Pathomechanisms of the most important renal symptoms and

Pathomechanisms of the most important renal symptoms and signs M. Tatár Ústav patologickej fyziológie JLF UK

The most frequent symptoms and signs of renal diseases • hematuria, lumbar pain, !proteinuria! • polyuria and polydipsia, oliguria and anuria, dysuria • edema, renal encephalopathy

Glomerular disorders proteinuria hematuria

Proteinuria • Prerenal higher plasmatic concentrations of low molecular proteins: tissue degradable products, proteins of acute phase (fever), myoglobin in rabdomyolysis, light immunoglubulin chains in myeloma • Glomerular protein leak through GBM; selective, nonselective • Tubular excretion of low-molecular proteins ( 1 -microglobulin, 2 microglobulin) with resorption in proximal tubule • pyuria and hematuria could mimic proteinuria

Proteinuria • Healthy adult subject : 150 mg/24 h plasma proteins from urinary tract • Intensity 1 g/24 h – small proteinuria 3. 5 g/24 h - proteinuria accompanying nephrotic syndrome (10 -30 g/24 h)

Hematuria • Renal glomerular origin nonglomerular hematuria of renal origin (tumor bleeding, cysts) • Subrenal Mucosal hyperemia due to inflammation Bleeding from urinary tract: urolitiasis, tumors, trauma

Tubular disorders oliguria polyuria glycosuria cystinuria edema

Oliguria ( 500 ml/day) • Renal hypoperfusion in low blood pressure hydrostatic pressure in glomerulus - GFR Prerenal ARF • Desquamation of necrotic tubular epithelial cells Na resorption – activation of TG mechanism tubular block leak of tubular fluid into the interstitium Intrarenal ARF (ischemic or toxic) • Block in urinary tract with hydronephrosis Postrenal ARF • Uremia: vomiting, apathy, somnolence, foetor azotaemicus, acidotic breathing; later bleeding, pericarditis, coma • Complications: hyperkalemia, lung and brain edema

Polyuria with polydipsia • High liquid intake Hypervolemia: natriuresis; low ADH production • Osmotic diuresis proximal tubule disorders: low resorption of Na a glucose hyperglycemia: tubular maximum chronic renal insufficiency: residual nephrons (increased GFR in nephron, insufficient Na resorption, decreased medullar osmolality) • Diabetes insipidus Hypoosmolal urine ( 100 m. Osm/1 kg); risk of dehydration) • Late diuretic phase of ARF epithelial regeneration; risk of dehydration and hypokalemie

Nephrotic syndrome • High proteinuria ( 3. 5 g/1. 73 m 2/day) • Hypoproteinemia increased protein katabolism increased transfer into the extravascular space lost in stool insufficient proteosynthesis in liver • Hyperlipidemia increased synthesis in liver • Edema

Edema • Subjects with hypovolemia and activation of RAA - (30%) - small glomerular abnormalities - clasic theory • Subjects with hypervolemia without RAA activation, low renin and aldosteron - more serious morphological disorder - diabetic nephropathy, membranous glomerulonephritis - increased total Na reabsorption – resorption in distal tubule (hyposensitivity to atrial natriuretic peptide) - primary edema

Izostenuria • Urine osmolality equal to plasma - disorder of countercarrent mechanism • Accompanied with negative concentration trial and polyuria = chronic renal insufficiency

Uremia in CRI Fatique – anemia Anorexy, nausea, vomitus – metabolic breakup Foetor azotaemicus – bacterial breakdown of urea to ammonia Diarrhea with bleeding - uremic gastroenteritis Dyspnoe – heart failure, metabolic acidosis, anemia Headache, visual troubles – arterial hypertension Polydipsia Apathy, insomnia, delirium, coma – renal encephalopathy Pain and deformity in bones – renal osteodystrophy

Uremic toxicity urea creatinin methylguanidine uric acide indol, fenol acetoin, buthylenglycol …

Urinary tract disorders renal colic disuria incontinence

Pain • Retroperitoneal in lumbar region hydronephrosis, cystic kidneys infarction pyelonephritis • Renal colic with hematuria ureter block with stone (increased peristalsis and dilatation) symptoms of acute abdomen with peritoneal irritation • Pain durin micturition (dysuria) cystitis, uretritis

Acute nephritic syndrome face edema macroscopic hematuria oliguria hypertension