Renal: The important stuff!!!

1. Renal
Dr T Jenyon

2. Plan
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Background
Symptoms and Signs
Renal medicine
Renal failure
Rare renal
UTI and calculi
Surgical renal

3. Background
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Kidney is retroperitoneal
11-14cm in length
Has a high proportion of cardiac output
Central role in fluid and electrolyte balance

4. Background
• Other roles:
– Erythropoetin
– Vitamin D metabolism
– Caltabolism of small proteins (insulin)
– Drug excretion

5. Background - Fluid and electrolytes
• ADH (posterior pituitary) controls Osmolality
• Renin-angiotensin-aldosterone controls
Extracellular volume (via Na)

6. Background – Urea and creatinine
• Urea – nitrogenous waste due to breakdown of
amino acids
• Raised in
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Renal failure
High protein intake
GI bleed (acts as high protein meal)
Dehydration
• Creatinine
• Raised in
• Renal failure
• Large muscle mass
• Acute muscle damage

7. Notes
• Alcoholics tend to have a very low urea as poor diet
and knackered liver
• Sudden increase in Urea but not creatinine think
dehydration or GI bleed
• Ratio should be around 1:20
• Altered ratio (1:5) suggests acute renal failure, GI bleed etc
• Low Hb, high urea, think GI bleed

8. Renal anatomy

9. Symptoms and signs
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Frequency/Polyuria
Oliguria
Dysuria/pain
Incontinence
Palpable kidneys
Glycosuria
Haematuria
Proteinuria

10. Frequency / Polyuria
• Frequency implies increaed frequency voiding –
different from polyuria (increased volume)
• Frequency – Think UTI
• Polyuria
• Excess intake
• Osmotic diuresis (DM)
• Defective concentrating ability of kidney
• Diuretics
• CRF
• Diabetes insipidus

11. Oliguria
• Urine output <0.5ml/kg/hr or less than 400mls per
day
• Causes (basically causes of ARF)
– Pre-renal - Decreased perfusion of kidneys
• shock/hypovolaemia
– Renal
• ATN/GN
– Post renal - Obstruction of urine flow
• Intra-lumen – stone
• In the wall – stricture/tumour
• Compressing wall – prostate/tumour/AAA
• Remember blocked catheter if catherised

12. Dysuria/Pain
• Dysuria – pain on urination
– Think of UTI/STI
– Can get sterile urethritis
• Renal stones classically cause ‘renal colic’
– loin to groin pain coming in waves, makes patient
roll around

13. Incontinence
• Involuntary voiding of urine
• If new onset suspect UTI, in men suspect protatism and overflow – check
for bladder
• Types:
– Functional, i.e. caught short
– Stress, weak pelvic floor, small amounts leak when coughing or laughing
• Do pelvic floor exercises, can try Duloxeteine, TFVT or colposuspension is surgical
option
– Urge, uncontrolled emptying of bladder, e.g. brain damage.
• Find cause, try timed voiding, oxybutynin/tolterodine can help

14. Palpable kidneys
• Bilateral palpable kidneys
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ADPKD
Bilateral hydronephrosis
Amyloid
Bilateral RCC
Tuberous sclerosis
• Unilateral palpable kidneys
– RCC
– Hydronephrosis
– Bilateral cause with only one palpable
• (In chronic renal failure kidneys tend to be small
and shrunken)

15. Kidney Vs Spleen
• Kidney
– Moves late on
inspiration
– Possible to get above
– Smooth shape
– Resonant to percussion
• Spleen
– Moves early on
inspiration
– Can’t get above
– Notched leading edge
– Dull to percussion
– Enlarges towards RIF

16. Glycosuira
• Blood glucose of >10mmol will spill over into
urine
• Think DM
• Can have congenital low renal threshold for
glucose

17. Haematuria
• Is it Blood?
– Rifampicin, beetroot, myoglobinuria
(rhabdomyolysis)
• Is it from urological tract
– DD Vagina/rectum
• Is it from kidney
– Look for red cell casts
• Is it painless
– Think cancer

18. Haematuria
• Generalised disorder
– IBE, coagulopathy, sickle cell, vasculitis
• Specific disorder
– Kidneys or Ureter/bladder/Urethra
• Medical
– GN – IgA or thin BM disease
– Infection - UTI/prostatitis/schistosomiasis
• Surgical
– Stone, tumour, trauma

19. Proteinuria
• Urine Dipstix react to albumin but not Bence Jones Protein (myeloma)
• ‘microalbuminuria’ is proteinuria in the range of 30-300mg/L (e.g. DM)
• Quantify proteinuria with 24hr urine of protein/creatinine ratio (PCR) or
albumin creatinine ratio (ACR)
• >3.5g/day suggests nephrotic syndrome this may make the urine frothy
• Proteinuria and heamaturia with red cell casts suggests Nephritic
syndrome

20. Proteinuria
• Benign
– Orthostatic proteinuria
– Exercise/febrile illness
• Excess circulating protein
– Myeloma
• Renal damage
– DM/GN/nephritic/nephrotic syndrome
• UTI

21. Renal Medicine
Nephrotic syndrome
Nephritic syndrome
GN
TIN

22. Renal Medicine
• Appears complex no definitive relationship
between syndromes/symptoms and
pathology/biopsy
• But
– Some patterns are present
– Results from biopsy can help guide treatment
• E.g. kid presents with nephrotic syndrome:
– They are assumed to have minimal change GN.
– Treat with Steroids.
– If they do not respond to steroids they will have a
biopsy that might reveal a different cause that might
need a different treatment

23. Nephrotic Syndrome
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Massive proteinuria (>3.5g/day)
Hypoalbuminaemia (<30g/L)
Oedema
Hyperlipdaema
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Increased thrombotic tendency (loose antithrombin III and protein S)
Increased susceptibility to infection (loose immunoglobulins)

24. Nephrotic syndrome
• Commonest cause in kids:
– Minimal change glomerulonephritis
• Not much to see on microscopy (minimal change), get fusion of
podocytes on electron microscopy
• Benign (only 1% progress to ESRF), treat high dose (60mg)
Prednisolone, only biopsy if not responding
• Commonest in adults
– Membranous nephropathy
• Thickened BM with spikes on silver staining (IgG)
• 1/3 better,1/3 same, 1/3 ESRF
• Idiopathic, or assoc Malignancy, drugs, SLE (V), Hep B

25. Nephrotic syndrome
• Other causes of Nephrotic syndrome:
– Focal Segmental Glomerulosclerosis
• Only some (focal) glomeruli have some (segmental)
sclerosis. Idiopathic or assoc HIV
• High recurrence in transplant
– DM
– Amyloid
– SLE

26. Nephritic Syndrome
• Symptomatic haematuria and proteinuria
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Haematuria with red cell casts
Proteinuria (<3.5g/day)
Oliguria
Hypertension
Oedema
– (remember UTI can give you haematuria and proteinuria)

27. Nephritic Syndrome
• Commonest cause:
– IgA nephropathy (Bergers disease)
• 3-4 days post infection – usually URTI
• 16-35 yr olds with episodic macroscopic haematuria
• IgA and C3 on biopsy with mesangial hypercellularity
• 2nd commonest:
– Proliferative GN / Post Strep GN
– 1-3 weeks post strep infection
• IgG and C3 on biopsy
• ASOT (anti streptolysin-O-Titre)

28. Nephritic syndrome
• Other causes:
– HSP (Henoch Schonlein Purpura)
• Systemic variant of IgA nephropathy
• Usually 3-10yrs old
– Plus fever, rash (purpura on legs and buttocks), joint pain,
abdo pain
– SLE
– Cryoglobulinaemia
– Infective endocarditis
– Tubulointerstitial nephritis

29. Asymptomatic haematuria and proteinuria
• Alports syndrome
– (inherited renal failure and deafness)
• Thin basement membrane disease
– (inherited AD, BP and renal function normal)
• Remember UTI
– But often plus frequency, dysuria, temperature

30. Parts of Kidney
• Simplified
– Glomerulus
– Blood vessels
– Tubules
– Interstitium

31. Glomerulonephritis
• Inflammation of glomerulus
• Usually present with:
– Haematuria with red cell casts
– +/- Proteinuria
– May present as ARF, nephritic or nephrotic
syndrome

32. GN
• IgA (bergers disease)
– IgA, young girl, 3-4 days post URTI
• Minimal change
– Commonest cause of nephrotic syndrome in kids, fusion of podocytes, treat
high dose Prednisolone, excellent prognosis
• Membranous
– Commonest cause of nephrotic syndrome in adults, thickened BM with spikes
(IgG), idiopathic, or malignancy, SLE, Drugs or Hep B
• Proliferative (post strep)
– Post Strep, 1-3 weeks post infection, IgG on biopsy, ASOT and low C3
• Focal Segmental Glomerulosclerosis
– Only some glomeruli have segmental sclerosis, assoc HIV, high recurrence in
transplants
• Thin BM disease
– AD – family history, heamaturia without renal failure or hypertension

33. GN
• Membranoproliferative/mesangiocapillary
– Mesangial proliferation with double BM
– Two types
• I - assoc Cryoglobulinaemia/Hepatitis C
• II - assoc Partial lipodystophy
• Rapidly progressive GN
– ESRF in weeks
– Focal necrotising GN with cresentic changes
– Assoc:
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Vasculitis – Wegners/Churg-Strauss
Goodpastures
SLE/ RA
Other GN (eg IgA)

34. Parts of kidney
– Glomerulus
– Blood vessels
– Tubules
– Interstitium
Act as one

35. Tubulointerstitial Nephritis
• A cause of a Nephritic type picture due to damage to
the tubules or interstitium
• Almost all due to hypersensitivity reactions to drugs
– Penicillins or NSAIDS
– Also Cadmodium, mercury, reflux, sickle cell or urate nephropathy
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Often get Eosinophilia
May have fever, arthralgia and rash
‘Non-oliguric renal failure’
(No red cell casts – signifies glomerular
damage)

36. Renal Failure
Acute Renal Failure
Chronic renal failure

37. Acute renal failure
• Suddenly and usually reversible loss in renal
function occurring over hours or days.
• Usually associated with a reduced urine
volume

38. Causes ARF
– Pre-renal - Decreased perfusion of kidneys
• shock/hypovolaemia
• (usually reversible but may progress to ATN)
– Renal
• ATN(85%)
• GN/interstitial disease
– Post renal - Obstruction of urine flow
• Intra-lumen – stone
• In the wall – stricture/tumour
• Compressing wall – prostate/tumour/AAA
• Remember blocked catheter if catherised

39. Acute tubular necrosis - ATN
• Tubular cells have a very high oxygen
requirement.
• If deprived of oxygen they die
• Take 7-21 days to regenerate
• If insult is prolonged the damage may be
irreversible
• Oliguria – polyuria - normal

40. Uraemia
• (a term loosely applied to describe the symptoms that accompany renal
failure, presumably due to build up of toxic products)
• Anorexia, nausea, vomiting
• Pruritis, hiccups
• Encephalopathy, fits, coma
• Pulmonary oedema, hyperkalaemia, acidosis

41. Approach to ARF
• Rule out or treat hypovolaemia
• Insert catheter (rules out obstruction and allows
close monitoring of fluid balance)
• Urine dip
• Bloods (U&Es, FBC, ABG, ECG, CRP (+/-ANA, anti GBM, ANCA))
• USS urinary tract
• Early nephrological advice
• Treat complication – e.g. hyperkalaemia, adjust drug
doses e.g. gentamicin

42. Dialysis in ARF
• 4 main indications
– Hyperkalaemia not responding to medical
treatment
– Pulmonary oedema not responding to medical
treatment
– Severe acidosis
– Complications of uraemia – pericarditis or
encephalopathy

43. Chronic Renal Failure
• Substantial and irreversible deterioration of
renal function, classically develops over a
period of years
• Commonest causes
– DM
– HTN
– Glomerulonephritis
– ADPKD

44. Chronic renal failure - Problems
• Fluid retention
• Anaemia (Burr cell)
• Metabolic bone disease
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Hyperparathyroidism (2 and 3rd), osteomalacia, osteoporosis
Infection
Hypertension, increased CVS risk
Pericarditis (uraemic)
Acidosis, hyperkalemia

45. Approach to CRF
• Identify cause
• Prevent further progression if possible
• Once creatinine hits 300 there is usually
progressive deterioration regardless of the
cause

46. Dialysis in CRF
• This should be started when patient has
advanced renal failure, but before they
develop complications
• Usually creatinine around 600-800
• Usually haemodialysis 4 hours 3x a week

47. Dialysis
• 2 main types
• Intermittent haemodialysis
– AV fistula
– Better filtration
• Continuous peritoneal dialysis
– ‘Tenckhoff’ catheter
– Better kids (growth) and elderly (less haemodynamic
fluctuations)
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(Haemofiltration – ITU, continuous)

48. Transplant
• Refer to transplant team early
• Transplant nurse, transplant coordinator etc
• Needs ABO and HLA compatibility
• 90%1 year graft survival
• 50% 10 year graft survival
• Best with living related donor

49. Transplant drugs
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Steriods
Azathioprine
Ciclosporin
Tacrolimus/Sirolimus
Mycophenolate

50. Complication of transplant
• Graft failure
– Acute – usually preventable with
immunosuppressant's
– Chronic – Slow decline in function – irreversible
• Infection
• Malignancy – skin (SCC), lymphoma
• Side effects of drugs – e.g. gum hypertrophy
with ciclosporin

51. Diseases which can reoccur in a graft
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IgA Nephropathy
Goodpastures
Focal Segmental Glomerulosclerosis
Metabolic diseases (DM)

52. Rare Renal

53. Goodpastures
• Autoantibodies against type IV collagen in
lung and kidney basement membrane (anti –
GBM)
– Haemoptysis
– Haematuira
• Immunosuppression and plasma exchange
(recurs in transplant)

54. Wegners
• A vasculitis with granulomas
• Get sinusitis, nose bleeds, nasal deformities,
arthritis, cavitating lung lesions, haemoptysis
and renal failure
• Circulating C-ANCA against PR3

55. SLE and Scleroderma
• Kidneys often involved
• No renal involvement in drug induced SLE
• SLE renal involvement graded I-V, V being
nephrotic syndrome due to membranous GN
• Scleroderma can get renal crisis – ACEi and
dialysis can be lifesaving

56. DM
• Diabetics often have kidney damage
• It is a microvascular complication
– (due to ischemia, glycosilation)
• Get Kimmelstiel-Wilson nodules in kidneys
• Microalbuminuria (30-300) is one of the first
signs – is screened for
• ACEi is renoprotective

57. Tumour Lysis Syndrome
• When cells die they release contents into
blood
• When large number of cells die all at once,
often in cancer on starting treatment urate
levels begin to cause issues
• Urate causes ARF
• Oncologists often start allopurinol (or
Rasburicase) prior to chemotherapy

58. ADPKD
• Autosomal dominant polycystic renal disease
• PKD1 (chromo 16) PKD2 (chromo 4)
• Multiple cysts in kidneys cause:
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Enlargement
Pain
Haematuria
Renal failure
At risk of SAH
• Screen with USS

59. Multiple Myeloma
• ARF is common in myeloma
– Immunoglobulins can block tubules – get
‘fractured casts with giant cell reaction’
– At risk of infection
– High calcium damages kidney

60. Renal Tubular Acidosis
• Rare cause of metabolic acidosis due to renal
issues
• “If patient is acidotic and urine is not the
suspect”

61. RTA
• Type I
– Don’t get rid of H+ in distal tubule
– Assoc stones and hypokalaemia
• Type II
– Leak bicarbonate
– No stones, usually assoc fanconi’s syndrome
• Type IV
– Get Hyperkalaemia
– Usually in diabetics with mild renal failure

62. Fanconi syndrome
• Generalised disturbance of renal function
• Can be inherited or acquired
• A cause of RTA II

63. Hepatorenal Failure
• Renal failure as a consequence of liver failure
• Very poor prognosis unless liver sorted out

64. Amyloid
• ‘Extracellular deposition of protein which form
B-pleated sheets’
• Tissues/organs become larger and firmer
• On microscopy get ‘apple green birefringence
in polarized light after staining with congo-red’
• Often due to myeloma (AL) or chronic
inlammatory diseases (AA)
• Can cause renal failure

65. Renal artery stenosis
• A cause of hypertension
• Narrowing in artery to kidney (e.g.
athersclerosis, NF) decreases perfusion
pressure
• That kidney begins to increase blood pressure
(renin-angiotensin-aldosterone)
• Get asymetrical kidneys on USS
• ACEi are contraindicated

66. UTI

67. UTI
• Mostly E-Coli (70% E-coli)
– Can use
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Trimethoprium
Nitrofurantoin
Amoxicillin
(Cefalexin a favourite if pregnant)
– Three day course if uncomplicated
• If developed pyelonephritis – needs i.v antibiotics
(renal angle tenderness, rigors)
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Staph Saprophiticus – UTI only
Proteus – staghorn calculi
Pseudomonas – long term catheter, green

68. UTI
• Remember STIs as a cause of dysuria
• Can get sterile urethritis
• Can get asymptomatic Bacteriuria – treat if
pregnant
• If suspect TB do three EMU
• Prostate can be infected perianal pain and
tender prostate, difficult to treat, long course
of Abx

69. Pyelonephritis
• Infection of the kidney
• Usually due to ascending infection
• Fever/Rigors
• Loin pain
• Needs admisison, treat often with gentamicin,
cephalosporin or ciprofloxacin

70. Renal stones (nephrolithiasis)
• Pain – loin to groin, can’t get comfortable, rolling
around
• 95% have haematuria on dipstix
• Commonest cause: Calcium oxalate,
• Others: triple phosphate (staghorn calculi),
uric acid (radio lucent)
• Risk factors – dehydration, UTI, hypercalcaemia,
high dietary oxalate

71. Renal stones
• Treat:
– Diclofenac, esp PR is excellent
– May need antiemetic
• Check U&Es to ensure no renal failure from obstruction
• Do X-ray KUB, IVU or CT KUB
• Often pass on their own can do lithrotripsy, esp for
renal pelvis
• (Don’t forget AAA as a cause of ‘renal colic’)

72. BPH
• Benign prostatic hyperplasia
• Protate gets uniformly enlarged – smooth on
pr
• PSA may be slightly raised
• May get symptoms of Bladder outflow
obstruction
– Hesitancy, poor stream, terminal dribbling,
nocturia

73. BPH
• Treatment
– Drugs
• Tamsulosin – a-blocker relaxes smooth muscle
particular in urogenital tract and eases some of the
outflow obstruction
• Finasteride – 5a blocker, interfers with testosterone
conversion to potent DHT, helps provent progression
– Surgery
• TURP – Transurethral resection of the prostate

74. Prostate cancer
• 2nd commonest malignancy of men
• Adenocacinoma that arises in peripheral
prostate
• PSA tumour marker
• Likes metasisizing to bone (sclerotic lesions on
x-ray)

75. Prostate cancer
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Craggy prostate on PR
Raised PSA (>4ug/l)
Do Transrectal ultrasound and biopsy
Bone scan/CT/MRI pelvis
• Gleason score – two scores 1-5
– Min score 2 max 10
• Treat
Prostatectomy/Radiotherapy/Brachytherapy/C
hemotherapy (Zolodex)Watch and wait

76. Torsion
• Urological emergency
– Testis twists and cuts off blood supply
– Will die in hours
– Sudden onset of pain
– Testis may lie high and transversely
– Needs surgery – untwist and if viable do
orchidoplexy, if not ochidectomy

77. Testicular lumps
• Can you get above it – ie is it a hernia
• Cold, hard, attached to testis – Cancer
• Whole testis swollen and tender – Epididymoorchitis
• Is it a lumpy ‘bag of worms’ ontop –
varicocele
• Is it cystic – above testis – epididymal cyst
• Is it cystic – surrounds testis - hydrocele

78. Testicular tumours
• Painless hard lump on testis
• Germ cell
– Teratomas, 20-30s, secrete BHCG and aFP
– Seminomas, 30-40s, secrete alk phos
• Treat Orchidectomy and chemo – esp cisplatin
• Non germ cell
– Leydig, sertoli and lymphoma

79. RCC
• Renal cell carcinoma, aka clear cell
• Classic triad of
– Pain
– Haematuria
– Renal mass
• Assoc smoking and von Hippel Lindau
• Can spread via direct extension, blood and lymph.
• Have a special ability to grow along vessels renal vein
to IVC
• Can secrete EPO

80. TCC
• Transitional cell carcinoma
• Can arise from Bladder, Ureter or renal pelvis
• Assoc smoking and analine dies
• Think in anyone >50 with painless haematuria
• Can do urine cytology, often do cystoscopy
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Schistosomiasis can cause SCC of the bladder

81. Paeds Urology
• Phimosis – narrowing of opening of foreskin
• Paraphimosis – swelling of glans due to tight
foreskin being retracted and not replaced
• Hypospadias – abnormal opening of urethra
• Undescended testis – common in prems, try
to surgically correct, if intra-abdominal
remove due to risk of malignant change
• Balanitis – inflammation of the glans

82. Notes
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Hyaline casts in normal individuals
Granular casts in renal damage
Dysmorphic RBCs indicate glomerular disease
Destruction of capillary loops – vasculitis
Tubular atrophy - CRF