Normal results of urine

Urinalysis is one of the most useful screening method, the results can provide basic information about the metabolic state and the state of genito-urinary system. 

Routine examination of the urine is one of the basic laboratory analysis. Any such examination shall consist of three parts:

First Description of the physical and physical-chemical properties of urine: appearance, color, odor, specific gravity and reaction.
Second Chemical analysis. The most common chemical analyzes of the analysis on the protein, sugar, ketone bodies, urobilinogen, bilirubin and nitrite.
3rd View the urinary sediment that is. microscopic examination of the sediment that gets stale after centrifugation.

First morning urine is collected in a sterile container with the necessary hygiene odgovarojuća patient and do not take the first, the second stream of the first morning urine. Urine should be collected in the appropriate bottle, which can be purchased at any pharmacy, and to avoid other types of packaging, because of possible contamination.

Appearance of urine - normal: bright appearance
-Turbid urine - indicating an increased number of leukocytes, in an inflammatory process, as well as fungi, bacteria, mucus and other elements that can be found in urine sediment.

Color - normal: yellow. Color may vary depending on the amount of liquid loaded - from light yellow to dark yellow, and it is influenced and increased body temperature, sweating, vomiting, diarrhea. What is urine more concentrated, the color is darker. Interestingly, the pink color of urine can occur, for example, when consumed higher amounts of beets or blackberries.

-Dark brown urine - indicating an increase in bilirubin, which is usually a sign of liver damage or the onset of jaundice. Some people normally have an increased bilirubin, so that they look like normal urine.

-The Red urine - indicating the presence of hemoglobin, which usually indicates kidney damage, which the blood appears in the urine (usually kidney stones or sand), but also in various inflammatory processes, damage to the urinary tract and bladder.

Response - normal: acidic pH, pH is between 5 and 6
• Alkaline reaction - usually indicates a bacterial infection.

Specific density - reference value of 1.012 to 1.025, varies depending on the amount of liquid loaded and ability of the kidneys to concentrate urine
-Increased density may be a sign of diabetes, hypertension, disorders of the adrenal gland hormones function, kidney damage. It occurs due to the increased water loss - vomiting, diarrhea and fever.
-Is usually reduced by the increased excretion of urine.

Proteins - Normal: negative
-Can be positive due to increased physical activity or during pregnancy, when it is not a sign of pathology. The appearance of protein in the urine in all other states is a sign of an inflammatory process.

Glucose - normal: negative
-Positive result of glucose in the urine is mainly associated with increased values ​​of this parameter in the blood (above 10 mmol / L), which usually happens in diabetics.

Acetone - Normal: negative
-Positive finding is present in diabetics

Bilirubin - Normal: negative

Urobilinogen - Normal: negative
-Positive results may be a sign of liver damage or bile.

Nitrites - Normal: negative
-Positive finding is an indicator of the presence of bacteria in the urinary tract

Erythrocytes - Normal: negative or a very few, one or two in the microscope field
-Found in the urine indicates disturbance in the functioning of the kidney or urinary tract, and a possible urinary stones. This finding may also occur after heavy physical work or injury

Erythrocytes fresh - Normal: negative
-Pozifivni are usually a sign of the presence of urinary stones or sand in the kidney and urinary
roads.

Erythrocytes fade - Normal: negative
-The most positive sign due to infection or chronic kidney disease.

Leukocytes - Normal: up to 5
-They are found in urine sediment when it comes to the existence of inflammatory processes and infections. Usually with a large number of white blood cells occurs and an increased number of bacteria, and in this situation, recommendations and urine culture done.

Cylinders - Normal: negative. Cylinders are forms that occur in the kidney tubules and take their shape.
-Positive findings indicate chronic renal disease. In the urine of healthy individuals can only be found so. hyaline casts and rare. Cell, granular and waxy casts are a sign of pathological conditions and their identification is important for the diagnosis or ask of the disease.

Epithelial cell panel - normal: small
-These cells line the urinal tract. Their appearance in the urine to any extent no greater diagnostic value.

Round epithelial cells - normal: negative
-A positive finding indicates the most damage to the kidneys.

Bacteria - Normal: negative
-Bacteria may be small, it does not necessarily indicate infection, but contamination due to improper sample taken. If there is enough urine sample (or how it's used in the lab report said "mass") that's a good sign of a urinary infection.
And salt crystals
Amorphous urates - Normal: negative
-A positive finding has no diagnostic value.

Crystals of calcium oxalate - normal: small
-A positive test result does not necessarily indicate disease, but may be a sign of kidney sand.

Uric acid crystals - Normal: negative
-A positive finding indicates a kidney disease.

Triple phosphate crystals - Normal: negative
-A positive finding may be a sign of bacterial infection.

Mucus - Normal: negative or slightly
-A positive finding is of little diagnostic value.

Fungi - Normal: negative
-A positive finding is the most common sign of a fungal infection, and can occur in diabetics.

Sperm - Normal: negative
-A positive finding occurs in older men and indicates damage to the prostate. 

Normal urine findings

Normal results of urine / urine: 
Appearance
Urine in healthy people is a clear liquid that can roil standing Zgog flocs secretion or due to the presence of different salts, while in various comorbid conditions may cause the presence of microorganisms, leukocytes, erythrocytes and crystals of various drugs.

Color
Light yellow - light straw and stems of urinary pigments such as urohrom (from hemoglobin), uroetrin (of melanin), urorosein (from indoloctne acid), urobilin (from urobilinogen), and standing in a dark air-oxidation of colorless chromogen into a colored product .
Odor
Aromatic. The smell of food influences, and some medications. Standing of urine is urea decomposes into ammonia, which results in the smell of ammonia. The unpleasant odor is a urinary tract infection due to the presence of bacteriuria and leukocyturia (pus). The conditions that result ketonurijom (diabetes - diabetes mellitus, starvation, malabsorption) can be stale smell of the fruit.
Osmolality
Osmolality and urine specific gravity indicators of renal concentration capacity and decrease in osmolality is the first sign of renal failure, even before the rise in blood urea nitrogen and serum creatinine.
pH
4.5-8 (approximately, 6):
Kidneys are the lungs, the organs in the regulation of acid-base balance as regulating the secretion of acid that is produced by normal metabolic processes. High pH of urine is an indication of urinary tract infection, but it may indicate that the urine is not fresh. An important role of pH of urine to create a urinary stones because ionic composition and solubility of substances that affect stone formation and the crystallization depend on the pH of urine.
Specific gravity
1005-1030
Specific gravity and osmolality of urine are indicators of renal concentration capacity.
Protein-protein: negative
The protein in the urine are a mixture of high-and low-molecular protein produced by filtration plasma proteins from kidney and those of uro-tract, which results in different proteinuria. Most proteins secreted in the urine of healthy individuals is postglomerulanog origin and detection of specific proteins, such as albumin sensitive test for the detection of renal disease.
Ketones: Negative
Ketone bodies (acetone, acetocetna acid and beta-hidroksimalačna acid) are the products of degradation of fatty acid normally present in the blood and urine in very small concentrations.Increased concentrations indicate the development of diabetic complications, and they are found in the urine of diabetic ketoacidosis, pediatric patients and pregnant women.
Glucose: negative
Glucose is reabsorbed in the tubules of the primary urine, and since they can not all tubule reabsorbed glucose, a certain amount of glucose in the urine passes, a 0.08 mmol / L glucose. The appearance of glucose in the urine, glycosuria, occurs when blood glucose exceeds the ability of reabsorption in the renal tubules and appears in people with high blood sugar caused by different states.

Sediment / microscopic examination:
Hematopoetičke station
Hematopoetičke cells are erythrocytes (ERC), leukocytes (Lkc), eosinophilic granulocytes, lymphocytes and macrophages.

Erythrocytes
The urine of healthy persons may contain several ERC, but never more than 3 per field Erc large increase. Erc presence in urine, hematuria, serious diagnostic findings and is always an indication of a urinary tract infection due to bleeding or kidney disease. If blood is macroscopically visible, called makrohematurijom, while the word microhematuria only when the blood can be determined by the microscopic examination. The causes are multiple and hematuria can be divided into renal parenchymal disease hematuria, renal vascular disease, urinary tract disease and ekskrecijske systemic coagulation disorder. Renal hematuria usually cause glomerulonephritis, tubulointerstitial damage and vasculitis that damage the blood stream nephron.
Makrohematurija the most urological problem should first check whether the patient has called.painless haematuria that appears in kidney cancer, coagulopathy, acute glomerulonephritis, check if there are any problems at dizurični urinary tract infections, bladder cancer, renal tuberculosis, hemorrhagic cystitis, check whether the present pain that occurs in polycystic kidney disease, renal cell carcinoma, or present to the extent as in nephrolithiasis, papillary necrosis. Finally, it should check whether the patient is taking anticoagulants or platelet aggregation inhibitors.

Mikrohematuriju pathology characterized by the number of urinary sediment (> 3 Erc in sight) and the appearance of red blood cells. Morphological changes of perfectly round "isomorphic" to the ERC significantly changed cell "dismorfičnih" ERC to locate origin of bleeding. "Isomorphic" Erc usually come from the lower part of the urinary tract, while "dismorfični" Erc indicate kidney disease. The presence of> 80% »dismorfičnih" ERC indicates glomerular hematuria. Acanthocytes, sub dismorfičnih erythrocytes, but it seems that the amount of> 5% of the total number of ERC, indicate glomerular bleeding origin.

Haemoglobinuria
The finding of hemoglobin in the urine occurs in hemolytic anemia after transfusion of incompatible blood, and the more intense states of decay ERC and the resulting increase in the concentration of hemoglobin in the blood. Give more blood red color urine (oxyhemoglobin). In acidic urine hemoglobin passes into methemoglobin, which gives the urine brown. In addition to hemoglobin in the urine could be extracted and myoglobin.

Leukocytes
Leukocytes in the urine of healthy persons normally found, but their number increased leading indicator for urinary tract infection, as well as non-infectious kidney disease.
Leukocyturia associated with bacteriuria due to inflammation of the bladder (cystitis) or kidney (pyelonephritis).

Leukocyturia may be: renal origin, and it is then related to the infection of the upper parts of the urinary tract (acute and chronic), acute glomerulonephritis, interstitial nephritis, reflux disease, polycystic kidney disease, nephrolithiasis, renal tuberculosis, urinary tract obstruction. originating from the lower part of the urinary tract in cystitis,
Stones in the bladder papillomas, bladder cancer, bladder diverticulosis.
originating in the prostate and urethra urethritis at different etiology (sexually transmitted infections, herpes, chlamydia, gonorrhea) and prostatitis, chronic and acute, inflammation of the gland (Cowper, Littre, the seminal bags).
illness adjacent organs at appendicitis, adnexitis, piosalpingitisa,
cancer of the uterus, rectum, cecum sigmoid part of the colon.

Eosinophils
Eosinophils are present in the urinary sediment of urine infection and then make up <5% of total Lkc.A higher percentage of eosinophils can be found in ateroembolijskih kidney disease, as well as in secondary acute interstitial nephritis due to drug allergy. In the urine of healthy people are not present.

Lymphocytes
Lymphocytes are a rare finding in the urinary sediment. The appearance of lymphocytes is associated with chronic inflammation, viral diseases, as well as in cases of rejection of transplanted kidney. In the urine of healthy people are not present.

Macrophages
Macrophages (mononuclear phagocytes), are cells that are found in the urine in the inflammatory process. In the urine of healthy people are not present.

Epithelial cells
Epithelial cells include: squamous epithelium, transitional epithelium, renal tubular epithelial cells and lipid.

Squamous epithelium
Squamous epithelium is the largest cells in the urinary sediment and dates from the end segments of the urinary tract (urethra) and the vagina, which is often present in small numbers in the urinary sediment. These are polygonal cells, and come individually, although often occur in clusters.Sometimes you can see the colonization of bacteria in the cytoplasm of the cell, which is thought to be an important step in the development of urinary tract infection.
If there is already a lot of sediment squamous epithelium cells, and the absence of Lkc, it shows that the cells come from the lower part of the urethra, and generally means pollution as improper collection or badly managed toilets vulva. Such a finding of no diagnostic value, and if there is a high number Lkc, must be excluded vaginal contamination to confirm urinary tract infections.

In very rare cases of malignant processes in the lower parts of the urinary tract can be found squamous epithelium cells in the urinary sediment, but then show the changes in the structure and shape of the nucleus. In the event of such findings require further cytological processing.

The transitional epithelium
The transitional epithelium or "urotel" is visokospecifični multilayer epithelium that lines the cistern pitchers renal, bladder in women and proximal urethra in men. Finding TCC cell is most common in the lower parts of the urinary tract infection or a urological disorders deeper layers, malicious processes, various infections, urinary stones or kidney hydronephrosis.

Renal tubular epithelium
Kidney tubular epithelium is a single layer epithelium lining the nephron, including the cells that line the glomeruli, proximal and distal tubules and collecting ducts, which occur in a large number of different forms. The appearance of these cells in the urine is associated with acute tubular necrosis and rejection of the transplanted kidney, with fever, various toxic damage (drugs, particularly aspirin, heavy metals), various inflammations, infections and tumors. Tubular cells are usually associated with findings suggestive of renal parenchymal disease. Sometimes, but very rarely, can be found in the urine of healthy individuals as a result of epithelial regeneration.

Lipid station
Lipid fatty degeneration cells signify-renal tubular epithelial cells in the urine usually appear as free lipid droplets of fat or saturated tubular epithelium cells, so-called. oval fatty corpuscles. They can also be embedded in fatty cylinders, as well as cholesterol crystals. How to bind to proteins, lipids, lipidurija is typically a sign of heavy proteinuria, which is related to the extensive damage to the kidneys. In the urine of healthy persons of lipid cells are not present.

Crystals
The appearance of crystals in the urine is dependent on urine pH and is relatively common finding, although in fresh urine is usually not present. How urine can be acidic or alkaline, the crystals may be present only or mainly in acidic or alkaline urine.
Acid crystals in the urine are normal: urate, calcium oxalate, hipurna acids and salts of amorphous urates.
Crystals in alkaline urine are normal: calcium phosphate, tripel phosphate, calcium carbonate, amorphous urate salts and ammonium biurat.
Pathological acid crystals in the urine are: cystine, leucine, tyrosine, cholesterol.
Other crystals: bilirubin, hemosiderin, sodium urate, kalcijef sulfate crystals and drugs.
Urates were clinically significant only if they are in fresh urine. Abundant presence of crystals is an indication for gout intoxication or drugs, for example. citostatičnim drugs, and can be found in diseases characterized by increased degradation of the cell nucleus, eg. leukosis.

Calcium oxalate are present in people who have a tendency to create urinary stones, or have any clinical relevance. They can be found in people who consume foods rich in oxalate, such as tomatoes, spinach or lettuce, for patients with diabetes and jaundice, and in ethylene glycol poisoning. The presence of crystals can cause mild hematuria.

Hipurna acid is found after administration of aspirin, such as fever and patients with liver disease.

Phosphates occur as calcium phosphate or phosphate tripel (magnesium-ammonium phosphate) in alkaline urine or urine in which the downtime occurred due to bacteria.

Bilirubin is a rarely occurs in people with liver disease or in different obstruction of bile ducts.

Hemosiderin can be found in patients with intravascular hemolysis.

Crystals are different drugs and crystals appeared after long-term use of some medications.

Cystine can be induced to aggregate the creation of urinary (kidney) stones.

Tyrosine is found in liver damage (hepatitis, cirrhosis) or intoxications organic solvents as well as in leukemia.

Leucine is usually found together with crystals of tyrosine in liver damage (hepatitis, cirrhosis) or intoxications organic solvents as well as in leukemia.

Cholesterol is a rare and always abnormal findings (extensive kidney damage - nefritički syndrome, urogenital tract infections, with hilurije which happens when torokalnoj or abdominal obstruction of lymphatic drainage.

Other crystals appear in the urine, but without any clinical significance (amorphous phosphates, amorphous urates - gout, fever, concentrated urine, calcium carbonate - after filling up on vegetables, biurat ammonium, calcium sulfate and sodium urate).

Cylinders
Cylinders are the elements that make up the casts of tubules that come from the distal tubule, loop of Henle and collecting ducts. Size and shape vary and depend on the source.

Hyaline casts
Their increased number can be found in fever, reinforced body burden, diuretics, heart disease, chronic kidney disease and acute glomerulonephritis and pyelonephritis.

Nehijalini cylinders with plasma proteins
Cylinders made of plasma proteins are divided into cylinders granulated (fine and coarse granular).The presence of coarse granular cylinders sign of the extensive glomerulonephritis, rarely appearing with pyelonephritis. In a healthy person can only occur after a very heavy physical exertion. In the urine of healthy people are not present.
Wax cylinders were built primarily of plasma proteins, and their presence in urine is always associated with serious renal disease such as glomerulonephritis, malignant hypertension, nephrotic syndrome, and the rejection of transplanted extensive chronic kidney disease. In the urine of healthy people are not present.

Hemoproteinski cylinders include hemoglobin (refer to parenchymal hemorrhage) and mioglobinske cylinders that can be found in patients with kidney disease caused by the "crush" syndrome. In the urine of healthy people are not present.

Nehijalini cylinders with cells
Nehijalini cylinders stations have built the inclusion of which is then divided into:
Erythrocyte cylinders denote mukoproteinske cylinders that are incorporated in the ERC. Their presence in urine is always an indicator of renal parenchymal hemorrhage or acute lesions of glomerular basement membrane (glomerulonephritis). They can be found in collagen, heart failure, malignant hypertension. In rare cases, may be present in acute pyelonephritis and in ischemic renal disease. In the urine of healthy people are not present.
Renal tubular epithelial cylinders are made of mukoproteinskoga matrix and cell-renal tubular epithelium. Such cylinders are present in the urine in cases where they can be found free kidney cells - tubular epithelial cells, which may be in acute glomerulonephritis and pyelonephritis, chronic kidney disease, diabetic nephropathy in the occasion of toxic damage to the kidneys, as well as in the initial phase of rejection transplanted. In the urine of healthy people are not present.
Fatty cylinders on the surface of fat droplets have, and their findings may be expected in the more extensive kidney damage, especially in nephrotic syndrome in subacute and chronic inflammatory kidney diseases, diabetes and nephrotic syndrome with massive proteinuria. In the urine of healthy people are not present. Composite cylinders, whose matrix is ​​made up of more than one protein, which may contain cells or other inclusions, indicate defects in several segments of the nephron.Erythrocytes in the cylinder warning of glomerular damage, whereas leukocytes suggestive of pyelonephritis or interstitial disease. In the urine of healthy people are not present.
Nehijalini cylinders with bilirubin
Nehijalini cylinders occur when bilirubin is excreted in urine conjugated bilirubin hyaline to yellowish-brown colored matrix. In the urine of healthy people are not present.

Other nehijalini cylinders
Bacterial and fungal cylinders are finding rare and occur in immunocompromised patients with bacterial and fungal infection of the kidney. Bacterial cylinders can be found in pyelonephritis. In the urine of healthy people are not present.

Pseudocilindri
Pseudocilindri are creations of cylindrical shape that occur outside the kidney, and appear in the urine and are morphologically similar to the right cylinders. It is also called cilindroidima, and their presence does clinical significance. These include phosphate, or urate cilindroidi cilindroidi urate crystals. May be present in the urine of healthy people.

Cause infections and infestations
Bacteria in the urine of healthy people are not present, but a small number can be found due to contamination caused by improper collection of urine or prolonged standing at room temperature.Exact identification can be made on the basis of microbiological tests.
Fungi are round or oval homogeneous structure without inclusions. They can occur in the form of hyphae. They are usually present in diabetics, women who use contraceptives in patients with long-term antibiotic or immunosuppressive therapy.

Parasites in the urine usually result from genital or fecal contamination. Trichomonas vaginalis is the most common finding. It can cause vaginitis in women and urethritis in men. If he is alive, it is easy to recognize by the irregular movement, as well as Flutter whip and undulating membrane. If he is dead, it is difficult to differ from small round or leukocytes, epithelial cells.

Artifacts / Pollution
Artifacts / pollution, all the elements that come into the urine by external means, such as hairs, fibers, cotton, grains, powders, granules of glass dust and the like.

Urinary tract infections in children

The term urinary tract infection means the invasion of microorganisms in the tissues of the urinary system. 
Urinary infections are the primary causes of intestinal bacteria. Escherichia coli causes 60-90% of uncomplicated urinary tract infections. The sources of one's own gut flora. Urinary tract infections are usually caused by so-called. "Uropathogen" serogroup Escherichia coli (UPEC), certain virulence properties. 

The term urinary tract infection means the invasion of microorganisms in the tissues of the urinary system. The vast majority of these are bacterial infections to urinary tract infections, the term refers to the practice of all the states in which a significant number of bacteria found in the urine. Urinary tract infections occur in both sexes in all age groups. The children's ages are most common immediately after the inflammation of the airways. The frequency depends on the age and sex of the child. In the neonatal age are often associated with an abnormality of the urinary system. The incidence of infections in the first three months is more common in boys, and then it became more frequent in girls. Short urethra female urinary system provides three times more often than men.Conducive to infection and anatomical malformations (eg, double ureter), the presence of obstructions (stones), vesicourethral reflux (return of urine from the bladder into the upper parts of the urinary system), diabetes and so on. When urinary tract infections occur in the normal urinary system, called primary (uncomplicated), while those in the urinary system anatomical abnormalities secondary means (complicated). Clinically, urinary tract infections can flow either symptomatic or asymptomatic. 
Asymptomatic UTI indicating the presence of significant bacteriuria without symptoms of urinary system. Symptomatic urinary tract infections can affect any part of the urinary system. When kidney surgery and its channel system speaks of pyelonephritis. Infections of the urinary bladder and the urethra is called urethritis and cystitis (cistouretritis). In children, especially young people, is prone to infection quickly spread to the entire urinary system, regardless of which part is started. Children with risk factors for Urinary infections, and those with completely normal urinary system, Urinary infections can be repeated. Such repeated urinary tract infections can be a relapse or reinfection. 
Relapse is the inflammation caused by the same microorganism that is detected before treatment sore back, and in the two weeks after the treatment was not detected by urine culture bacterial growth.When a small group of patients relapse due to the silent (subclinical) infection kidney (pyelonephritis).It is believed that relapse may be due to duplication of the same bacteria in the vagina or the area around the urethra and anus. These recurrent infections occur due to "climb" and again multiplied microorganisms in the urinary system. This mechanism inflammation occurs again two weeks after cessation of antibiotic therapy prior to infection. "Silent" inflammation of the kidneys in the beginning can cause symptoms of inflammation of the lower part of the urinary system, and look like an inflammation of the urethra or bladder. Since the initial dose of antibiotics do not cure kidney infection, symptomatic relapse occurs shortly after the termination of their intake. Proper and sufficiently long treatment with antibiotics can cure the infection. 
Reinfection is a new episode of propagation of microorganisms and the development of inflammation caused by bacterial infection other than the former (ie the inflammation caused by Klebsiella spec. Following the inflammation caused by the Escherichia coli). Infection can be caused by the same organism as the inflammation passed, in which case a relapse and reinfection distinguished by the fact that reinfection is separated from the previous period of asymptomatic infection of at least one month after discontinuation of antibiotics and regular urine. The difference between relapse and reinfection is important because it is used differently in each treatment. Relapsing infections associated with a more comprehensive diagnostic, treatment, and longer in some cases surgical intervention. It is believed that most of inflammation due to repeated reinfection. 
Cause - "uropathogen" Escherichia coli 
Urinary infections are the primary causes of intestinal bacteria. Escherichia coli causes 60-90% of uncomplicated urinary tract infections. The sources of one's own gut flora. Urinary tract infections are usually caused by so-called. "Uropathogen" serogroup Escherichia coli (UPEC), certain virulence properties. Uropathogen Escherichia coli differs from the others by the presence of specific growth on the surface (saw), which specifically bind to the epithelial cells of the urinary tract. This has prevented their mechanical removal of the urine stream. This explains why some children, even when they have no more prone to urinary tract anomaly, urinary tract infections, particularly pyelonephritis.Infections caused by Escherichia coli Uropathogen is usually more severe, longer lasting, more repeats and takes longer antimicrobial treatment. So, out of a total of 150 serotypes of E. coli Uropathogen only some (01, 02, 04, 06, 07, 025, 075, 0150), of which again only one cause infection of renal parenchyma. 
The clinical picture 
Clinical symptoms of urinary tract infections depend on the site of the infection, the cause of the infection, a person's age, the presence anomlija urinary system and the number of previous infections.When the site of infection lower urinary tract, the typical symptom is dysuria. Body temperature is usually elevated. In contrast, inflammation of the upper urinary tract and kidney parenchyma is manifested by a sharp increase in body temperature with Treskavica and a feeling of general illness.Often there is pain in the lumbar area. The symptoms are especially pronounced for E. coli infection, while other bacterial infections give significantly fewer symptoms. The rule is that the symptoms of urinary tract infections that are less typical younger child. 
Diagnostic 
When a suspected urinary infection is necessary to prove the direct causes of the causes of urine. In adults and older children, that control urination, it is best to use the first morning urine. To avoid contamination of urine in natural discharge, it is a mild soap and water to wash the external genitalia.The first stream of urine should be left to her otplavili microorganisms that live in front of the urethra and then into a sterile sample container. For the collection of urine in young children using the pediatric bags which are placed immediately after washing genitals and removed immediately after the urine. If the urine does not show up within 45 minutes of putting a new bag after repeated washing genitals. Urine for culture should be sent to the microbiology laboratory immediately after taking it, but if this is not possible, the sample can be kept at a temperature of 4 º C up to 24 hours after ingestion. To determine the presence of pathogens, urine biochemical and microbiological examination. Microscopic examination required signs of inflammation, including: leukocytes, erythrocytes and bacteria. For the purpose of isolation of bacteria, urine is sown on nutrient media, ie.It is a urine culture. Normal urine contains no bacteria (it is sterile). If the underlying growth of bacteria, urine culture is positive. Positive urine determines the number of bacteria per ml of urine, type isolates, and to determine the sensitivity tj.resistance to certain groups of antibiotics. 

Urinary tract infections in adults

Urinary tract infections are the most common infectious disease group. Urinary infections are a diverse group of diseases that present with clinical signs of inflammation of the bladder, kidney, prostate, urethra and epididymis and testis. 

They differ in etiology, epidemiology, localization, symptoms and treatment options, and prognosis and complications. It is a very common practice in clinical settings, family physicians, infectious disease specialist, internist and urologist. Although the urinary system can be affected by the spread of microorganisms by blood (hematogenous) or lymphoma, the most common urinary tract colonization is a retrograde spread of infection in the urethra of the upper parts of the urinary tract which refers particularly to intestinal bacteria (E. coli and other Enterobacteriaceae). 

In addition to the above-mentioned diseases, which have their own specific clinical picture, there may be bacteria in the urine, which does not lead to the onset of symptoms, and this condition is called "asymptomatic bacteriuria". It should be noted, and sexually transmitted infection caused by Mycoplasma, Ureaplasma chlamydia, trichomonas, and Neisseria gonorhoeae Human papilloma virus (HPV). Such infections are usually present as inflammation of the urethra (urethritis), inflammation of the prostate (prostatitis) or epididymis (epididymitis). Some types of HPV can lead to cervical malignancies. 
Furthermore it is very important to distinguish between uncomplicated and complicated infections.Uncomplicated occur in healthy people, mostly in women due to the anatomical structure and relations of pelvic organs. Complicated infections imply the existence of another, functional or organic diseases of the urinary system that supports the creation and support infection (eg, stones, urinary tract malformations, diabetes, other chronic diseases that weaken the body's resistance ...). 

The most common infection is certainly uncomplicated cystitis in women (inflammation of the bladder) in which more than 80% of cases caused by E. coli. It is advisable, before prescribing antimicrobial therapy, a urine bacterial pathogens but that's not always possible to relatively frequently prescribed antibiotic susceptibility testing and with no finding. In this situation also advises the use of empiric treatment nitrofurantoin (Ninura) 2 times daily 100 mg for 5 days or ciprofloxacin (Cifloxa) 2 250 mg twice a day during the same time. It is important to note that it is necessary to take the 2-3 liters of fluid per day. 
Due to the upward spread of bacteria urinary system often develop inflammation of the kidneys (pyelonephritis), which is regularly monitored the appearance of general symptoms such as high fever, pain in the lumbar region, chills and shivering sometimes also vomiting. Such a situation, if the infection is uncomplicated, it can be cared for at home and empirical antibiotic therapy of choice is ciprofloxacin (Ciflox) but now at a dose of 2 500 mg twice a day for 10 days. 

Often uncomplicated infection in women persistently recur so we need to give prophylactic antibiotics taking low doses over a long period of time. Certainly a previous infection should prior to cure, and to confirm the findings of two sterile urine at intervals of 1-2 weeks. Then we can start where prophylaxis is usually prescribed nitrofurantoin (Ninur) once daily at a dose of 50 or 100 mg. There is also a so-called. postcoital prophylaxis where nitrofurantoin (Ninur) is taken after sexual intercourse, and only one tablet of 100 mg. 
Patients with diabetes, and those taking immunosuppressive therapy, are particularly vulnerable to the emergence and spread of urinary tract infections. Nearly a quarter of women with diabetes has značajnju amount of bacteria in the urine and usually it is enterobacteria or Klebsiella. Pregnant women are particularly exposed rizinku occurrence of urinary tract infections and cystitis is most at risk of progression to kidney inflammation. If a pregnant woman has no symptoms, but the urine has more than 1000 bacteria per milliliter ("more than 10 on the third") are advised to take nitrofurantoin (Ninur) 2 times daily, 100 mg, for 3-5 days. 

Urological diseases that are further complicated by an infection requiring removal of the primary cause, or the underlying disease, usually surgically. In such circumstances it is necessary to first remove the obstruction caused by concrement, stricture or enlarged prostate, but of course at the same time treat the infection, where a group of fluorinated quinolones (eg, ciprofloxacin - Ciflox) plays an important role. If it is a urological operations that are not followed by the infection, then with sterile urine-so. Perioperative antibiotic prophylaxis with a single dose usually during induction of anesthesia. If the procedure works without anesthesia, such as prostate biopsy prophylaxis is given orally and ciprofloxacin (Ciflox) 2x500 mg a day before the biopsy, the biopsy day and three days later. 

Other urological diseases such as urethritis, prostatitis and epididymitis is often treated with antibiotics and other, sometimes in the form of combination therapy, but in the case of poor therapeutic effect is often used fluorinated quinolones - ciprofloxacin (Ciflox) and later in the prevention of recurrence of nitrofurantoin (Ninur) . 

In patients who have permanent urinary catheter antibiotic therapy is not required if there is evidence of infection, which is necessary for a couple of days after the catheter. Most are due to high fever and chills and shivering and frequently develop and epididymitis. 

It is important to emphasize that every antibiotic treatment with urinary tract infections need to take plenty of fluids, and all kinds of urethral and ureteral catheter removed as soon as possible, or as soon as circumstances permit. 

Urinalysis

Pathological urine is more than 10 white blood cells in 1 ml of urine and more than 10 white blood cells in the sixth 12-hour urine. 


Urine sample for analysis taken after the patient for at least three hours is not urinating, mostly by pure MSU, less frequent urinary catheter or suprapubic puncture.

At UTI point leukocyturia, bacteriuria and cilindriurija. Occasionally encountered hematuria, often as a sign of terminal hemorrhagic cystitis and proteinuria up to 2g in 24-hour urine. Pathological finding is considered to be more than five leukocytes in each field of view of the urinary sediment obtained by centrifugation at 2000 rpm for five minutes and looking under high magnification.

As this value depends on the amount of urine centrifugiranog and quantity of supernatant, a more accurate method of determining leukocyturia considered counting of leukocytes in the Fuchs-Rosenthalovoj chamber, and pathologic findings of more than 10 white blood cells in 1 ml of urine and more than 1 out of WBC sixth in the 12-hour urine (Addisov number). Skrinining tests for bacteriuria and Piura
A positive leukocyte esterase finding of 8 to 10 white blood cells in each field of view.


There are rapid screening test for pyuria and bacteriuria "dipstick" method. The sensitivity of leukocyte esterase test is 75-95%, with a specificity of 94-98%. A positive test corresponds to the findings of 8 to 10 white blood cells in each field of view of the urinary sediment obtained by centrifugation at 2000 rpm for 5 minutes and looking under high magnification.


Casts in the urine

Finding leukocytic and coarse granular cylinders consisting of inflammatory cells, the damaged epithelium and the precipitated protein is considered a sign of pyelonephritis.


Determination of bacteriuria

In 95% of the samples isolated to only one type of bacteria.


For the determination of bacteriuria is of particular importance sampling urine properly. It can be proved by various commercial chemical or enzymatic methods, unspun urine microscopy drops of Gram staining, microscopic examination of urine sediment centrifugiranog or various bacteriological methods, one of which is the best method of cultivation is properly taken sample of urine, enumeration of bacteria in 1 ml of urine and testing their sensitivity to various antimicrobial agents. In 95% of the samples isolated to only one type of bacteria, and in 5% of isolating two or more types of bacteria.

Approximate test for bacteria is nitrate test. Performs "dipstick" method. Its sensitivity is 35-85% and specificity of 32-100%. False-negative test will give the bacteria that do not reduce nitrate (staphylococci, enterococci, Pseudomonas aeruginosa).

A positive leukocyte esterase and clinical symptoms of sufficient criterion for the diagnosis of acute uncomplicated cystitis. In these patients prior to the initiation of antimicrobial therapy and during the period of control, urine culture is not strictly indicated.


Differential diagnosis of urine analysis

In patients with clinical symptoms of the disease urinary and / or genital tract is leukocyturia and the absence of significant bacteriuria, to look for other possible causes, which are primarily Chlamydia trachomatis and urogenital mycoplasmas.


When do urine culture?

Urine culture should be done in pregnant women, diabetics, recurrent infections and pyelonephritis before treatment.


Urine culture should be performed prior to initiation of antimicrobial therapy of UTI in pregnant women, diabetics, recurrent UTI, if there is no success before the treatment with pyelonephritis.

A diagnosis of chronic bacterial prostatitis must be confirmed by examining leukocytes and bacteria in the samples of the first and midstream urine, expressed prostatic and urine samples taken after prostate massage and taking exprimate (Meares and Stamey method).
Patients with frequent relapses and reinfections and they suspected the existence of possible complicating factors, are subject to various urological, radiological and radioisotopic examinations (cystoscopy, urography ekskrecijska, mikcijska cystography, sonography, computed tomography, determination of residual urine, dynamic renal scintigraphy, etc. .). 

Blood in the urine

Blood in the urine often causes patients to a medical examination. Patients is usually associated with tumor processes, which fortunately does not have to be the case. In assessing the risk of bleeding is very important to identify the accompanying symptoms. Sudden appearance of blood in the urine accompanied by burning and frequent urination, occurs in strong inflammation of the bladder and prostate cancer in men. Following the implementation of targeted antibiotic therapy problems, and thus stop the bleeding and further tests are usually not necessary. Sometimes the patient can find bladder stones, which then requires removal. 

Blood stream at the beginning indicates a pathological process in the urethra and the bladder at the end of a process called. neck of the bladder. If the entire stream of bloody, then the cause usually lies in the wall of the bladder or if the bleeding from the kidney. If bleeding is not accompanied by any other symptoms, it is highly likely that the cause of bladder tumor process. In these cases require further urologic treatment.


Blood in urine is always a worrying sign of kidney or urinary tract and requires a detailed search. One of the most common causes of kidney stones, which run along the urethra mucosal injury and bleeding, which is usually accompanied by severe pain (kidney or renal colic).

"Painless" blood in his urine contains more detailed diagnostic evaluation to determine from which part of the urinary tract and blood. In view of the islands and high blood pressure, it is very likely that the blood in the urine due through the renal glomeruli, and this is supported by the appearance of protein in the urine.

Mandatory Search

Since it is usually caused by glomerular immune response and inflammatory damage to the kidney tissue, laboratory tests of this assumption must be confirmed or rejected.

It is the case of a young person, it is necessary to exclude an autoimmune disease that can affect the kidneys. Besides immunological laboratory tests, how they are damaged glomeruli can be determined indirectly by measuring the amount of protein excreted in 24 hours.

Determining the number of deformed red blood cells in the urine can be determined whether the red blood cells pass through the damaged glomeruli or originating from the urinary tract.

Be sure to do an ultrasound examination of the kidneys. It is determined by their size (small, shrunken kidneys are the long-term, chronic disease, and enlarged, swollen with acute) and checks to see if there are cysts that can also cause these symptoms.

The final diagnosis is kidney biopsy - removal of tissue for microscopic analysis of the kidneys. On this basis, it can be appropriate to spend Terpija you conclude about the prognosis of the disease.

Islands that are repeated often on the limbs and eyelids are a sign of salt retention and therefore water in the body, resulting in the pathophysiology of many renal impairment occurred. This leads to an increase in arterial pressure, which is often the cause of headaches, in which patients complain.

Staying in hospital

For diagnostic evaluation and begin proper treatment will require a hospital stay, and then you need to reduce your intake of salt, do not take overly large amounts of fluids, do not expose the greater physical exertion and often during the day to rest in the supine position.

At this stage of the disease, while not yet done a complete diagnostic evaluation, it is necessary to take regular doses of appropriate drugs for lowering blood pressure, so that it is held within approximately 14o / 8O mmHg.

Then one can expect that the headache gradually disappear. Sure do and kidney function tests and other diagnostic procedures provided.

When symptoms of late

Chronic kidney disease can develop silently, and symptoms appear only when lose about 50 percent of the kidney. In this case, one can observe the island leg, arm and face, headaches, high blood pressure and extreme tiredness. In addition, almost the only sign that would point to kidney disease is the finding of protein in the urine that is dark in color.

Renal cysts

Renal cysts are often diagnosed last few decades, since the ultrasound came into widespread use. This means that they usually do not cause any problems, but they represent an incidental finding on ultrasound examination of abdominal organs. This is a "bubble" of different size and number, which are filled with clear liquid. They can only be found in one or both kidneys, and by position can be located on the periphery of the kidney (cortical) or central (peripijeličke cysts). The latter knows its growth push blood vessels and nerves of the kidney, which usually results in dull pain. 

Rare tumors are described within the cyst wall. The etiology of the cyst is not completely known, but is thought to be an error in connecting tubule, ie. canals that permeate the kidney. The gradual increase in the absence of any symptoms usually requires only periodic monitoring by ultrasound. If the cysts are very large (7-10 cm or more) and cause a dull pain, it is possible to try a relatively simple percutaneous puncture and sclerosing cysts. It is a procedure that is usually performed under local anesthesia. Under ultrasound is a special needle stabs and evacuate the cyst contents. Then the injected agent whose task sclerosing wall and prevent the re-accumulation of fluid. The procedure is simple, but, unfortunately, often fail, because there is a re-accumulation. If it is peripijeličkim cysts, such procedures are not performed, as this may cause unwanted damage to the large blood vessels in the kidneys. In these, as in the case of sclerosing unsuccessful, whichever is open surgery. A particular problem is finding a large number of cysts of various sizes, which leads to gradual kidney failure, and after years of suffering can end up on chronic hemodialysis (artificial kidney) or kidney transplantation. 

Diagnosis of Kidney Disease

The kidneys are organs whose main task of purifying blood of harmful products of metabolism, and the regulation of water in the body. This also means that it is highly vascularized organs through which pass every minute fifth of the total blood volume. At the intersection of the kidney can distinguish two anatomical areas: the crust and the core. 

Crust consists mainly renal glomeruli, which represent a large number of tiny filters through which purifies the blood. Chronic glomerulonephritis characterized by diffuse scarring changes in the glomeruli, whose wall is thickened and connective changed. Simply put, we can say that there is a flaw in the grid glomeruli, which is why it comes out in the urine and substances that are beneficial organism (proteins) and that it would not filtered. So in laboratory analysis of urine sediment found in protein, casts and blood. It leads to the gradual loss of kidney function over a long period of time, so it may take several months or years before they become symptomatic. It is likely that there are several causes that may lead to chronic glomerulonephritis. Immune complexes on the walls of the glomeruli can be seen in this disease, but they are probably the result not the cause. Only rarely in history may encounter suffered acute glomerulonephritis. The disease usually reveals abnormal laboratory findings in the sediment of urine during a routine medical examination. Sometimes patients come because they noticed blood in the urine. Blood pressure is often elevated.

Search on blood urea and creatinine may show elevated concentrations in their blood. These are the products of protein metabolism that is normally eliminated by the kidneys. Their levels in the blood speaks of the degree of renal impairment. In rare cases, patients come with nausea, vomiting, itching and skin discoloration as a reflection of the advanced stages. Diagnosis is based on the pathological findings in urine and blood, and in doubtful cases confirms the possible kidney biopsy. Treatment of this disease is to control drug-pressure, and dietary recommendations is limited primarily in terms of protein and salt intake. In advanced cases of terminal renal failure there is a need for hemodialysis (artificial kidney) and subsequent renal transplantation. 

Problems with urination

Changes in the urine, such as color, smell and consistency, can be indicators of your body.

The urine can reveal what you ate, how much fluid you have entered into the body, but that the disease might have.
For decades urinalysis is one of the ways that doctors use in diagnosis. From a historical point of view, the urine is one of the major indicators of what is happening in the body, due to the fact that many substances that circulate in the organism, including bacteria, yeasts (single-celled fungi that belong to the group of microorganisms), excess protein and sugar, finally ending up in urine.

Urine is primarily the task of eliminating toxins and other harmful substances, remove excess water and waste filtering kidneys.

If the urine has changed color or odor, it might be innocuous, such as dinner that included beets, asparagus or anything, but it can also be a sign of a more serious condition, such as an infection or tumor.
Changes in urine that you should watch out for, which could be an indicator of your health are:

Change the color of urine
Physiological urine gets yellow color from the pigment called urobilin. The color usually varies from pale yellow to amber, depending on the concentration in the urine urobilina.
Darker urine is usually a sign that you are not consuming enough fluids, and clear urine mean the opposite - you've probably consumed a large amount of fluid or diuretics, which force the body to release the excess water.
Urine can also be other colors and unusual shades are not necessarily cause for alarm. Specifically, certain medications can turn the urine fluorescent green or blue. In addition, urine color may be orange, as a result of taking laxatives or consumption of orange, yellow, which may occur due to excess vitamin B, and hereditary disease called Porphyria can give urine color of the wine.
Red urine is usually a sign of the presence of blood in the urine, but a very small amount can produce a dramatic color change, therefore you should not panic immediately. However, even a small amount of blood in the urine can be an indication of serious health problems, such as infection or tumor, so in that case you should definitely see a doctor or urologist.
If the urine is a small amount of blood, and he is also the dim, there is a good chance that you have a urinary tract infection.

Change the smell of urine

Urine normally has no strong smell, and if you notice a change in the smell of urine, it is possible to have an infection or urinary stones, which make urine smell ammonia can take.
If the urine has a sweet smell, it could be a sign that you have diabetes. In the past, the sweet taste and smell of urine were the only way to diagnose the disease. Some foods can also change urine odor, especially asparagus.

Frequency of urination

The frequency of urination may also be an indicator of your health. Most people have a need to urinate six to eight times a day, but more or less, depending on how much fluid you drink.
If you feel the frequent need to urinate, and not because they consume a large quantity of fluid, causes can be:
Overactive bladder - involuntary muscle contractions in the bladder
Urinary Tract Infection
Interstitial cystitis - a condition that causes soreness and irritation of the bladder
Benign prostate enlargement - prostate growth causes compression of the urethra and block the normal flow of urine
Neurological disorders, including stroke and Parkinson's disease
Diabetes
The opposite problem, rarely a need to urinate, may occur when there is a blockage or infection, which may be the result of bad habits delay urination, which can become a chronic problem.
Regular urination helps consuming enough fluids. Drink fluids when you are thirsty and in the amount that's right for you, except in the case of problems with kidney or urinary stones, you'll have to increase her intake.
If you urinate frequently during the night, fluid stop drinking three to four hours before bedtime. Also, limit your intake of caffeine, which can irritate the lining of the bladder, and may have a similar effect, and alcohol.
Finally, do not put off urination! If you feel the need to go back to the bathroom, so it does not turn into a chronic problem. 

Congenital kidney disease

The importance of hereditary and familial incidence, justify the classification of congenital kidney disease proposed by Perkoffa (see the following images). Although relatively rare in the general population, congenital kidney disease must be known, because it allows early diagnosis and treatment of other family members and provides genetic counseling. 

Many kidney disease, which can occur as a hereditary listed in 30tom chapter. (Some illnesses with a known mode of inheritance.) Selected diseases will be briefly presented.


First Congenital chronic nephritis

Symptoms of the disease usually appear in childhood, with episodes of hematuria, usually after an upper respiratory tract. Renal failure often develops in men, but only rarely in women. Survival for more than 40 years is rare.

In many families, together with kidney disease occur deafness and abnormalities of the eyes, frequent complications were urinary tract infection.

Histology reminiscent of glomerulonephritis. Often there are fat-filled cells (foam cells) or macrophages, which are derived from or tubular cells. This characteristic appears to kortikomeđularnom date.

Laboratory findings are commensurate with existing renal insufficiency whose.

Treatment is symptomatic.

Second Cystic kidney disease

Congenital abnormalities of renal structure, must always be considered in any patient with hypertension, pyelo, nephritis or renal insufficiency. Events abnormalities of renal structure in connection with priđodadm disease whose course and prognosis of renal disorders altered structure.

Polycystic kidney disease

Polycystic renal disease is often familial and procedures in addition to the kidney and liver, and pancreas.

It is thought that the formation of cysts in the kidney cortex due to a disturbance in the binding collection and konvolutnih individual tubules of the nephron. New cysts are not created, but those that exist beyond the pressure and made the destruction of adjacent tissues. Cysts can be found in the liver and pancreas. The incidence of aneurysms of cerebral blood vessels is higher than normal.

Cases of polycystic disease are discovered during investigation for hypertension, using diagnostic tests in patients with pyelonephritis or hematuria, or researching the family of patients with polycystic disease. Sometimes, lumbar pain, caused by bleeding into the cyst, may draw attention to kidney disorders. Other symptoms and signs are those that are often seen in hypertension or renal insufficiency. At physical examination, it is easy to grope extended, irregular kidneys.

The urine can be found leukocytes and erythrocytes. With bleeding into the cyst, bleeding may occur in the urinary tract. Biochemical blood tests reflect the degree of renal insufficiency. X-ray examination showed enlarged kidneys urography demonstrates a classic elongated calix, renal pelvis, stretched over the surface clean.

There is no specific treatment and surgery is contraindicated if there is no obstruction of the ureter with adjacent cyst. Hypertension, infection and uremia are treated in the usual way.

Although the disease may become symptomatic during childhood or early adolescence, often revealed in the fourth or fifth decade. If there are no fatal complications in the form of nfekcije hypertension and urinary tract infection, uremia develops very slowly and live longer than patients with renal failure due to other causes.

Renal cystic disease of the heart

With increasing frequency, the two syndromes are discovered, because their diagnostic features became better known.

Medullary cystic disease

Familial disease that can cause symptoms during adolescence. Anemia is usually the initial manifestation, and azotemia, acidosis, and hiperfosfatcmija fast becoming manifest. Hypertension can also occur. Finding urine is no abnormality, though there is often a lack of opportunities urinary concentrating. Many small cysts are scattered through the medulla of the kidney.

Sponge kidneys are not producing symptoms and are detected by the characteristic appearance of the urogramu. At the intravenous pyelogram see the expansion cup and papilla and small cavities inside the pyramid. Many small stones often meet cysts and infections can be persistent. Quo ad vitam prognosis is good. 

Acute renal failure

The basic elements of diagnosis 

- The sudden emergence of oliguria. The amount of urine 20-200 ml / day.
- Proteinuria and hematuria. Izostenurija with a specific gravity of urine from 1010-1016.
- Anorexy, nauzea and vomiting, lethargy, high blood pressure. Signs of uremia.
- Progressive increase in serum urea, creatinine, potassium, phosphate, sulfate. The reduction of sodium, calcium and CO3 concentrations.
- Spontaneous recovery in a few days.

General Considerations

Under acute renal failure podrazumcvamo sudden cessation of renal function that occurs after various insults in an otherwise healthy kidneys. The following causes can lead to acute renal failure: (1) toxic agents, eg. carbon tetrachloride, mercurv bichlorid, arsenic, diethylene glycol, sulfonamides and mushroom poisoning, (2) traumatic shock after a serious injury, surgical shock, myocardial infarction, renal ischemia, resulting in surgical intervention on the abdominal aorta, (3) destruction of tissue caused by karst injuries, burns, intravascular hemolysis, (4) Infectious diseases eg. leptospirosa, hemorrhagic fever, septicemia gram-negative bacteria (septic shock), (5) severe dehydration and electrolyte disturbances, (6) pregnancy complications eg.: bilateral cortical necrosis.


The re-establishment of renal function can be expected, but even the most appropriate aggressive therapy on appearing, the mortality rate is high. Renal tubular necrosis is a characteristic finding. In some cases, after exposure to specific toxins, primarily damaged proximal tubule. In both kidneys, occurs uniformly disintegration of renal tubule cells, their deskvamaciaj and collecting their remains in the lumen of the tubule. In other cases, in addition to the destruction of tubular cells, there is damage to the basement membrane and end. In case of violation of hemolysis or limestone, may be cylindrical or myoglobin heme, but they differ from us Tali cylinder destruction of tubular cells.Speckled distribution of damage is consistent with changes in the blood that cause ischemic necrosis.In bilateral cortical necrosis, ishemičnj infarcts are deployed in both kidneys.

Clinical findings

The cardinal sign of the development of acute renal failure is a decrease in urine output after injury, surgery, blood transfusion, incompatible, or other causes listed above. Diurcza within 24 hours may be reduced to only 20-30 ml per day, and this reduction was not so hard, so patients 400-500 ml of urine excreted per day. After a few days to 6 weeks, slowly increasing the diuresis. Anorexia, and lethargy nauzea are common symptoms. Other symptoms and signs related to the causative agent or consequences. The course of the disease can be divided into diuiretičnu and oliguric phase.

A. Oliguric phase: during the oliguric phase of urine is very reduced. Urine contains proteins, erythrocytes, granular cylinders. The specific gravity of urine is usually 1010-1016. Speed ​​increases of end products of metabolism in the body fluids, depends on protein catabolism. In the case of trauma or fever, serum urea, creatinine, potassium, phosphate, sulfate, and organic acids are rapidly increasing. Because of dilution and intracellular movement, the serum sodium concentration drops to 120-130 mEq / Iitar, with a corresponding decrease in serum chloride. If organic acids and phosphates accumulate in the serum bicarbonate concentration in serum decreases. Normochromic anemia is common. With prolonged oliguria, there are signs of uremia: nauzea, vomiting, diarrhea, irritability, neuromuscular, convulsions, somnolence and coma. Often develop hypertension, which can be accompanied with retinopathy, left ventricular failure and eneefalopatijom. During this phase of the disease, curing by significantly modifies the clinical picture. Hiperhiđracija causes intoxication with water, followed by convulsions, edema and sometimes very serious complications - pulmonary edema.Giving large amounts of salt can lead to edema and Brake heart failure. Errors related to potassium intake, or if you do not use agents for the removal of potassium at the right time, can lead to intoxication with potassium. High level of extracellular potassium causes neuromuscular depression that progresses to paralysis: disturbances in cardiac conduction pathways leading to the formation of arrhythmias. Death can result from respiratory muscle paralysis or cardiac arrest. While the increase in serum potassium ECG shows peaked Ttalas initially, and then expand QRSkompleksa Ptalasa loss.The severe degree of hyperkalemia appears biphasic ventricular complex occurs at the end of a cardiac arrest or ventricular fibrillation. If appropriate aggressive therapy on appearing potassium intoxication is almost always reversible and death is rare.

B. Diuretic phase: after a few days to 6 weeks after the occurrence of oliguria begins diuretic phase, indicating that the nephrons recovered from taoke in which the excretion of urine possible. Diuresis usually increases gradually from a few milliliters to 100 ml per day until 300-500 ml after which the rate of increase is usually much higher. Rarely had the receiver increases the excretion of urine during the first day or the day after uspostavijanja diuresis. Diuresis can lead to the deterioration nefronske function and loss of water and electrolytes, but this is rare and is running a deficit of water, sodium and potassium occurs only in rare cases. More often, diuresis is the release of excess extracellular fluid that accumulated during the oliguric phase of hyperhydration during aggressive therapy on appearing due to unusual or metabolic water production. Diuresis usually occurs when the total nefronska function is insufficient to secrete urea, potassium and phosphate mind. The concentration of these substances in the serum that can continue to grow for a few days after the elimination of one liter of urine a day. Renal function was slowly returning to normal, and biochemical blood tests become normal.

Differential Diagnosis

Because acute glomerulonephritis, urethral obstruction due to edema at the junction ureterovezikalnom uretcralne after catheterization or due to neoplasm, bilateral renal artery occlusion due to embolism or aneurysm disekantne and rarely rupture the bladder, may be accompanied by symptoms and signs that are indistinguishable from those with tubular necrosis, they need to be off the appropriate diagnostic procedures if they are suspected on the basis of history and physical examination. Sometimes difficult condition can cause severe dehydration Oliguria. Rapid infusion of 500-1000 ml of 0.45% sodium chloride will increase the volume of blood to the point where it will improve the glomerular filtration rate, which will lead to the establishment of diuresis.

Treatment

A. Specific treatment: removal of the causes which led to the oliguria important thing is for the treatment of acute renal failure.
First Shock - to eliminate renal ischemia is necessary to take serious measures to restore blood pressure to normal levels. Note: If you have already occurred tubular necrosis fluid intake must be very limited. If needed vazopresorni drugs they must be given only in the permitted amounts of liquids.
Second Transfusion reaction: see section 10
3rd Obstruction uretena: Occasionally, ureteral catheterization and cystoscopy.
4th Heavy metal poisoning: Dimercaprol (BAL) may be useful in arsenic or mercury poisoning, although at the time of occurrence of renal lesions its effect may be too late.

B. General measures: slodeća scheme of conservative treatment often is sufficient and adequate for uncomplicated cases. If oliguria lasts longer than a week or if the patient has suffered severe trauma, or if a strong "catabolic" state because of infections and toxins is indicated dialysis. Hemodialysis is effective and peritoneal dialysis may be of benefit. Indications for dialysis are precursors to hyperkalemia, severe hyperhydration or elevation of serum electrolytes, or the inability to maintain a relatively stable state with increase of oliguria.

First Oliguric phase. - The purpose of therapy is to maintain a normal body fluid volume and electrolyte concentrations, reduction of tissue catabolism to a minimum and prevent infection during treatment.

a. Bed rest: patients isolated to protect the mtrahospitalnih infekoija.
b. Liquids: limit fluid intake to basal needs of 400 ml per day for the average adult. Additional fluids may be given in order to compensate losses due to unusual vomiting, diarrhea, sweating, etc.. During the metabolism of fats, carbohydrates and proteins created by burning water, and tissue catabolism produces intracellular water. These water sources must be included in the calculation of the water balance, and for them there is only a small amount of water that is allowed as input. (See section E).
c. Diet: In order to limit the sources of nitrogen, potassium, phosphorus and sulfate, prohibit entry protein. Glucose, 10-200 gm per day, given in order to prevent ketosis and reduce protein catabolism.Although fat can be given to the patient in the form of butter or emulsions for oral or intravenous use, it is usually better that the patient realizes caloric needs from their own fat depots. Fluid and glucose can be given orally or intravenously. When given intravcnski 20-50% glucose, 400 ml of fluid should be given continuously for 24 hours through an intravenous catheter that is inserted into a large vein in order to reduce the risk of thrombosis. Should be given vitamin B complex and vitamin C.
d. Compensation electrolyte: prcdhodne offset losses. In other words, the electrolyte therapy is not necessary, unless there is a clear loss for example. vomiting, diarrhea and so on. Note: Potassium must not be given if there is no deficit in his case this gives very carefully.
email. Observation: daily recording of fluid intake and losses is essential. Bladder catheterization is usually required in order to exact measurement of diuresis. It is necessary whenever it is possible to follow the course of the day the body weight of the patients. Because the patient consumes its own tissue, you should lose about 0.5 pounds per day. If the patient does not lose weight he has received too much fluid. It is important to measure serum electrolytes (particularly potassium) and creatinine several times a day. ECG may help in assessing the level of potassium in the serum.
f. Infection: It takes a rigorous treatment of infection with appropriate antibiotics but it should be noted that drugs can be excreted through the kidneys. Isolation of patients is very useful protective measure.
g. Congestive heart failure: see section 8
h. Anemia: hematocrit less than 30% is an indication for transfusion careful it is best washed erythrocytes.
and. Potassium intoxication
j. Uremia: artificial kidney and peritoneal dialysis are effective but require supervision in well-equipped hospitals. With the proper equipment, dialysis proved evils of great value if the use of "prophylactic" when it is obvious that it is. Conservative treatment is insufficient to prevent acidosis, uremia progression and clinical deterioration.
k. Convulsions and encephalopathy: given paraldehid, rectally. Barbiturates should be limited to pentobarbitalNa amobarbitalNa them to be metabolized by the liver. Chlorpromazine and promazin are also useful.

Second Diuretic phase: unless there is a clear deficit of water and electrolytes, should not be given fluids and electrolytes (for the purpose of forcing diuresis); collection of excess water and electrolytes will be extracted. Liquid and dietary intake can be liberalized if urine output progressively increased until it reaches the normal daily intake. Protein restriction should be continued until no urea and creatinine begin to shrink. Infection is a risk in the diuretic phase. Sometimes diuresis may be accompanied by sodium retention, hypernatremia and hiperhloremijom, followed by confusion, neuromuscular irritability and coma. In this case they must be given in sufficient quantity of water and glucose, to correct hipernatremiju. Is often necessary to measure electrolytes, urea and creatinine levels.

Forecast

If there are no serious complications in the form of trauma or infection, skillful flow often overcome the oliguric phase and spontaneous healing. Death may occur due to water intoxication, Brake heart failure, acute pulmonary edema, potassium intoxication and encephalopathy. Consequence of curing the disease is damage to the small degree of renal function.

Of the authors:
Dr. Henry Brainerd, professor of medicine
Dr. Marcus A. Krupp, Professor of Medicine
Dr. Milton J. Chatton, Professor of Medicine
Dr. Sheldon Margen, professor of medicine 

Nephrotic Syndrome

The basic elements of diagnosis

- Generalized edema.
- Proteinuria greater than 3.5 gm per day.
- Hypoalbuminemia less than 3 gm/100 ml.
- Hyperlipidemia: Cholesterol greater than 300 mg/100 ml.
- Lipidurija: fat free, oval fat bodies, fatty casts.

General considerations

Renal tissue obtained by biopsy or necropsy, showing the changes that are characteristic of the underlying disease, for example. of disseminated lupus erythematosus, amyloidosis, diabetic nephropathy. However, in many cases, the development of nephrotic syndrome is not attributable to a specific disease. These idiopathic nephrosis are classified according to the nature of glomerular lesions.

1 Minimal glomerular lesions: (about 20% of cases of idiopathic nephrosis). An ordinary microscope can not see the pathological disorders. Electron microscope, the Mõigu videtd change glomerular basement membrane. These characters are swelling, vacuolization and loss of the prstastih extensions epitclnih cells called lipoic or pure nephrosis, disease Earleovih epithelial cells, disease prstastih (nežičastih) extensions.


2 Membranous type of the disease: (about 70% of cases of idiopathic nephrosis). Under an ordinary microscope shows thickening of the basement membrane. Under the electron microscope, in addition to thickening of the basement membrane shows distortion, blunt ost and connect prstastih (nežičastih) extensions of epithelial cells.

3 Proliferative lesions: (about 5% of cases of idiopathic nephrosis). An ordinary microscope can quickly identify the increase in the number of epithelial cells and the formation of polumesečastih Bowmanovoj thickening in the capsule, glomerular capillary turning into the scar tissue of different degrees.

4 Meat vite membranousand proliferative lesions: (make up about 5% of cases of idiopathic nephrosis).

Clinical Features

A. Symptoms and signs: edema can occur insidiously and slowly increasing. Often, however, appears suddenly and builds up quickly. If the fluid builds up in scroznim cavity, the abdomen is enlarged and the patient may have problems in terms of anorexia, and breathlessness. Other symptoms that are related to the mechanical effects of edema in serous cavities are not significant.

At physical examination revealed signs of generalized edema. There are often signs hiđrotoraksa and ascites. Edema emphasizes pale skin color, and stretch marks often appear on the skin of the extremities istegnutoj. Hypertension, changes in the retina and its blood vessels and cardiac and cerebral manifestations of hypertension are much more pronounced in the presence of collagen disease, diabetes mellitus or renal insufficiency.

B. Laboratory findings: urine contains a large amount of protein, 1-10 gm/24 hours or more. Sediment containing cylinders, including oily and waxy types, renal tubular cells, some of which contain fat droplets (oval fat bodies) and erythrocytes in varying numbers. The road is normochromic anemia light degree, but anemia can be much more difficult if the kidney damage higher. Nitrogen retention varies to the degree of renal function. Plasma is often lipemic and cholesterol in the blood is usually very high. Protein levels were really low. Albumin fraction may fall below 2 gm or even below 1 gm/100 ml. In pure nephrosis there is some reduction of gamma globulin, while on the contrary in systemic lupus erythematosus, they can be very elevated. Electrolyte concentration in the serum is often normal, although serum sodium can be easily reduced. Total kalcijuni levels may be low, according to the degree of hypoalbuminemia, which leads to a reduction in the amount of calcium bound to proteins. Sodium little is excreted in the urine, and urinary excretion of aldosterone is increased. If there is renal failure, blood tests and urine characterizes the change (see renal insufficiency). To confirm the diagnosis and prognosis of disease, renal biopsy is essential.

Differential Diagnosis

Nephrotic syndrome (nephrosis), may occur in different renal diseases, including glomerulonephritis, (membranous and proliferative), collagen diseases (disseminated lupus erythematosus, poliartervtis iLd.), Amyloidosis, renarnih vein thrombosis, diabetic nephropathy, syphilis, and reactions to toxins such as poisons, Rhus antigen drugs like trimetadion (Tridion), and heavy metals. In young children nephrosis can occur without clear evidence of any cause.

Treatment

There is no specific treatment for syphilis except for heavy metal poisoning. Patients with very izražeruim edema or infection needs to rest in bed. The infection should be treated quickly and effectively with appropriate antibiotics. If a patient receiving corticosteroids, it is desirable to hospitalization. Diet should contain the normal protein ratio (0.75 to 1.0 gm / kg per day) and an adequate amount of calories. Potassium intake should not be restricted.

Experience in the past ten years, has confirmed the value adrenokortikosteroidnih hormone in the treatment of nephrotic syndrome in children and adults whose basic disease causes minimal glomerular lesions (lipoic nephrosis) in the system lupuseritematozusa, glomerulonephritis, or idiosyncrasies of toxins and poisons. Corticosteroid therapy is less effective in the case of membrane disease, proliferative lesions, or mixed lesions in the glomerulus. This therapy has no value or is of little value in amyloidosis, renal vein thrombosis, is contraindicated in diabetic nephropathy.

The goal of therapy is to:

1 cause diuresis,
2 to create no urine protein,
3 to raise albumin levels to normal levels
4 to reduce lipidemija to normal values.

With increasing experience, there was a tendency that the treatment is for a long time and during periods of remission.

Although prednisone is widely used, can be used and other corticosteroids in equivalent doses.Prednisone is given 1-2 mg / kg per day for children or 80-120 mg per day for adults to underestimate the doses, orally for 10 days 3-4 weeks. If urine output is established early in the course of treatment, the dose of corticosteroids may be slightly reduced after a period of 3-4 weeks, trying to find the minimum dose that will achieve the therapeutic goal and maintain remission. When there is no response to corticosteroid therapy, rapid reduction in intake of corticosteroids may result in diuresis and improvement. In case you did not report improvement after stopping corticosteroid therapy should attempt to further treatment with high daily doses of this medication before a definite conclusion that the patient is refractory to corticosteroids.

When you establish a good diuresis and to reduce proteinuria and edema, corticosteroids may be administered intermittently every other day. This intermittent therapy can satisfactorily maintain disease remission. The total daily dose of continuous, daily allowances, given as a single dosage at breakfast every other day. This method of treatment usually does not lead to suppression of the adrenal gland, normal growth can be expected in children, and cushingoid changes and hypertension are rare. In some cases, the introduction of intermittent therapy, taking medication every 48 hours, yielded good results.

Another way to intermittent therapy, which are widely used, consists in giving prednisone 60 mg orally in divided doses for three consecutive days in a week, which follows četvorođnevna break.Unsuitability of this therapeutic schemes have a number of adverse effects of high doses of corticosteroids, with signs of adrenal suppression, which manifests itself in vrcme četvorodnevnc break.

For now, it is considered justified to intermittent therapy apply for one year, if the patient remains free of edema and proteinuria reduced to a negligible amount. If a minor exacerbations, therapy can be increased. Compensation potassium is preferred during corticosteroid therapy, although it may be unnecessary for administering corticosteroids every other day.

Diuretics are often ineffective. The most useful are derivatives of chlorothiazide, for example.hydrochlorothiazide, 50 mg - 100 mg every 12 hours. Other products chlorothiazide, chlorthalidone or other diuretics, can also be used in the respective effective doses. Aldosterone antagonists may help you. Together with the use of thiazides. Salt-free albumin, dextran, and other onkotični agents are of little help, and their effect in causing a transient diuresis.

Attention: Increase in serum potassium, the development of hypertension, a sudden strong increase in edema, a contraindication for further continuation of corticosteroid therapy. These complications usually occur during the first two weeks of continuous treatment.

Immunosuppressive drugs such as cyclophosphamide, mercaptopurine, azathioprine (Imuran) and others are currently attempting to treat nephrotic syndrome. The use of corticosteroids in the community with similar immunosuppressive agents used to prevent rejection in homotransplatata man. The experience is still scarce but the results of treatment of this type of therapy encouraging.This type of therapy leads to improvement in children and adults with proliferative, membranous, and mixed lesions with systemic lupus erythematosus. In patients with minimal lesions that are refractory to corticosteroids, giving, giving immune suppressive agents did not improve. Glomerular changes in renal function and in many cases have responded well to this treatment. The frequency of improvement was not found.

During the treatment, it is often plagued by serious side effects, which apply both to corticosteroids and cytotoxic agents. For now, this form of therapy should be used only in patients who are refractory to conventional treatment regimen, and by physicians who are experienced in the treatment of nephrotic syndrome.

Forecast

The course and prognosis depend on the underlying disease that is responsible for the occurrence of nephrotic syndrome in about 50% of nephrosis in childhood, the disease appears suddenly, and doing a benign course in the case of appropriate treatment and leaves a slight squeal. However, many patients are going to relentlessly terminal condition with renal insufficiency. Adult patients with nephrosis go lower, especially when the primary disease is glomerulonephritis, systemic lupus erythematosus, amyloidosis, renal vein thrombosis and diabetic nephropathy. In patients with minimal lesions or spontaneous remission or after corticosteroid therapy is common.

Treatment is much more frequent failures or only leads to 'improvement when there are other glomerular lesions. Hypertension and nitrogen retention are poor prognostic signs.

Of the authors:
Dr. Henry Brainerd, professor of medicine
Dr. Marcus A. Krupp, Professor of Medicine
Dr. Milton J. Chatton, Professor of Medicine
Dr. Sheldon Margen, professor of medicine