Renal System

Assessment
By:
Ayman Mohamed Gamil Hassan
Master degree
Critical care dep.
2016

Objectives
By

the end of this research, the

students will be able to:

Identify functions of the urinary

system.
Identify anatomy and physiology
of the urinary system
Identify mechanism of formation
of urine.

Cont.
Identify

elements and steps of

patient assessment of renal
system
Identify laboratory investigations
to assess urinary system
Identify Imaging studies to
assess urinary system

Outlines:Introduction.
Functions

of the urinary system.

Anatomy of urinary system.
Formation of urine.
Patient Assessment of renal
System:
History
Physical examination
Laboratory assessment

Introduction
The

Urinary System is a group of

organs in the body concerned with

filtering out excess fluid and other
substances from the blood stream.
The substances are filtered out
from the body in the form of urine.

Cont.
Urine

is a liquid produced by the

kidneys, collected in the bladder

and excreted through the
urethra. Urine is used to extract
excess minerals or vitamins as
well as blood corpuscles from the
body.

Functions of the Urinary

System
Regulation

of plasma ionic composition.

Regulation

of plasma osmolality

Regulation

of plasma volume

Regulation

of plasma hydrogen ion

concentration (pH).

Cont.
Removal

of metabolic waste products and

foreign substances from the plasma.

Secretion

of Hormones.

1-Regulation of plasma ionic

composition
Ions

such as sodium, potassium,

calcium, magnesium, chloride,

bicarbonate, and phosphates are
regulated by the amount that the
kidney excretes.

Regulation of plasma
osmolality
The

kidneys regulate osmolality

because they have direct control

over how many ions and how
much water and salts a person
excretes.

Regulation of plasma volume

The

plasma volume has a direct

effect on the total blood volume,

which has a direct effect on your
blood pressure. Salt(NaCl)will
cause osmosis to happen; the
diffusion of water into the blood.

Cont.
Regulation

ion

of plasma hydrogen

concentration

(pH).

The

kidneys partner up with the lungs

and they together control the pH.
The

kidneys

have

major

role

because they control the amount of

bicarbonate excreted or held onto.

Cont.
The

kidneys help maintain the

blood Ph mainly by excreting

hydrogen ions and reabsorbing
bicarbonate ions as needed.

Removal of metabolic waste

products and foreign
substances from the plasma.
One of the most important things the kidneys
excrete is nitrogenous waste. As the liver
breaks down amino acids it also releases
ammonia. The liver then quickly combines that
ammonia with carbon dioxide, creating urea
which is the primary nitrogenous end product
of metabolism in humans

Cont.
We can

also excrete, creatinine and uric

acid. The creatinine comes from the

metabolic breakdown of creatine phospate
(a high-energy phosphate in muscles).

Secretion of Hormones
Renin

is released by the kidneys. Renin

leads to the secretion of aldosterone
which is released. Which promotes the
kidneys to reabsorb the sodium (Na+)
ions.
Erythropoietin stimulate the bone marrow
to produce red blood cells.

Cont.
The

Vitamin D from the skin is also

activated with help from the kidneys.

{Calcifrolcalcitrol bone+intestine}

Organs in the Urinary System

The

kidneys

bean shaped, brown organs about

the size of your fist
measures 10-12 cm long.
They are covered by the renal
capsule.
They are considered retroperitoneal.

blood supply to the

kidney:
Renal Vein
They connect the kidney to the
inferior vena cava.
Renal Artery
The renal arteries normally arise
off the abdominal aorta and
supply the kidneys with blood

Ureters
The ureters are two tubes that drain
urine from the kidneys to the bladder.
Each ureter is a muscular tube about
10 inches (25 cm) long.
Urinary Bladder
The urinary bladder is a hollow,
muscular and distensible or elastic
organ that sits on the pelvic floor
(500 to 530 ml) of urine

The urethra

Its a muscular tube that connects the

bladder with the outside of the body.
It measures about 1.5 inches (3.8 cm) in
a woman but up to 8 inches (20 cm) in a
man
There are two distinct areas of muscle:
the internal sphincter, at the bladder
neck and the external, or distal,
sphincter.

Nephrons
A

nephron is the basic structural

and functional unit of the kidney.
Its chief function is to regulate
water and soluble substances by
filtering the blood, reabsorbing
what is needed and excreting the
rest as urine.

Formation of Urine

Urine is formed in three steps:

Filtration in the glomerulus

Reabsorption of {glucose
,Water ,amino acids }

Secretion.

cont.
Maintaining

Water-Salt Balance

Direct control of water excretion in

the kidneys is exercised by the antidiuretic hormone (ADH), released by
the posterior lobe of the pituitary
gland.

Cont.
Reabsorption

of Salt by

Aldosterone
Steroid hormone
Sex hormones

Patient Assessment of renal

System
History
Physical

examination

Inspection
Auscultation
Palpation
Percussion

Cont.
Additional

assessments

Laboratory
Imaging

assessment

studies

History: The

history begins with a

description of the chief

complaint, stated in the patients
own words. A description of the
chief complaint includes the
onset, location, duration, and
factors or strategies that lessen

Common Kidney-Related
Symptoms

Dyspnea
Peripheral dependent edema
Nocturia
Nausea
Metallic taste in mouth

Cont.
Loss of appetite
Rapid weight gain.
Dry, scaly skin
Weakness, fatigue.
Cognitive function changes.
Mental status changes.

Cont.
Risk

Factors

Family history
Hypertension
Diabetes mellitus
Prior acute kidney failure

Cont.
Medical

History

Nephrotic

syndrome,

streptococcal infection,
hypoplastic kidneys, obstructive
uropathy.

Cont.
Frequent

urinary tract

infections ,Calculi, Vasculitis,Use

of iodine-based radiographic
contrast media, Use of
nonsteroidal anti-inflammatory
medications.

Cont.
Family

History
Hypertension
Diabetes mellitus
Polycystic kidney disease
Kidney disease
Chronically swollen extremities

Cont.
Current

Medication Use

Nonsteroidal anti-inflammatory
medications (e.g., ibuprofen)
Antibiotics (especially
aminoglycosides)
Antihypertensive
Diuretics.

Cont.
Past

Kidney Studies
Urinalysis with proteinuria
Creatinine clearance
Kidney-ureter-bladder (KUB)
Intravenous pyelogram
Kidney ultrasound
Renal arteriography
Kidney biopsy.

Physical examination:-

Inspection
Bleeding

signs:

Visual inspection related to the kidneys

focuses on the patients flank and
abdomen. Kidney trauma is suspected if a
purplish discoloration is present on the
flank (Grey-Turner sign) or near the
posterior 11th or 12th ribs. Bruising,
abdominal distention.

Cont.

Blood volume: -

Inspection is especially helpful in

looking for signs of volume depletion
or overload that may signal or lead
to kidney problems:
Jugular

veins

Cont.
Hand

vein inspection {venous distention

,Venous filling=5 seconds, When the

hand is elevated the distention should
disappear within 5 seconds} .
Assessment
oral

of skin turgor provides.

cavity provides clues to fluid

volume status.

Cont.
Edema:

is the presence of

excess fluid in the interstitial

space, and it can be a sign of
volume overload.
Edema

may appear in the hands

and feet, around the eyes, and in

the cheeks or in lower extremities

Cont.
Edema

can be assessed by

applying fingertip pressure on the

swollen area over a bony
prominence.

Pitting edema scale:

Auscultation
Auscultation

of the kidneys yields

virtually no useful information.

However, the renal arteries are
auscultated for a bruit.
A

renal artery bruit usually indicates

stenosis, which may lead to acute or

chronic kidney dysfunction.

Cont.
A

bruit over the upper portion of

the abdominal aorta may indicate

an aneurysm or a stenosis area
that can decrease blood flow to
the kidneys.

Cont.
Heart

Auscultation: Auscultation of the heart

requires assessing the rate and rhythm

and listening for extra sounds. Fluid
overload is often accompanied by a third
or fourth heart sound, which is best,
heard with the bell of the stethoscope.

Cont.
Blood
Blood

Pressure

pressure and heart rate changes

are very useful in assessing fluid volume

deficit. In stable critically ill patients or
in patients on a telemetry unit,
orthostatic vital sign measurements
provide clues to blood loss, dehydration.

Palpation
palpation

of the kidneys in stable

patients provides information about the

kidneys size and shape. Palpation of
the kidneys is achieved through the
bimanual capturing approach. Capturing
is accomplished by placing one hand
posteriorly under the flank of the.

Cont.
supine

patient with the

examiners fingers pointing to the

midline and placing the opposite
hand just below the rib cage
anteriorly. The patient is asked to
inhale deeply while pressure is
exerted to bring the hands

Percussion
Kidneys

Percussion is performed

with the patient in a side lying or

sitting position, with the
examiners hand placed over the
costovertebral angle (lower border
of the rib cage on the flank).

Cont.
Produces

a dull thud, which is

normal. Pain may indicate

infection (e.g., urinary tract
infection that has extended into
the kidneys) or injury resulting
from trauma.

Cont.
Abdomen

Ascites, or excess fluid accumulation

and distention of the abdominal cavity,
is an important observation in
determining fluid overload.

Cont.
Differentiating

ascites from distortion

caused by solid bowel contents is

accomplished by producing a fluid
wave A fluid wave is elicited by
exerting pressure to the abdominal
midline while one hand is placed on
the right or left flank.

Additional assessments
Weight

Monitoring.
Intake and Output Monitoring
Hemodynamic Monitoring
. Measurements such as central
venous pressure (CVP), pulmonary
artery occlusion pressure (PAOP),
cardiac index (CI), and mean
arterial pressure (MAP)

 Other

Observations

LA
AS BO
SE RA
SS TO
M RY
EN
T

A-Serum Components
Blood

Urea Nitrogen
Serum Creatinine
BUN to Creatinine Ratio
Cystatin C
Serum Osmolality
Hemoglobin and
Hematocrit
Serum Albumin

Blood Urea Nitrogen: Blood

urea nitrogen (BUN) is a

byproduct of protein and amino acid
metabolism. The normal value for BUN
is 5 to 20 mg/dL, which is increased
when kidney function deteriorates.
With kidney dysfunction, the BU`N is
elevated because of a decrease in the
glomerular filtration rate (GFR) and
resulting decrease in urea excretion.

Cont.
the

rise in BUN may be caused

by a decreased GFR in the

presence of normal kidney
function (hypovolemia and
dehydration, nephrotoxic
medications, or a sudden
hypotensive episode)

Cont.
BUN

is also increased by changes

in protein metabolism that occur

with excessive protein intake and
catabolism.

Cont.
A

catabolic state may occur with

starvation (or chronic poor

nutrition in a critically ill patient),
severe infection, surgery, or
trauma.
A

decrease in the BUN level may

indicate volume overload, liver

Serum Creatinine: Creatinine

is a byproduct of

muscle and normal cell

metabolism.
normal

serum creatinine level is

about 0.5 to 1.2 mg/dL, slightly

higher in males than females.

Cont.
serum

creatinine level is a more

sensitive and specific indicator of

kidney function than BUN.
Creatinine excess occurs most
often in persons with kidney
failure resulting from impaired
excretion.

Cont.
Other

factors may increase

S.Creatinine
Muscle wasting in acute illness.
Muscle growth disorders such as

acromegaly
Traumatic skeletal muscle injury
Medications that decrease creatinine

removal (e.G., Trimethoprim, cimetidine)

BUN to Creatinine
Ratio
Another

useful diagnostic
parameter in kidney disease is
the ratio of blood urea nitrogen
(BUN) to creatinine.
The usual ratio of BUN to
creatinine is 10 to 1, and a
change in the ratio may indicate
kidney dysfunction.

Cont.
if

BUN and creatinine levels are

elevated and maintained at an
approximate ratio of 10 to 1, the
disorder is intra renalor affecting
the tubules of the kidneys.
If the ratio of BUN to creatinine
levels is greater than 10 to 1, the
cause is most likely prerenal
(e.g., hypovolemia).

Cont.
In

prerenal kidney failure, the

creatinine is excreted by
functioning tubules, but the urea
nitrogen is retained because of
the poor GFR and
hemoconcentration, leading to
the increased ratio.

Serum cystatin C :
Although

not widely used in

practice, cystatin C is another
serum marker for kidney function
Cystatin C is a substance
synthesized and released by
most cells in the body at a
constant rate.

Cont.
The

advantage of cystatin C is

that it is metabolized by the

tubules.
Normal

range (0.50 - 1.09), mg/L

Serum Osmolality: The

serum osmolality reflects the

concentration or dilution of
vascular fluid and measures the
dissolved particles in the serum.
The normal serum osmolality is
275 to 295 mOsm/L.
An elevated osmolality level
indicates hemoconcentration or
dehydration.

decreased

osmolality level indicates

he
serum osmolality level may indicate
syndrome of inappropriate ADH
secretion (SIADH), or too much ADH,
whereas an elevation of the serum
osmolality level may indicate
diabetes insipidus (DI), or too little
ADH.
2Na (mEq/L) +BUN/3 (mg/dL) +

Hemoglobin and Hematocrit

The

hemoglobin and hematocrit

levels can indicate increases or
decreases in intravascular fluid
volume.
the hemoglobin level in males is
normally 13.5 to 17.5 g/dL, and in
females, it is 12 to 16 g/dL.
The hematocrit level is 40% to 54%
in males and 37% to 47% in
females.

Serum albumin.
Slightly

more than 50% of the

total plasma protein is serum
albumin. It is manufactured in the
liver, and a normal blood level is
3.5 to 5 g/dL.
nephrotic syndrome (increased
glomerular capillary permeability
to protein and protein loss in the
urine), albumin is lost from the
vascular space.

B- Urinalysis
Analysis

of the urine provides

excellent information about the

patients kidney function and
condition relative to fluids and
electrolytes.

Cont.
In

the critically ill patient a routine

urinalysis specimen may be

obtained to rule out the presence of
urinary protein or glucose.

A sterile urine culture may be

obtained if a urinary tract infection

(UTI) is suspected.

cont
Urine

Appearance
Physical examination of the urine
focuses on a general inspection
of the urines color, clarity, and
odor.

Cont.
Normal

urine is pale yellow, but it may

vary due to food intake (carrots, beets,

rhubarb), medications (phenytoin,
nitrofurantoin, phenazopyridine), or
metabolic byproducts (bilirubin, met
hemoglobin).

Cont.
Clarity

of the urine may be affected by

bacteria, white blood cells (WBCs), or

urates
Normal

urine has minimal odor; a strong

odor may be caused by concentrated

urine (as in dehydrated states), infection,
medicines (especially vitamins), or foods
(broccoli, asparagus).

Cont.
Urine

pH

Urine pH indicates the acidity or alkalinity

of the urine.
The normal urinary pH is acidic but has a
range from 4.5 to 8.
Changes in metabolic function and
kidney function produce changes in
urinary pH.

cont
Changes

in metabolic function
and kidney function produce
changes in urinary pH.
An increase in urinary acidity
(decreased pH) indicates
retention of sodium and acids by
the body, which occurs in
intrarenal AKI.

Cont.
A

decrease in urinary acidity

(increased pH or more alkaline)

means the body is retaining
bicarbonate

Cont.
,urinary

pH levels are greatly affected

by diet and medications, Certain food

groups, such as citrus fruits and
vegetables, lead to alkaline urine
whereas

a diet high in protein can

produce acidic urine.

Cont.
In

the

critical

care

unit,

patients

receiving total parenteral nutrition or a

high-protein tube-feeding formula may
have acidic urine because of high
protein intake.

Cont.
Urine

Specific Gravity

Specific gravity measures the

density or weight of urine compared
with that of distilled water.
The normal urinary specific gravity
is 1.005 to 1.025.

Cont.
Decreases

in specific gravity reflect

the inability of the kidneys to excrete
the usual solute load into the urine
(less dense with fewer solutes).

Increases

in specific gravity are

caused by dehydration (more
concentrated urine)

Cont.
Urine

osmolarity
The simultaneous measurement
of the serum and urine osmolality
levels provides an accurate
assessment of fluid status.
The normal urine osmolality level
is 500 to 1200 mOsm/kg

Cont.
Urine

Protein
Protein normally is absent from
urine because protein molecules
are too large to be filtered across
the intact glomerular capillary
membrane. Protein amounts
greater than 150 mg/day signal
compromise of the glomerular
membrane and intrinsic kidney
damage.

Cont.
Traditionally,

quantitative
measurement of the amount of
protein in the urine required a 24hour urine collection.
Urine Glucose
Glucose normally is completely
resorbed by the kidney tubules,
and the urine should be free of
glucose.

Cont.
Urinary

glucose should not

exceed 130 mg per day.
In the presence of acute or
chronic kidney failure, glycosuria
may not be a reliable indicator of
the level of hyperglycemia
because of the damaged
nephrons.

Cont.
URINE

TOXICOLOGY SCREEN
Urine can be screened to detect
the presence of alcohol, illegal
drugs, prescription and
nonprescription medications, and
other substances that are excreted
via the kidneys.

IM
AG
IN
G

ST
UD
IES

Kidney-ureter-bladder (KUB)
radiograph
Flat-plate

radiograph of the
abdomen; determines position,
size, and structure of the kidneys,
urinary tract, and pelvis; useful
for evaluating the presence of
calculi and masses; usually
followed by additional tests.

Intravenous pyelogram (IVP)

Intravenous

injection of contrast
with radiography; allows
visualization of internal kidney
tissues.

Ante grade Pyelogram

(nephrostogram)
is

an x-ray to evaluate the upper

urinary tract when there is allergy to
contrast media or decreased renal
function and when abnormalities
prevent passage of a ureteral catheter.
Contrast medium may be injected
percutaneously into the renal pelvis or
via a nephrostomy tube that is already
in place when determining tube
function or ureteral integrity after
trauma or surgery.

Nephrotomogram
Multiple

exposures are taken to

visualize specific sections of the
kidney after IV injection of
contrast material.

Retrograde Pyelogram
Retrograde

pyelogram is an x-ray of
urinary tract taken after injection of
contrast material into kidneys. It may
be done if an IVP does not visualize the
urinary tract or if the patient is allergic
to the contrast material or has
decreased renal function. A cystoscope
is inserted and ureteral catheters are
inserted through it into renal pelvis.
Contrast material is injected through
catheters.

Renal Arteriogram
(angiogram)
Purpose

of renal arteriogram is to visualize

renal blood vessels. Findings can assist in
diagnosing renal artery stenosis, additional
or missing renal blood vessels, and
renovascular hypertension. Can assist in
differentiating between renal cyst and
renal tumor.
A catheter is inserted into the femoral
artery and passed up the aorta to the level
of the renal arteries. Contrast medium is
injected to outline the renal blood supply.

Cystogram
Cystogram

is used to visualize bladder and

evaluate vesicoureteral reflux. Also used to

evaluate patients with neurogenic bladder
and recurrent urinary tract infections. Can
also delineate abnormalities of the bladder,
such as diverticula, calculi, and tumors.
Contrast material is instilled into bladder via
cystoscopy or catheter.

Voiding Cystourethrogram
(VCUG)
Voiding

cystourethrogram is a voiding
study of the bladder opening (bladder
neck) and urethra. The bladder is filled
with contrast material. Fluoroscopic
films are taken to visualize the bladder
and urethra. After urination, another
film is taken to assess for residual
urine. Can detect abnormalities of the
lower urinary tract, urethral stenosis,
bladder neck obstruction, and prostatic
enlargement.

Computed tomography (CT)

Radioisotope

is administered by
intravenous route and absorbed
by the kidneys; scintillation
photography is then performed in
several planes; spiral or helical
CT allows rapid imaging; density
of the image helps evaluate
kidney vessels, perfusion,
tumors, cysts, stones/calculi,
hemorrhage, necrosis, and
trauma.

Ultrasound
High-frequency

sound waves are

transmitted to the kidneys and
urinary tract, and the image is
viewed on an oscilloscope;
noninvasive; identifies fluid
accumulation or obstruction,
cysts, stones/calculi, and masses;
useful for evaluating kidney
before biopsy.

Magnetic resonance imaging

(MRI)
A

scanner produces threedimensional images in response

to the application of high-energy
radiofrequency waves to the
tissues; produces clear images;
density of the image may
indicate trauma, cysts, and
masses, malformation of the
vessels or tubules stones/calculi,
and necrosis.