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Late Effects

Renal and Genito-Urinary

 

Investigation


To investigate bladder damage:

History

Ask about:

  • Are the following symptoms present?
    • Frequency/voiding pattern changes
      • Voiding pattern (number of voids per day)
      • Character of the urinary stream (caliber and force)
      • Evidence of straining to void or intermittency of the stream
      • Nocturia
      • Incontinence
      • Dribbling/spotting of underwear
      • Urgency
      • Dysuria
      • Hematuria
      • Pain in pelvic/suprapubic regions

The best means is for the patient to complete a voiding diary and questionnaire at home over several days.

 

Examination

All patients at risk for long-term health problems involving the kidneys or bladder should have their blood pressure checked at least once a year.

Patients with a positive history should have:

  • Palpation of the abdomen and pelvis to detect a distended bladder.
  • Examination of the genitalia including direct visualization of the urethral orifice.
  • Rectal examination to exclude a pelvic mass and to assess anal sphincter tone.
  • A limited neurologic examination to assess innervation of the genital and perineal area.

 

Urinalysis

Survivors treated with alkylating agents should undergo annual urinalysis to screen for microscopic hematuria.

  • If >5 RBC/HPF on at least two occasions, then the following investigations should be done:
    • urine culture
    • spot urine calcium/creatinine ratio
    • ultrasound of the kidney and bladder

 

Patients with culture-negative microscopic hematuria and macroscopic hematuria and/or abnormal calcium/creatinine ratio should be referred to a nephrologist or urologist.

Significant proteinuria on urinalysis is often a sign of renal damage/disease

Proteinuria is first detected by urinary dipstick, which primarily detects albumin.

False positive urine protein may be caused by alkaline urine, antiseptic cleanser, radiocontrast agents, or a highly concentrated sample.

Children with very dilute urine may have significant proteinuria, which may not be detected by dipstick alone.

 

Blood Work

The kidneys have a large functional reserve and clinical renal function remains normal until there is a serious problem with glomerular or tubular function.

Renal reserve:

  • There are approximately one million nephrons per kidney
  • A significant number of nephrons have to be injured or lost before a clinically detectable change in renal function occurs.

Elevated serum creatinine and blood urea nitrogen (BUN) suggest a need for more accurate tests to assess glomerular function.

 

Measures of glomerular function:

GFR = Glomerular filtration rate  is a measure of renal function.

The incidence of decreased GFR after exposure to any nephrotoxic agent is affected by the method used to measure GFR.

GFR is usually measured by clearance techniques that estimate GFR by measuring the clearance of a substrate which is excreted primarily by glomerular filtration.

Creatinine clearance and radionuclide scans both provide measures of glomerular function.

  • An abnormal GFR is most often detected by elevated serum creatinine concentrations
  • Even mild elevations are important since as much as 50% of renal parenchymal loss must occur before detectable changes in the creatinine occur
  • Early renal insufficiency is often asymptomatic and measurement of creatinine may be the only way to detect its presence
  • Creatinine clearance provides a quantative measure of glomerular function

Meaures of tubular function:

Glomerular filtration is only one component of renal function. After presentation of plasma filtrate to Bowman’s space via the process of glomerular filtration, the filtrate is processed by a highly specialized renal tubular epithelium, which controls solute and fluid excretion.

Non-specific proximal tubular injury from ischemia or toxins such as ifosfamide often results in the wasting of more than one substrate (Fanconi syndrome is a clinical syndrome of proximal tubular wasting with increased urinary excretion of phosphate, bicarbonate, Na, K, glucose, and amino acids).

Polyuria and hypouricemia may complicate proximal tubular dysfunction.

Tubular function is assessed by measuring serum:

The urine may contain glucose and amino acids

 

Bladder Dysfunction:

Patients who have any suggestion of bladder dysfunction should be referred to the urologist, who will if appropriate, organize further investigation:

Problem

Investigation

Decreased force of the urine stream (stranguria)
  • A urinary flow rate and ultrasound measurement of residual urine is performed.
  • The urinary flow rate is calculated by measuring volume voided divided by the number of seconds required to empty the bladder, and can be compared to established normal values.

 

Abnormalities of bladder thickness, capacity, and adequacy of emptying, hydronephrosis and renal abnormalities:

 
  • A renal and bladder ultrasound.

History of infection and or hematuria

 
  • Voiding cystourethrography  This study can visualize the urethra in males with stranguria and exclude vesicoureteral reflux, which is more common in patients with a decreased functional bladder capacity.

 

Incontinence
  • More formal urodynamic evaluation of bladder function is undertaken. Cystometry can measure the bladder capacity and determine bladder compliance.

 

Hematuria, with or without elevated protein
  • Cystoscopy may be indicated

 

 


 

 

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