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

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

3. Glomerular disorders proteinuria hematuria

5. 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

7. 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)

8. 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

9. Tubular disorders oliguria polyuria glycosuria cystinuria edema

11. 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

12. 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

13. 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

14. 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

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

16. 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

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

18. Urinary tract disorders renal colic disuria incontinence

19. 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

20. Acute nephritic syndrome face edema macroscopic hematuria oliguria hypertension