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

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

3. 3 Classification of Renal Disease Usually by specific structural component affected by disease 1.Glomerular Disease 2.Tubular Disease 3.Interstitial Tissue Disease 4.Vascular Disease

4. 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. 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. 6 Glomerular Injury Clinical features dependent upon –Number of glomeruli involved –Mechanism of injury –Rapidity of disease onset

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

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

9. 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. 10 Acute Glomerulonephritis Urinalysis –Physical Color? Clear? –Chemical –Microscopic

11. 11 Acute Glomerulonephritis Urinalysis –Physicalyellow, hazy –Chemical? –Microscopic

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

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

14. 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. 15 Acute Glomerulonephritis Majority (>95%) of children recover Approx 60% of adults recover Only 1-2 % post-strep acute glomerulonephritis develop chronic glomerulonephritis

16. 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. 17 Chronic Glomerulonephritis Urinalysis –PhysicalColor? Clear? –Chemical –Microscopic

18. 18 Chronic Glomerulonephritis Urinalysis –Physicalyellow, hazy –Chemical? –Microscopic

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

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

21. 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. 22 Nephrotic Syndrome Selective filtering capability of glomerulus is lost Many conditions may lead to NS Clinical findings: ‘pitting edema’, azotemia, hypertension, oliguria

23. 23 Nephrotic Syndrome Urinalysis –PhysicalColor? Clear? –Chemical –Microscopic

24. 24 Nephrotic Syndrome Urinalysis –Physicalyellow, hazy (cloudy ?) –Chemical? –Microscopic

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

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

27. 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. 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. 29 Diabetes Mellitus (Nephropathy) Clinical findings: –Polyuria –Polydipsia –Nocturia

30. 30 Diabetes Mellitus (Nephropathy) Urinalysis –PhysicalColor? Clear? –Chemical –Microscopic

31. 31 Diabetes Mellitus (Nephropathy) Urinalysis –PhysicalYellow, hazy –Chemical? –Microscopic

32. 32 Diabetes Mellitus (Nephropathy) Urinalysis –PhysicalYellow, hazy –Chemical + Glucose Proteinuria (mild-moderate) –Microscopic ?

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

34. 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. 35 Tubular Disease Altered tubular function Necrosis of tubular epithelium

36. 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. 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. 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. 39 Necrosis of Tubular Epithelium Destruction of tubular epithelial cells –Toxin –Ischemic event Most common cause of renal failure

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

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

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

43. 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. 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. 45 Lower UTI ~85% of lower UTI caused by gram-negative rods (fecal E.coli) Urinalysis –PhysicalColor? Clear? –Chemical –Microscopic

46. 46 Lower UTI Urinalysis –Physicalyellow, hazy (cloudy, turbid) –Chemical? –Microscopic

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

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

49. 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. 50 Acute Pyelonephritis Urinalysis –PhysicalColor? Clear? –Chemical –Microscopic

51. 51 Acute Pyelonephritis Urinalysis –PhysicalYellow, hazy (cloudy, turbid) –Chemical? –Microscopic

52. 52 Acute Pyelonephritis Urinalysis –PhysicalYellow, hazy (cloudy, turbid) –Chemical+ protein (<1.0 gram/24 hr) + leukocyte esterase (WBC) + nitrite + blood specific gravity: normal to low –Microscopic?

53. 53 Acute Pyelonephritis –Microscopic WBC (may see clumping) Bacteria RBC RTE Casts: WBC, granular, RTE, waxy

54. 54 Yeast Infection Urinary tract of both men and women are susceptible to yeast infection Most often vaginal yeast infection contaminates urine Often caused by Candida species (candida albicans)

55. 55 Yeast Infection Candida species (candida albicans) –Normal flora of GI tract and vagina –Normal bacterial flora keep yeast proliferation under control –Catheters provide mode of inoculation

56. 56 Yeast Infection Urinalysis –PhysicalColor? Clear? –Chemical –Microscopic

57. 57 Yeast Infection Urinalysis –PhysicalYellow, hazy (cloudy) –Chemical? –Microscopic

58. 58 Yeast Infection Urinalysis –PhysicalYellow, hazy (cloudy) –Chemical+ WBC ? + blood ? –Microscopic Yeast Mycelial elements RBC? WBC? Casts? Why or why not?

59. 59 Vascular Disease Any disorder that affects the blood flow to the kidneys can cause renal disease –Cardiac disease (25% of cardiac output) –Atherosclerosis –Hypertension –Diabetes –Eclampsia –Etc

60. 60