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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, 2microglobulin) with  resorption in proximal tubule
• pyuria and hematuria could mimic proteinuria
Proteinuria
• Healthy adult subject : 150 mg/24h
plasma proteins
proteins from urinary tract
• Intensity
1g/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 mOsm/1kg); risk of dehydration)
• Late diuretic phase of ARF
epithelial regeneration; risk of dehydration and hypokalemie
Nephrotic syndrome
• High proteinuria ( 3.5 g/1.73 m2/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