Renal disease

The kidneys are 11-14 cm in length and lie retroperitoneally on either side of the vertebral column from T12-L3. The functions of the kidneys are:

■ Elimination of waste material

■ Regulation of volume and composition of body fluid

■ Endocrine function - production of erythropoietin, renin and vitamin D in its active form

■ Autocrine function - production of endothelin, prostaglandins, renal natriuretic peptide.

The functional unit of the kidney is the nephron, which is composed of the glomerulus, proximal tubule, loop of Henle, distal tubule and collecting duct (Fig. 9.1). The renal artery (a branch of the abdominal aorta) supplies the kidney and divides many times to form afferent arterioles each of which supplies one of the two million nephrons. The wider diameter of the afferent compared to efferent arterioles increases the pressure of blood within the glomerulus and forces water and solutes (but not red blood cells or larger molecular weight plasma proteins) out of the glomerular capillaries into Bowman's capsule forming the glomerular ữtrate - about 170-180 L per day. The proximal renal tubules reabsorb most of the filtered solute required to maintain fluid and electrolyte balance, but elimination of potassium, water and non-volatile hydrogen ions is regulated in the distal tubules. As renal perfusion and glomerular filtration fall, reabsorption of water and sodium by the proximal tubules increases so that minimal fluid reaches the distal tubule. Hence hypotensive or hypovolaemic patients cannot excrete potassium and hydrogen ions. Patients with distal tubular damage, e.g. caused by drugs, also cannot excrete potassium and hydrogen ions. Normally only about 1% of the original filtered volume, but containing high concentrations of urea and creatinine, passes into the renal pelvis as urine.

PRESENTING FEATURES OF RENAL DISEASE

The most common diseases of the kidney and urinary tract are benign prostatic hypertrophy in men and urinary tract infection (UTI) in women.

Symptoms suggesting renal tract disease are dysuria, frequency of micturi-tion, haematuria, urinary retention and alteration of urine volume (either polyuria or oliguria). In addition there may be pain situated anywhere along the renal tract, from loin to groin. Non-specific symptoms, e.g. lethargy, anorexia and pruritus, may be the presenting features of chronic kidney disease (CKD). Renal disease may be asymptomatic and discovered by the incidental finding of hypertension, a raised serum urea, or proteinuria and haematuria on Stix testing.

Dysuria

Dysuria (pain on micturition) is caused by:

■ Inflammation involving the urethra (urethritis) or bladder (cystitis). Dysuria is common in adult women and is usually due to lower urinary tract bacterial infection (p. 370) with inflammation of the urethra and bladder. Other causes of urethritis include infection with Chlamydia trachomatis or Neisseria gonorrhoeae (p. 42).

■ Inflammation involving the vagina in women or glans penis in men. Causes include infection with Candida albicans and Gardnerella vaginalis.

Polyuria and nocturia

Polyuria is an excessive urine output of greater than 2.5-3 L in 24 hours. It must be differentiated from the more common complaints of urinary fre-quency and nocturia (night-time urination), which are not necessarily associ-ated with an increase in the total urine output. Causes of polyuria include polydipsia (defined as excessive thirst leading to increased fluid intake >3 L per day), solute diuresis (e.g. hyperglycaemia with glycosuria), diabetes insip-idus and CKD. Nocturia is most often due to drinking before bed or, in men over 50 years, prostatic enlargement (p. 401).

Oliguria

Oliguria is a low urine output, and maintained over several hours indicates acute kidney injury (AKI, p. 383) or urinary tract obstruction. It may be ‘physi-ological', as in patients with hypotension and hypovolaemia, where urine is maximally concentrated in an attempt to conserve water. Anuria (no urine) suggests bilateral ureteric or bladder outflow obstruction. Management of the oliguric patient is in three steps:

1. Exclude obstruction. The patient with outflow obstruction (acute retention of urine) is typically in great discomfort with an intense desire to mictur-ate. The bladder is palpable as a tender mass that is dull to percussion, arising out of the pelvis. The diagnosis is confirmed by passing a urethral catheter and releasing a large volume of urine. If the patient is already catheterized, the catheter should be flushed with sterile saline to relieve any blockage. Obstruction proximal to the bladder (e.g. ureteric obstruc-tion) is often painless, and ultrasound examination is indicated to exclude pelvicalyceal dilatation.

2. /Issess for hypovolaemia. Once obstruction is excluded clinically, the patient is assessed for evidence of hypovolaemia by measurement of blood pressure, pulse, jugular venous pressure (JVP), and urinary elec-trolytes (p. 385). If the patient is hypovolaemic, the urine output in response to a fluid challenge (500 mL saline 0.9% intravenously over 30 minutes) is assessed.

3. Management of established AKI (p. 385) once obstruction and hypo-volaemia have been excluded.

Haematuria

See urine dipstick testing (p. 357).

Pain

Loin/flank pain occurs in kidney infections (acute pyelonephritis), upper urinary tract obstruction and occlusion of the renal artery due to either thrombosis in situ or emboli. Chronic renal pain occurs in cystic renal disease and renal tumours. Acute severe pain radiating from the flank to the iliac fossa and testes or labium is typical of ureteric colic due to a calculus.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

KEYWORD : Phác Đồ Chữa Bệnh, Bệnh Viện Bạch Mai, Từ Dũ , 115, Bình Dân, Chấn thương chỉnh hình, Chợ Rẫy, Đại học Y Dược, Nhân Dân Gia Định, Hoàn Mỹ, Viện Pasteur, Nhi Đồng Ung bướu, Quân Đội 103, 108,Phụ Sản Trung Ương, Bộ Y Tế,Phòng Khám, Hà Nội, Hải Dương, Thái Bình, Hồ Chí Minh, Sài Gòn, Đà Nẵng, Huế, Vinh, Đồng Nai, Bình Dương, Hải Phòng, Quảng Ninh, Hiệu Quả Cao, Chữa Tốt, Khỏi Bệnh, Là Gì, Nguyên Nhân, Triệu Chứng, Ăn Uống, Cách Chữa, Bài Thuốc - Bài Giảng - Giáo Án - Điện Tử
Thông Tin Trên Web Là Tài Liệu Lưu Hành Nội Bộ Cho Các Bạn Sinh Viên - Y, Bác Sĩ Tham Khảo : Liên Hệ : Maikhanhdu@gmail.com