1. Introduction and Clinical Manifestations of
Renal Disease (1)
Salwa Ibrahim, MD MRCP (UK)
Professor of Nephrology

2. Objectives
• To know basic structure and functions of the kidney
• To know main symptoms of renal disease
• To know how to assess kidney functions

3. Anatomy
• The kidneys are retroperitoneal
organs lie on either side of the spine
at level of T12-L3
• Normal kidneys are 11-14 cm in
length
• Right kidney lies 1.5 cm lower than
the left because of the liver

4. Histology
Each kidney contains one
million nephrons comprising a
glomerulus, PCT, Loop of Henle,
distal tubule and collecting duct

5. Blood and nerve supply to the kidney
• The kidneys receive 25% of the cardiac
output
• T10-12/L1 roots innervate the renal
capsule and the ureter and pain from these
structures is felt in these dermatomes

6. The Glomerulus
• A glomerulus is a capillary tuft that is surrounded by Bowman's
capsule
• A glomerulus receives its blood supply from an afferent arteriole
Unlike most other capillary beds, the glomerulus drains into an
efferent arteriole
• The resistance of these arterioles results in high pressure within
the glomerulus, aiding the process of ultrafiltration, where fluids
are forced out of the capillaries and into Bowman's capsule
• A glomerulus and its surrounding Bowman's capsule constitute a
renal corpuscle, the basic filtration unit of the kidney
• The rate at which blood is filtered through all of the glomeruli, and
thus the measure of the overall renal function, is the glomerular
filtration rate (GFR).

7. The glomerular layers
Podocytes
Glomerular basement membrane
Endothelial cells

8. Primary functions of the kidneys
• Excretion of waste products e.g. urea
• Maintain body water and electrolytes
• Regulation of BP through renin angiotensin system
• Endocrine function in erythropoiesis and vitamin D metabolism

9. The kidneys produce urine which is passes
to the bladder through the ureters
As the bladder fills completely, the smooth
muscle layer (detrusor) contracts
under parasympathetic control to allow
urine to pass through the urethra

10. Symptoms of renal disease
I. Kidney (upper urinary tract symptoms): Pain and swelling
II. Lower urinary tract symptoms: voiding pain (pain passing urine),
frequency, urgency, hesitancy
III. Change in urine volume (polyuria, oliguria, anuria) or color (haematuria),
content (proteinuria)
IV. General symptoms: oedema, fatigue, nausea, vomiting, shortness of breath

11. Kidney (Upper urinary tract) symptoms

12. Pain
A. Renal colic
• A severe sudden sustained loin pain
• It often radiates to the groin
• It is caused by sudden obstruction in the
urinary tract usually by a calculus or a
blood clot
• It is often associated with nausea and
vomiting

13. B.Dull ache in the loins
• Usually due to stretch of the capsule of the kidney e.g.
in glomerulonephritis, polycystic kidney and
hydronephrosis
• Lion pain with fever, rigors, pain on voiding suggest
infection of the kidneys (acute pyelonephritis)
• Many patients with chronic obstruction are however
pain-free

14. Lower urinary tract symptoms

15. Dysuria
• Pain or discomfort felt during or immediately after passing urine
• It is often described as a burning sensation felt at the urethral
meatus , or the suprapubic region
• The most common cause is infection and /or inflammation of the
bladder[cystitis]and frequency(desire to pass urine more often) is
usually present

16. Voiding symptoms

17. Voiding symptoms
• During storage phase
• During voiding phase
• After micturition
• Incontinence

18. Storage symptoms
 Urgency
• A sudden strong need to pass urine and may cause incontinence if there is no
opportunity to urinate. Is due to overactivity of detrusor muscle or abnormal stretch
receptor activity from the bladder
 Frequency
• Means frequent micturition of relatively small amounts of urine

19. Causes
• Cystitis, urthritis or stone bladder causing irritation of the bladder wall
• Contracted bladder as occurs in Bilharziasis; the diminished capacity of the bladder
leads to frequent micturition
• Chronic retention of urine e.g. by enlarged prostate small amount of urine overflow
from the bladder at frequent intervals
• Cancer bladder
• Psychogenic factors as anxiety.

20. Voiding phase symptoms
 Hesitancy: delay or difficulty in initiating urine flow
• In men over 40, it is commonly due to bladder outlet obstruction by prostate
enlargement
• In women, it suggests urethral obstruction due to stenosis or uterine
prolapse
 Poor flow: reduction in urinary stream

21. After micturition symptoms
• Dribbling and incomplete emptying are caused by obstruction
• Incontinence : involuntary release of urine may occur
I. With the need to void (urge incontinence) caused by overactive
detrusor
II. or with increased intra abdominal pressure (stress incontinence) due
to weakness of pelvic floor following childbirth

22. Symptoms of bladder outlet obstruction
• Urgency
• Frequency
• Hesitancy
• Poor flow
• Dribbling

23. Change in urine volume

24. Polyuria
Means increased volume of urine as the capacity of the bladder is limited, polyuria is associated
with frequency
N.B : In healthy adults urine out put will approximate to the fluid intake minus the insensible fluid
losses through the skin and respiratory tract[500-800 ml/day], average 2-3 liters/day
Causes
1-Diabetes mellitus (due to osmotic effect of glucose)
2-Chronic renal failure especially with chronic tubulointertsitial fibrosis
3-Diabetes insipidus
4- Hypercalcaemia (due to impaired tubular concentrating mechanism)
5- Hypokalemia (due to impaired tubular concentrating mechanism)
6- Excessive fluid intake due to psychiatric disease.

25. Oliguria
Means diminished volume of urine <500 mlday
Causes
1- Diminished intake of fluids
2- Hot weather
2- Pre-renal failure
3- Initial stage of acute renal failure
4- Terminal stage of chronic renal failure

26. Anuria
Means complete absence of urine formation so that no urine reaches the
bladder and the patient has no desire to micturate
Causes
• lower urinary tract obstruction when bladder neck or urethral obstruction
causes urinary retention
• Spinal injury through neurological damage

27. Change in urine colour

28. Haematuria
• Means passage of red blood cells
in urine
• It can be
I. Macroscopic causing a reddish
discoloration of the urine
I. Microscopic when excess red
cells are detected in urinary
sediment

29. • Causes
1- Prerenal e.g. Haemoragic diseases as purpura
and over dose of anticoagulants
2-Renal e.g. Stones, tumours, glomerulonephritis,
and renal T.B
3-Ureter: stone and tumours
4- Bladder : cystitis, stone and tumours
5- Prostate : prostatitis, prostatic hypertrophy and
tumours
6- Urethra: trauma, stricture, stone and tumours

30. It should be noted that
• Terminal haematuria indicates a lesion in the
urethra, prostate , or bladder neck while total
haematuria means the lesion is higher up
• Haematuria associative with renal colic is
suggestive of stone
• Painless frank haematuria is suggestive of
tumour
• Microscopic haematuria is suggestive of a
parenchymatous lesion as glomerulonephritis

31. Differential diagnosis of haematuria (causes of reddish urine)
• Contamination of urine by menstrual blood
• Free hemoglobin due to intravascular hemolysis
• Free myoglobin in rhabdomyolysis
• Drug therapy : rifampcin

32. Change in urine contents

33. Proteinuria
 Proteinuria is usually asymptomatic unless
gross > 2-3 g/day
 Severe proteinuria may produce frothy urine
 Lowering the plasma albumin concentration,
oncotic pressure
 Generalized oedema and nephrotic
syndrome

34. Nephrotic syndrome

35. Causes of proteinuria
1. Renal disease
• Glomerulonephritis
• Diabetes mellitus
• Lupus nephritis
2. Non renal disease
• Fever
• Severe exertion
• Heart failure

36. General symptoms of chronic kidney disease

37. General symptoms of renal disease
• Broadly non specific
• Occur in chronic kidney disease due to
retention of uremic toxins
• Nausea vomiting itching disturbed
consciousness
• Fatigue and pallor secondary to anemia
• Bony aches and muscle weakness
• Shortness of breath (anemia, volume
overload)

38. Uremic symptoms

39. Symptoms secondary to anemia

40. Symptoms secondary to bone disease
• Bone pain
• Joint pain
• Bone fracture

41. Symptoms secondary to volume overload
1. Lower limb swelling
2. Pleural effusion
3. Pulmonary edema

42. Investigations

43. Renal function tests
• Serum creatinine
• Blood urea
• Serum electrolytes
• Complete blood count
• Creatinine clearance
• Serum calcium and phosphorus

44. Urine analysis
Flat colorless hexagonal plates, which often aggregate
Stix test for blood protein sugar
Red cell cast
Cystine crystals
Flat colorless hexagonal plates which often aggregate

45. Microscopic examination
Uric acid
White cells
Phosphate crystals
RBCs

46. Radiologic assessment of UT

47. Plain X-ray Abdomen
Detection of calcification and radiopaque stones
Ureteric stone bilateral staghorn stones Right staghorn stone

48. Intravenous Pyelogram (IVP)

49. Hydronephrosis

50. Renal ultrasonography
No exposure to radiation and no dye is used
1. Assess renal dimensions
2. Exclude obstruction
3. Polycystic kidney Disease

51. Renal biopsy
Indications
1. Nephrotic syndrome
2. Nephritic syndrome
3. Acute renal failure
4. Proteinuria, haematuria

52. Normal glomerulus

53. Membranous nephropathy

54. Necrotizing GN