Assessment of the Renal/Urinary System

Professor Minodora Mazur

Chisinau 2019

Why person has 2 eyes or 2 ears? And only one nose?

 How many kidneys does the person have?

Urinary system

• Kidneys
• Ureters
• Urinary bladder
• Urethra
 Kidneys
• Paired organs
• Located retroperitoneally
on the posterior wall of the
abdomen from T12-L3
• The average adult kidney
weighs 4.5oz = 125-150 gr
• The right kidney sits is
lower in the abdomen due
to liver placement
• An adrenal gland sits are
on top of each kidney
 Kidney Anatomy
Each kidney has two parts
• The renal medulla is the inner
portion
– consists of renal pyramids which
are collecting ducts that drain
into renal pelvis
– Once urine leaves the renal pelvis
the composition or amount of
urine does not change
• The Cortex is the outer portion
– contains nephrons
 Nephron
• Each kidney has approximately 1 million
nephrons
• If the function is less than 20% replacement
therapy is usually initiated
• The nephron is responsible for the initial
formation of urine

Glomerulus
 Kidney functions
• Urine formation
• Excretion of waste products
• Regulation of electrolytes
• Regulation of acid-base balance
• Control of water balance
• Control BP
• Regulation of RBC production
• Synthesis of vitamin D to active form
• Secretion of prostaglandins
• Regulation of calcium and phosphorus balance
 Urine Formation
• Urine is formed in the nephrons in a three step process
– Glomerular filtration
– Tubular reabsorption
– Tubular secretion
• Glomerular Filtration produces ultrafiltrate which enters the
tubules
• Selective reabsorption of H2O & solutes occurs in tubules
• Selective secretion of solutes occurs in
tubules
• 99% of ultrafiltrate is reabsorbed into the
bloodstream
• 1000-1500mL of urine is produced each day
 Excretion of Waste Products

• The kidney is the body’s main excretory organ

• The major waste product of protein metabolism is
urea
– 25-30 g are produced and excreted daily
• Other waste products include:
– Creatinine
– Phosphates
– Sulfates
– Uric acid
– Drug metabolites
 Regulation of Electrolytes
• In normally functioning kidneys the amount of electrolytes
excreted per day is equal to the amount ingested
• Sodium
– Linked to blood volume and pressure
– Significant effects on osmotic pressure
– 90% of Na in ultrafiltrate is reabsorbed in the proximal
tubules and loops of Henle
– Aldosterone causes kidneys to reabsorb sodium
• Potassium
– The kidneys excrete more than 90% of K intake to
maintain a normal serum balance
– Aldosterone causes the kidneys to excrete potassium
 Regulation of acid-base balance
• Normal serum pH is 7.35-7.45
• Normal urine pH is 4.6-8
• Kidneys 3rd line of defense in acid-base balance
– respiratory & other buffer systems respond more rapidly
– kidneys require several hours to a day or more to readjust
balance
• Reabsorb bicarbonate from ultrafiltrate
• Excrete large quantities of acid in the urine (phosphoric
and sulfuric acids) by buffering with ammonia
 Control of water balance
• The human body is made up of 60% water
• Regulated by Antidiuretic hormone (ADH) or
vasopressin
• Secreted by the posterior pituitary in response to
serum osmolality
• ADH increases reabsorption of water to return
serum osmolality to normal
• Decreased water intake stimulates ADH release
• ADH controls volume & concentration of urine by
regulating permeability of distal tubule to H2O
 Control blood pressure

• The kidney secrets the hormone renin when there is a

decrease in BP
• Renin converts angiotensinogen to angiotensin I
• Angiotensin I converts to angiotensin II
• Angiotensin II is a powerful vasoconstrictor and causes
BP to increase
• Increase in BP stops the excretion of renin
• The adrenal cortex also releases aldosterone in response
to increasing serum osmolality or poor perfusion to
increase BP
 Regulation of Red Blood Cells production

• The kidneys release erythropoietin when

they sense a decrease in oxygen in the blood
• Erythropoietin stimulates the bone marrow
to produce (Red Blood Cells) RBCs
 Vitamin D Synthesis

• The kidneys convert inactive vitamin D to

1,25-dihydroxycholecalciferol
• Vitamin D is necessary for calcium balance
 Urination
• approximately 150-350 mL of urine triggers stretch
receptors & stimulates afferent nerves sending signal to
CNS
• Functional Capacity of bladder is 350mL
• The efferent pelvic nerve stimulates the bladder to
contract, relaxing the urethral sphincter. The decrease in
urethral pressure and contractions of the detrusor
muscle opens the proximal urethra and leads to flow of
urine
• reflex action however external sphincter can be
contracted with voluntary control
Ghilon was asked what is more difficult:

Keep a secret?
Make good use of your free time?
Can you endure an injustice?

And for you what is more difficult?

Ilan Ghilon (b. May 12, 1956, Galați, Romania) is an Israeli
socialist politician originally from Romania, who is currently
serving as a deputy in the Knesset (Parliament) of the
State of Israel
 Tulburări ale diurezei

Urinary volume normally varies in physiological

conditions between 800-2000 ml / 24 hours, during
intake and fluid losses.
Urinary Quantitative Changes:
• Polyuria - 2000 ml
• Oliguria - Reduction of urinary volume <500 ml/24h
• Anuria - Decreased diuresis <100 ml
• Nicturia - Equalization or inversion of the ratio
between nocturnal and diurnal diuresis
 Terminology
• Micturation—Urination
• Frequency—Frequent voiding >every 3hours
• Urgency—Strong desire to void
• Hesitancy—Delay or difficulty in initiating voiding
• Nocturia—Excessive urination at night
• Oliguria—Output <400mL/day
• Anuria—Output <50mL/day
• Polyuria—Increased volume of urine voided
• Hematuria—RBCs in urine
• Dysuria—Painful or difficult voiding
• Enuresis—Involuntary voiding during sleep
• Incontinence—Involuntary loss of urine
 Renal/Urinary System Changes with Aging

• Reduced renal blood flow causing kidney loss of

cortical tissue by 80 years of age
• Thickened glomerular and tubular basement
membranes, reducing filtrating ability
• Decreased tubule length
• Nocturnal polyuria and risk for dehydration
• Decreased glomerular filtration rate
 Diagnostic Tests

• Blood Tests
– Serum Creatinine (0.5 – 1.2 mg/dl)
– Blood Urea Nitrogen (10-20 mg/dl)
– BUN/Creatinine Ratio (12:1 to 20:1 mass)
• Urine Tests
– Urinalysis
– Urine for C&S
– Composite (e.g., 24hr) urine collections
– Creatinine Clearance Test
– Urine Electrolytes
– Osmolality (plasma; urine)
 Diagnostic Tests (cont)
• Bedside sonography; Bladder scanners
• Radiographic Examinations
– Kidneys, Ureter, and Bladder X-ray
– Intravenous Urography
– Computed Tomography
– Cystography and Cystourethrography
• Other Renal Diagnostic Tests
– Renal Arteriography (Angiography)
– Renal Biopsy
– Renography (Kidney Scan)
– Ultrasonography
 Assessment

• Family history and genetic risk assessment

• Demographic data and personal history
• Diet history
• Socioeconomic status
• Current health problems
 Physical Assessment

• Inspection
• Auscultation
• Palpation
• Percussion
• Assessment of the urethra
 Local objective examination

Inspection of the abdomen

increase in volume (diffuse bombardment) -
meteorism from R-U colic
lower abdomen inspection - pumping of the
hypogastric region into the bladder
inspection of external genital organs
- women - cistorectocel (RVP with parent-urinary
prolapse)
- men - inflammation of the urinary meatus
(erythema, swelling) in acute anterior urethritis
 Palpation

Palpation of the kidney

Normally the kidney is not accessible to palpation, except:
pregnant women,
of asthenic constitution at which one can feel the lower
pole of the kidney in deep inspiration.
The kidneys become accessible to palpation in case of:
renal ptosis,
increase in volume due to different causes
(Hydronephrosis.
 Techniques of palpation
Palpation in the dorsal decubitus (Guyon)
The patient seated in the dorsal decubitus, with the thighs
flexed on the pelvis in slight abduction, with the relaxed
abdominal muscles.
The examiner is placed on the examined kidney side (right, left). Apply
the hand on the same side as the kidney examined in the lumbar
region with the fingers towards the costovertebral angle, and the
other hand is applied to the level of the right hypochondrium with the
fingers pointing towards the costal rim and outside the right
abdomen (hands are applied "cross")
By pushing down the hand on the abdominal wall, the
"kidney ball" is performed, the hand placed
posteriorly feeling the lumbar contact of the kidney,
the kidney is palpated thus by approaching the two
hands (anterior and posterior)
 Methods of palpation

Regardless of the method used, the diagnostic

criteria for palpation of the kidney are:
posterior position, deep
lumbar contact
mobile with inspiration
The kidney has:
an elastic-remittent, smooth consistency,
sliding under the hands like "cherry kernels";
"bean bean" form when not distorted by a
pathological process
 Palpation of painful points
– Previous painful points
– Upper pain point (BAZY basin, Pasteau upper ureteral)
– It is located at the intersection of the horizontal line passing through the
navel, with the vertical line passing through the McBurney point and
corresponds to the tip of the XII coast.
– It is painful to affect the kidney basin. The pain at this point is associated
with the urge to urinate due to a skin-reflex reflex
 Palpation of the bladder

The bladder balloon resulting from acute or chronic

retention of urine is palpated in the form of a
formation:
hypogastric, located in the middle, of hemispherical,
suprapubian form, shallow clearly delimited, elastic,
sensible.
Palpation of the bladder gives patients a feeling of
imperious urination.
Old forms of bladder or neurogenic bladder do not show
palpatory sensitivity
Differential diagnosis in women (pregnant uterus,
uterine tumors)
- Bladder tumor formation can sometimes palpate in
advanced stages (hard, irregular formation)
 The objective exam

Endorectal palpation for prostate exploration

and urethral palpation - performed by urologist
 Percution
lumbar - Giordano maneuver =
Costovertebral angle tenderness (CVAT)
(Murphy's punch sign, Pasternacki's sign,
or Goldflam's sign (Latin: succusio renalis)
is a medical test in which pain is elicited
by percussion of the area of
costovertebral angle, an angle made by
the vertebral column and the costal
margin). The test is positive in people with
an infection around the kidney
(perinephric abscess), pyelonephritis,
hemorrhagic fever with renal syndrome or
renal stone. Because the kidney is directly
anterior to this area, known as the
costovertebral angle, tapping disturbs the
inflamed tissue, causing pain.of the
bladder - hypogastric, round-oval shape
with inferior concavity
 Auscultation
• abnormalities of the renal artery (stenoses,
aneurysms)
• It can be heard obliquely in the lumbar region
or previously paraombilical, subcostal a breath
• with trill character
• synchronous with the
pulse
 Urinalysis

• Color, odor, and turbidity

• Specific gravity
• pH
• Glucose
• Ketone bodies
• Protein
• Leukoesterase
• Cells, casts, crystals, and bacteria
 Other Urine Tests

• Urine for culture and sensitivity

• Composite urine collections
• Creatinine clearance—best indication of
overall kidney function
• Urine electrolytes
• Osmolarity, blood/plasma osmolarity, urine
osmolarity
 Macroscopic examination
Appreciation of urinary volume / 24h - diuresis variation
between 800-2000 ml; ¼ diuresis - nocturnal, yellowish
color
transparency - clear, odor - characteristic
-ammoniacal (urinary tract infections),
-acre apples (diabetes with ketonuria),
-pour (urinary tract infections with anaerobic flora)
Microscopic examination

Highlight 3 categories of elements:

-celule,
-cilindrii
-cristale
-simple sediment
leucocite
-minute sediment (Addis – Hamburger)
RBC
Hematii dismorfe-leziune glomerulară
Celulele sternheimer-malbin
Blood casts in the tubes histological appearance
Erytrocytes casts
Leukocyte cylinders
Epithelial cylinders - tubular injury
Cilindrii hialini
Granular cylinders
WAXI CAST
Hyaline casts in a patient with hyperbilirubinuria
Greasy casts
Fatty cylinders look like a Maltese cross in polarized light
 Cristals

Precipitated urine salts in the form of crystals

they also occur in the urinary tract of normal people
means a pathological condition only if they are in large quantities
Depending on the type of diet, urinary pH, genetic predisposition, the
following types are found (more frequently):
Urates (crystals, amorphous urates) - after uricozurics: Probenecid,
sausage foods, urinary pH <
Oxalates (oxaluria)
Ammonia-Mg phosphates (alkaline, infected urine)
Cholesterol (SN)
the presence of germs - smears stained with methylene blue, Gram,
special collor (Ziehl – Nielsen)
Oxalate-looking envelopes
Rectangular-looking phosphates or coffins
 Others Diagnostic Tests

• Bedside sonography/bladder scanners

• Computed tomography
• Kidney, ureter, and bladder x-rays
• Intravenous urography
– Bowel preparation
– Allergy information
– Fluids
 Renal Arteriography (Angiography)
• Possible bowel preparation
• Light meal evening before, then
nothing by mouth
• Injection of radiopaque dye
into renal arteries
• Assessment for bleeding
• Monitoring of vital signs
• Absolute bedrest for 4 to 6
hours
• Serum creatinine measured for
several days to assess effects of
test
 Para-clinical investigation

USG organelor interne (rinichi)

 CT kidney

GN
MRI kidney
Renal biopsy
Renal artery angiography
Adult kidney
Horseshoe kidneys
Hydronephrosis
Rinichi atrofic unilateral ischemic
Polycystic kidneys
 Renal Biopsy

• Percutaneous kidney biopsy

• Clotting studies
• Preprocedure care
• Follow-up care
– Assessment for bleeding for 24 hours
– Strict bedrest
– Monitoring for hematuria
– Comfort measures
 Renography

• Small amount of radioactive material, a

radionuclide, used
• Procedure via intravenous infection
• Follow-up care:
– Small amount of radioactive material may be excreted.
– Maintain standard precautions.
– Client should avoid changing posture rapidly and avoid
falling.
 Other Diagnostic Tests

• Ultrasonography
• Cystoscopy and cystourethroscopy
– Procedure is invasive.
– Consent is required.
– Postprocedure care includes monitoring for
airway patency, vital signs, and urine output.
– Monitor for bleeding and infection.
– Encourage client to take oral fluids.
 Retrograde Procedures

• Retrograde procedures go against the normal flow

of urine.
• Procedure identifies obstruction or structural
abnormalities with the instillation of dye into lower
urinary tract.
• Monitor for infection.
• Follow-up care is the same as for a cystoscopic
examination.
 Urodynamic Studies

• Studies that examine the process of voiding

include:
– Cystometrography
– Urethral pressure profile
– Electromyography
– Urine stream test
Thanks