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Renal Disease

Renal Disease. Ricki Otten MT(ASCP)SC uotten@unmc.edu. Review the Objectives. Those objectives marked with ‘*’ will not be tested over during the Student Lab Rotation. Classification of Renal Disease. Usually by specific structural component affected by disease Glomerular Disease

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Renal Disease

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  1. Renal Disease Ricki Otten MT(ASCP)SC uotten@unmc.edu

  2. Review the Objectives • Those objectives marked with ‘*’ will not be tested over during the Student Lab Rotation

  3. Classification of Renal Disease Usually by specific structural component affected by disease • Glomerular Disease • Tubular Disease • Interstitial Tissue Disease • Vascular Disease

  4. Glomerular Disease • Most often due to damage to glomerular basement membrane • Immunologic disease • Metabolic disease • Hereditary disease • Basement membrane damage leads to • Morphologic changes • Altered glomerular function • Increased permeability allowing leakage of cells and protein into urine

  5. Glomerular Disease • Classification • Primary: specifically affects the kidney • Acute glomerulonephritis • Chronic glomerulonephritis • Nephrotic syndrome • Secondary: another disease process affects the health of the glomerulus • Systemic disease (diabetes mellitus, SLE) • Hereditary disorder

  6. Glomerular Injury • Clinical features dependent upon • Number of glomeruli involved • Mechanism of injury • Rapidity of disease onset

  7. Glomerular Injury • Clinical findings: • Urinalysis: proteinuria, hematuria • Oliguria • Physical findings: edema, hypertension • Blood evaluation: hypoproteinemia, azotemia (increased urea, creatinine)

  8. Glomerular Disease • Acute glomerulonephritis • Chronic glomerulonephritis • Nephrotic syndrome • Diabetes mellitus (nephropathy)

  9. Acute Glomerulonephritis • Acute post-streptococcal glomerulonephritis • Relatively common, often in children, also adults • Occurs 1-2 weeks post streptococcal infection • Antibody mediated: blood cultures negative • Clinical findings: • Sudden onset, fever, malaise, nausea • Oliguria • Edema (lower extremities (ankles), eyes) • Mild hypertension

  10. Acute Glomerulonephritis • Urinalysis • Physical Color? Clear? • Chemical • Microscopic

  11. Acute Glomerulonephritis • Urinalysis • Physical yellow, hazy • Chemical ? • Microscopic

  12. Acute Glomerulonephritis • Urinalysis • Physical yellow, hazy • Chemical + Blood Proteinuria (mild) (<1.0 gram/24 hour) • Microscopic: ?

  13. Acute Glomerulonephritis • Urinalysis • Microscopic: RBC (some dysmorphic) WBC RTE Casts: RBC  hemoglobin  granular

  14. Acute Glomerulonephritis • Other testing: • Blood • ASO titer • Decreased complement (Antigen-Antibody mediated) • Increased BUN, increased creatinine • Decreased albumin • Urine • Decreased CrCl = Decreased GFR • Proteinuria (mild: <1.0 grams/24 hr)

  15. Acute Glomerulonephritis • Majority (>95%) of children recover • Approx 60% of adults recover • Only 1-2 % post-strep acute glomerulonephritis develop chronic glomerulonephritis

  16. Chronic Glomerulonephritis • Numerous glomerular diseases develop chronic glomerulonephritis • Onset is slow and insiduous taking many years to develop clinical signs and symptoms • If not treated, may result in death (uremia) • Clinical findings: same as acute, but worse

  17. Chronic Glomerulonephritis • Urinalysis • Physical Color? Clear? • Chemical • Microscopic

  18. Chronic Glomerulonephritis • Urinalysis • Physical yellow, hazy • Chemical ? • Microscopic

  19. Chronic Glomerulonephritis • Urinalysis • Physical yellow, hazy • Chemical + Blood Proteinuria (mild-moderate) (>2.5 and < 3.5 grams/24 hr) Specific gravity: low and fixed (isosthenuric) • Microscopic: ?

  20. Chronic Glomerulonephritis • Urinalysis • Microscopic RBC WBC RTE Casts (RBC, hemoglobin, granular, waxy)

  21. Chronic Glomerulonephritis • Other testing: • Blood: • Increased BUN, increased creatinine • Decreased albumin, decreased TSP • Urine: • Decreased CrCl = decreased GFR • Proteinuria (moderate: >2.5 grams/24 hr)

  22. Nephrotic Syndrome • Selective filtering capability of glomerulus is lost • Many conditions may lead to NS • Clinical findings: ‘pitting edema’, azotemia, hypertension, oliguria

  23. Nephrotic Syndrome • Urinalysis • Physical Color? Clear? • Chemical • Microscopic

  24. Nephrotic Syndrome • Urinalysis • Physical yellow, hazy (cloudy ?) • Chemical ? • Microscopic

  25. Nephrotic Syndrome • Urinalysis • Physical: yellow, hazy (cloudy ?) • Chemical: + Blood Proteinuria (severe) (>3.5 grams/24 hour) • Microscopic: ?

  26. Nephrotic Syndrome • Urinalysis • Microscopic RBC WBC RTE Oval Fat Bodies (OFB) Free fat droplets Casts (granular, fatty, waxy, RTE)

  27. Nephrotic Syndrome • Other testing: • Blood: • hypoproteinemia (decr albumin, decr TSP) • Increased lipids • Increased sodium • Urine: • Decreased CrCl = decreased GFR • Proteinuria (severe: > 3.5 grams/24 hr)

  28. Diabetes Mellitus (Nephropathy) • Disorder of carbohydrate metabolism • Renal disease is a major cause of death in the diabetic patient • Diabetes is leading cause of • Blindness • End-stage renal disease • Limb amputations

  29. Diabetes Mellitus (Nephropathy) • Clinical findings: • Polyuria • Polydipsia • Nocturia

  30. Diabetes Mellitus (Nephropathy) • Urinalysis • Physical Color? Clear? • Chemical • Microscopic

  31. Diabetes Mellitus (Nephropathy) • Urinalysis • Physical Yellow, hazy • Chemical ? • Microscopic

  32. Diabetes Mellitus (Nephropathy) • Urinalysis • Physical Yellow, hazy • Chemical + Glucose Proteinuria (mild-moderate) • Microscopic ?

  33. Diabetes Mellitus (Nephropathy) • Urinalysis • Microscopic RBC Casts Yeast, possibly Depends on extent of renal involvement (disease)

  34. Diabetes Mellitus (Nephropathy) • Other testing: • Blood • Increased glucose • Increased ketones (diabetes mellitus, type 1) • Urine • Proteinuria: leads to chronic renal failure and death

  35. Tubular Disease • Altered tubular function • Necrosis of tubular epithelium

  36. Altered Tubular Function • Caused by • Reabsorption-secretion capability lost • Concentrating-diluting capability lost • Results in • Build up of waste products in bloodstream • Loss of essential substances into urine

  37. Altered Tubular Function • Renal glycosuria • Glucose in urine, renal threshold not exceeded • Cystinuria • Cystinosis • Renal tubular acidosis • Tubules unable to secrete adequate H+ despite systemic acidosis Inherited disorders Cystine crystals in urine

  38. Urinalysis Findings • Renal glycosuria: + glucose • Cystinuria, cystinosis: cystine crystals • Renal tubular acidosis: pH not as acid as is needed to compensate for systemic acidosis

  39. Necrosis of Tubular Epithelium • Destruction of tubular epithelial cells • Toxin • Ischemic event • Most common cause of renal failure

  40. Necrosis of Tubular Epithelium • Clinical presentation: 3 phases • Onset • Renal failure • Azotemia • Hyperkalemia • Metabolic acidosis • Oliguria • Recovery

  41. Acute Tubular Necrosis • Toxic ATN • Drugs: Aminoglycosides Anesthetics Radiographic dyes Chemotherapy Anti-rejection drugs • Toxins: Mercury Lead Cadmium Ethylene glycol Pesticides Mushrooms

  42. Acute Tubular Necrosis • Ischemic ATN: decreased perfusion of kidneys as a result of hypotensive events • Sepsis: bacterial infection of bloodstream • Shock • Trauma

  43. Acute Tubular Necrosis • Urinalysis • Physical: Yellow, hazy • Chemical: Proteinuria (mild), +blood, low specific gravity • Microscopic: RBC, WBC, RTE Casts: RTE, granular, waxy, broad

  44. Interstitial Tissue Disease • Lower urinary tract infection • Cystitis (bladder) • Urethritis (urethra) • Acute pyelonephritis (upper UTI) • Yeast infection • Any bacterial or fungal agent can cause a UTI

  45. Lower UTI • ~85% of lower UTI caused by gram-negative rods (fecal E.coli) • Urinalysis • Physical Color? Clear? • Chemical • Microscopic

  46. Lower UTI • Urinalysis • Physical yellow, hazy (cloudy, turbid) • Chemical ? • Microscopic

  47. Lower UTI • Urinalysis • Physical yellow, hazy (cloudy, turbid) • Chemical + protein (<0.5 grams/24 hr) + leukocyte esterase + nitrite + blood • Microscopic ?

  48. Lower UTI • Microscopic WBC Bacteria RBC Transitional epithelial cells (cystitis) Absence of casts: why?

  49. Acute Pyelonephritis • Most common upper UTI • Two mechanisms causing infection • Bacterial moving from lower to upper urinary tract • Septicemia localizing in the kidneys • Incomplete voiding due to obstruction or dysfunction or anatomic abnormality • Catheterization, pregnancy, diabetes

  50. Acute Pyelonephritis • Urinalysis • Physical Color? Clear? • Chemical • Microscopic

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