Biochemical diagnostics of kidney diseases, their monitoring, functional tests.
Urinary sediment.
Elimination techniques.
Jan Novák

Kidney Physiology
in a Nutshell
Jan Novák

Kidney Functions
•Excretory function (= removal of unnecessary or harmful substances from the body)
•Urine and N-substances in it (urea, creatinine)
•Xenobiotics (drugs, toxic substances)
•Maintenance of stable ionic composition (Na+, K+, Cl-, Ca2+, PO32-)
•Maintenance of acid-base balance (HCO3-, H+)
•Endocrine function
- renin production (part of RAAS)
- vitamin D metabolism
•Control of body volume and blood pressure

Blood flow through the kidney
•20% of cardiac output (1 liter per minute)
•"Plasma skimming“
•vas afferens - glomerulus - vas efferens
•the difference between cortical and juxtamedullary nephrons
Renal Blood Flow and its Regulation | Anatomy and Physiology II

Nephron – the functional morphology
•Glomerulus and Bowman's body = GF
•Proximal tubule = volume resorption
•Loop of Henle = countercurrent system and osmotic stratification of the medulla
•Distal tubule = controlled resorption
•Collection channel = water resorption due to ADH
Hormones Acting on the Nephron - Diuretics and Their Site of Action

Basic urine examination and kidney function tests
Jan Novák


Urine collection
•Disposable  (one-time)
- First / second morning urine
- Random sample
- Catheterized
•
•Genital cleansing
•Medium urine flow (after 2-3s)
•Urine collection
•
•24 hours
•4 hours
•
•
•The right technique (the patient urinates and collects 24 hours from that moment)

Physical evaluation (by sight, smell)
•Colour
•
•Shades of yellow = state of hydration
Light = polyuria
"Normal" = normal
Dark = dehydration
Amber = severe dehydration
•Shades of red / brown = hematuria
•Green, “cafe au lait", bluish - mostly infections
•Turbidity
Typically for infections
but also sperm, erythrocytes, precipitated substances (when storing urine in the refrigerator)
•Odor
Fruit sweet = ketonuria
Mouse = phenylketonuria
Disgusting putrefactive = infection

Urine „chemically + sediment“
•Specific density(dimensionless number; ratio of sample density to distilled water; reflects
tubular function)
•pH (normal 4.5 - 8; e.g. Klebsiella lowers urine pH; important in calcium oxalate stones =
formation in acidic environment)
•Leukocytes (leukocyte esterase)
•Nitrites (bacteria reduce nitrates to nitrites)
•Protein (above 150mg / l, the first sign of glomerular or tubular proteinuria)
•Blood (heme detection, microscopic x macroscopic, prerenal x renal x subrenal)
•Glucose
•Ketone bodies (beta-hydroxybutyrate and acetetoacetate)
•Bilirubin (conjugated is released into the urine)

Urine „chemically + sediment“
•Erythrocytes
- if the blood has been proven "chemically" and if there are no erythrocytes in the "sediment",
this indicates a prerenal source (hemoglobin, myoglobin in the urine)
- if there are erythrocytes in the sediment, we distinguish between glomerular ("wrinkled" =
dysmorphic erythrocytes) and subrenal (normal shape)
•Leukocytes
•Epithelium
•Bacteria and yeasts
•Parasites
•Sperm
•Mucus, cylinders, crystals…
•

Other detectable analytes from a disposable urine
•Pregnancy test (HCG)
•
•The indicative drug tests
•amphetamine (AMP)
•barbiturates (BAR)
•benzodiazepins (BZD)
•cocaine (COC)
•metamphetamine (MET)
•morphine (MOR)
•metadone (MTD)
•phencyclidine (PCP)
•propoxyphen (PPX)
•tricyclides (TCA)
•marihuana (THC)
•ecstasy (XTC)
GA Magazín - on-line magazín - O dětech - Těhotenství - Těhotenský test
https://cdn3.volusion.com/7ewna.rufa3/v/vspfiles/photos/DOA194-2.jpg?v-cache=1567517754

24 (4) hours urine collection
•
•Calculation of glomerular filtration => Creatinine clearance
•The volume of blood purified from a given substance per unit time
•GF = urine volume in 24 h * C creatinine in urine / C creatinine in serum
•Examination of tubular functions => Fractional excretion
The amount of filtered substance that we can find in the definitive urine
e.g. 180 l of primary urine is produced per day, we urinate 1.8 liters = FE 1%
•Calculation of excreted substances per day (typically proteinuria)
•

What are the N-substances?
•Urea 1,7 – 8,3 mmol/l
•the most quantitatively significant degradation product of amino acids and proteins
•blood urea concentration depends on dietary protein content, renal excretion and hepatic metabolic
function
•
•Creatinine 44 – 104 μmol/l in women
• 44–110 μmol/l in men
•formed in the muscles from creatine and creatine phosphate
•serum levels also reflect the proportion of muscle mass
•used to calculate or estimate the glomerular filtration

Estimation of glomerular filtration
Cystatin C: a low molecular weight protein, expressed in a constant amount, freely by the
glomerular membrane and is fully resorbed and degraded in the tubule. If serum levels rise, it
reflects a decrease in GFR.

Estimation of glomerular filtration
www.mdcalc.com


Estimation of glomerular filtration – why?
•We use estimation because accurate calculations over 24 hours of urine collection are often
lengthy and burdensome for the patient.
•According to GFR, the dosage of various drugs is adjusted (most of the antibiotics, DOACs, LMWH),
when GFR is reduced below a certain limit, other drugs are completely contraindicated (eg
metformin) or are ineffective (some "weaker" diuretics)

Case study 1: Examination of urine
Jan Novák


Case report # – title
•Case description
Description of what happened and why the patient is coming.
•Medical history
Basic and relevant patient data
•FH = family history
•PH = personal history
•MH = medication
•AA = alergies
•Abusus

Case report # – title
Urine - chemically
pH
Proteins
Glucosis
Urobilinogen
Bilirubin
Ketones
Nitrites
Leukocytes
Blood
Urine - Sediment
Leucocytes
Erytrocytes
Bacteries
Mucus
Epithelium flat
Epithellium round
Basic biochemistry
Na
132-142 mmol/l
K
3,5-5,2 mmol/l
Cl
97-108 mmol/l
Urea
1,7 – 8,3 mmol/l
Crea
44–110 μmol/l
GFR
> 1 ml/s/1,73m2
Gly
3,9 - 5,5 mmol/l
CRP
1 – 10 mg/l

Case report 1 – Unconscious patient
Ambulance brings a 88-year-old lady to an internal clinic.
Ambulance was called by the lady‘s family for the gradual deterioration of the mental and body
condition during the day, until the unconsciousness, she does not react to the family.
Upon arrival:
BP 100/60 mmHg, P 70/min, afebrile
Vitals: unconsciousness, without jaundice, without dyspnea, miotic pupils, breathing is clean,
quiet, slow, heart rate regular, no abdominal pain, legs without swelling, 3 patches of Fentanyl on
the back
Medical history
•PH: hyertension, light cognitive deficiency, vertebrogenic algic syndrome of lumbar spine
•Alergies: no
•Mediaction:
•Prestarium Neo 5mg tbl 1-0-0
•Fentanyl 100ug/h – one patch change every 72 hours
•Abusus: non smoker, no alcohol, no drugs (by family)

Case report 1 – Unconscious patient
Urine - chemically
pH
5,0
Proteins
0
Glucosis
0
Urobilinogen
0
Bilirubin
0
Ketones
0
Nitrites
0
Leukocytes
0
Blood
0
Urine - Sediment
Leucocytes
0
Erytrocytes
0
Bacteries
0
Mucus
0
Epithelium flat
0
Epithellium round
0
BB
Na
132-142 mmol/l
140
K
3,5-5,2 mmol/l
4,8
Cl
97-108 mmol/l
100
Urea
1,7 – 8,3 mmol/l
2,0
Crea
44–110 μmol/l
39
GFR
> 1 ml/s/1,73m2
1,25
Gly
3,9 - 5,5 mmol/l
5,2
CRP
1 – 10 mg/l
8
What next ???

Case report 1 – Unconscious patient
•The indicative drug tests
•amphetamine (AMP)
•barbiturates (BAR)
•Benzodiazepins (BZD) +++
•cocaine (COC)
•metamphetamine (MET)
•Opiates +++
•metadone (MTD)
•phencyclidine (PCP)
•propoxyphen (PPX)
•tricyclides (TCA)
•marihuana (THC)
•ecstasy (XTC)
https://cdn3.volusion.com/7ewna.rufa3/v/vspfiles/photos/DOA194-2.jpg?v-cache=1567517754

Case report 1 – Unconscious patient
•Conclusion:
•Intoxication of benzodiazepines
•Intoxication of opiates
•
•Checkpoints:
•Miotic pupils and respiratory depression = signs of opiate overdose
•
•Explanation:
•The patient could not sleep for the last 3 days due to back pain, so she borrowed Lexaurin (BZD)
from a neighbor to make her sleep better
•Because Lexaurin was not enough, she applied one extra patch in the morning, and because she
forgot about it at noon, she applied a third…thus overdosing herself

Case report 2 – Domestic violence
The patient, 29 years old, calls the Police that she was attacked by a friend who beat her, kicked
her, maybe even raped her and injected her with some drugs, she is now lying on the ground and
unable to get up.
Police arrives at the place, calls ambulance. The patient was found in the apartment in the living
room, a laceration on her head, bruises all over her body.
Brought to the surgical outpatient clinic – there was a fracture of the humerus without dislocation
and fracture of L2 vertebra according to X-ray, both without dislocation. Ultrasound of the abdomen
shown no internal bleeding. Wound on the head was sewed, orthosis and spine corset were applied.
Due to possible intoxication with an unknown substance, she was reffered to internal department.
Upon arrival:
BP: 120/70 mmHg,  pulse 105/min, afebrile
Vitals: conscious, oriented, anxious, wound on the headsewed, right arm in the orthosis,
respiration clean,  heart rate regular, no abdominal pain, peristaltics +,hematomas over the body,
legs without swelling
Medical history:
PH: sine
Medication: sine
Alergies: sine
Abusus: smoker (10 cigarettes a day), a week ago she had marijuana, alcohol occasionally, she
hadn't drank at all for the last month
Drugs test: THC ++, others neg.

Case report 2 – Domestic violence
Urine - chemically
pH
5,0
Proteins
0
Glucosis
0
Urobilinogen
0
Bilirubin
0
Ketones
0
Nitrites
0
Leukocytes
0
Blood
3
Urine - Sediment
Leucocytes
0
Erytrocytes
0
Bacteries
0
Mucus
3
Epithelium flat
3
Epithellium round
1
BB
Na
132-142 mmol/l
139
K
3,5-5,2 mmol/l
3,8
Cl
97-108 mmol/l
103
Urea
1,7 – 8,3 mmol/l
3,5
Crea
44–110 μmol/l
82
GFR
> 1,5 ml/s/1,73m2
1,23
Gly
3,9 - 5,5 mmol/l
3,9
CRP
1 – 10 mg/l
4,4
Myo
30 - 80 µg/l
1424
CK
0,45-2,45 ukat/l
77,9
CKMB
0,2–1,8 ukat/l
2,13

Case report 2 – Domestic violence
•Conclusion:
•Muscle trauma after domestic violence = elevation of CK (indirectly CKMB), myoglobin
•In the chemical examination of urine we can see a positive test for blood („heme“) but a negative
sediment for erythrocytes = evidence of prerenal "overload" of the kidneys with heme
•The cylinders and epithelium indicate myoglobin overload of the tubules

Case report 2 – Domestic violence
Urine - chemically
pH
5,0
Proteins
0
Glucosis
0
Urobilinogen
0
Bilirubin
0
Ketones
0
Nitrites
0
Leukocytes
0
Blood
3
Urine - Sediment
Leucocytes
0
Erytrocytes
0
Bacteries
0
Mucus
3
Epithelium flat
3
Epithellium round
1
BB
Na
132-142 mmol/l
139
137
138
K
3,5-5,2 mmol/l
3,8
3,7
3,7
Cl
97-108 mmol/l
103
105
104
Urea
1,7 – 8,3 mmol/l
3,5
2,9
2,6
Crea
44–110 μmol/l
82
60
59
GFR
> 1,5 ml/s/1,73m2
1,23
1,97
1,99
Gly
3,9 - 5,5 mmol/l
3,9
4,4
5,0
CRP
1 – 10 mg/l
4,4
14,3
4,1
Myo
30 - 80 µg/l
1424
332
160
CK
0,45-2,45 ukat/l
77,9
90,8
50,4
CKMB
0,2–1,8 ukat/l
2,13
--
--

Case report 3 – Apartment opened by the Police
The ambulance arrives to the internal departement with an 84-year old patient from an apartment
opened by Police.
Ambulance was called by neighbors - the man has not left the apartment for 2 days. The ambulance
crew found the patient lying on the ground in the kitchen. Hypothermic, dehydrated, wet, stiff.
The patient states that he has not been well for the last few days, he urinated a lot, while
urinating he felt  burning. He tried to drink enough, but he had no appetite, then he probably had
a fever and when he got up from his chair, he got dizzy and fell and was unable to get up nor to
call for help.
Upon arrival:
  - BP 80/40 mmHg, pulse  86 bpm , TT 36.1 C
  - V: conscious, slowed psyhomotoric pace, decreased skin turgor, no jaundice, no dyspnea,
breathing clean, heart rate regular, no abdominal pain, legs without swelling. After the
introduction of urine catheter, it drains amber turbid urine.
Medical history:
PH: hypertension, dyslipidemia, CHOPN, DM2T
Medication:
•Prestance 5/5mg tbl 1-0-0
•Atorvastatin 20mg tbl 0-0-1
•Ultribro breezhaler 1 vdech 1-0-1
•Metformin 1g tbl 1-1-1
•Alergies: sine
•Abusus: The smoker about 20 a day from the age of 18, no use of drugs and alcohol

Case report 3 – Apartment opened by the Police
Urine - Chemically
pH
6,0
Proteins
2
Glucosis
0
Urobilinogen
0
Bilirubin
0
Ketones
1
Nitrites
3
Leukocytes
4
Blood
1
Urine - Sediment
Leucocytes
4
Erytrocytes
1
Bacteries
2
Mucus

Epithelium flat
3
Epithellium round
1
Appearance
Turbidity
Colour
Amber
BB
Na
132-142 mmol/l
129
K
3,5-5,2 mmol/l
4,0
Cl
97-108 mmol/l
96
Urea
1,7 – 8,3 mmol/l
10,1
Crea
44–110 μmol/l
133
GFR
> 1 ml/s/1,73m2
0,76
Gly
3,9 - 5,5 mmol/l
6,2
CRP
1 – 10 mg/l
107,5

•Conclusion:
•The patient had a urinary tract infection for the last few days, gradually weakening and
eventually falling
•Initially, he had no temperature because he was hypothermic from lying on the ground
•From the urinary sediment we can clearly say that the patient has a urinary tract infection
(bacteria, nitrites present), is dehydrated with deterioration of kidney function (reduced GFR), BB
then confirms inflammation in the body (CRP)
•Ketone bodies in urinary sediment reflect starvation
•Patient hydrated and treated with ATB
•
Case report 3 – Apartment opened by the Police

Case report 3 – Apartment opened by the Police
Urine - Chemically
pH
6,0
Proteins
0
Glucosis
0
Urobilinogen
0
Bilirubin
0
Ketones
0
Nitrites
0
Leukocytes
0
Blood
0
Urine - Sediment
Leucocytes
0
Erytrocytes
0
Bacteries
0
Mucus

Epithelium flat
0
Epithellium round
0
Appearance
clear
Colour
yellow
BB
Na
132-142 mmol/l
129
142
K
3,5-5,2 mmol/l
4,0
3,7
Cl
97-108 mmol/l
96
105
Urea
1,7 – 8,3 mmol/l
10,1
7,0
Crea
44–110 μmol/l
133
94
GFR
> 1 ml/s/1,73m2
0,76
1,16
Gly
3,9 - 5,5 mmol/l
6,2
5,1
CRP
1 – 10 mg/l
107,5
37,4

Case report 4 – Unconsciousness and dyspnea
The ambulance arrives to emergency with a young patient, 22 years old, found by a roommate around
noon on the dormitory lying on the ground, unresponsive, hyperventilating.
According to a roommate, the patient has been complaining for the last 2 weeks that he has to drink
a lot, he urinates a lot, that he has a headache, his vision was blured. That's why he didn't even
go to lectures in the morning and after the lectures he found him.
Upon arrival of ambulance the patient is unconscious, hyperventilating, acetone odour from breath.
Blood glucose immeasurably high. Transfer to the emergency room.
Vitals at ER: normostenic, unconsciousness, blood pressure 80/60 mmHg, pulse 125 bpm,
hyperventilation, respiration otherwise clean, abdomen without pain, peristaltics +, legs without
swelling
Medical history:
PH: till now sine
Medication: sine
Alergies: neg.
Abusus: non-smoker, no drugs and alcohol
Drugs test: negat.

Case report 4 – Unconsciousness and dyspnea
Urine - chemically
pH
5,0
Proteins
1
Glucosis
4
Urobilinogen
0
Bilirubin
0
Ketones
2
Nitrites
0
Leukocytes
0
Blood
1
Urine - sediment
Leucocytes
0
Erytrocytes
0
Bacteries
0
Mucus
1
Epithelium flat
1
Epithellium round
0
Appearance
clear
Colour
yellow
BB
Na
132-142 mmol/l
132
K
3,5-5,2 mmol/l
5,4
Cl
97-108 mmol/l
82
Urea
1,7 – 8,3 mmol/l
16,1
Crea
44–110 μmol/l
217
GFR
> 1 ml/s/1,73m2
0,47
Gly
3,9 - 5,5 mmol/l
61,8
CRP
1 – 10 mg/l
6,7
pH
7,36-7,44
6,98

Case report 4 – Unconsciousness and dyspnea
•Conclusion:
•The patient shows signs of higher glycemia (polyuria, polydipsia, blurred vision, headache) for
the last two weeks
•Brought in a hyperosmolar hyperglycemia and ketoacidotic coma with Kussmaul (acidotic) breathing,
severely dehydrated
•Diagnosis of DM recens (=newly diagnosed DM; later DM1T type LADA was confirmed)
•

Acute kidney injury,
chronic kidney disease
Jan Novák

Acute kidney injury (AKI)
•AKI term: acute kidney injury (often AKI on CKD) – previously also acute renal failure (ARF)
•rapid loss of renal function, increasing N-substances, decrease in GFR and urine production,
disturbance of ionic balance (life-threatening is especially hyperkalaemia)
•potentially reversible
•ETIOLOGY:
•Prerenal: heart failure, hypovolemia, hypotension, sepsis
•Renal: glomerulonephritis, interstitial tubulonephritis, drug-induced
•Postrenal: urinary tract obstruction
•classification : RIFLE, AKIN (according to KDIGO)

Acute kidney injury - classification
https://www.uspharmacist.com/CMSImagesContent/2015/8/_AcuteKidney-T1.gif
https://img.grepmed.com/uploads/2950/nephrology-diagnosis-kidney-acute-kdigo-original.jpeg

Chronic kidney disease (CKD)
•Slow progressive process, with renal function declining over the years
•Etiologically: diabetic nephropathy, hypertensive nephrosclerosis, polycystic kidneys, chronic
glomerulonephritis
•Classification:
- according to the GFR
- according to albuminuria

Stages of CKD. Reprinted with permission from KDIGO 2012 Clinical... | Download Scientific Diagram
> 1,5
1 – 1,49
0,75 – 0,99
0,5 – 0,74
0,25-0,49
< 0,25
https://www.researchgate.net/publication/335386364/figure/fig1/AS:795585133170688@1566693685000/Sta
ges-of-CKD-Reprinted-with-permission-from-KDIGO-2012-Clinical-Practice-Guidelines-for.png

Case reports 2:
AKI, CKD
Jan Novák

Case report 1 – Sportsman
•A young man, 19 years old, comes to your clinic for chest pain. Its were formed about 3 hours ago
when he was in the gym and doing bench-press. Its haven't stopped since. It is a dull pain, it is
related to movement. His uncle had a heart attack recently, so he's afraid he has it too.
Medical report:
PH: sine
Medication: sine
Alergies: neg.
Abusus: smoker about 5 a day from the age of 15, negates drugs and alcohol

Case report 1 – Sportsman
Urine - chemically
pH
6,0
Proteins
0
Glucosis
0
Urobilinogen
0
Bilirubin
0
Ketones
0
Nitrites
0
Leukocytes
0
Blood
0
Urine - sediment
Leucocytes
0
Erytrocytes
0
Bacteries
0
Mucus

Epithelium flat
0
Epithellium round
0
Appearance
clear
Colour
yellow
BB
Na
132-142 mmol/l
138
K
3,5-5,2 mmol/l
4,2
Cl
97-108 mmol/l
101
Urea
1,7 – 8,3 mmol/l
6,0
Krea
44–110 μmol/l
127
GFR
> 1,5 ml/s/1,73m2
1,16
Gly
3,9 - 5,5 mmol/l
4,6
CRP
1 – 10 mg/l
2
TnT
1-14 ng/l
8

Case report 1 – Sportsman
•Concusion:
•
•The patient is an athlete, he goes to the gym often and he takes creatine supplements – he de not
have AKI, only the preanalytic phase was affected by non-standard conditions with increased
creatinin production and intake
•
•Yyou ask the patient not to take these products for a week and come back for a check-up after 48
hours of non exercising

Case report 1 – Sportsman
Urine - chemically
pH
6,0
Proteins
0
Glucosis
0
Urobilinogen
0
Bilirubin
0
Ketones
0
Nitrites
0
Leukocytes
0
Blood
0
Urine - sediment
Leucocytes
0
Erytrocytes
0
Bacteries
0
Mucus

Epithelium flat
0
Epithellium round
0
Appearance
clear
Colour
yellow
BB
Na
132-142 mmol/l
138
138
K
3,5-5,2 mmol/l
4,2
4,2
Cl
97-108 mmol/l
101
101
Urea
1,7 – 8,3 mmol/l
6,0
6,0
Krea
44–110 μmol/l
127
87
GFR
> 1,5 ml/s/1,73m2
1,16
1,85
Gly
3,9 - 5,5 mmol/l
4,6
4,6
CRP
1 – 10 mg/l
2
2
TnT
1-14 ng/l
8
8

Case report 2 – Too honest family
•The family brings a completely devastated patient, 89 years old woman, to your internal medicine
clinic. The daughter reports mother had diarrhea, vomiting, anorexia for the last 3 days, the
mother practically does not eat, she drinks a maximum of 0.5 liters of water a day or Coca-Cola in
spoons.
•The condition gradually worsens, she vomits more and more, the anorexia worsens, she is getting
weaker, she can't even walk anymore, she collapsed in the morning, so the family no longer knows
what to do.
•However, the daughter says, that the mother takes her chronical medication honestly every morning…

Case report 2 – Too honest family
•Medical history:
•PH: CAD, st.p. STEMI of anterior wall 1998, chronical heart failure due to CAD, atrial fibrilation
– med. Warfarine, hypertension, st.p. breast cancer (in remission, disp. oncology)
•Medication: Prestance 5/5mg tbl 1-0-0 Furon 40mg tbl 1-1-0
• Concor cor 5mg tbl 1-0-0 Verospiron 25mg tbl 0-1-0
• Digoxin 0,125mg tbl 1-0-0
• Warfarin 5mg tbl dle INR
•Alergies: neg.
•Abusus: non-smoker, no drugs or alcohol

Case report 2 – Too honest family
•Vitals:
•BP 80/40 mmHg, pulse 40 bpm irreg (atrial fibrilation)
•conscious, oriented, slowed psychomotor pace, decreased skin turgor
heart rate irreg, breathing alveolar clean
Abdomen soft, no pain, peristaltics +
legs without swelling
•

Case report 2 – Too honest family
BB
Na
132-142 mmol/l
141
K
3,5-5,2 mmol/l
7,5
Cl
97-108 mmol/l
106
Urea
1,7 – 8,3 mmol/l
64,2
Krea
44–110 μmol/l
984
GFR
> 1 ml/s/1,73m2
0,06
Gly
3,9 - 5,5 mmol/l
6,2
CRP
1 – 10 mg/l
3
Hyperkalemia (+ betablocker + digoxin) causes bradycardia
Hyperkalemia is caused by renal failure + medication which elevates potassium levels (aldosteron
blocker + ACEi)
Hyperuraemia leads to uremic symdrome with nausea and vomiting
Nausea, vomiting and diarrhea lead to dehydratation. State is even worse, that patient is still
using her chronical medication with diuretics … it leads to prerenal kidney injury.

Case report 2 – Too honest family
•Conclusion:
•
•The patient has acute renal failure most likely of prerenal etiology with severe dehydration and
hypotension
•Due to bradycardia (and a history of collapse) and potassium 7.5, she is indicated for acute HD,
but due to age and condition (fragile elderly lady), it is possible to conservatively hydrate the
patient on the monitored bed.

Case report 2 – Too honest family
BB
before
After HD
Conservative therapy
Na
132-142 mmol/l
141
138
139
140
137
K
3,5-5,2 mmol/l
7,5
5,5
5,3
4,9
4,5
Cl
97-108 mmol/l
106
100
100
101
100
Urea
1,7 – 8,3 mmol/l
64,2
24,5
18,3
16,4
12,1
Krea
44–110 μmol/l
984
345
287
221
156
GFR
> 1 ml/s/1,73m2
0,06
0,26
0,26
0,26
0,56
Gly
3,9 - 5,5 mmol/l
6,2
CRP
1 – 10 mg/l
3

Case report 3 – Swelling of the lower limbs does not have to be caused the heart
•The patient, man, 56 years old, comes to his general practitioner in the middle of December 2018,
saying that his limbs are swollen for the last month – right limb more, he feels more tired
overall.
•Due to asymmetric swelling, the patient was sent for vascular examination, deep vein thrombosis
was detected in the right limb, DOAC (Rivaroxaban) was used; but due to the swelling of both limbs
the patient was issued a request for a complete internal examination
•The next day, the patient wakes up with leaky eyelids, he breathes heavily after standing,
swelling of the limbs is still progressive, he comes to the internal medicine…

Case report 3 – Swelling of the lower limbs does not have to be caused the heart
•Medical history:
•PH: hypertension, astma bronchiale allergy, sekundary artrosis of talocrural joint, recently
treated DVT of right leg
•FA: Agen (Ca blocker) 5mg 1-0-0
• Controloc (PPI) 40mg 1-0-0
• Alvesco 1 inbreathe in the evening
• Xarelto 20mg tbl 1-0-0
•Alergies: dust, pollen
•Abusus: non-smoker, no drugs or alcohol abuse

Case report 3 – Swelling of the lower limbs does not have to be caused the heart
•Vitals and other examination:
•BP 170/80 mmHg, pulse 66 bpm
conscious, well oriented, resting eupnoea, without jaundice, swollen eyelids,
HB reg, breathing generally quiet, weakened basally with crackles
Abdomen in niveau, soft, painless, subcutaneous penetration
lower limbs with swelling to the groin
•
•EKG: low voltage
•RTG of chest: pleural effusion bilat., heart shadow dilated in both directions Echokadiography:
pericardial effusion, otherwise normal EF

Case report 3 – Swelling of the lower limbs does not have to be caused the heart
Urine - chemically
pH
6,0
Proteins
4
Glucosis
0
Urobilinogen
0
Bilirubin
0
Ketones
0
Nitrites
0
Leukocytes
0
Blood
0
Urine - sediment
Leucocytes
0
Erytrocytes
0
Bacteries
0
Mucus
0
Epithelium flat
0
Epithellium round
0
Appearance
Turbid
Colour
yellow
BB
Na
132-142 mmol/l
131
K
3,5-5,2 mmol/l
4,4
Cl
97-108 mmol/l
102
Urea
1,7 – 8,3 mmol/l
23,0
Krea
44–110 μmol/l
284
GFR
> 1,5 ml/s/1,73m2
0,33
Gly
3,9 - 5,5 mmol/l
4,9
CRP
1 – 10 mg/l
1
Alb
36-63g/l
22,8
Urine collection:
Albumin 776 mg/l
Proteins 3,7 g/24h
Lipids:
Cholesterol 8,4
TAG 6

Case report 3 – Swelling of the lower limbs does not have to be caused the heart
•Conclusion 1:
•The performed examinations show that the patient suffers from nephrotic syndrome:
- proteinuria > 3.5 g/24 hours
- hypalbuminemia (below 30g/l)
- peripheral edema
- hypercholesterolemia > 8 mmol/l
•The cause of nephrotic syndrome is usually glomerulonephritis = biopsy verification required

Case report 3 – Swelling of the lower limbs does not have to be caused the heart
•Renal biopsy
•Invasive procedure, we obtain a sample of kidney tissue under ultrasound control
•The patient is monitored after the procedure, including urine ch + s
Kidney biopsy - Mayo Clinic
Urine - sediment
0
+4
+8
+12
+24
Leukocytes
0
0
0
0
0
0
Erytrocytes
0
1
4
3
1
0
Bacteries
0
0
0
0
0
0
Mucus
0
0
0
1
0
0
Epitelia
0
0
0
0
0
0

Case report 3 – Swelling of the lower limbs does not have to be caused the heart
•Conclusion 2:
•The biopsy revealed a minimal change disease
•
•
•
•
•
•
•
•
•Corticosteroid therapy initiated with a very good effect
Minimal Change Disease | UNC Kidney Center
https://unckidneycenter.org/files/2017/10/minimal-change-capillary.png

Case report 3 – Swelling of the lower limbs does not have to be caused the heart
BB
GP 01/2017
2 years withouth controll
18.12. 2018
26.12. 2018
29.12. 2018
18.1. 2019
Na
132-142 mmol/l
131
137
136
142
K
3,5-5,2 mmol/l
4,4
4,3
3,9
4,7
Cl
97-108 mmol/l
102
104
104
102
Urea
1,7 – 8,3 mmol/l
6,9
23,0
18,9
10,2
5,7
Krea
44–110 μmol/l
80
284
162
99
93
GFR
> 1 ml/s/1,73m2
0,33
0,65
1,18
1,27
Gly
3,9 - 5,5 mmol/l
4,9
CRP
1 – 10 mg/l
1
Alb
36-63g/l
22,8
28
35
42,5

Case report 4 – „Unnecessary“ permanent urinary catheter
•The patient, 88 years old, was transferred to your internal department from a psychiatric
hospital, where he was hospitalized for a dementia syndrome with delirious conditions to set up
psychiatric medication.
•Before admission to a psychiatric hospital in terms of internal – the patient was stable, kidney
stage CHRI CKD3a
•In a psychiatric hospital, the development of swelling of the lower limbs, Furosemide increased in
medication, the swelling does not flare up too much due to this medication
•Therefore, blood samples were taken and, with reference to them, a translation of the patient to
the internal clinic / see below /
•

Case report 4 – „Unnecessary“ PUC
•Medical history:
•PH: Dementia Syndrome, probably vascular etiology, behavioral disorders
Chronic heart failure due to CAD, st.p. decompensation 2016
Prostate Ca (2006) pT1c (T3) N0 M0G 3 (combined Gleason score 3 + 5), low-differentiated acinar
prostate adenocarcinoma, stp. neoadj. hormone therapy, stp. RT on the prostate and small pelvis
Macrocytic anemia from B12 and folic acid deficiency
Mixed hyperlipidemia
Hypothyroidism, for substitution
St.p. herpes zoster reg. glutei lat. hall. v.s. 2016
St.p. stroke 2007 according to doc.
•Med.: Nolpaza 40 mg tbl 1-0-0 Carsaxa 100 mg tbl 0-1-0 Ketilept 25 mg tbl 0-0-1 Letrox 50 mg tbl
1/2- 0-0 Mirtazapin 15 mg tbl 0-0-1 Memigmin 10 mg tbl 2-0-0
• Furon 40 mg tbl 1-0-0
•Alergies: neg. Abusus: neg.
•

Case report 4 – „Unnecessary“ PUC
•Vitals:
•Conscious, manifestations of dementia - confused, unfocused
HR reg, breathing alveolar, clean
abdomen soft, palpable resistance in the lower abdomen, painful under pressure, peristaltics
present
lower limbs swollen to half shin

Case report 4 – „Unnecessary“ PUC
BB
24.7.
29.8.
Na
132-142 mmol/l
139
133
K
3,5-5,2 mmol/l
4,6
6,6
Cl
97-108 mmol/l
103
98
Urea
1,7 – 8,3 mmol/l
10,6
39,4
Krea
44–110 μmol/l
107
803
GFR
> 1 ml/s/1,73m2
0,99
0,08
Gly
3,9 - 5,5 mmol/l
4,4
4,5
CRP
1 – 10 mg/l
19,6
249,5

Case report 4 – „unnecessary“ PUC
•Conclusion:
•The patient has acute renal failure which has developed within a month
•the renal cause unlikely in his age (glomerulonephritis not suspected)
•prerenal cause of dementia (decreased fluid intake) and furosemide drainage may be affected
•tactile resistance in the lower abdomen is the bladder, after the introduction of PUC drains 2.5
liters of urine
•The patient is after radiotherapy due to carcinoma of prostate, he has a stricture of the ureter
and should have PUC permanently - after admission to Psychiatry dep. it is pulled out and not
placed back again by mistake
•
•After the instillation of PUC, the renal parameters are rapidly corrected, intercurrent infection
is cured by ATB

Case report 4 – „Unnecessary“ PUC
BB
24.7.
29.8.
30.8.
1.9.
3.9.
Na
132-142 mmol/l
139
133
137
143
140
K
3,5-5,2 mmol/l
4,6
6,6
6,1
4,7
4,2
Cl
97-108 mmol/l
103
98
105
113
104
Urea
1,7 – 8,3 mmol/l
10,6
39,4
32,4
18,6
5,8
Krea
44–110 μmol/l
107
803
624
269
114
GFR
> 1 ml/s/1,73m2
0,99
0,08
0,11
0,29
0,83
Gly
3,9 - 5,5 mmol/l
4,4
4,5
4,3
4,1
4,4
CRP
1 – 10 mg/l
19,6
249,5
308,0
214,8
133,0

Elimination techniquies
Jan Novák


Hemodialysis
•Blood from the patient's body is pumped into the capillary of the device
•Here, N / toxic substances pass into dialysis soluton after a concentration gradient - dialysis
solution, thereby purifying the patient's blood
princip hemodialýzy
https://www.dialyza.cz/cs/porozumet/nahrada-funkce-ledvin/hemoeliminacni-metody/hemodialyza/

Hemodialysis
•Dialysis capillary is a system of very small tubes formed by a highly permeable membrane, inside
which blood flows and which are washed with a dialysis solution
•Countercurrent system
Výhody designu krytu FX-class®
https://www.freseniusmedicalcare.cz/cs/odborna-verejnost/hemodialyza/dialyzatory/dialyzatory-fx-cla
ssix/

The 4 Types of Dialysis Access | Azura Vascular Care
Hemodialysis - access
•Acute HD = temporary intravenous HD catheter
•V. Jug. Int.
•V. Subclavia
•V. femoralis
•
https://www.azuravascularcare.com/infodialysisaccess/types-of-dialysis-access/
Permanent HD Cath insertion - YouTube

Hemodialysis - access
•
•Chronic HD
•PermCath
•V. Jug. Int.
•V. Subclavia
•V. femoralis
•Translumbar
•
•AV shunt
Hemodialysis: Using an AV graft or AV fistula for ease of access
https://www.aboutkidshealth.ca/article?contentid=1034&language=english

Hemodialysis
•Indications to acute HD
•
•Hyperkalemia > 6 mmol / l
•Hypercalcaemia > 3.5 mmol / l
•Hyperuricemia > 1000 μmol / l
•uncorrectable metabolic acidosis, pH <7.1
•hyperhydration with heart failure
•oligouria lasting longer than 3 days
•intoxication with low molecular weight water-soluble substances

Hemodialysis
•Indications to chronic HD program:
•
•urea > 30 mmol/l,
•creatinine 600–800 μmol/l,
•clearance of creatinine < 0,25 ml/s

Peritoneal dialysis
Peritoneal-Dialysis-Catheter
https://www.azuravascularcare.com/infodialysisaccess/types-of-dialysis-access/

Case reports 3:
Elimination techniques
Jan Novák

Case report 1 – From predialysis to dialysis
•
•A 45-year-old patient with CKD based on diabetic nephropathy and hypertensive nephrosclerosis has
been monitored in your nephrology clinic for many years.
•Despite proper treatment of blood pressure and diabetes over the years, you can see a gradual
decline in renal function, progression of CKD, the patient stops urinating, his lab results worsen
(levels of Ca, P,…), so you agree to start HD.
BB
2015
2016
2017
2018
Urea
1,7 – 8,3 mmol/l
17,2
20,0
20,7
40,0
Krea
44–110 μmol/l
276
357
353
642
GFR
> 1 ml/s/1,73m2
0,46
0,33
0,34
0,16

Case report 1 – From predialysis to dialysis
•The patient goes to a vascular examination - he has good quality vessels on both upper limbs, so
an AV shunt is created on a non-dominant upper limb
•After the operation, you wait about 4 weeks for AV shunt to dilate and gain its function, after
that you can start regular dialysis treatment twice a week.
BB
2015
2016
2017
2018
after HD
before HD
after HD
before HD
after HD
Urea
1,7 – 8,3 mmol/l
17,2
20,0
20,7
40,0
18,5
34,1
16,7
17,4
5,0
Krea
44–110 μmol/l
276
357
353
642
262
502
357
588
287
GFR
> 1 ml/s/1,73m2
0,46
0,33
0,34
0,16
0,49
0,14
0,21
0,11
0,46

Case report 1 –  From dialysis to kidney transplant
•The patient gradually gets from the HD program twice a week to the three times a week program and
at the same time is included in the waiting list for patients for kidney transplantation.
•A suitable cadaveric donor appears for the patient after about 2 years.
BB
21.7.
22.7.
23.7.
24.7.
25.7
28.7.
1.8.
14.8.
1.9.
10.9.
Urea
1,7 – 8,3 mmol/l
25,1
31,5
33,5
34,1
30,7
31,5
25,0
19,3
7,2
6,0
Krea
44–110 μmol/l
766
759
728
502
357
297
236
178
99
91
GFR
> 1 ml/s/1,73m2
0,08
0,08
0,09
0,14
0,21
0,26
0,34
0,48
0,98
1,09
Transplantation of kidney
dimision

Case report 2 – Peritoneal dialysis
•Patient, 54 years old, with CKD based on chronic IgA nephropathy + FSGS (biopsy verified 2006). He
also has nephrogenic anemia, hypertension and hyperparathyroidism, treated with DM2T, is after
radical prostatectomy for prostate Ca.
Gradually, over the last year, the renal function worsened, so the patients need renal replacement
therapy (RRT).
ZBV
11/2019
5/2020
6/2020
7/2020
Urea
1,7 – 8,3 mmol/l
29,0
35,9
36,8
35,1
Krea
44–110 μmol/l
401
521
588
580
GFR
> 1 ml/s/1,73m2
0,23
0,17
0,14
0,15
Start of RRT

Case report 2 – Peritoneal dialysis
•The patient is an active businessman, he does not want to come to the hospital for hemodialysis
twice of three times a week.
He prefers a peritoneal dialysis, therefore the Tenckhoff catheter was operated and the peritoneal
dialysis program started.
•
•Regime:
1.Filling (within 15 minutes, 2300 ml of solution), 1st filling in the evening
2.Delay (time when the solution is in the peritoneal cavity: 1h 28 minutes), then draining
3.This cycle runs 4 times during the night by an automatic device
4.After the last change, fill with 500 ml and drain in the evening before the next cycle

Case report 2 – Peritoneal dialysis
•Patients in a chronic peritoneal dialysis program tend to have higher urea and creatinine levels
than they would on a hemodialysis program.
•They will get used to them in the long run.
•In the event that the diuresis disappears, solutions with a higher osmolarity are used, which
osmotically withdraw water from the body (then the patient fills about 2300 ml and discharges 2500
or more ml)
BB
11/2019
5/2020
6/2020
7/2020
8/2020
9/2020
10/2020
Urea
1,7 – 8,3 mmol/l
29,0
35,9
36,8
35,1
21,6
24,5
25,0
Krea
44–110 μmol/l
401
521
588
580
543
540
590
GFR
> 1 ml/s/1,73m2
0,23
0,17
0,14
0,15
0,16
0,16
0,14
Start of PDP

Thank you for your attention!
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