Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Examination in Nephrology MUDr. Zuzana Lichá MUDr. Petra Divácká The University Hospital Brno April 20, 2020 1 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Structure of the presentation 1 Medical History 2 Physical Examination 3 Examination of kidneys and urinary system 4 Laboratory Examination 5 Imaging methods 6 Therapy 2 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Medical History Family history: do you have any of kidney disease in the family? - eg. polycystic disease of kidney (her, autoimmune disease { eg. SLE, familiar haematuria, has anyone in the family been treated for renal failure by renal replacement therapy (RRT)? Personal history: do you have any metabolic disease? { eg. diabetes? or vascular disease: hypertension?, chronic hearth failure?, autoimmune disease, oncological disease, urological disease { prostatic hyperplasia, nephro- or urolithiasis, vesicourethral re ux? Gynecological anamnesis: gestational hypertension? preeclampsia? Pharmacological history: using any of nephrotoxic drugs? { eg. analgetics (mainly NSAIDs), antibiotics, chemotherapy, high osmolar contrast agents i.v. Physiological functions: urological problems { dysuria, pollakiuria, renal colic, haematuria, nycturia, stools - regular, irregular, pathological substances in the faeces { blood, mucus, melena, diarrhoea Nefrological history: infectious focuses (sinusitis, tonsilitis) in connection with renal injury, frequent in ammations of urotract, recurrent lithiasis, haematuria, proteinuria (during pregnancy, after angina...) 3 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy The most common problems of a patients with kidney disease swelling { permanent/temporary headache, vertigo, problems of vision (eg. because of hypertension) lumbal pain/in kidney area/ hypogastric area dysuria (burning or cutting during urine), pollakiuria (painful dysuria and frequency), haematuria (change color of urine- red/brown), problems with holding urine fatigue, weakness (anemia?) dyspepsia, nausea, vomiting (kidney failure) fever, shivers during of in ammation of urotract 4 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Physical Examination Basics Including height, weight, body mass, blood pressure and pulse General examination: conscious, lucid, oriented, without icterus or cyanosis. Pallor? { anemia with erythropoietin de ciency. Skin turgor? { reduced for dehydration, skin clean? With numerous excoriations? Rush? Breathing odor of urea (uremic syndrome), Anasarca? Head: percussively painless, output of cranial nerves V a VII intact, isocoric pupils, without nystagmus, sclera anicteric, swelling of eyelids? { for autoimmune in ammation of the kidneys or with a decrease in diuresis with kidney damage?, nose and ears and mouth without secretion, sick mucous membranes during dehydration Neck: free movement in all directions, normal lling of cervical veins, thyroid non-enlarged, elastic, lymph nodes not palpable Chest: alveolar and clean breathing, without pathological phenomena, Kussmaul`s faster and deeper breathing in acidotic uremia (blood pH below 7,2 = acidosis in renal failure and high serum urea)? Cardiac regular action (bradycardia / tachycardia in case of potassium metabolic disorders), echoes intact, no murmur (pericardial murmur in uremia) 5 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Physical Examination Belly: in niveau (ascites?), soft, palpable, painless, without palpable resistance, peristalsis +, any scars? (after nephrectomy?), liver and spleen not palpable, tappotment bilaterally negative, kidney palpation { palpable? Enlarged? (polycystic of kidney) Extremities: Upper limbs: no swelling, no in ammation, free movement, palpable pulsations on the periphery Lower limbs: no swelling, no signs of in ammation, free movement, varices?, signs of chronic venous insuciency? Lymphedema? palpable pulsations on the periphery 6 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Examination of kidneys and urinary system Tappotment - hitting the lumbar region by the edge of the hand just below the rib arch - the pain of kidney´s in ammation Bimanual palpation of the kidneys (Israeli´s touch) { the patient lies on his back with knees bent, when examining the right kidney, the examiner stands on the right side of the bed, his left hand examines the kidney by pressure in lumbar region, ” lifts\ against the palpating right hand (palpation of enlarged kidney eg. polycystic kidney) Palpation and tapping of the bladder { just above the symphysis, to detect pain or greater residue (= residual urine) in the bladder after urination Figure: Kidneys examination 7 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Urine assessment Color light - decreased urine concentration (patient drinks a lot) orange { sign of dehydration and fever dark - with bilirubin for jaundice = obstructive icterus pink - weaker admixture of blood in urine dark brown - massively blood in urine = macrohematuria Turbidity Pus in the urine Odor e.g. after rotten apples - in diabetic ketoacidosis, after medication - endiaron, antibiotics 8 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Urine assessment Foam Foam with higher content of bilirubin or protein Amount Oliguria (urine amount below 500ml / day), anuria (urine amount below 100ml / day), polyuria (more than 3l urine / day) 9 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Urine examination Proteinuria examination Orientation test with strips Quantitative proteinuria in 24 hours { urine collection (possibly morning urine sample or from second micturition) In adults physiologically max. 0.15g/24 hours (pregnant 0.3g/24h) Proteinuria levels Small (up to 1g/day) Medium (1-3g/day) Large - nephrotic syndrom (more than 3g/day) Albuminurie Standard up to 30mg/24h, albumin/creatinine ratio in urine = ACR standard up to 3mg/mmol albuminuria over 30mg/24h - is an early symptom in diabetic and hypertensive nephropathy, is a bad predictor of cardiovascular risk 10 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Urine examination Urine & sediment 10ml morning urine (medium ow, watch out for menses and discharge) Biochemical examination Density, pH, protein, sugar, ketones, blood, leukocytes, nitrites, bilirubin, urobilinogen Microscopic examination Rating: Erythrocytes - norm 0-10/µl, glomerular (acanthocytes) x from outlet pathways Leukocytes - norm 1-15/µl, in ammation, sterile pyuria in TB Rollers - hyaline, granulated, cellular, waxy, fat, bacteria, epithelium ( at, round), Crystals (urates, oxalates) Diagnostics Protein, erythrocytes, urine cylinders in immune non-infectious in ammations (glomerulonephritis) Leukocytes, bacteria and erythrocytes in urine due to infectious bacterial in ammation (pyelonephritis) 11 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Examination of microerytrocyturia Examination of erythrocytes in phase contrast Glomerular hematuria suggests: Dysmorphic red cells ≥ 80% Acantocytes (” budding erythrocytes\) ≥ 5% Presence of erythrocyte cylinders The evaluation requires experience, is always subjective Between glomerular and nonglomerular ndings there is a wide gray zone Diagnostic sensitivity for glomerular hematuria in phase contrast is 53 − 74%, speci city 50-98%. 12 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Laboratory examination Biochemistry: urea, creatinine (high retention of nitrogen catabolites?), CKD EPI { is laboratory calculated value of renal function, sodium, potassium (hyperkalemia?), chloride, calcium, phosphorus, parathyroid hormone (hypercalcemia, hyperphosphatemia, secondary hyperparathyroidism), proteinemia, albumin - hypoproteinemia in nephrotic syndrome, liver test + bilirubin - hepatitis? hepatorenal syndrome?, glycemia (diabetes?), lipidogram, anemic group { metabolism of iron, vitamin B12 and folate Blood count: normocytic normochromic anemia?, microcytic sideropenic anemia? Urine + sediment: micro erythrocyturia?, proteinuria?, leukocyturia?, cylinduria? epithelium in urine? crystalluria? Albuminuria and proteinuria from a single urine sample. Urine collection for 24 hours for renal function: creatine clearance, tubular reabsorption, urine and protein waste. Urine for cultivation Immunological examination: suspected glomerulonephritis or systemic autoimmune disease, in ammatory parameters (CRP, FW, procalcitonin), serum immunoglobulins, complement components, cryoglobulins, antistreptolysin O (ASLO), autoantibody collection (e.g. ANA, ENA, ANCA, antiGBM), antiPLA2R...) 13 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Laboratory Examination 1.examination of serum urea concentration standard up to 8mmol/l a poorly accurate indicator of kidney function, in uenced by the intensity of protein metabolism and protein intake increases with dehydration Urea is synthesized in the urea cycle in the liver, it is a waste substance that removes excess nitrogen from the body 2. examination of serum creatinine concentration standard for women up to 84 µmol/l for men up to 104 µmol/l nal product of creatine phosphate degradation (it is an energy reserve for muscle contraction) in addition to endogenous synthesis, creatinine is also fed into the body through food 14 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Laboratory Examination 3. examination of glomerular ltration creatinine clearance C (clearance = amount of plasma that is completely cleaned from the substance of interest per time unit) C = U × V P (1) P = blood concentration of the substance V = urine volume over 24 hours U = concentration of the substance in the urine standard 1.5-2ml/sec, determination of glomerular ltration by calculation from serum creatinine (MDRD or CKD-EPI formula) 15 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Laboratory Examination 4. examination of kidney concentration ability examination of tubular function monitoring of urine osmolality in: a) adiuretine test { the patient does not drink at night, in the morning apply 2 drops of ADH in the nose, urine collection at 1-hour intervals, osmolality at least 900mosmol/kg b) uid withdrawal test - stopping water and fruit intake for 36 hours, similar evaluation { sensitive examination (glomerular ltration rate may still be normal) 5. examination of renal dilution ability we observe the reaction to increased water supply (20ml/kg b.w.), standard elimination of 3 4 of the uid within 4 hours and decrease of urine osmolality below 100mosmol/kg 6. examination of kidney acidi cation ability after administration of an acidic substance (ammonium chloride) we monitor the ability to eliminate hydrogen ions and reduce the urine pH to 5.4-5.5. 16 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Factors in uencing examination of glomerular ltration Stage of chronic kidney disease _ Pregnancy ^ Decreased renal perfusion _ Increase and decrease in volume ECF ^ _ Drugs (NSAIDs, cyclosporin A, ACE-I, sartans...) _ Protein or amino acid intake ^ Hyper- and hypoglycemia ^ _ Hypertension / hypotension ^ _ 17 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Imaging methods 18 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Sonography in nephrology First choice method - easy availability, non-invasiveness, relatively low price Assessment of the shape, size and placement of the kidneys, breadth, echogenicity and homogeneity of the parenchyma, delineation and echogenicity of the renal sinus, lling of the pelvis and calyx Assessment of adrenal size, including possible bearing changes Assessment of the bladder, prostate and vascular supply of the kidney Basic examination method in transplantation nephrology Biopsy of autologous and transplanted kidneys, or other interventional procedures under ultrasonographic control 19 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Renal Biopsy sampling of kidney tissue indications: protein in urine over 3g/day = nephrotic syndrome (CVP>3g/day, _ albuminemia, ^ cholesterol), unclear renal deterioration, unclear acute renal failure, erythrocyturia, suspected nephropathy in systemic diseases contraindications: bleeding state, non-cooperating patient, morbid obesity, polycystic kidney disease, uncorrected hypertension, acute infectious kidney in ammation (pyelonephritis) design: patient lies on the abdomen, local anesthesia with 1% mesocaine, ultrasound measurement and control, biopsy needle sampling after surgery: the patient is lying on his back for 24 hours, with a sandbag compression, blood pressure checks, blood count control, coagulation after 3-4 hours, urine color control, ultrasound kidney control 2nd day to exclude hematoma 20 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Possibilities of renal replacement therapy 1. Kidney transplantation: living donor, deceased donor 2. Dialysis treatment: hemodialysis (HD), home hemodialysis, peritoneal dialysis (PD), assisted peritoneal dialysis (APD); 3. conservative treatment: "non-dialysis treatment", "maximum conservative management" (MCM); indications: decrease in renal function to the terminal stage of chronic kidney disease, uncontrollable hypertension, uncontrollable hyperhydration, uremic syndrome (pericarditis, encephalopathy, bleeding, gastritis, anorexia, pruritus), conservatively uncontrollable acid-base imbalance and severe hyperkalaemia the most optimal replacement therapy for kidney function is transplantation (better survival and quality of life in most patients with chronic kidney disease than dialysis treatment). However, due to the lack of donor organs, most patients are treated with dialysis. 21 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Renal replacement therapy Kidney transplantation { placement of a kidney (from a living or cadaverous donor) to the hip pit. Transplants have a 70% lower risk of death than dialysis patients. Pre-emptive kidney transplantation before commencing regular dialysis therapy is the best and most natural replacement for renal function. Hemodialysis/hemodia ltration { in dialysis centers is the most widespread method of treatment of the terminal stage of chronic kidney disease in the Czech Republic (over 90% of patients). Chronic hemodialysis program { individual 3 times a week, 4-5 hours. Blood puri cation through semipermeable membrane (di usion principle, convection, ltration through capillary dialyser). Chronic vascular input { AV shunt, central permanent catheter. Peritoneal dialysis { CAPD (continuous ambulatory peritoneal dialysis), APD (automated peritoneal dialysis). Blood puri cation via peritoneum (di usion, ltration, peritoneal pores ltration { according to solute concentration in dialysis solution) via peritoneal catheter inserted in the abdominal cavity. Advantages: greater patient autonomy, more exible time scheduling, travel options, home-based method, dialysis center independence, the ability to combine dialysis with work responsibilities, lower uctuations in body uid volume and longer persistence of residual renal function, less cardiovascular stress { no vascular access required blood puri cation is smooth). Disadvantages: possible use only in cooperating patients with sucient family background, other contraindications are severe obesity, stoma and adhesions after abdominal surgery. 22 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Renal replacement therapy Conservative therapy of chronic kidney disease - treatment of basic disease (eg diabetes, glomerulonephritis), good blood pressure control (blood pressure target values below 130-139 / 80-85 mm Hg), avoid nephrotoxic substances - high osmolar contrast agent, drugs (eg. aminoglycoside antibiotics, non-steroidal anti-in ammatory drugs), adjustment of the internal environment - adjustment of uid intake, titration of diuretic therapy, risk of hyperkalaemia (diet, education of the patient, adjustment of medication). Cardiovascular risk factors, a reduced protein diet (e.g 0.8 g/kg body weight) should be identi ed and in uenced. 23 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Where to send the patient? Urology retention of N-substances-postrenal etiology (urinary retention, according to sonography of kidney) dysuria, frequent urination, urge to urinate... recurrence of uroinfects (cystoscopic exam.) macroscopic / microscopic haematuria (<80% of dysmorphic red cells) Nephrology N-retention proteinuria { swelling of legs, eyelids, foamed urine hematuria (>80% of dysmorphic era, acantocytes) 24 / 25 Medical History Physical Examination Examination of kidneys and urinary system Laboratory Examination Imaging methods Therapy Have a nice day! References: Prof. Zadra¾il: Vy¹etøovací postupy v nefrologii Prof. Tesaø, prof. Viklický: Klinická nefrologie MUDr. Jitka Øehoøová: Diagnostika onemocnìní ledvin 25 / 25