Inquiry and general inspection of patients with

diseases of urinary system.Palpation of kidneys.

Examinationodpatients with kidney diseases

Nino Kandelaki MD:

PhD

Normal sizes of kidneys in

men()and women().

Complaints.
Patients with diseases of the kidneys most
commonly complain ofpain in lumbar
region,
disordered
urination,
oedema,headache, and dizziness.
They may also complain of deranged vision,
pain in the heart, dyspnoea, absencei of
apjjetite,
nausea,
vomiting,
and
elevatedbody temperature.
But diseases of the kindeys may also
proceed withoutany symptoms of renal or
general clinical insufficiency.

pain

If the patient complains ofpain,its

location should first of all be determined.

Pain of renal origin often localizes in the

lumbar region.

If theureters are affected, the pain is felt

by their course.

If the bladder is involved, pain is

suprapubical. Radiation of pain into the
perineal region ischaracteristic of an
attack of nephrolithiasis.

The character of pain should then

be determined

It is necessary toremember that the renal tissue is

devoid of pain receptors.

The pain isfeltwhenthe capsule or the pelvis is

distended.

Dull and boring pain in the lumbar region occurs in

acute glomerulonephritis, abscess of the
perirenalcellular tissue, in heart decompensation
("congestive kidney") in chronicpyelonephritis
(usually unilateral) and
less frequently inchronic glomerulonephritis.

Pain arises due to distension of the renal capsule

because of the inflammatory or congestive swelling of
the renal tissue.

2. Sharp and suddenly developing pain on one side

of the loin can be due tothe renal infarction.
The pain persists for several hours or days and then
subsides gradually. The pain is rather severe in acute
pyelonephritis: inflammatory oedema of the
ureter interferes with the normal urine
outflowfrom the pelvis and thus causes its
distension.
The pain is usually permanent.
Some patients complain of attacks of severe
piercing pain in the lumbar region or by the course of
the ureter

3. Thepain increases periodicallyand then subsides,

i.e. has the character ofrenal colic.

Obstruction of the ureter by a calculus or its bending

(movable kidney) is the most common cause of this pain,
which is usually attended by spasmodic contraction ofthe
ureter, retention of the urine in the pelvis, and hence its
distension.

Thespasmodic contractions and distension of the

pelvis account for the pain.

Pain in renal colic is usually unilateral.

It radiates into the correspondinghypochondrium and

most frequently by the course of the ureter to the bladder,
and to the urethra.

This radiation of pain is explained by thepresence of

nerve fibres (carrying the impulses from
kidneys,
ureters,
se
organs
and
the
corresponding skin zones) in the immediate
vicinity of therelevant segments of the spinal
cord (DX-DXI1and L,-Lu).
This facilitatepropagation of the excitation ()
Patients with renal colic (like those with coicof other
aetiology) are restless; they toss in bed.
Patients with severe pain of other aetiology would
usually lie quiet in their beds (movements may
intensify the pain).

The conditions promoting pain should be

established.
For examplepain in nephrolithiasis can
be provoked by taking much liquid,
jolting nution, or the like; pain is provoked
by urination in cystitis. Difficultanpainful
urination is observed in stranguria.
Patients with urethritis feel burning pain in
the urethra during or after urination.

 It is necessary also to establish the agent that

lessens or removes the pain. For example,
atropine sulphate, hot water-bottle or warm
bath hein renal colic.
Since these remedies only help in spasmodic pain by
removing spasm of the smooth muscles, their
efficacy in renal colic confirmsthe leading role of the
ureter contraction in the pathogenesis of this pain.
Painof the renal colic-type in patients with
movable kidney may lessen withchanging posture:
urine outflow improves with displacement of
the kidney

 Pain slightly lessens in patients

with acute paranephritis if a bag
with iceplaced on the lumbar
region and if the patient is given
amidopyrine or other analgesics.
Many renal diseases are attended
byderanged
urination: changes in thedaily
volume of excreted urine and in
the circadian rhythm of urina

Secretion of urine during a certain

period of time is calleddiuresis
Diuresis can be positive (the amount of urine
excreted exceeds the volumeof liquid taken)
or negative (the reverse ratio). Negative
diuresis is observedin cases of liquid
retention in the body or its excess excretion
through the skin, by the lungs (e.g. in dry and
hot weather). Positive
diuresisoccursresolution of oedema, after
administration of diuretics, and in some
othercases. Deranged excretion of urine is
calleddysuria.

Increased amount of excreted urine

(over 2 1 a day) is calledpolyuria

It canbe of renal and extra-renal aetiology.

Polyuria is observed in personswho take much liquid,
during resolution of oedema (cardiac or renal), andafter
taking diuretics.
Long-standing polyuria with a high relative densityof urine is
characteristic of diabetes mellitus.
In this case polyuria arisesdue to a deranged
resorption of water in renal tubules because of
increasedosmotic pressure of the urine rich in glucose.
Polyuria occurs in diabet insipidus because of
insufficient supply of antidiuretic hormone secretinto blood by the
posterior pituitary- .
Polyuria also occurs in the absencesensitivity of the
tubules to the ADH, in affected interstice of the renal medulla of
various nature, in hypokaliaemia.

Decreased amount of excreted urine (less than 500 ml a day) is

callediguria.

It can be not connected directly with renal

affections (extrarenaliguria).
For example, it can be due to limited intake of
liquid, during staying in a hot and dry room, in
excessive sweating, intense vomiting, profuse
diarrhoea, and during decompensation in cardiac
patients.
But in certain cases oliguria is the result of diseases
of the kidneys and the urinaryacts (renal oliguria),
such as acute nephritis, acute dystrophy of
the kidneys in poisoning with corrosive
sublimate, etc.

A complete absence of urine secretion

and excretion is calledanuria.
Anuria persisting for several days threatens with
possible development of uraemia and fatal
outcome.
Anuria may be caused by the deranged
secretion of urine by the kidneys (secretory
anuria) which occurs in severe formof acute
nephritis, nephronecrosis (poisoning with
sublimate or other nephrotoxic substances),
transfusion of incompatible blood, and alsosome
generaldiseases and conditions such as severe
heart failure, shock, or profuse blood loss.

Pollakiuria(frequent micturition) is
observed in certain cases.

Ahealthy person urinates from 4 to 7 times a day.

The amount of excreted urine during one micturition
is from 200 to 300 ml (1000-2000 ml a day).

But frequency of micturition may vary within wider

range under certainconditions: it may decrease in
limited intake of liquid, after eating muchsalted food,
in excessive sweating, in fever, and the like, or the
frequencymay increase (polyuria);

if the person takes much liquid, in getting cold, and

the like circumstances.

Frequent desire to urinate with excretion

ofmeagre quantity of urine is the sign of cystitis.

This conditionis calledisuria.

A healthy person urinates4-7 times during the day time;
a desire to urinate during night sleep doesnot arise more
than once.
In the presence of pollakiuria the patient feels thedesire
to urinate during bothdayany night.
In the presence of chronicrenal insufficiency and if the
kidneys arc unable to control the amount
andconcentration of excreted urine in accordance with
the amount of liquid taken,
physical exertion, the ambient temperature, or other
factors important for the liquid balance in-the body, the
patient urinates at about equalintervals with evacuation
of about equal portions of urine.

 Under certain pathological conditions, the frequency of

urination isnormal during the day time but increases
during night.
The amount ofurine excreted during night often exceeds
the amount of daily urine(nycturia).Nocturnal enuresis
(nycturia) and oliguria during day time occur incardiac
decompensation and are explained by a better renal
function atnight, i.e at rest (cardiac nycturia).
Nycturia may concur with polyuria in renal dysfunction,
at the final stage of chronic glomerulonephritis, chronic
pyelitis, vascular nephrosclerosis, and other chronic renal
diseases (rerialnycturia).

 In the presence of isuria and nycturia of renal origin,

which arisedue to the loss by the kidneys of their
concentrating ability, the specificgravity of the urine
is monotonous.
The condition is known asisosthenuria.
The specific gravity of urine is usually
decreased(hyposthenuria).
The specific gravity of urine varies from 1.009 to
1.011,i.e. approaches the specific gravity of primary
urine (plasma ultrafiltrate)in patients with
pronounced nephrosclerosis, which is the final stage
ofmany chronic renal diseases.

PALPATION
The posterior location of the kidneys, and also the absence
of anterior approach to them due to the interference of the
costal arch, makes palpation of the kidneys difficult.

Relaxation of the pleum and pronounced cachexiacan be

attended by certain ptosis of the kidneys and make them '
accessible to palpation even in healthy subjects.

But the results of palpationcan only be reliable in

considerable enlargement of the kidneys (at least 1.5-2
times, e.g. due to formation of a cyst or a tumour), or their
displacement by a tumour, or in cases with a floating kidney.

Bilateral enlargementof the kidneys is observed in

polycystosis.

 Some diseases of the bladder and the urethra are

attended by difficultand painful urination. The patient
would complain of change in the colourof the urine,
its cloudiness, and traces of blood.
Oedemais observed in acute and chronic diffuse
glomerulonephritis, nephrotic syndrome,amyloidosis',
and acute renal excretory dysfunction(anuria).
It is important to ask the patient about the site that
was the firstto be attacked by oedema, the sequence
of oedemaspreading,and the rateof intensification
of this phenomenon (see "Renal Oedema").

 Headache, dizziness,andheart painmay

result from kidney affections.
These symptoms occur in those renal
diseases which are attended byconsiderable
increase in the arterial pressure, e.g. in
acute and chronicglomerulonephritis or
vascular nephrosclerosis.
A pronounced and persistent increase in the
arterial pressure can be among the causes
of derangedvision (neuroretinitis).

 Patients with diseases of the kidneys can complain of

weakness, indisposition, impaired memory and work
capacity and deranged sleep.
Vision may be deranged along with skin itching and
unpleasant breath.
Dyspeptic disorders sometimes join in: loss of appetite,
dryness andunpleasant taste in the mouth, nausea,
vomiting, and diarrhoea.
All thesephenomena are associated with retention in the
body decompositionproducts due to renal insufficiency
(see "Renal Insufficiency") whichdevelops at the final stage
of many chronic renal diseases, and sometimesin acute
diseases attended by retention of urine during several days.

Palpation of the right kidney of the

lying patient

Palpation of kidney in recumbent

and vertical position of a patient

Palpation of kidney in recumbent

and vertical position of a patient
http://intranet.tdmu.edu.ua/data/kafe
dra/video/prop/eng/index.php?
name_film=38

Fever is the common symptom of infectious inflammatory affections ofthe

kidneys, the urinary ducts and perirenal cellular tissue.

History of the present disease.When questioning the

patient, it isnecessary to establish the connection of the
present "disease with previousinfections (tonsillitis, scarlet
fever, otitis, acute respiratory diseases).
Thissequence is especially characteristic of
acuteglomerulonephritis.
But it issometimes difficult to establish the time of onset of
the disease becausesome chronic affections of the kidneys
and the urinary ducts can for a longtime be latent.
Moreover, when questioning the patient, it is necessary
to find out if he had deranged hearing or vision in
his childhood that might be -suggestive of
congenital renal pathology.

 Special attention should be given to the presence in the patient's

pasthistory of diseases of the kidneys-and the urinary duels.(acute
nephritis,pyelitis, cystitis) or symptoms that might suggest them
(dysuria,haematuria, oedema, arterial hypertension, attacks of
pain in the abdomenor loin resembling renal colics),
since these symptoms can be connectedwith the present renal
pathology. In certain cases the cause and the time of onset of grave
kidney affections (necronephrosis) can be established byrevealing
industrial or domestic poisoning, intentional (or by mistake) taking
of some poisons (corrosive sublimate, preparations of
bismuth,phosphorus, silver, large doses of sulpha preparations, or
of some antibiotics, e.g. aminoglycosides, expired tetracyclines,
phosphorus compounds), transfusion of incompatible blood, etc.
Amidopyrin, phenacetin,barbiturates, camphor, and some other
medicines can cause allergic changes in the kidneys.

 The patient must be asked about the character of

the disease course: itmay be gradual
(arteriolosclerosis, chronic diffuse
glomerulonephritis, amyloidosis of the kidneys), or
with periodical exacerbations
(chronicpyelonephritis, chronic diffuse
glomerulonephritis).
It is necessary toestablish the cause of
exacerbations, their frequency, clinical signs,
thecharacter of therapy given and its efficacy, the
causes inducing the patientto seek medical help.

Anamnesis.

Special attention should be given to the factors that mightprovoke the present disease or have
effect on its further course.

For example, a common factorpromoting

development of acute and chronicnephritis and
pyelonephritis is chilling and cooling (poor housing
or woking conditions, drafts, work in the open, acute
cooling of the body beforethe disease).
Spreading of genital infection onto the urinary
system canthe cause of pyelonephritis.
It is necessary to establish the presenceabsence in
the past of tuberculosis of the lungs or other organs.
This helpsestablish the tuberculous nature of the
present disease of the kidneys.

 It is necessary to establish if the patient has some other

diseases themight cause affections of the kidneys
(collagenosis, diabetes mellitus, certain diseases of the
blood, etc.).
Various chronic purulent diseases (osteomyelitis,
bronchiectasis) can be the cause of amyloidosis ofkidneys.
Occupations associated with walking, riding, weight
lifting,ets.,can have their effect on the course of
nephrolithiasis and provoke attacksrenal colic.
Some abnormalities of the kidneys,
nephrolithiaamyloidosis, etc., can be inherited. It is also
necessary to record thorougthe information on past
operations on the kidneys or the urinary duct.

When examining women, it is

important to remember that
pregnancycan aggravate some
chronic diseases of the kidneys and
be the cause ofso-called
nephropathy of pregnancy (toxaemia
of late pregnancy).

Physical Examination
INSPECTION
Inspection of the patient should give the physician the idea of the
gravity of the patient's condition. Very grave condition with loss
of consciousness may be due to severe affections of the kidneys
attended byrenal, insufficiency and uraemic coma; the
condition may be satisfactory orof moderate gravity (in milder
cases).It is necessary to pay attention to the patient's posture in
bed: active (at initial stages of many diseases of kidneys),
passive (in uraemic coma), or forced (in paranephritis;the patient
may lie on his side with the leg flexed, bringing the knee to the
abdomen on the affected sider.
In the presence of renal colic the patient restless, tosses in bed,
groans or even cries from pain.
Convulsions observed in the presence of uremic coma,
renal eclampsia,tnephropathy of pregnancy (toxemia of late
pregnancy with involvementof the kidneys).

 Oedema is characteristic of acute and

chronic glomerulonephriinephrotic
syndrome, and amyloidosis of the kidneys.
The appearancethe patient with oedema
of the renal origin is quite specific.1face
is pallid, swollen, with oedematous eyelids
and narrowed eye-s(facies nephritica). In
patients with more pronounced signs of
pathologyoedema affects the upper and
lower extremities and the trunk (anasarca)

Patient with renal oedema.

The colour of the patient's skin is also important.
Oedematous skinin cronic nephritis is pallid due to the
spasm of skin arterioles, and anaemia which attends this
disease. The skin is wax-pallid in amyloidosis and
lipoidnephrosis. It should be remembered that in cardiac
oedema (as distinct from renal oedema) the skin is more
or less cyanotic.
When inspecting a patient with chronic nephritis, it is
possible toobserve scratches on the skin and coated dry
tongue; an unpleasant odour if ammonia can be felt from
the mouth and skin of the patient (factoruremicus).
All these signs characterize chronic renal
insufficiencyuraemia).

 Inspection of the abdomen and the loin does not

usually reveal anynoticeable changes. But in the
presence of paranephritis, it is possible tonotice
swelling on the affected side of the loin.
In rare cases, an especially large tumour of the
kidney may be manifested by protrusion of the
abdominal wall.
Distended bladder can be protruded over the pubic
bone in thin persons. The distension can be due to
overfilling of the bladder, forexample, due to
retention of urine in adenoma or cancer of
theprostate.

PALPATION
The posterior location of the kidneys,
and also the absence of anterior
approach to them due to the
interference of the costal arch,
makes palpation of the kidneys
difficult. Relaxation of the pleum and
pronounced

PALPATION

 cachexiacan be attended by certain ptosis

of the kidneys and make them ' accessible
to palpation even in healthy subjects. But
the results of palpationcan only be reliable
in considerable enlargement of the kidneys
(at least 1.5-2 times, e.g. due to formation
of a cyst or a tumour), or their displace
ment by a tumour, or in cases with a
floating kidney. Bilateral enlargementof
the kidneys is observed in polycystosis.

 It is necessary to remember that the kidneys can move about in

therange of 2-3 cm in the proximal and distal directions when the
subjectchanges his position from horizontal to vertical, and also
during respiratory movements of the diaphragm.
Passive movements of thekidneys transmitted from the
diaphragm during inspiration and expirationshould be taken into
consideration during palpation: the Obraztsov-Strazhesko
palpation method should be used. T
he patient should be palpated in the lying or standing
position.When the patient is in thehorizontal position, his
kidneys acre better palpated because the strain ofthe prelum is
absent.
But the movable kidney can be palpated in the standing patient
because it hangs by gravity and is displaced downward by
thepressure of the low diaphragm.

 During palpation of the patient in the lying position, his

legs should be andthe prelum is relaxed and the arms
are freely placed on the chest. The physician should
assume his position by the right side of the patient with
his left hand underthe patient's loin, slightly below the
12th rib so that the finger tipsbenearthe spinal
column. During palpation of the left kidney, the
physician'shand should be moved further, beyond the
vertebral column, to reach theleft part of the lumbar
region. The right hand should be placed on the ab
domen, slightly below the corresponding costal arch,
perpendicularly to it and somewhat outwardly of the
rectus abdominis muscles.

 The patient isasked to relax the abdominal muscles as much as

possible and breathedeeply and regularly. The physician's right
hand should press deeper with each expiration to reach the
posterior abdominal wall, while the left handpresse
urnbarregion to meet the fingers of the right hand. When
theexamining hands are as close to each other as possible, the
patient shouldbe asked to breathe deeply by "the abdomen"
without straining theprelum.
The lower pole of the kidney (if it is slightly descended or
enlarged)descends still further to reach the fingers of the right
hand.
As the physician feels the passing kidney, he presses it slightly
toward the posterior abdominal wall and makes his fingers slide
over the anterior surface of thekidney bypassing its lower pole.

 If ptosis of the kidney is

considerable, both poles and the
entire anterior surface of the kidney
can be palpated.T
he physician should assess the
shape, size, surface (smooth or
tuberousptenderness, mobility, and
consistency of the kidneys. Bimanual
palpationof the kidney can also be
done with the patient lying on his

 In contrast to other organs, an enlarged or ptosed

kidney can be Examined by ballottement (Guyon's
sign): the right hand feels the kidney while the
fingers of the left hand strike rapidly the lumbar
region in theangle between the costal arch and
the longissimus thoracic muscles: thefingers of
the right hand feel vibration of the kidney. In
deranged urineoutflow through the ureter and in
pronounced distension of the renal pelvisby the
accumulated urine or pus, liquid fluctuation can
be felt duringpalpation of the kidney.

 If the physician palpates some formation where he expects

to find akidney, he must check reliably if this is actually a
kidney because it is easyto mistake for the kidney an
overfilled and firm part of the large intestine,tumor of
perirenal cellular tissue (lipoma, fibroma), an enlarged right
lobeof the liver, the gall bladder (during palpation of the
right kidney), or anenlarged or displaced spleen (during
palpation of the left kidney).
The kidney is a bean-shaped body with a smooth surface,
slipping upwardsfrom under the palpating fingers and
returning to normal position, tossedup by ballottment and
giving tympany during percussion over the kidney(by
overlying intestinal loops)

 Protein and erythrocytes appear in the urineafter

palpation. But all these signs are of only relative
importance. For example, if a malignant tumour
develops, the kidney may lose its mobilitydue to
proliferation of the surrounding tissues;
its surface becomes irregular and the consistency
more firm; if the tumour is large, the kidneymoves
apart the intestinal loops and percussion gives
dullness. But thekidney can nevertheless be
identified by the mentioned signs by
differenttaiting it from the neighbouring organs
and other formations.

 Palpation of the kidneys in the standing patient was

proposecDuringpalpation the patient stands facing the
physiciapsits on a chair. The prelum muscles should be
relaxed and the trunk slinghtlyinclined forward.
Palpation can be used to diagnose ptosis of the kidneys.
Three degreesof nephroptosis can be distinguished: the
lower pole of the kidney canpalpated in cases with ptosis
of the first degree; the entire kidney can be palpated in
the second degree; and the kidney freely moves about
iidirections to pass beyond the vertebral column, to the
side of the okidney, and to sink downwards to a
considerable distance, in the trirddegree ptosis.

 Palpation is "also used to examine the bladder. If it contains much

urineespecially in persons with thin abdominal wall, the urinary
bladder canpalpated over the pubic jone as aplastic fluctuating
formation.
If thebladder is markedly distended, its superior border reaches the
umbilicus.
Tenderness in palpation of the ureter along its course and
sensitiveover the kidneys (sensitive to pressure exerted in the angle
between the 12thrib and the longissimus thoracic muscles) is of
certain diagnostic importance.
The area overlying the ureter extends on the anterior abdominal
wallbetween the superior ureter point (at the edge of the rectus
abdominis muscle at the level of the umbilicus) and the inferior point
(at the intersectionof the bi-iliac line and the vertical line passing the
pubic tubercle).

PERCUSSION
It is imgossible to percuss the kidneys in a healthy subject
because tare covered anteriorly by the inteslmal
loopswhith give tympany. Dullnesscan only be determined
in the presence of very marked enlargement ofkidneys.
A much more informative method for examination of the
kidneytapping.The physician places his left hand on the
patient's loin and ushis right hand (palm edgefor fingers)
taps with a moderate force onright hand overlying the
kidney region on the loin. If the patient feels pain, the
symptom "is positive (Fasterhatsky's symptom). This
symptomtorn is also positive in nephrolithiasis,
paranephritis, inflammation of pelvis, and also in myositis
and radiculitis. This decreases the diagnosticvalue of
Pasternatsky's symptom.

 A full urinary bladder gives a dull

sound on percussion of suprapubic
region. The percussion is carried out
from the umbiliiownward, along the
median line; the pleximeter-finger is
placed parallelto the pubic bone.

Determining Pasternatsky's
Symptom.

Instrumental and Laboratory Methods

URINALYSIS

tiestudy of urine is important for establishing a

diagnosis of and concluding on the course of the
pathology. Various pathological processes occuring
in the kidneys and the urinary tracts have their
effect on the properties urine. Pathological
metabolites may be released into the blood inus
diseases. Excreted by the kidneys, these
metabolites are also founde urine and their
determination is therefore important
diagnostically.isamples taken after night sleep are
usually studied. The analysisis with the study ofits
phystcal properties:

 henormaldaily amount of urine(daily diuresis)

excreted by an adults from 1000 to 2000 ml,
the ratio of the urine evacuated during the:o
the nocturnal diuresis being 3:1 or 4:1. The daily
amount of urineN500 ml and over 2000 ml can
be considered pathological under cer-conditions.
hecolourof normal urine depends on its
concentration and variesi straw-yellow to the
colour of amber. Concentration of
urochromes,ilinoids,uroerythrinand of some
other substances accounts for theur of urine.

 The most marked changes in the urine colour depend on

presence of greenish-brown bilirubin, large quantity of
erythrocytesearance of meat wastes), reddish-brown
urobilin, and medicinestylsalicylic acid and amidopyrine
give pink colour to the urine, lylene blue colours it blue,
and rhubard greenish-yellow). Normalurine is
clear.Cloudinessmay be^due to salts, cell elements,
mucus, fats,and bacteria.
Thesmellof urine is specific and not pungent. When
decomposed by bacteria in- or outside the bladder,
urine smells of ammonia. In the 'presence of ketone
bodies (in grave forms of diabetes mellitus), urine
smells "fruity" (the odour of decomposing apples).

 Thespecific gravityof the urine varies from 1.001

to 1.040. It ismeasured by an urometer
(hydrometer) with the scale reading from 1.000to
1.050. Determination of the specific gravity of the
urine is of greatclinical importance because it
gives information on the concentration of
substances dissolved in it (urea, uric acid, salts)
and characterizes the concentrating and diluting
capacity of the kidneys. It should be
rememberedthat specific gravity depends not
only on the amount of particles dissolvedbut
mainly on their molecular weight.

 High-molecular substances (e.g. proteins) account for

increased specific gravity of the urine without influenc
ing substantially the osmotic concentration of the
urine. The osmotic concentration of the urine depends
mainly on the presence of electrolytes andurea.
Osmotic concentration is expressed in mosm/1. The
maximumosmotic concentration of urine in a healthy
person is 910 mosm/1 '(maximum sp. gravity, 1.025
1.028). The specific gravity of the urine may exceed
1.030-1.040 in the presence of high quantity of
glucose (glucosuria),because the concentration of 10
g/1increasesgravity of the urine by 0.004.

 Chemical analysis of urine.Reaction of the urine.The

kidneys are important for maintaining acid-base equilibrium in
the body. The kidneys are/capable of removing the
ions_af_hyikogen and hydrocarbonate from the- blood and this
is a mechanism by whicb pH_of bloodis maintained constant.
The concentration of the hydrogen ions is the true reaction of
urine(active acidity or pH of the medium). The sum of
dissociated and un-dissociated hydrogen ions is the titration
(analytical) acidity. The true reaction of urine may vary from pH
4.5 to 8.4. The pH of urine can be determined colorimetrically
and electrometrically. Colorimetry includesmethods employing
litmus paper, bromthymol blue, and other indicators,by which
the pH is determined only tentatively. More accurate determina
tion of pH is done by comparing colour intensity of test solutions
withstandard solutions (the Michaelis method).

 Special indicator papers can also be used for sufficiently

accurate determination of the pH of urine in the range
from 5.0 to 9.0. The mean pHvalue of the urine in
healthy subjects (with normal nutrition) is about 6.0.
The value of pH is affected by the use of medicinal
preparations (diuretics,corticosteroids). Acidity of urine
can increase in diabetes mellitus, renal in
sufficiency,tuberculosisof the kidneys, acidosis, and
hypokaliaemicalkalosis.
Urine reacts alkaline in vomiting and chronic infections
of theurinary tracts due to bacterial-ammoniacal
fermentation

Novel Biomarkers

Bonventre Nature Biot 28(5),

Biomarker: Definition (FDA)

A characteristic, usually a laboratory test, that is objectively

measured and evaluated as an indicator of normal biologic
processes, pathogenic processes, or pharmacologic
responses to a therapeutic intervention.

Characteristics of an optimal biomarker:

Sensitive to derangement(s)

Specific to the disease(s)

Predictive of clinical outcomes

Robust, i.e. reproducible, inexpensive, simple, and

accessible

hyposthenuria
Persistent polyuria with low specific
gravityof urine(hyposthenuria) is usually
a symptom of a severe renal disease, e.g.

chronic nephritis,

chronic pyelonephritis,

renal arteriolosclerosis, etc.

Polyuria in such cases indicates the
presence of a neglected disease with renal
insufficiency and decreasedabsorption in
renal tubules.

Fold Increase in Concentration

Early Diagnosis of AKI:

Hit or Miss?
KIM, CysC (0.83)
IL-18 (0.75)
A1M, AAG (0.87)
NGAL (0.95)

Marker (AUC)

Time post-CPB

Mishra et al, Lancet 2005

Portilla et al, Kidney Int 2008
Han et al, Kidney Int 2008
Parikh et al, Kidney Int 2006

Impact of using or not using

the urinary output criterion in
the definition of AKI

Vanmassenhove et al, ERA-EDTA Paris, 201

Diuresis as AKI criterium

Macedo et al, KI, 2012

Impact of diuresis on mortality in AKI

Ralib et al, Critical Care, 2013

Oliguria as predictor of AKI in SEPSIS

Leedahl et al, cJASN, 20

Oliguria as predictor of AKI in SEPSIS

Leedahl et al, cJASN, 20

Conceptual model for

development and clinical course of
AKI

Himmelfarb et al, Clin J Am Soc Nephrol march,2008

elayed vs timely nephrology consultation in AK

delayed

timely

Torres Costa e Silva, PloS, 20

Diuresis as AKI criterium

Potential problems:
how to measure?
expressed as ml/min/kg:
what in overweight patients?
what in cachectic patients?
what in edematous patients?

iuresis can only be measured in patients at ICU

as they need an indwelling bladder catheter

Definition of AKI:
KDIGO vision

ERBP Position statement on diagnosis of AKI

Fliser et al, NDT, 2012

Transient vs intrinsic AKI and tubular injury

Based on the creatinine criterion

Based on the urinary output criterion

Vanmassenhove et al, Istanbul, 20

Transient vs intrinsic AKI and tubular injury

Based on the creatinine criterion

Based on the urinary output criterion

Vanmassenhove et al, Istanbul, 20

AKI in the SAPS3 database

Joannidis M., Intensive Care Mecicine, 200

Early intervention

Colpaert et al, CCM, 2012

Early intervention

Colpaert et al, CCM, 2012

92.8% of alerts
induced by low urinary
output criterion

Fluid responsiveness

Furosemide stress test

hydrated patients (clinical assumption)

tage I or II
osemide 1mg/kg
hesis: Furosemide activity signals normal tubular function

Furosemide stress test

hydrated patients (clinical assumption)

tage I or II
osemide 1mg/kg
hesis: Furosemide activity signals normal tubular function

Furosemide stress test

hydrated patients (clinical assumption)

tage I or II
osemide 1mg/kg
hesis: Furosemide activity signals normal tubular function

KaplanMeier survival curves grouped by diuretic efficiency (DE) and diuretic dose in the
Penn (A) and ESCAPE cohorts (B).

Jeffrey M. Testani et al. Circ Heart Fail. 2014;7:261-270

Copyright American Heart Association, Inc. All rights reserved.

Impact on outcome of increased awareness of AKI

Selby et al, Current Opin Nephrol Hypertension 20

Conclusion
Diuresis and urinary output is an
important biomarker for the
prevention, diagnosis and
management of AKI
Its implementation is a matter of
WILLING rather than of possibility