectomy <1%
• Volume • Death <1%
• Red alert – rising
puls/haematuria/anaemia,
decreasing BP/LOC
• Avoid weight bearing 2wks
Conclusion
• Investigations in kidney diseases is dignostic and
prognostic, thus assisting immensely in managing of these patients.
•
• However there is need for detailed clinical assessment to determine
proper investigations needed by the patient
 Thanks
for your
attention