Chapter 045. Azotemia and Urinary Abnormalities (Part 1)

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Harrison's Internal Medicine Chapter 45. Azotemia and Urinary Abnormalities Azotemia and Urinary Abnormalities: Introduction Normal kidney functions occur through numerous cellular processes to maintain body homeostasis. Disturbances in any of these functions can lead to a constellation of abnormalities that may be detrimental to survival. The clinical manifestations of these disorders will depend upon the pathophysiology of the renal injury and will often be initially identified as a complex of symptoms, abnormal physical findings, and laboratory changes that together make possible the identification of specific syndromes. These renal syndromes (Table 45-1) may arise as the consequence of a systemic illness or...

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Chapter 045. Azotemia and Urinary Abnormalities (Part 1) Harrison's Internal Medicine > Chapter 45. Azotemia and Urinary Abnormalities Azotemia and Urinary Abnormalities: Introduction Normal kidney functions occur through numerous cellular processes to maintain body homeostasis. Disturbances in any of these functions can lead to a constellation of abnormalities that may be detrimental to survival. The clinical manifestations of these disorders will depend upon the pathophysiology of the renal injury and will often be initially identified as a complex of symptoms, abnormal physical findings, and laboratory changes that together make possible the identification of specific syndromes. These renal syndromes (Table 45-1) may
arise as the consequence of a systemic illness or can occur as a primary renal disease. Nephrologic syndromes usually consist of several elements that reflect the underlying pathologic processes. The duration and severity of the disease will affect these findings and typically include one or more of the following: (1) disturbances in urine volume (oliguria, anuria, polyuria); (2) abnormalities of urine sediment [red blood cells (RBC); white blood cells, casts, and crystals]; (3) abnormal excretion of serum proteins (proteinuria); (4) reduction in glomerular filtration rate (GFR) (azotemia); (5) presence of hypertension and/or expanded total body fluid volume (edema); (6) electrolyte abnormalities; or (7) in some syndromes, fever/pain. The combination of these findings should permit identification of one of the major nephrologic syndromes (Table 45-1) and will allow differential diagnoses to be narrowed and the appropriate diagnostic evaluation and therapeutic course to be determined. Each of these syndromes and their associated diseases are discussed in more detail in subsequent chapters. This chapter will focus on several aspects of renal abnormalities that are critically important to distinguishing among these processes: (1) reduction in GFR leading to azotemia, (2) alterations of the urinary sediment and/or protein excretion, and (3) abnormalities of urinary volume. Table 45-1 Initial Clinical and Laboratory Data Base for Defining Major Syndromes in Nephrology
Syndromes Important Findings Locati Clues to Diagnosis That Are on of Common Discussion of Disease- Causing Syndrome Acute or Anuria Hypertensi Chaps. rapidly progressive on, hematuria 273, 277, 279, Oliguria renal failure 283 Proteinuria Documented , pyuria recent decline in GFR Casts, edema Acute Hematuria, Proteinuria Chap. nephritis RBC casts 277 Pyuria Azotemia, Circulatory oliguria congestion Edema,
hypertension Chronic renal Azotemia for Proteinuria Chaps. failure >3 months 272, 274 Casts Prolonged Polyuria, symptoms or signs of nocturia uremia Edema, Symptoms or hypertension signs of renal osteodystrophy Electrolyte disorders Kidneys reduced in size bilaterally Broad casts in urinary sediment Nephrotic Proteinuria Casts Chap. syndrome >3.5 g per 1.73 m2 per 277 Lipiduria
24 h Hypoalbumine mia Edema Hyperlipidemi a Asymptomati Hematuria Chap. c urinary 277 Proteinuria abnormalities (below nephrotic range) Sterile pyuria, casts Urinary tract Bacteriuria >10 Hematuria Chap. 5 infection/pyelonephr colonies per 282 Mild itis milliliter azotemia Other Mild
infectious agent proteinuria documented in urine Fever Pyuria, leukocyte casts Frequency, urgency Bladder tenderness, flank tenderness Renal tubule Electrolyte Hematuria Chaps. defects disorders 278, 279 "Tubular" Polyuria, proteinuria (
defects Hypertension Systolic/diastol Proteinuria Chaps. ic hypertension 241, 280 Casts Azotemia Nephrolithias Previous Hematuria Chap. is history of stone 281 Pyuria passage or removal Frequency, Previous urgency history of stone seen by x-ray Renal colic Urinary tract Azotemia, Hematuria Chap. obstruction oliguria, anuria 283 Pyuria Polyuria, Enuresis,
nocturia, urinary dysuria retention Slowing of urinary stream Large prostate, large kidneys Flank tenderness, full bladder after voiding Note: GFR; glomerular filtration rate; RBC, red blood cell.