DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi (reddias@umdnj.

edu)
February 17, 2009 9am Anne Chin (chinab@umdnj.edu)
Page 1 of 6 Recorded, (Not) Corrected
Welcome to Unit 7. This hour serves primarily as an introduction to the world of nephrology. Basically, this lecture covers the exciting
topic of urine. The slides posted on WebCT are incorrect, but lucky for you, the ones in the syllabus are correct. Dr. Reddi finished this
first lecture on urinalysis in the 10am hour, so if you’re looking for information on the last few slides, you must look elsewhere. As
usual, Dr. Reddi primarily stuck to reading off the slides. If you have any questions, he can be reached at extension # 6052.

Renal Syndromes and Urinalysis

INTRO TO THE KIDNEY

The kidney – size really matters. The normal adult kidney is about 11-12 cm long,
5-7cm wide, and 2-3 cm thick, with a weight of 125-170g. Clinically, it’s useful to
know the normal size values of a kidney because size can give you a clue about the
underlying renal disease and helps you narrow your differential diagnosis. Size is
measured using renal ultrasound.

Large (>12cm) Small (<9cm)

Solitary kidney Chronic glomerulonephritis
Polycystic disease Chronic hypertension
Diabetes Bilateral renal artery stenosis
Amyloidosis Congenital hypoplasia
Acute renal failure
Infiltrative kidney (lymphoma)
AIDS nephropathy

Anatomy Review: renal components. Each component can be affected by disease processes, so a basic knowledge of the kidney
anatomy is also handy to know (e.g., glomerular vs. tubular vs. arterial disease)
- Parenchyma:
o Outer cortex: contain the glomeruli
o Inner medulla: consists of mainly tubules

Tubules extend into the medulla from the cortex and play a role in urinary concentration and dilation
- Renal pelvis: The pelvis is formed by the convergence of several calyces draining the medullary pyramids. Eventually, the
pelvis becomes the ureter.
- Blood supply:
o Renal artery
o Renal vein (drains to the IVC)

Normal Function. Renal function is disturbed by renal disease. There are 3 classes of functions performed by the kidney.
- Regulatory. Maintain fluid, electrolyte, acid-base balance and normal blood pressure
- Excretory. Remove various nitrogenous metabolic products in urine
- Endocrine. Produce important hormones such as renin, active vitamin D3 and erythropoietin.

When things go wrong. Since the kidney performs so many important functions, kidney dysfunction can lead to problems all over
the body. Here is a preview of pathology covered in the renal portion of this unit – in list form. These will all be discussed in more
detail at a later point in the unit, so don’t worry about memorizing this not so fun list.
- Major syndromes: acute nephritic syndrome; nephritic syndrome; asymptomatic urinary abnormalities (isolated proteinuria
and hematuria); acute renal failure (features elevated serum creatinine); chronic renal failure; tubulointerstitial disease
(caused by long-term antibiotic use); vascular disease; urinary tract obstruction; renal tubule defects (present in children –
e.g., Fanconi syndrome – loss of electrolytes due to poor proximal tubule function); hypertension; nephrolithiasis
- Common abnormalities of renal disease:
o Urine abnormalities: e.g., hematuria; proteinuria (appears as frothy urine)
o Edema (periorbital or generalized)
o Disturbances of micturition: urine output and frequency

Oliguria (<400 ml/d)

Anuria (<100ml/day)

Nocturia (frequent urination at night)

Polyuria (excess urination >3-4L/d)
DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi (reddias@umdnj.edu)
February 17, 2009 9am Anne Chin (chinab@umdnj.edu)
Page 2 of 6 Recorded, (Not) Corrected
o Uremia (symptoms; fatigue, weakness, anorexia, bone or abdominal pain, poor appetite – loss of appetite is often
the first symptom)
o Hypertension: volume dependent hypertension due to the inability to excrete Na+
o Renal colic
o Urinary tract infection (dysuria) – more common in females
o Electrolyte disorders (hypo- or hypernatremia, hypo- or hyperkalemia, elevated creatinine and BUN (azotemia),
metabolic acidosis)
- Signs & Symptoms of Chronic Renal Failure:
o Lethargy, fits, coma
o Anorexia, nausea, vomiting
o Hypertension, pericarditis, heart failure
o Pleurisy, dyspnea on exercise
o Nail changes
o Bone pain
o Edema
o Peripheral neuropathy, myopathy (muscle weakness)
o Amenorrhea, impotence, infertility
o Bruising, pruritic excoriations, sallow pigmentation, mucosal pallor (anemia), epistaxis

Now we will discuss specific abnormalities in a little more detail…

Acute Nephritic Syndrome: acute illness

- Macroscopic or microscopic hematuria
o Microscopic hematuria = observation of RBCs under the microscope
- Edema (mostly periorbital and also generalized)
- Oliguria (urine volume <400 ml/day)
- Hypertension (due to edema and oliguria)
- Mild to moderate proteinuria (<3.5 g/day) – usually in the non-nephrotic range (1-3g)

Nephrotic Syndrome:
- Proteinuria >3.5g/day
- Edema
- Hypoalbuminemia
- Hyperlipidemia
- Lipiduria

Asymptomatic Urinary Abnormalities:

- Isolated hematuria:
o IgA nephropathy: most common type of glomerulonephritis
o Alport’s syndrome: autosomal dominant disease featuring hematuria and deafness

Epidemiology: More common in Japan; young people

Eventually progresses to end stage renal disease and requires dialysis
o Thin basement membrane disease: does not feature much edema

Diagnosis: by urinalysis and biopsy
• Normal thickness ~300 nm
• Thin basement membrane disease <200nm

No treatment, just conservative management
- Orthostatic proteinuria:
o Definition: protein in the upright position, but none in the supine position
o Epidemiology: young adults (18-30 years)
o Prognosis: benign – no renal biopsy needed, no treatment needed (only assurance)
o Generally asymptomatic
o Diagnosis: Measure protein with standing or walking (7am-7pm) vs. supine at night (8pm – 6am)

If these measurements are the same, then there is something wrong with the glomerulus and the patient
needs a biopsy (i.e., it isn’t orthostatic proteinuria)
DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi (reddias@umdnj.edu)
February 17, 2009 9am Anne Chin (chinab@umdnj.edu)
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Acute Renal Failure (Acute Kidney Injury): Skipped - See later lecture

Chronic Renal Failure (Chronic Kidney disease): Skipped – See later lecture

Tubulointerstitial Diseases (TIDs): group of clinical disorders that affect principally the renal tubules and interstitium. The glomeruli
and renal vasculature are generally spared. These disorders often follow antibiotic use and feature elevated creatinine and
electrolytes on urinalysis.
- Urinalysis: hematuria, proteinuria, WBCs, eosinophils
- Classes based on morphology and rate of deterioration of renal function
o Acute tubulointerstitial disease
o Chronic tubulointerstitial disease
- ~15% of all cases of acute renal failure and 25% of all cases of chronic kidney disease are attributable to primary TIDs.

Vascular Diseases of the Kidney: diseases that affect the renal vasculature – 5 diagnostic categories
- Atherosclerotic renal vascular disease (renal artery stenosis)
- Hypertensive renal vascular disease (hypertensive nephrosclerosis)
- Systemic vasculitis (Wegener’s granulomatosis)
- Microangiopathic diseases (hemolytic uremic syndrome, thrombotic thrombocytopenic purpura)
o Thrombotic thrombocytopenic purpura (TTP) – acute injury that is associated with annoying flank pain

Increased with AIDS epidemic
- Renal vein thrombosis

URINALYSIS. Urinalysis is the weapon of choice for a nephrologist when developing differential diagnoses. The urinalysis includes
macroscopic (dipstick) and microscopic evaluation
- Macroscopic evaluation (dipstick)
o Appearance
o Specific gravity (SG)
o pH
o Glucose
o Protein
o Ketones
o Blood
- Microscopic evaluation: sediment

Appearance:
Color Cause
Red Hematuria, hemoglobin, myoglobin, beets, rifampin
Orange Bilirubin, pyridium (drug for treatment of cystitis)
Black Malignant melanoma (due to melanin), black water fever (malaria)
Blue Pseudomonas infection, methylene blue
White Chyle (filariasis, pulmonary TB, obstruction of the thoracic duct); phosphates, pyuria (WBCs)
Normal = light yellow to amber

Specific Gravity: determines the concentrating and diluting ability of the kidney (e.g.,can be used to help diagnose nephrogenic
diabetes insipidus)
- Measures the density and number of particles in the urine
- Normal SG: 1.005-1.030
- Glucose, protein, contrast material increase SG. In these situations, urine osmolality is the best measurement

Urine Osmolality (Uosm): colligative property that reflects the number of particles
- Normal osmolality: 50-1200 mOsm/kg H2O
- ADH is the primary regulator of urinary osmolality
- Urine osmolality is useful in the differential diagnosis of hyponatremia, hypernatremia, polyuria, and acute renal failure.

pH: reflects the degree of urinary acidification – acid is produced by the body and excreted in the urine to maintain the blood at a
pH of approximately 7.4 (more in Baskin’s lecture)
DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi (reddias@umdnj.edu)
February 17, 2009 9am Anne Chin (chinab@umdnj.edu)
Page 4 of 6 Recorded, (Not) Corrected
- Normal: pH = 4.5-6.5
- Clinical use:
o Renal tubular acidosis (RTA)
o Renal stones (uric acid and cystine stones precipitate in acid urine)
o Treatment of salicylate, phenobarbital ingestion and rhabdomyolysis (alkalinization of urine improves these
conditions)
o Urinary tract infection (UTI)
o Follow therapy in metabolic alkalosis (alkaline urine indicates improvement)

Glucose:
- Special reagent strips measure only glucose
- Clinical use:
o Detect uncontrolled diabetes mellitus
o Detect proximal tubular defect (Fanconi syndrome)
o Glucosuria occurs in normal pregnancy due to increased filtered load of glucose

Protein: Normal protein excretion is < 150mg/day

- Reagent strips (dipsticks) can detect albumin only
- Sulfosalicylic acid (SSA) detects or precipitates all proteins
o Negative dipstick but positive SSA indicates proteins other than albumin (diagnostic for multiple myeloma and
other plasma cell dyscrasias)
- Clinical use: detect proteinuric conditions

Ketones: there should be no ketones in the urine except during starvation conditions. Ketonuria can result from excess alcohol or
diabetic ketoacidosis.
- Ketones: Acetone, acetoacetic acid (AcAc), 3-beta hydroxybutyric acid (BHB)
- Dipstick sensitivity:
o AcAc: 4+
o Acetone: 2+
o BHB: 1+
- Clinical use: Diabetic ketoacidosis; starvation ketosis; alcoholic ketosis; recovery from ketosis

Blood:
- Detects Hgb and myoglobin
- Clinical use: detect hematuria
- Dipstick positive urine, but no RBCs in sediment suggests hemoglobinuria or myoglobinuria (not frank blood) (diagnostic for
rhabdomyolysis)
o Differentiation by serum color

Hemoglobinuria: pink serum

Myoglobinuria: clear serum

Urinary Sediment:
- Includes such things as: cells, casts, crystals, bacteria, yeast, and miscellaneous particles – as you can imagine these can get
pretty disgusting
- Cells:
o Epithelial: squamous – usually arise from the urethra and are not pathognomonic of anything
o Transitional: spindle or pear-shaped cells from the bladder – these indicate cystitis if there are >5 transitional cells
per high power field
o Renal tubular: arise from the renal tubules – indicate acute tubular necrosis if > 4 cells per high power field
o RBCs
o WBCs
DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi (reddias@umdnj.edu)
February 17, 2009 9am Anne Chin (chinab@umdnj.edu)
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A. Epithelial Cells
B. Transitional Cell
C. Renal Tubular Cell (RTC)

A B C
- Casts: consist of Tamm-Horsfall proteins (mucus protein + cell debris – often conforms to a cylindrical shape)
o Hyaline: pure Tamm-Horsfall proteins that have the same refraction constant as glass (thus the name)– not
pathognomonic of any disease
o Granular: Tamm-Horsfall + albumin – are of no clinical significance because they are found in both normal and
abnormal urine
o RTC (renal tubular cell): round, cells with eccentric nuclei - indicated acute tubular necrosis
o RBC: usually a very bad sign that indicates glomerulonephritis or severe hypertensive disease

Hemoglobin cast – hemolysis of red cells  acute nephritic syndrome, low SG (same pathology as RBC
casts)
o WBC: indicates urinary tract infection, acute interstitial disease (TID)
o Waxy: enlarged ~2x – indicate chronic kidney disease
o Broad: 2-3x the size of a normal cast – indicative of chronic kidney disease
o Fatty: fat, cholesterol, triglycerides – appear as maltese crosses – associated with nephrotic syndrome

Look a lot like RBC casts – can be distinguished by proteinuria and clinical manifestations

A B C

D E F

G H I

Urinalysis Casts
A. Hyaline Cast B. Granular Cast C. WBC Cast D. RTC Cast E. RBC Cast F. Hemoglobin Cast G. Fatty Casts (maltese cross) H. Broad Cast I. Waxy Cast
DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi (reddias@umdnj.edu)
February 17, 2009 9am Anne Chin (chinab@umdnj.edu)
Page 6 of 6 Recorded, (Not) Corrected
- Crystals:
o Calcium oxalate: envelope-like appearance – nonpathognomonic (in normal urine)

Metabolite of ethylene glycol – can help diagnose ethylene glycol ingestion – associated with metabolic
acidosis, respiratory distress and increased osmolar gap
o Triple PO4 (NH4-Mg-PO4): coffin-lid appearance – suggestive of infection (UTI)
o Uric acid: football shape (but can vary) - gout
o Cystine: looks like a benzene ring – suggests cystinuria

Urinalysis Crystals:
A. Calcium oxalate crystals –
nonpathognomonic or
A B metabolite of ethylene
glycol
B. Triple PO4 (NH4-Mg-PO4)
crystal – infection
C. Cystine crystal – cystinuria
D. Uric acid crystals - gout

C D
. .

~FIN~