DR.

AHMAD

YASENE
Functions :
Regulation of water & electrolyte balance.
Regulation of acid base balance.
Excretion of water soluble waste : urea , uric acid , creatinine , drugs ……
Endocrine : Renin – angiotensin system , erythropoietin , vitamin D
activation.
Definitions

Red blood cell- Glomerulonephritis, bleeding, Vasculitis

White blood cells- pyelonephritis
(Costto vertebral tenderness and bacteria)

Eosinophils-
- Allergic interstitial nephritis WBC and Haematuria
- Cholesterol emboli
Muddy-brown- Acute tubular necrosis=>hypotension,
high sodium, high BP. Muddy-brown
 Hyaline Casts
PreRenal PostRenal
Oliguria = less than 400 ml urine/24 hours » Acute kidney
injury .

Anuria = no urine output at all » Severe acute kidney injury »

End stage renal disease.

Polyuria = more than 3 liter urine/24 hours » Diabetes

insipidus » Hypercalcemia .
 Anuria

Nephrotic Vs. Nephritic??

*Nephrotic syndrome: proteinuria,loss of protein causes (edema).

*Nephritic syndrome:- hematuria,loss of blood causes(Anemia).

..
 Proteinuria

TX.
ACEIs and ARBs - nephroprotective
SIDE Effect?
Loss of protein:-in causes edema,hypertension and
hypercoagulability (Renal vein thrombosis).
..
RHABDOMYOLYSIS

Dipstick show blood no RBC seen on microscope:-myoglobin

Rhabdomyolysis will cause k to be high
What drug can cause rhabdomyolysis =>statin
2021
..
 Haematuria

Microscopic vs macroscopic haematuria

Hematuria

Initial hematuria = Urethral

Terminal hematuria = Prostate,

bladder, kidney,ureter
 Hematuria with signs of obstruction ?

Prostate cancer(androgens)

Hematuria with colicky abdominal pain ????

Urolithiasis

Hematuria with smoking history, panting ??

bladder cancer

Hematuria after chemotherapy ????

čyclophosphamide (hemerrhagic cystitis)

Renal failure
Acute renal failure – ARF is a clinical syndrome characterized by a rapid
( days to week ) deterioration of renal function with or
without oliguria. It is usually reversible with treatment of
the cause.

Renal failure= failure to excrete certain

substances/toxins
Pre-renal: Decreased renal perfusion (hypovolemia, hypotension , renal artery stenosis , NSAiDs)

Hypovolemia : Haemorrhage, dehydration, burns, cardiogenic shock.

Hepato-renal syndrome.
Renal: kidney damage (ischemia, myoglobin, contrast, amino glycosides , infections.)

Postrenal:
urinary outflow obstruction (prostate, urolithiasis)
Bilateral uretericobstruction.
Unilateral ureteric obstruction with contralateral non-functioning kidney.
Obstruction of the bladder or urethra

Etiology
( 3 Pre-renal, 3 Renal, 3 Post-renal ) 3x3
 Pre-renal : renal perfusion
1- Hypovolemia:Hemorrhage,dehydration,burns,cardiogenicshock( COP).
2- Renal arterystenosis.
3- Hepato-renal syndrome.

Renal ( Intrinsic )

Acute tubular necrosis

(ATN):The most common cause.
Acute interstitial nephritis (AIN )
Acute papillary necrosis : DM, Sickle cell anemia.

Post-renal
urinary outflow obstructione.g.
Bilateral uretericobstruction.
Unilateral ureteric obstruction with contralateral nonfunctioning kidney
 Kidney failure/injury
BUN:CREA Sodium:- we usually absorb sodium to regulate
20:1 pre-renal or BP Kidney injury(renal)= no sodium absorption=
postrenal increased sodium in the urine= increased urine
osmolality.
20:1= renal
..
 TX

Acute Kidney Injury Management

Perform Renal Ultrasound → to rule out post renal
cause [10%] –
If post renal → insert a urinary catheter
If dehydrated → Give IV fluids
If volume overload → Give IV diuretics
If ESRD → Consider hemodialysis
 In ARF : remember these 3 "No"

• No Bonemanifestations.
• No endocrinalmanifestations.
• No or mildanemia.
...
Kidney
Laboratory pf renal failure:-
Hyperphosphatemia
Hyperkalaemia(ECG-T wave tall)
Hyperuricemia
Tx:
Allopurinol
Normal saline

2022

A 63-year-old male with end stage renal disease is treated with dialysis 3 times a week. He now
complains of bone pain and several pathological limb fractures. Which of the following is the
most common electrolyte abnormality in this patient?

1 Hypokalemia

2 Hypernatremia

3 Hyperphosphatemia

4 Hypercalcemia
chronic kidney disease
 2021

……
 2021

..
202

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1
 Hepato-Renal syndrome
Cirrhosis causing renal failure by constriction of renal arteriole (and vasodilation of •
(splanchnic circulation

Classified as pre-renal renal failure so, urine sodium will be low •

Tx. Octreoide,midodrine •

TIPS, liver transplantation. (Transjugular intrahepatic portosystemic shunt) •

Cholesterol Embolism

After thrombectomy/cardiac catherization

renal failure Livedo reticularis digital ischemia/necrosis Eosinophilia and
eosinophiluria Low C3 complement levels

Good pasture disease

ANCA against GBM of kidney and alveoli Dx.
Antiglomerular basement membrane anvibodies
Tx. Plasmapheresis and steroids.
 Alport syndrome (hereditary Rephritis)
Will progress to ESRD

Collagen 4 defect
 2022

A 15-year-old boy presents with a few months of deteriorating hearing. Hearing tests
reveal bilateral sensoneuronal deficit. The boy reports recurrent episodes of hematuria,
and a maternal uncle with similar symptoms. Which of the following is the most likely
diagnosis?

1 Goodpasture disease

2 Penderd syndrome

3 Berger’s disease

4 Alport syndrome
IGA nephropathy (Berger)
The most common tvpe of glomerulonephritis
Most common cause of episodic gross hematuria after 1-2
days URI 50% resolve, 50% progress
..
Post streptococcal glomerulonephritis
Gross.hematuria1-2 weeks after
URi decreased C3 levels
Antistreptolysin titers O (ASO)
95% will resolve without compieations
(penicillin )
..
Focal Segmental Glomerulosclerosis

Tx - steroids and cytotoxic agents

Polycystic Kidney Disease

Simple Cyst = Smooth thin shape, no echogenicity

Complex Cyst = irregular thick shape, mixed echogenicity
Hematuria, Palpable mass, flank pain, hypertension
Will progress to renal failure
Dx. US- showing renal cysts
Extra-renal manifestations of PCKD
1. Liver cyst
2. Berry aneurysm
we can see enlarged in the kidney disease in :
DM
Polycystic kidney disease
HIV
Amyloidosis

Renal Cell Carcinoma

Can secrete erythropoietin causing polycythemia
Clinical presentation :Flank pain, hematuria?

RCC compresses gonadal vein > scrotal varicoceles that fail to empty when lying
down
Nephrolithiasis

Clinical presentation: (Sudden colicky pain, hematurial,patient constantly moves to

reduce the pain
Best test for nephrolithiasts: CT

Stones <5 mm pass spontaneously

stones 5-7 mm . nifedipine
stones>7mm: lithiotripsy/surgery(2cm)

Calcium oxalate (70-80%); mast common type of stones, envelope shane

.thiazides?, furosemide?
Struvite/infection (5-10% )(Mg-NH4-PO4}: caused by urease production, proteus.
klebsielia
Uric acid (5 % ) : gout, tumor lysis syndrome , cant he seen on xray.
 End Stage Renal Disease (ESRD)

Very severe chronic renal failure that requires (dialysis)

It is not defined based on CREA,BUN

 ESRD is a complication of hypertension, and diabetes mellitus

anemia because erythropoietinIt causes

Low ESRD affects calcium because low Ca leading to vitamin D

ESRD causes_on ECG ? hyperphosphatemia is treated by Sevelamer

(prevents absorption) and calcium supplement

Dyalisis

Complications of Hemodialysis ??

The most common side effect of dialysis s hypotension

 Complications of Peritoneal dialysis ??

The most common complication of peritoneal dialysis

is peritonitis Hyperglycemia

Indications for acute dialysis

Severe (Resistant) hyperkalemia
Severe (Resistant )metabolic acidosis
Pulmonary edema Uremic pericarditis
Uremic encephalopathy
Fluid overload resistant to diuretics
GFR -15
2021
..
SOME CASES
Heroin and AIDS cause FSGN (Focal segmental Glomeruiosclerosis)
Mutiple Myeloma, HCV will cause Membranoproliferative glomerulonephritis
Diabetes will cause Nodular glomerulosclerosis (Kimmelstiel-Wilson noduies)
 Hypertension
With DM : ACEls (side effect?)
with osteoporosis ?
With BPH?
With CAD?

Hypertensive crisis: headache, blurry vision, 200/100 - intravenous drugs •

Renal Artery Stenosis

Fibromuscular Dysplasia

Polycystic kidney disease

 Sodium Disturbances
Na = important for nerve functions confusion) seizures, lethargy, coma •

Hyperatremia : hemoconcentration , high aldosterone, diabetes insipidus •

Tx. Treat the cause. •
Should you use hypertonic saline?

Complication of lowering Na too rapidly : cerebral edema

Hyponatremia : hypervolemia (edema, cirrhosis, CHF), SIADH, adrenal failure, •
polydipsia psychogenica
Tx. Treat the cause.
Should you use hypotonic saline
 Diabetes insipidus vs
SIADH
ADH is released from the posterior pituitary DI= no ADH, SIADH -much
ADH.
ADH aka vasopressin works through aquaporin channels in the renal
tubules.
Central (neurogenic - no secretion): Sheehan, trauma, infarction,
infiltrations.
Peripheral (nephrogenic -no action) : Lithlum, hypercalcemia,
hypokalemia
 Diabetes Insipidus
Signs of DI: Polyuria, polydipsia, "pees a lot des pite not
drinking"
DI vs psychogenic polydipsia/primary polydipsia : water
deprivation test Changes in osmolarities after desmopressin?
Central vs peripheral DI: Desmopressin test (ADH) : central=
yes effect, nephrogenic=no effect
Osmolarity: very concentrated serum (high), very dilute urine
(low)-changes after desmopressin?
Tx.
Central: Desmopressin (nasally).
 Nephrogenic DI : thiazides (to reduce intravascular
volume)
Short QT hypercalcemia