Since the classification of kidney diseases is so broad, their symptoms naturally vary. It must be remembered that kidney disease can exist without any symptoms. Kidney diseases can generally be divided into two main categories. Symptoms are include urinary tract symptoms and general symptoms. Urinary Tract Symptoms-

Pain

The pain is usually very mild or moderate in the back of the abdomen on either side of the spine (Loin Pain) in the flanks or between the rib bones and the abdomen near the navel. Again, severe pain can be felt during kidney stones. Again, the definition of the urinary duct or ureter will go down according to the movement of the ureter and the testicles and the vulva or the sides of the thighs. However, it takes a long time for the capsule of the kidney to grow, so sometimes even if there is a kidney disease or stone, pain may not be felt.

Urinary symptoms

1. Frequent urination or frequency (Frequency), urge to urinate or urge (Urgency) and excessive urination at night or nocturia (Nocturia), decrease in quantity or oliguria (Oliguria) cessation of urination or anuria (Anuria) etc. Which is also be due to inflammation of the kidneys which can be caused by inflammation of the genitals. If there is too much inflammation there will be a constant urge to urinate and very few milliliters of urine. The urge to urinate and nocturnal urination are usually due to some disease of the bladder or nervous debility. As a result a large amount of urine was stored in the bladder which is called retention. Frequent and profuse urination at night is common in: heart failure, renal inconsistency, mobilization of edema from any cause, diabetes insipidus, hyperadolescence, and excessive fluid intake.

2. Pain and burning to urinate : Dysuria and burning due to inflammation of the bladder and prostate.

3. Frequent urination at night: Due to any disease of urinary tract or nervous and mental diseases.

4. Incontinence: It is caused by anatomic abnormalities of the bladder, physical stress, inflammation and neurological disease or overdistended flaccid bladder.

Urine characteristics in kidney disease

A. Proteinuria (albuminuria): It is a significant symptom of renal disease, as a normal person can excrete up to 150 mg of protein in urine every 24 hours. A normal person without kidney disease may excrete more protein than normal due to exercise, metabolic syndrome, extreme hunger, or dehydration. In rare cases a normal person may have proteinuria while standing, but it will go away when semi-recumbent or supine. A proteinuria of more than 200-500 mg/dL would indicate Ripple's disease or kidney disease.

B. Hematuria or presence of blood in the urine: Although hematuria without kidney disease may cause PTTS, the importance of PTTS is outstanding in kidney disease. Other causes of hematuria other than kidney disease are given below. Important causes of hematuria due to kidney disease are glomerulonephritis, neoplasms, vascular accidents, inflammation, abnormalities, stones, coagulation defects, urinary tract injuries etc. If blood comes first in the urine, then it should be understood that it is coming from the anterior urethra or prostate gland. Again, the blood at the end of urination should be understood if it is caused by any disease of the urethra, bladder neck, or trigone. And if blood comes throughout the urine, then it should be understood that it is coming due to any disease of kidney, ureter or bladder. The causes of hematuria are now described.

Localized: 

• Urethra: Trauma or injury, infection or inflammation.
• Bladder: Infection or inflammation, stones, tumors, varices, drug reaction, radiation injury, parasitic infection.
• Ureter: Ifection, stone, tumor.
• Kidney: Glomerular disease, infection, stones, anatomic abnormalities, thrombosis in regal artery or vein, neoplasm, trauma.

Systemic:

• Anticoagulant therapy.
• Bleeding diathesis-hemophilia, thrombocytopenia, DIC.
• Hemolytic disease-hemoglobinuria, hemolytic uremic syndrome.
• Sickle cell crisis.
• Anaphylactoid purpura with renal involvement.

Also, there are some common symptoms that has suspected to be the cause of kidney disease.

If there is renal or kidney disease, the tubules of the kidneys try to absorb and hold more sodium and water and the Regal Person decreases. Retained water further dilutes plasma proteins and lowers plasma oncotic pressure. In addition to albuminuria, the oncotic pressure is further reduced resulting in edema or fluid retention in the body. However, where there is loose connective tissue in the body, like the face specially under the eyelids there are more edema for which kidney disease can cause edema anywhere in the body but it is especially observed under the eyes or on the face.

• Swelling of the face, under the eyes, feet, hands, or all over the body.
• Hypertension, Anemia
• Pruritis, Pyoderma, Sore Throat
• Diarrhoea, Vomits, Dehydration
• Various organs due to complications of kidney disease.
• Fever
• Retardation of growth, Failure to thrive

Tests in the diagnosis of kidney disease

The diagnosis of kidney disease can be divided into 6 main categories. They are-

• Urine Examination
• Blood biochemical and other tests
• X Ray
• Ultrasound
• Radionucleotide Scanning
• Biopsy

Urine test

If a patient is suspected of having kidney disease the physician should first perform a urine test. Although kidney function refers to both glomerular function and tubular function. With urine tests, we can understand whether the patient has any kidney disease? But how much his kidney function has decreased due to the disease is not really understood by the urine test. Urine tests include proteinuria, hematuria, presence of white corpuscles or casts in urine, 24-hour urine volume and total protein, and urine culture and sensitivity tests. To the naked eye, the color of urine may be red for hematuria, milky white for bile. Urine test for albumin by heat test or albumin test is very important in case of kidney disease. As the urine heat test and albumin test can detect 150 mg/L of protein. Test 2 above is very important for clinical examination where 200 mg protein excretion in 24 hours is normal. Trace proteinuria is often considered normal if the urine is concentrated.

Blood biochemistry and other tests

These tests are needed to diagnose kidney disease and review its functional capacity. Since kidney disease reduces the normal functional capacity of the kidney, these tests measure the extent to which the kidney's normal capacity to excrete, absorb, and reverse hemostasis is reduced. Prominent among these will be described below.

Non-protein nitrogenous substances in blood

 Among the non-protein nitrogenous substances notable are urea, and creatinine. They are particularly metabolic: they are produced in the liver from carbon dioxide and ammonia (via biochemical processes) and by the ornithine cycle.

• After urea is formed, it is excreted through the glomerulus and reabsorbed through some tubules.
• In addition to kidney disease, the following causes of high urea or BUN should be kept in mind.
• Preregular-surgical shock, Addison's disease, conjunctive heart failure, bleeding especially from arms, high protein intake.
• Obstruction of postrenal-urinary tract especially hypertrophy of prostatic gland.
• If the amount of urea in the blood is high, it is called azotemia.

Creatinine

A nitrogenous substance 98% of which is found in muscle. It plays a significant role in muscle contraction. It is excreted in the urine as its anhydride, creatinine. Since creatinine is derived from endogenous metabolism and is not reabsorbed in the tubules and has no association with food, its blood value, if determined correctly, is essential for the diagnosis of kidney disease. As the severity of kidney disease increases, so will the level of creatinine. Its normal ratio is 10 41. It is more than 15 41 due to pre and post renal azotemia and bleeding of arms.

Blood urea and plasma creatinine are the two most commonly used tests to check kidney ie glomerular function. 

Urea and creatinine increase in proportion

• Chronic renal failure.

• Established acute renal failure.

Urea is more elevated than creatinine in the following conditions.

• Give more protein food.
• G, Bleeding hole in I tract.
• When protein catabolism is increased eg trauma, infection, steroid therapy dehydration.

Lower than urea-creatinine

• Pregnancy, low protein intake, liver disease and oder hydration.

Plasma creatinine is relatively higher than urea in rhabdomyolysis.

Glomerular Filtration Rate

Inulin clearance is the main method of glomerular filtration rate (GFR) test. It is measured by looking at plasma levels after an injection of 51 Cr Edetate. This can be seen clinically by testing creatinine clearance. It is also be diagnosed by looking at plasma creatinine and blood urea levels. Because if their amount increases in the blood, it should be understood that the filtration rate is low. It can be determined by determining the value of serum creatinine using the formula below.

GFR (GFR / mL / minute) = (140- age) weight (kg)/72× serum creatinine

This result will be 14% lower for men and 14% for women.

Clearance test

Most of the substances that was excreted in the urine are absorbed from the blood by the kidneys. So if the substance is X then Umg means how much of that substance is excreted in urine in 1 minute and if its concentration is Pmg /dL then in one minute-
U × 100 ml/p

Plasma will clear. Inulin, a polysaccharide (molecular weight $5000), is completely filtered through the glomerulus and is not reabsorbed through the tubules. Thus, inulin clearance is a direct measure of glomerular function and glomerular blood flow. Similarly, PAHp aminohippuric acid is excreted through glomeruli and tubules. Thus glomerular function can also be measured by the clearance of these substances. However, inulin and PAH clearance are generally limited to laboratory work. Creatinine clearance is tested clinically. This can be done by measuring urine and serum creatinine values ​​with a 24-hour urine sample. Determination of Renal Plasma and Blood Flow Values ​​Renal plasma and blood flow can be determined based on urine output and applying Fick's formula.

Kidney Tubule Function Test: Diseases of kidney tubules are rare.

• To test the function of proximal tubules, more glucose, phosphate, amino acid and uric acid will be released in the urine. A patient with glucose in the urine and normal blood glucose and amino aciduria in the urine is considered to have proximal tubule disease.
• Functions of distal tubules: Urinary concentrating and diluting test which 12-24 hours without water will normally increase urine osmolality. And adding more water will reduce the osmolality.
• Acidification test: If NH4CL 100 mg per kg body weight is given, the pH of urine should not come down to 5.3, then it should be understood that the distal tubule is bad or diseased.

Impaired Concentrating Power (Urine Concentration and Dilution Test)

Normally 99% of the glomerular filtrate is reabsorbed by the tubules. Part of this (12.5%) depends on the integrity of the cells lining the tubular epithelium. If the tubule does not have this ability, then the solution that has an isosmotic pressure of 1010 will be released whether the body needs water or not. Generally, when the body's need for water is high, very concentrated urine (which will have a high relative importance) is excreted. Again, if more water is excreted with the urine, the urine will be diluted (relatively less important). First, the patient is told to drink less water, then the physiological response to drinking more water is observed. If more kidney urine (relative importance constant 1010) is excreted it is called isothenuria. Because the kidney's ability to excrete water is reduced, most patients urinate more at night (nocturia). This test can now be done in a modified form called the Mosenthal and Feisberg test where urine osmolarity or urine/serum osmolarity ratio is measured. If urine osmolality is below rom Osm/Kg then kidney disease should be assumed. In very severe kidney disease it will fall below 30om Osm / Kg. And the normal ratio of urine/serum osmolarity should be 3: 0. If it varies, it should be understood that there is kidney disease. Generally, this imposed concentrating power may be due to the reasons mentioned below.

1. Kidney disease especially where tubule damage is extensive such as pyelonephritis.
2. During temporary improvement from acute rappel sit down.
3. If too much potassium is released. For hypercalcemia, vitamin V intoxication.
4. Congenital tubule diseases such as nephrogenic diabetes insipidus and Fanconi syndrome.
5. Organic diabetes insipidus
6. Functional diabetes insipidus due to consumption of alkaline beverages

x-ray

X-rays are an essential resource for the diagnosis and evaluation of kidney disease. Kidney size, shape, position, etc. can be understood well in X-ray. There are many types of x-rays that can be done in kidney disease, the following are the main ones-

• Plain x-ray abdomen
• Intravenous pyelography
• Micturating cystourethrography
• Renal arteriography

IVU

IVU test is a widely used and effective test for kidney ureter and bladder examination. This is a safe method if done carefully. It may cause minor complications in 5% of patients and very severe complications requiring immediate treatment in 0.05% of patients. To do IV, V, U, because a large amount of medicine is given in the IVU route with very large syringes, so there is a fear for it in the public mind. Patients must be informed and radiologists must be prepared to deal with side effects. Those who have allergies should take a test dose. Patients with bronchial asthma, multiple my elometosis, and recent myocardial infarction should avoid IVU. Even if there is kidney failure, if IVU is required, Late films should be taken after 24 hours.

Benefits of IVU

Kidney size, calices pattern, ureter, bladder etc. can be seen from IDU. A stone or tumor is understood. If the kidney is small on one side then the following possibilities can be contemplated.
• Unilateral pyelonephritis
•Congenital hypoplasia
• Renal artery stenosis
• Infarction etc

If bilateral small kidneys

•Chronic glomerulonephritis
• Chronic bilateral pyelonephritis
• Polyuria
• Nephro sclerosis

Many times, because a kidney is not seen in IVU, many people want to throw away this kidney. That's not right at all. When a kidney is not visible on IVU, the size of the kidney should be seen. If the kidneys are of normal size, obstruction (stones), polyuria, tuberculosis, disease should be suspected and investigated and IVU should be repeated after a few days. If the size of the penis is found to be large by IVV, then the following reasons should be considered.

If one side kidney is enlarged

• Unilateral hydronephrosis
• Cyst of one side
• Tumor on one side

And if two kidneys are big, you have to worry

• Polycystic kidney disease
• Polycystic kidney
• Bilateral hydronephrosis

Ultrasound (sonography)

In recent years, ultrasonography has been widely used in the diagnosis of kidney and other diseases. It is a non-invasive technique that is risk-free. Radar can detect the boundaries of solid or fluid field organs using sound waves of similar design or high-powered sound waves. Kidney size, sepsis, cystic kidney disease, stones, calcification can be very well diagnosed by other methods. Acts as a good guide for renal biopsy and is also good for bladder and prostatic tumors.

Gamma Camera Study:

This means that two kidneys are separated or partial function of one kidney by injection of temnitium 19 dtpa. This method measures the glomerular filtration rate of both kidneys. This test is very helpful in serial starling as a result of obstruction or after operation.

CT scanning:

Although first used for imaging the brain in 1973, the technique has advanced and is now used in the diagnosis of other organs in the body and is very helpful in the diagnosis of kidney disease, especially small tumors. However, IVU in kidney disease, although a bit difficult, is widely used and occupies a special place in the diagnosis of kidney disease.

Scanning with radionuclides

Radioisop tagged compounds (eg hipipuret sodium 1131 fluoromeredrin Hg2O3, technetium 99m Tc) sensitive detectors with scintillation camera to visualize renal blood flow, size and sep, ureteral obstruction, dilated ureter and bladder etc.

Regal biopsy

Percutaneous rectal biopsy has an important contribution to diagnosis of rectal disease. Many people think that regal biopsy is scary because the kidney is very vascular and flows between the 5/1 cardiac output. But the interesting thing is that there are many oddities that would rule in favor of a biopsy. For example: the kidney is monoperitoneal, its number is two, it is located below the funica, it is wrapped by a tight facial compartment so that it does not allow excessive bleeding from the biopsy wound and above all its fine anatomy helps to obtain good samples. Bran and Jungmann performed the first surgical regal biopsy in 1924 according to Rasku. Allwal then performed a Regal biopsy in 1944 but was aborted by a patient. In 1954 Perez Aya did a biopsy. However, Iversen and Braun of modern biopsies between 1950 and 1960.

Technical Considerations:

The following factors should be carefully considered before performing a kidney biopsy.

A. X-ray anatomy: normal ratio of kidney height and gland to lumbar vertebra level 3.7 0.37 cm. Because the kidney is surrounded by dense fat, it shows a radiographic opacity on X-ray. The hilus of the kidney, like the kidney parenchyma, is usually opposite the 2nd lumbar vertebra. During inhalation the right kidney will go under the first lumbar vertebra. If you breathe too hard, the kidney can move up to 3 cm if it is too high. Obtained at or below the lower pole of the kidney is ideal for this biopsy, as the hole in the lower pole contains the least number of large vessels and is less vascular. In addition, the kidney is very subcutaneous in this position.

B. Kidney localization is also rarely seen. The easiest way is to do a plain x-ray of the abdomen, after clearing the GI tract. Many, however, prefer intravenous pyelograms. However, before doing intravenous pyelography, it should be checked that the BUN is normal or does not go above 60 mg. Azotemic patients with a BUN above 60 mg/m3 often undergo renal localization by ultrasound.

C. Nowadays kidney biopsies are performed by marking the surface anatomy of the kidney with an ultrasound machine.

D. Variation in position and type of needle to use: Different surgeons perform kidney biopsies in different situations. Perez Aya performed a kidney biopsy with a simple cannula and syringe, first in the lateral and then in the supine position. Iverson and Rana then performed the biopsy in a seated and lateral position. Parrett performed the biopsy with a sandbag under the abdomen in the prone position. However, currently it is more common to do this kidney biopsy with a pillow under the abdomen in a prone position. Different types of needles have been used in biopsy such as eversion needle, Turfle needle, Franklin modification, Vim silver man needle and modification of Vim silver man needle. However, the Vim Silverman needle is currently the most commonly used needle for renal biopsy.

What are the procedures for percutaneous renal biopsy?

The following points should be carefully considered whenever percutaneous renal biopsy is decided.
1. After the patient's written consent, the operative procedure and its complications are explained to the patient.
2. X-ray and intravenous pyelography, ultra sound.3. Blood Tests Hematocrit, BT CT, Platelet Count, Prothrombin Time, BAN, GroupR H.
4. Place the attached items in a tray. One surgical drug, three sterile towels, one syringe of 10 ml, three needles (19,26,23 gauge), one No. 11 blade, scalpel, Vim Silverman needle, bottles of various fixatives, skin sterilization solution, leucoplast, cotton, banks, Atropine, Procaine.
5. Kidney biopsies are usually best done at the patient's bedside (where the patient may not be sedated) so that the patient does not have to move too much after the biopsy to get to the operating table or elsewhere. The patient is placed in a prone position with a soft pillow under the abdomen. Care should be taken to keep the patient's body leaning forward, shoulders down and head out of the way of the biopsy being performed. Shoulders and bed are parallel and spine is straight. After that, the biopsy site should be determined by looking at the patient's breathing pattern. Usually the preferred biopsy site would be within a triangle with the lateral border by the sacrospinalis, the inferior border by the last rib, and the superior border by the coyodotus lumborum. In this case, only the flesh of the latissimus dorsi and serratus posteriori needs to be dissected for biopsy. A pressure cuff should be worn to monitor and record blood pressure and pulse. Then procaine should be injected locally around the biopsy site. The needle should be inserted through a small linear incision until the renal capsule can be felt.

A solid barrier will be felt when the needle is inserted into the renal capsule. Then ask the patient to inhale and inject some more Procaine Regal capsules. Take out the needle and insert the biopsy needle while the patient is not breathing. After this the patient should be asked to inhale 2/3 times and again should be asked to hold the breath and the patient should be told that this time he may feel some pain. The cannula should then be rotated 360° with the needle upwards and the entire device withdrawn from the patient very quickly. A normal renal biopsy will show ocher to red tissue because of the high vascularity of the cortical or cortical medullary junction. It can be seen with the naked eye or with a hand lens. Capsules with perirenal fat are also detectable in many cases.

The biopsy specimen should then be immersed in a suitable fixative. And then the biopsy site is covered with a pressure bandage and the patient can be placed on his stomach with his head on a pillow. The patient should not cough, smoke, or sneeze for at least the next 4 hours to avoid increased inspiratory muscle tightness and be asked to rest in bed for another 24 hours. The patient should be asked not to do any heavy work for the next 10 days. Then the patient can do normal activities.

Importance of renal biopsy

The importance of renal biopsy in nephrology is described below.

1. For accurate histological diagnosis of various kidney diseases like nephrotic syndrome etc. If there is multiple renal disease to see the proportion like: Kimen Steele Wilson disease etc.

2. To see the prognosis of the disease in sequence.

3. Reversal to observe the timing and degree of kidney disease.

4. Appropriate drug therapy such as hypertension due to pyelonephritis, nephrotic syndrome, collagen disease etc.

5. For early correct diagnosis when diagnosis is not possible by other means like sarcoidosis etc.

6. View prognosis.

7. For examination of EM, iminofluorescence cytology etc. for facilitating research work.

Contraindications

1. If there is a kidney.
2. There is no breeding or coagulation defect.
3. Uremia is progressing too soon.
4. Severe malignant hypertension.
5. Known malignancy.
6. Patients who cannot be operated on such as patients under 6 years of age with neurological disorders, psychosis, severe disease, uncooperativeness, severe skeletal defects.
7. When death is imminent and where biopsy would not be beneficial to the patient.
8. Relative contraindications and 

• If more school or more fat
• Small kidneys
• Abnormal position
• Pregnancy