TAKING HISTORY SIGNS AND SYMPTOMS IN KIDNEY DISEASES

TAKING HISTORY, SIGNS AND SYMPTOMS IN KIDNEY DISEASES Prof. Dr. Tekin AKPOLAT Liv Hospital-İSTANBUL İstinye Üniversitesi Tıp Fakültesi 2020 -2021 www. tekinakpolat. com

l http: //tekinakpolat. com/dersler-2020 -2021/ l http: //tekinakpolat. com/ogrenciler-icin- yararli-kitaplar/ www. tekinakpolat. com

Plan l General information l Signs and symptoms l History taking l Nephrologic diseases l Summary www. tekinakpolat. com

General information 1 l Many patients learn their kidney disease from laborotary tests which were done for another problem l This means they get a diagnosis of kidney disease despite the absence of signs and symptoms www. tekinakpolat. com

General information 2 l Practically we can say most common sign of kidney disease is no sign l The most common reason of this is the underlying kidney diseases l Diabetes mellitus and hypertension are the main causes l The patients learn they have kidney problem during routine follow up www. tekinakpolat. com

General information 3 l You should also learn kidney function tests to evaluate an asymptomatic kidney patient l You can download my ebook from website but it is Turkish www. tekinakpolat. com

Sign and symptoms 1 1. Abdominal/flank pain 2. Poliuria 3. Nocturia 4. Frequent urination/dysuria 5. Hematuria 6. Edema www. tekinakpolat. com

Sign and symptoms 2 7. Hypertension 8. Urine colour changes 9. Oliguria/anuria 10. Uremic symptoms/weakness 11. Abdominal mass 12. Other signs and symptoms www. tekinakpolat. com

General information 4 l Many systemic diseases may affect kidney or they can be with kidney disease l Therefore, symptoms and signs not related to kidney may be helpful in the differential diagnosis www. tekinakpolat. com

Plan l General information l Signs and symptoms l History taking l Nephrologic diseases l Summary www. tekinakpolat. com

Abdominal pain l Site l Time and mode of onset l Nature l Duration l Severity l Radiation l Progression l Relieving factors l Exacerbating factors l Cause

Flank pain 1 l Acute and intermittent (renal colic) or chronic and blunt. l Renal colic differential diagnosis: Biliary colic, appendicitis, diverticulitis, irritable bowel syndrome, muscle-skeletal system disease, urinary tract infection, testicular-scrotalor labial diseases and systemic-metabolic diseases (acute intermittent porphyria, Familial Mediterranean fever, lead intoxication. . . ) düşünülmelidir.

Flank pain 2 l It could be from kidney or elsewhere. l Kidney diseases: acute nephritis, pyelonephritis, urinary tract obstruction, renal infarctus, renal cell carcinoma, renal vein thrombosis, perinephritic inflammation.

Poliuria l In an adult, urine volume more than 3 liters/day l It is not dangerous unless patient takes fluid l If poliuria is much and fluid taken by the patient is not enough, hypotension and shock develops shortly l Main diseases: Solute diuresis (glucosuria, mannitol. . . ), central or nephrogenic diabetes insipitus and psychogenic polydipsia.

Nocturia 1 l Urination during sleep. l In normal conditions, urine amount is less than bladder capacity. l Habits, sleep problems and drinking much fluid can cause nocturia but it is generally pathological

Nocturia 2 l Polyuria causes, edema causing diseases, chronic kidney disease, decrease in bladder capacity, bladder irritation and inflammation or problems in bladder emptying lead to nocturia. l Nocturia may be the first symptom of chronic kidney disease.

Frequent urination/dysuria 1 l Usually it is with frequent urination, urgency, fullness sensation after emptying of bladder l These are characteristic for bacterial cyctitis and urethritis l Frequent urination (pollakiuria) is more prominent than dysuria, sometimes only symptom

Frequent urination/dysuria 2 l Dysuria: beginning, end or continuous l More frequent in females l Upper urinary tract infection: costovertebral angle tenderness, fever, flank pain l Vaginitis: External pain, vaginitis, itching, discomfort

Frequent urination/dysuria 3 l Bladder’s chemical and physical injury l Ostrogen deficiency in postmenopausal women: atrophic vaginitis and dysuria l Psychogenic polydipsia: frequently pollakiuria, dysuria and fullness sensation after emptying of bladder

Hematuria 1 l Microscopic or macroscopic l Microscopic hematuria: more than 3 -4 erythrocytes per high power field l Erythrocytes can orginate from kidney or urinary system. l They may also come from systemic diseases or coagulative diseases. l Urinary casts, proteinuria and dysmorphic erythrocytes suggest parenchymal kidney disease

Isomorphic non-glomerular erithrocytes

Dismorphic glomerular erithrocytes

Hematuria 2 l Erithrocytes normal size and shape: Renal pelvis, ureter, bladder or prostate l Painless: Tumour, polycystic kidney disease, exercise, tbc. . . l Pain: Nephrolithiasis, renal infarct, urinary tract infection l Pyuria and bacteriuria: Urinary tract infection

Hematuria 3 l Macroscopic hematuria differential diagnosis: l l l myoglobinuria and hemoglobinuria Erythrocytes in urine microscopy: Hematuria Centrifuged urine: Supernatant is red in myoglobinuria ve hemoglobinuria Serum colour is helpful in the differential dignosis of myoglobinuria ve hemoglobinuria Hemoglobinuria: Red Myoglobinuria: Clear

Edema 1 l Increase of interstitial fluid l It is always with sodium retention l Decrease in oncotic pressure, increased renal sodium retention or fluid overload are the mechanisms

Edema 2 l In hypoalbuminemic states (malabsorption, nephrotic syndrome, chronic liver disease), plasma oncotic pressure decreases and intravascular fluid passes through interstitial space l Increased sodium retention also occurs in hypoalbuminemic states l In congestive heart failure, renal sodium retention increases due to renal hypoperfusion and contributes to edema formation l Hypothyroidism, lymphatic obstruction and blockage of venous circulation can also lead to edema

Edema 3 l Pitting or soft edema is helpful in the differential diagnosis of edema l Nephrotic syndrome: pitting or soft edema l Hypervolemic edema: pitting or soft edema may be absent, if present it is not as soft as hypoalbuminemic states

Edema 4 l Dyspnea, history of cardiac disease, enlarged heart, heart murmur, prominent neck veins: Cardiac disease l Icterus, spider angioma, hepatomegaly, ascite and abnormal liver function tests: Cirrhosis l Massive proteinuria, hypoalbuminemia, pallor and hyperlipidemia: Nephrotic syndrome

Edema 5 l Protein losing enteropathy or venous obstruction can be diagnosed easily with clinical and laboratory findings l Idiopathic edema diagnosis depends on exclusion of other edematous disease.

Hypertension l Kidney parenchymal diseases or renal artery stenosis are one of the most common causes of secondary hypertension. l In general, hypertension is more common in glomerular diseases than tubular diseases.

Urine colour changes 1 l Normal colour is straw yellow due to urochrome. l It changes light to dark depending on fluid intake l Many diseases, medicines change its colour

Urine colour changes 2 l Red: Hematuria, hemoglobinuria and myoglobinuria l Red-violet: Porphyrinuria l Dark yellow-brown: Bile and rectovesical fistula l Green: Pseudomonas infection l Blue black: Melanin pigment and alkaptonuria l Milky white: Pyuria, phosphate crystallluria and chyluri l Blurred: Infection, oxalate and urate crystals

Urine colour changes 3 l Medicines: Rifampisin, metilen blue, indomethacin, methyldopa, metronidazol… l Food: Beetroot, carotene, rhubarb… How to Color Your Urine Safely https: //www. thoughtco. com/how-to-color-urine-606179

Oliguria-Anuria 1 l Oliguria: Daily urine volume less than 400 -500 ml l Anuria: Daily urine volume less than 50 -100 ml l Oliguria: Hourly urine volume less than 20 ml Other definitions l Severe oliguria: Daily urine volume less than 50 -100 ml l Anuria: Zero urine

Oliguria-Anuria 2 l Diseases causing acute kidney injury l If daily urine volume fluctuates partial urinary obstruction l In chronic kidney disease, oliguria and anuria can be seen when DAILY GFR less than 1 liter

Uremic signs l We can assume uremia can affect all organs or systems, therefore, uremia can cause very different symptoms. l Encephalopathy, concentration difficulty, percarditis, anemia, pleural effusion, bone disease, nausea, vomiting, loss of appetite, weight loss… l It can resemble many diseases.

Abdominal mass 1 l Enlarged kidneys can be palpated. l Kidney mass can be seen every age, but is common before than 10 th age or after than 40 th age l Patients may feel a mass due to hydronephrosis, polycystic kidney disease or kidney tumour. www. tekinakpolat. com

Abdominal mass 2 l Normal kidneys can be palpated in lean patients sometimes. l Hydronephrotic and polycystic kidneys move with breathing. l Malign tumours do not move because they are bound to surrounding tissue. www. tekinakpolat. com

Other signs and symptoms 1 l Kidney stone, bladder, prostate, urethra pain, urinary incontinence, urinary retention, loss of ability to throw far, drop by drop

Other signs and symptoms 2 l These sign and symptoms are mostly related to mechanical problems and interest of urology l Nephrologic problem may complicate an urologic disease www. tekinakpolat. com

Plan l General information l Signs and symptoms l History taking l Nephrologic diseases l Summary www. tekinakpolat. com

General information l All information taken from patient about his/her disease l It must include all complaints chronologically l Records must be correct

Why do we need history? l It helps physical examination l Give information about lab tests needed l First impression about diagnosis

Patient doctor relationships l It must be confidential l Patient must trust her/his physician l Patient is a human l Patient is anxious

Basic principles of History taking 1 l Listening l Observation l First main complaint l Experience-theoretical informatiom l Sufficient time

Basic principles of History taking 2 l Initiating time of complaint l Factors affection duration of complaint l Accompanying factors l Response to treatment l Its nature

Questions must be asked 1 l Dysuria l Nocturia l Hematuria l Urine amount l Urinary incontinence, drop by drop l Frequent urination www. tekinakpolat. com

Questions must be asked 2 l Kidney stone l Flank pain, colic l Weak flow, seperation, loss of ability to throw far l Urine color change www. tekinakpolat. com

Questions must be asked (woman) l Menses l Vaginal discharge l Pregnancy history l Sore www. tekinakpolat. com

Questions must be asked (man) l Sore, discharge l Testis swelling l Impotence www. tekinakpolat. com

Taking history It is the art of to know what to ask to a patient www. tekinakpolat. com

Plan l General information l Signs and symptoms l History taking l Nephrologic diseases l Summary www. tekinakpolat. com

Nephrologic diseases 1 l Chronic kidney disease l Acute kidney failure/injury l Nephrotic syndrome l Nephritis l Tubular diseases l Hypertension

Nephrologic diseases 2 l Hemodialysis l Peritoneal dialysis l Renal transplantation l Congenital diseases l Asymptomatic proteinuria/hematuria

Nephrologic diseases 3 l Fluid electrolyte disturbances l Kidney involvement in systemic diseases l Hereditary kidney diseases l Toxic nephropathy l Amyloidosis

Nephrologic diseases 4 l Vascular diseases l Obstruction l Infection l Stone l Tumour

Plan l General information l Signs and symptoms l History taking l Nephrologic diseases l Summary www. tekinakpolat. com

Summary l Signs and symptoms show great variation in kidney diseases l Taking history is important l Many systemic diseases may affect kidney or they can be with kidney disease l Therefore, symptoms and signs not related to kidney may be helpful in the differential diagnosis www. tekinakpolat. com

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