Common Symptoms of Kidney

Diseases
Dr. Md. Asiqur Rahman
MBBS(DMC)
FCPS( Medicine)
MD ( Nephrology)
 Local symptoms of urinary tract
disease
Pain:
Loin pain.
Ureteric colic.
Suprapubic pain.
Haematuria.
Change in urine appearance.
Changes in urine volume:
Polyuria.
Oliguria and anuria.
Lower urinary tract symptoms (LUTS):
Obstructive (voiding) symptoms:
— Impaired size or force of the urinary stream.
— Hesitancy or abdominal straining.
— Intermittent or interrupted flow.
— Post-micturition dribble.
— A sensation of incomplete emptying.
— Acute retention of urine.
Storage (filling) symptoms:
— Nocturia.
— Daytime frequency.
— Urgency.
— Urge incontinence.
— Dysuria
 Pain
• Most kidney disease is painless.
• Pain may arise from kidney capsule (loin pain), ureter
(ureteric colic) or bladder/urethra.
• Flank pain suggests upper tract obstruction.
• Acute ureteric colic can be severe. It is usually
unilateral and may radiate to the ipsilateral groin .
• Flank pain, fever, and signs of pyelonephritis suggest
obstruction with infection.
• Pain radiating to the flank during micturition is
suggestive of vesicoureteric reflux
• Pain after high-volume fluid intake occurs in pelvi-
ureteric junction (PUJ) obstruction .
• Retroperitoneal fibrosis may cause backache.
 Loin Pain
• Severe loin pain is usually due to ureteric obstruction;
renal calculi are the most common cause. The pain
often comes in waves and is described as ‘colicky’. The
patient is unable to find a comfortable position and will
move around the bed (unlike a patient with peritonism,
who lies still).
• Loin pain may also occur due to bleeding from a renal
or ureteric tumour, or due to infection.
• Non-renal causes of loin pain, such as a leaking aortic
aneurysm (in older patients with vascular disease) and
ectopic pregnancy (in women of child-bearing age),
should be considered.
 Storage symptoms
• Frequency- micturitating more often with no
increase in total urine output.
• Urgency- A sudden strong need to pass urine.
• Nocturia – waking more than twice at night to
void.
• Dysuria- pain during or immediately after
passing urine.
 Causes
• Lower urinary tract infections.
• Tumor
• Urinary stones
• Prostatic enlargement
• Neurogenic bladder
 Voiding symptoms
• Hesitancy- difficulty or delay in initiating urine
flow.
• Stranguary – slow and painful discharge of
small volume of urine related to involuntary
bladder contractions.
• Common cause-
prostatic enlargement
Genital prolapse
Urethral stenosis
 Haematuria
• Can result from bleeding at any site in the urinary tract, from
the kidney to the tip of the urethra. Causes range from benign
to serious illness.
• Most common cause:
1. Infection
2. Glomerulonephritis
3. Stone
4. Uroepithelial malignancy
5. Cystic disease of kidney
Macroscopic:
1. Blood is visible to the naked eye. Gross
haematuria startles the patient and presents
early.
2. Macroscopic haematuria always requires
investigation.
3. Heavy bleeding with clot formation almost
never occurs in glomerular disease.
Microscopic:
1.Blood only visible under high-powered
microscopy.
2. Often detected on dipstick examination in an
asymptomatic patient.
3. Arbitrary. >2 red cells/hpf.
Transient haematuria
▪ Exercise ( ‘ joggers ’ nephritis ’ ).
▪ Menstruation.
▪ Sexual activity.
▪ Viral illnesses.
▪ Trauma.
 Glomerular vs non-glomerular
• Provides a framework for considering pathology.
• Both can present with macro- or microscopic
bleeding (particularly non-glomerular
haematuria).
• Always assume bleeding is non-glomerular
(particularly age >40) until investigation proves
otherwise.
• Locally agreed nephrological and urological
referral and management pathways are highly
desirable, particularly for microscopic
haematuria.
 Investigations of Macroscopic
Haematuria
• Urinalysis: A – ve dipstick in a patient with documented
macroscopic haematuria should not stop further investigation.
• Urine M,C+S: infection? Ova of Schistosoma haematobium
• Urine cytology: malignant cells? Casts and dysmorphic red
cells?
• FBC, U&E, clotting, G&S ( cross-match when severe), PSA, Hb
electrophoresis in black patients.
• Imaging: CT, with and without contrast, is the investigation of
choice. If unavailable, USS + IVU.
• Cystoscopy (in virtually all patients):
• ureterography or ureteroscopy.
• Angiography (rarely). May demonstrate a vascular lesion
 Protienuria
• Protein excretion< 150mg/day is normal.
• <30mg of this is albumin; the rest is LMW
protein, including B2 microglobulin, enzymes,
and peptide hormones.
• A small proportion is secreted by the renal
tubules, including Tamm – Horsfall
mucoprotein (uromodulin).
 Importance
• It is a marker of intrinsic renal disease,
particularly glomerular injury.
• It is a risk factor for the progression of renal
insufficiency.
• It is an independent risk factor for CV
morbidity and mortality
 Types of Proteinuria
Glomerular :
The most important cause of proteinuria in clinical
practice. The predominant protein is albumin.
Tubular :
Damage to the proximal tubule disrupts this cycle and
results in tubular proteinuria.
Overflow:
Overproduction of LMW plasma proteins
exceeds the capacity of the normal proximal
tubule to reabsorb them.
Secretory :
Protein added to the urine lower in the urinary
tract (e.g. bladder tumour, prostatitis). Blood
(>50mL/24h) will also cause proteinuria
 Transient Proteinuria
• Fever.
• Exercise.
• Extreme cold.
• Seizures.
• CCF.
• Severe acute illnesses.
 Postural (orthostatic) proteinuria:

▪ Normal subjects demonstrate a small i in

protein excretion on standing.
▪ Postural proteinuria is an exaggeration of this.
▪ Relatively common in young adults ( 3 – 5%).
Rare age >30.
▪ Usually <1g/24hrs
 Microalbuminuria
• The term microalbuminuria describes albuminuria
above the normal range (>30mg) but below the
threshold of traditional dipsticks (<300mg).
• It is a sensitive indicator of: • Early renal disease. •
CV risk in DM, HTN, and several other conditions.
• It is detected by spot microalbumin/creatinine ratio,
ultrasensitive dipstick, or radioimmunoassay on a
24h urine collection
 Change in Urinary volume
▪ Polyuria: >3L/24h.
▪ Oliguria: <400ml/24h
▪ Anuria : <100ml/24h
 Polyuria
▪ Physiological:
Excessive fluid intake
▪ Pathological :
Osmotic diuresis: glycosuria, mannitol, contrast
agents.
Tubular disorders:
• Nephrogenic diabetes insipidus,
• Acquired tubular defect (e.g. caused by
pyelonephritis, post-obstruction, chronic
hypercalcemia, Hypokalaemia)
• Nephrotoxins (e.g. aminoglycosides, cisplatin,
lithium)
• Diuretics
• Bartter ’ s syndrome
• polyuric recovery phase of AKI
Endocrine
• Central diabetes insipidus
• Addison ’ s disease
• hyporeninaemic hypoaldosteronism
 Oliguria/Anuria
Causes:
1. Urinary obstruction
2. Reduced renal perfusion:
- Severe ATN
-pre renal AKI
- Aortic dissection
3. RPGN
 Edema
• Oedema is caused by an excessive accumulation of
fluid within the interstitial space.
• Non pitting edema-
- Hypothyroidism
- Lymphatic obstruction
- Systemic Sclerosis
 Acute Urethral Syndrome
Urinary frequency and dysuria without demonstrable
infection.
Causes:
➢ Post-coital bladder trauma
➢ Vaginitis
➢ Urethritis in elderly
➢ Infection – clamydia,TB
➢ Stone
➢ Malignancy
➢ Interstitial Cystitis
Treatment:
▪ No antibiotic is necessary.
▪ Options:
➢ HRT
➢ Anti-spasmotic
➢ TCA
➢ Muscle relaxant
 Interstitial Cystitis
Characteristics:
➢ unpleasant sensation related to urinary bladder
( pain,pressure,discomfort).
➢ Associated with LUTS
➢ More than six week duration
➢ Absence of infection or other identifiable causes
Treatment:
1. Patient eduation, stress management, relaxation
therapy.
2. Oral- amityptyline,cimetidine
3. Intravesical- Heparin,lidocaine
4. Neuromodulation & pain management
5. Cystoscopy with hydrodistension
 Investigations
Urine Examination:
Appearance-
• normal urine is clear or given a light yellow
• Cloudy- high conc. Of leukocytes,epithelial
cells or bacteria
• Causes of a coloured urine
➢ Beetroot ingestion (red).
➢ Blood (pink/red to brown/black).
➢ Haemoglobin (pink/red to brown/ black).
➢ Myoglobin (pink/red to brown/ black).
➢ Chloroquine (brown).
➢ Chyluria (milky white).
➢ Hyperbilirubinaemia (yellow/ brown).
➢ Methylene blue (er . . . blue).
➢ Nitrofurantoin (brown).
➢ Onchronosis (black). • Phenytoin (red). • Propofol
(green). • Rifampicin (orange). • Senna (orange)
Specific gravity:
Normal- 1.010-1.020
SG of 1.000 to 1.003 is seen with marked urinary
dilution, as observed in patients with diabetes
insipidus or water intoxication.
SG above 1.040 almost always indicates the
presence of some extrinsic osmotic agent,
such as radiocontrast.
Osmolality:
➢The ability to vary urine osmolality (range 50 –
1350mOsmol/kg) plays a central role in the
regulation of plasma osmolality (maintained
across a narrow range: 280 – 305mOsmol/kg).
➢ Investigation of polyuria and hypo-
/hypernatraemic states.
Urinary PH:
➢Urinary pH ranges from 4.5 to 8.0 (usually 5.0
– 6.0), depending on systemic acid base
status
➢Their main clinical use is the investigation of
systemic metabolic acidosis.
Therapeutic urinary alkalinization
➢ Urinary stone disease (cysteine and urate stones)
➢ Poisoning :
• Salicylates.
• Barbiturates.
• Methotrexate.
➢ Rhabdomyolysis
➢ AKI s to cast nephropathy in myeloma
 Urinalysis: protein
Dipsticks are semi-quantitative. As a rough
guide:
➢Trace 0.15–0.3g/L
➢+ 0.3g/L
➢++ 1g/L
➢+++ 2.5–5g/L
➢++++ >10g/L
 Quantification of Protein
• 24 hrs UTP
Untimed ( ‘ spot ’) urine samples are now used virtually
universally for the detection and monitoring of
proteinuria.
• uACR:
➢ uACR is more sensitive than uPCR if screening for
early disease in high-risk groups (especially diabetes).
➢ Normal: <30mg/g
➢ Microalbuminuria : 30-300mg/g.
➢ Overt protienuria: >300 mg/g
• uPCR:
➢ It can be helpful to multiply uPCR x 10 to provide an
estimate of 24h excretion, e.g. uPCR of 125mg/mmol
approximates to 1.25g/24h.
➢ A first morning urine specimen is preferable.
 Cells
Leukocytes: leucocytes are a prominent feature of
urinary infection but may also be present in infl
ammatory renal conditions (GN, TIN)
Sterile pyuria: refers to the situation wherein
leucocytes are seen consistently on microscopy, but
subsequent culture is sterile.
Causes of sterile pyuria • Partially treated UTI or
fastidious organism (e.g. Chlamydia ). • Calculi. •
Prostatitis. • Bladder tumour. • Papillary necrosis. •
TIN. • TB • Appendicitis.
 Cast
Casts are plugs of Tamm – Horsfall mucoprotein within
the renal tubules, with a characteristic cylindrical
shape.
Non cellular cast: Hyaline,granular,waxy cast.
Cellular:
RBC cast- GN.
WBC cast- Acute pyelonephritis, TIN.
Epithelial cell cast- ATN,GN
 Aspects of renal function
• Glomerular filtration rate (GFR).
• Tubular function (including Na + and K + handling
and urinary concentrating/diluting capacity).
• Acid – base balance.
• Endocrine function:
➢ Renin – angiotensin system (RAS).
➢ Erythropoietin production.
➢ Vitamin D metabolism
 GFR measurement
Direct: Inulin,Iohexole,iothalamate, 99mTc-DTPA, 51Cr-
EDTA.
Indirect:
eGFR-
Creatinine based formula: C-G formula,MDRD,CKD-EPI
equation 2012,2021
Cystatin C based formula
 Tubular Function test
• Solute conc.- osmolality,specific gravity
• Unine sediment
• Proximal tubular function
• Urinary sodium
• Fractional excretion of sodium
• Fractional excretion of urea
• Acid base balance- urinary pH&HCO3, serum
pH& HCO3
• Water deprivation test
• Water load test
• Biomarkers of tubular injury-
➢ Cystatin C
➢B2 microglobulin
➢NGAL
➢KIM-1
asiqur870@gmail.com