Nephrology for the Family Physician - O.I. Bakaliuk 2003

Peculiarities of clinical examination of patients with kidney diseases

There is no doubt that a detailed clinical examination is the cornerstone of diagnosing Kidney diseases, and its findings ultimately determine the strategy for employing further laboratory and instrumental Methods to clarify the Diagnosis.

A clinical examination includes analyzing the patient's Complaints and medical history, as well as symptoms identified through inspection, Palpation, Percussion, and Auscultation.

In this process, factors such as the patient's sex, age, occupation, and place of residence must be taken into account. For instance, Pyelonephritis (PN) is more common in certain age groups (children, pregnant women, the elderly), whereas Glomerulonephritis (GN), Renal Amyloidosis, and urolithiasis predominantly affect males. Collagen nephropathies, diabetic glomerulosclerosis, Nephroptosis, and Polycystic Kidney Disease are more frequently observed in females. Hereditary Nephropathies typically manifest in childhood and adolescence, GN usually presents between the ages of 20 and 40, while diabetic glomerulosclerosis, renal amyloidosis, and Renal Arterial Hypertension (RAH) tend to develop in individuals aged 40 to 60. Prolonged exposure to occupational or domestic hazards contributes to The Development of interstitial nephritis. Certain pathologies (such as polycystic kidney disease, urolithiasis, Gout, and primary amyloidosis) are of hereditary origin, whereas others are more prevalent in specific endemic regions (such as familial Mediterranean fever, urolithiasis, and hemorrhagic fever with renal syndrome).

Patient complaints associated with renal diseases can be divided into specific and non-specific.

Specific complaints include pain in the lumbar region. It is essential to determine its localization, intensity, persistence, radiation, and association with other symptoms of renal involvement. Kidney-related pain is most commonly localized in the lower back when the renal parenchyma itself is affected (due to the stretching of the fibrous capsule), along the Ureters in cases of ureteral pathology, or above the pubic bone when the bladder is involved. A dull, mild lower back pain is observed in GN and chronic PN, whereas acute, unilateral pain is characteristic of renal infarction, Renal Colic, acute PN with renal obstruction, renal artery or vein thrombosis, and perinephritis. Radiation of pain along the Ureter toward the Urethra and genitalia, accompanied by restless behavior during pain attacks, is typical of renal colic.

Edema is encountered in various conditions. It is important to emphasize that renal edema does not always manifest on the face and occur in the morning; occasionally, it may be localized in the lower legs or lumbar region. Its severity and rate of development vary widely—ranging from slow-onset, mild Swelling around the eyelids and so-called 'hidden' edema (in GN, renal amyloidosis, and diabetic glomerulosclerosis) to anasarca with fluid accumulation even in large joint cavities (in Nephrotic Syndrome (NS) and Preeclampsia (PE)), with anasarca potentially developing within 10–12 hours. For instance, the onset of GN with NS in a young woman should prompt immediate consideration of systemic lupus erythematosus. In such cases, one should check for arthralgia, transient facial erythema, chest pain and shortness of breath (pleuritis!), and leukopenia, while carefully evaluating the status of Protein METABOLISM (hyper-gamma-globulinemia without prominent hyper-alpha₂-globulinemia) and Lipid Metabolism (normal Blood Cholesterol levels).

Impairments in urine production and excretion are symptoms primarily characteristic of renal pathology.

The daily urine volume varies depending on dietary habits, fluid intake, ambient Temperature, and physical activity. Men excrete an average of 1.5–2 L of urine per day, while women excrete 1.2–1.6 L. Values below 0.5 L/day or above 2 L/day are considered pathological. The majority of urine (70–80%) is produced during the day, with peak excretion occurring between 3:00 PM and 6:00 PM, and the lowest volume between 3:00 AM and 6:00 AM.

Under pathological conditions, disturbances in Urine Formation and Excretion may arise, including polyuria (an increase in daily urine volume exceeding 2 L), oliguria (a decrease in daily urine volume below 500 mL), anuria (cessation of urine excretion), urina spastica (excretion of a large volume of low-specific-gravity urine following neuropsychiatric agitation, epileptic seizures, hypertensive, diencephalic, or pheochromocytoma crises, migraines, or angina pectoris), pollakisuria (frequent urination at short intervals), oligokisuria (urination at prolonged intervals), dysuria (painful and difficult urination), nycturia (predominant nocturnal urine excretion), stranguria (painful, drop-by-drop urination), enuresis (Urinary Incontinence), enuresis nocturna (nocturnal enuresis), and ishuria paradoxa (urinary retention with overflow, where urine discharge occurs despite a full bladder).

Polyuria as a symptom of kidney disease is observed in the Cytology/cytology/16.html">Early stages of renal failure (RF), acute GN, PE, diabetic glomerulosclerosis, senile nephrosclerosis, and during the resolution phase of edema. Extrarenal polyuria occurs in diabetes insipidus, primary hyperaldosteronism, diuretic therapy for Heart Failure, high fluid intake, consumption of large amounts of watermelons or grapes, and under pronounced emotional stress.

Renal oliguria is seen in acute GN, acute interstitial nephritis, NS of various origins, and the terminal stage of RF. Extrarenal oliguria is associated with restricted fluid intake, exposure to a hot environment, excessive sweating, frequent vomiting, diarrhea, massive blood loss, and progressive heart failure.

Anuria is a cardinal symptom of ACUTE RENAL FAILURE (ARF) of prerenal, renal, or postrenal origin. Always a formidable sign of impaired renal function, prolonged anuria lasting several days can be fatal. A distinction must be made between anuria and Acute Urinary Retention. The latter may accompany organic Diseases of the Brain or Spinal Cord, prostate adenoma, prostate tumors, unconsciousness, hysteria, or severe pain resulting from trauma.

Pollakisuria is observed in kidney diseases complicated by chronic renal failure (CRF). In these cases, the Kidneys lose their ability to regulate urine volume and concentration, and urine is excreted at fairly equal intervals and in roughly equal portions (isosthenuria). Pollakisuria is characteristic of bladder pathology (frequently combined with stranguria) and often accompanies Disorders of the spinal cord and diencephalic region.

Oligokisuria is encountered in pregnant women.

Dysuria is more typical of Urinary Tract disorders (PN, urolithiasis), whereas in GN it appears when a hematuric component is present. Dysuria combined with stranguria occurs in inflammatory conditions of the bladder and urethra, tuberculosis, tumors, Bladder stones, and prostate adenoma.

Nycturia without polyuria can be one of the earliest signs of renal impairment. When accompanied by polyuria, it is observed in glomerulosclerosis as the end-stage of various inflammatory, metabolic, and immune renal disorders.

Enuresis is predominantly functional in nature—in children, it results from immature neural regulation of urinary tract tone, while in the elderly, it is due to the loss of this tone.

Paradoxical ishuria is characteristic of decompensated prostate adenoma or bladder stones.

Non-specific complaints in kidney diseases are extremely diverse. They may be associated with various syndromes, such as endogenous intoxication, arterial hypertension (AH), anemia, acidosis, or functional failure of specific Organs and systems.

Cough, asphyxia, hemoptysis, dyspnea, and chest pain are often caused by conditions or diseases that simultaneously affect both the kidneys and the Lungs (collagenoses, Goodpasture's syndrome, Wegener's granulomatosis, heart failure). In other instances, these complaints serve as additional criteria for Renal Dysfunction (for instance, uremic Bronchitis with bronchial obstruction syndrome, hydrothorax in RF, or cough with respiratory distress in pronounced NS).

Cardiovascular complaints are most commonly linked to AH as a manifestation of acute GN, the development of hypertensive heart disease secondary to various chronic renal pathologies (GN, secondary renal amyloidosis, PN, senile glomerulosclerosis, diabetic glomerulosclerosis, etc.), or cardiac involvement in RF (myocardial dystrophy, pericarditis).

Gastrointestinal disorders with corresponding subjective symptoms occur quite frequently in renal pathology. Severe abdominal pain is observed in acute PN (especially purulent cases complicated by perinephritis), nephrotic crisis, renal vessel thrombosis, and renal colic attacks. Symptoms of gastroenterocolitis, fasting vomiting, decreased appetite, and food aversion are more typical of primary or secondary renal amyloidosis and RF.

Involvement of The Musculoskeletal System occurs As a result of phlebitis in patients with renal amyloidosis; micro- and macroangiopathies or polyneuropathies in Diabetes Mellitus (DM) and collagenoses; and Arthritis in gout. Myalgia, Muscle cramps, and bone pain are frequently caused by calcium-phosphorus metabolism disorders (hypocalcemia, hyperphosphatemia, osteodystrophy, Osteoporosis) in CRF.

Complaints regarding the Sensory Organs are quite common in kidney diseases. They are associated with complete loss of function (such as deafness in Alport syndrome, blindness in PE or diabetic glomerulosclerosis) or partial impairment (decreased visual or auditory acuity, cenesthesias).

Endogenous Intoxication syndrome is typically characterized by fatigue, decreased work capacity, reduced libido, Sleep pattern disturbances, headaches, Skin pruritus, and irritability.

When interviewing a patient with renal pathology, it is essential to clarify the onset of the disease (acute or gradual) and determine its connection with a prior infection, hypothermia, trauma, intoxication, Pregnancy, use of specific medications, or other influencing factors. It is crucial to ascertain the sequence in which the symptoms developed, their nature, and their severity. In cases of a gradual onset, one should determine the presence of other diseases or systemic conditions that can lead to kidney damage (tuberculosis, DM, blood disorders, chronic purulent processes, collagenoses, pregnancy), the frequency of relapses, their causes, duration, previous therapy, its efficacy, side effects and complications, as well as the timing and results of prior examinations (blood pressure measurements, urinalysis, blood glucose levels, consultations with an ophthalmologist, endocrinologist, etc.).

The personal history (anamnestic data) should include information about the patient's place of residence, susceptibility to allergic diseases, exposure to occupational hazards, contact with tuberculosis patients, and the frequency of using certain groups of medications (analgesics, Antibiotics, Hormones, immunosuppressants, antineoplastic and contraceptive agents). In female patients, it is necessary to evaluate the Menstrual cycle, The Nature of its disorders, the number and course of pregnancies, history of miscarriages, and Inflammatory Diseases of the genitals.

Physical examination of the patient allows for the assessment of their general condition and physical development status.

An active posture is observed in the early stages of many kidney diseases, as well as during renal colic attacks; a passive posture is seen in uremic coma; and a forced posture (lying on the affected side with the leg on that side flexed at the Hip and knee joints and drawn toward the abdomen) is characteristic of paranephritis. Convulsions may occur during uremic coma, Acute Nephritic Syndrome, or Eclampsia. Orthopnea is not typical of renal diseases.

Lagging in physical and sometimes mental development, along with sensory impairments (such as deafness), are frequently encountered in congenital nephropathies. A distinctive facial appearance (skin pallor, eyelid edema, detachment — facies nephritica), skin dryness, and excoriation marks are indicative of renal failure. In gouty nephropathy, tophi in the Cartilage of the ears and signs of joint involvement are often identified; diabetic glomerulosclerosis is characterized by the so-called diabetic flush. Changes in the Tongue (macroglossia, smoothing of the lingual papillae) are common signs of primary renal amyloidosis. Regional lymphadenopathy, hepatomegaly, and Splenomegaly are encountered in lupus glomerulonephritis and lymphoproliferative disorders.

In cases of renovascular hypertension, patients exhibit a blood pressure Asymmetry (exceeding 10-15 mm Hg), and a systolic murmur can sometimes be auscultated in the umbilical region. Prolonged hypertension leads to the development of a hypertensive heart (expansion of relative cardiac dullness boundaries, altered heart sound intensity, Left Ventricular Hypertrophy, arrhythmias, and signs of heart failure). A pericardial friction rub is a direct sign of uremic pericarditis, although it can also be auscultated in patients with collagen vascular nephropathies even before the onset of renal failure. The intensity of the cardiac impulse is reduced in the presence of hydropericardium or severe diffuse myocardial damage. The latter may also be accompanied by a protodiastolic gallop rhythm and relative mitral regurgitation.

The most frequent sign of pulmonary involvement in renal pathology is an altered breathing pattern (harsh breathing with dry rales in uremic bronchitis), moist non-sonorous rales (uremic lung), dullness on percussion, and absent breath sounds (in hydrothorax).

Inspection of the abdomen and lumbar region typically reveals no noticeable changes in renal diseases. However, in paranephritis, unilateral bulging of the lumbar region may be noted; in polycystic kidney disease or acute urinary retention, bulging of the anterior abdominal wall due to enlarged kidneys with an irregular surface or a large, distended Urinary Bladder can be observed; in the presence of a tumor, unilateral Varicocele may be present.

Upon superficial palpation, the abdomen may be tender in patients with nephrotic syndrome or renal vessel thrombosis. Deep palpation can reveal unilateral or bilateral local tenderness in the projection area of the kidneys, the inguinal regions, and along the ureters. Under certain circumstances (nephroptosis, polycystic kidney disease, tumors, contralateral renal enlargement following unilateral nephrectomy), the kidneys can be palpated.

Renal palpation is initiated with the patient in a supine position (Fig. 14).

As seen in the figure, the physician's left hand is placed in the lumbar region, elevating the lumbar Tissues and the kidney upward. The physician's right hand sinks into the Abdominal cavity. The patient is asked to take deep breaths, which induces a respiratory excursion (a downward displacement of 1-2 cm) of the kidney. During inhalation, the fingers of the physician's right hand advance inward toward the costal margin. When the kidney is sufficiently mobile, enlarged, or prolapsed, it can be palpated between the two hands.

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Fig. 14. Technique of renal palpation.

Renal palpation in the standing patient position is performed similarly.

It should be noted that under normal conditions, only the lower poles of the kidneys are palpable, most frequently the right one, and only a 1.5- to 2-fold enlargement of the kidneys allows for the assessment of their configuration and true size via palpation.

Renal percussion is impractical due to their anatomical Location; therefore, significance is attributed to the interpretation of the tapping (succussion) method. Pain elicited in the right or left costovertebral angle upon percussion is most frequently observed in acute glomerulonephritis, acute pyelonephritis, paranephritis, renal vessel thrombosis, urolithiasis, and polycystic kidney disease. Suprapubic percussion is used to determine the presence of urine in the urinary bladder.

Thus, despite the absence of strictly defined clinical symptoms unique exclusively to renal diseases, the analysis of patient complaints, medical and personal history, and the identification of specific clinical signs make it possible to timely suspect kidney pathology and determine the appropriate strategy for clarifying its genesis.