水肿、少尿、尿检异常是临床上诊断有无肾脏疾病的主要依据。水肿可由内分泌系统、心血管系统、消化系统、泌尿系统等全身各系统疾病引起。问诊应明确水肿的部位、性质、持续时间，诱发因素、加重与缓解因素，尿量，尿液颜色以及诊疗经过。患者的病史、伴随症状均有助于病因学的诊断。

Edema refers to the accumulation of fluid in the tissue interstitial space caused by fluid extravasation, due to inflammation, low intravascular oncotic pressure(e.g.,when blood albumin level is low), or fluid overload(e.g.,excessive fluid intake in heart/renal failure patients).

Oliguria refers to a clinically significant decrease in urine output, defined as when the urine output is less than 0.5ml/（kg·h）in adults.Anuria is present when urine output is less than 50ml per day.Poor urinary output(oliguria/anuria)may be a sign of dehydration, circulatory shock, heart or renal failure, urinary obstruction or retention.The etiology of renal failure can be categorized into pre-renal(e.g., dehydration/circulatory failure), renal(e.g., glomerulonephritis)and post-renal(e.g., urinary obstruction by renal stone/prostate).

When a patient comes to us complaining about abnormal urine test, the first thing we should ask is if he had some special symptoms like edema, gross hematuria,or oliguria.Then we should make sure whether he took the urine sample in the right way and also ensure that the urine was taken under these conditions: morning,fasting, cleansing, midstream urine, before or after the menstruation three days at least, take the urine after it stored in the bladder for more than three hours, finally send it to check promptly.Besides, to test it repeatedly is important.

D: Nice to meet you, Mr Smith.

P: Nice to see you doctor.

D: How can I help you?

P: My eyelids and legs are swollen.

D: How long have you been like this?

P: Six years on and off.

D: Have you noticed anything or any symptoms that led to the swelling? For example, a cold?

P: Not exactly, but when I have a cold or do strenuous work, the swelling comes on or gets worse.

D: What time of the day is the swelling worse?

P: I notice some swelling in the mornings, and it gradually gets worse as the day goes on.

D: How much water or fluid are you drinking per day?

P: May be one and half liter, I’m not sure.I usually drink 5 cups of tea per day.

D: How much urine are you passing per day?

P: I don’t know.I haven’t measured it.May be half of a bottle or 300ml per day?

D: Do you have any discomfort urinating or passing water?

P: No.But I have been passing water frequently at night in the last 2 months.

D: Have you gained or lost any weight?

P: I have lost 4kg in the last two months.

D: Do you have any other symptoms, like nausea,vomiting, palpitations, or breathlessness?

P: No, but I feel exhausted most of the time.

D: Do you sleep well?

P: No, even with sleeping tablets.

D: What kind of sleeping tablets have you been taking?

P: Melatonin.

D: How much melatonin do you take?

P: I used to take one tablet every night for three years,but in the last four weeks I’ve been taking two tablets every night.

D: Have you seen any doctor about your swellings before?

P: I have gone to “People’s Hospital” to take the following inspections: blood and urine routine,thyroid function tests, renal ultrasound and so on.

D: Were any tests carried out?

P: I had a few tests.They tested my blood and urine.They also did an ultrasound scan of my kidneys.

D: What were the results?

P: The blood test showed that my kidneys were not good,the creatin in was 160 two years ago.They also found blood and protein in my urine before that.However, I have never seen blood in my urine.

D: Have you taken any medication or received any treatment since being unwell?

P: Yes, I took traditional Chinese medicine.

D: Did it work?

P: Well, the urine test showed the amount of blood and protein stayed the same.However, the blood test showed the creatin in continued to rise.

D: Do you have any other medical condition?

P: Yeah, twelve years ago I was diagnosed with high blood pressure(hypertension).Since then I have been taking blood pressure tablets.Now my blood pressure is kept in a level that it doesn’t bother me any more.

D: What led to the finding of high blood pressure?Did you have any symptoms, like dizziness or headache?

P: Yes, I had a bad unbearable headache at the time and my blood pressure was found to be as high as 200/100mmHg.

D: Was the blood pressure measured when you got a headache? What’s the highest number of your blood pressure?

P: Yes, I had measured it every time that I felt uncomfortable.The most serious, it could reach to 200/100mmHg.

D: What medicine are you taking to control your blood pressure now?

P: I am taking one tablet of Adalat in the morning and evening.

D: Did you ever have nephritis as a child?

P: No, as far as I am aware.

D: Do you have any family members or relatives who also have high blood pressure or kidney disease?

P: Yes, my father and sister have high blood pressure,but none of them has kidney disease.

D: Have you had any operations or allergies in the past?

P: No.

D: Please may I examine you?

P: Yes, please doctor.

D: Ok, please take off your clothes, keep your underwears on, and lie on the bed.You may cover yourself with the blanket.After the examination, you may go and have some tests, including blood test, urine routine, renal function, ion and ultrasound scan of the kidney.

P: Doctor, is it that bad?

D: We need to complete the examination and investigations to find out what is wrong, so that we can plan the best treatment for you.

D: Mr Smith, from the examination and test results, you have a condition called “chronic renal failure”.This means your kidneys have been damaged for quite some time, and so they are not able to remove water and toxins from your body properly.It explains why you feel nauseous because of the toxins in the body,and become swollen because of too much water in the body.Your renal ultrasound shows that both your kidneys have shrunk, while the blood test results suggest that you now have a mild anemia, disorder of electrolyte metabolism.Now your serum creatinine has reached 460mmol/L, which suggests the renal failure have progressed to the renal failure stage.The declining of renal function that leads to the reducing ability of excluding water and toxins causes your symptoms of edema and nausea now.

I recommend that you be admitted to hospital right away to start treatment.First, you will need medication by injection to help remove the excess water in your body, this will get rid off or reduce the swellings.During your hospital stay, we’ll also perform a more detailed evaluation of your kidneys.

You will need to take low salt, low protein diet, and restric fluid intake to 1～1.5 liters per day.We will explain everything again and answer any questions you may have during your inpatient stay.I expect the treatment will make you feel better.Do you have any question?

D: Hi, I am Doctor Li.What can I do for you and your little boy?

P: I think my child is sick.He is only four years old,what can I do?

D: What is the problem?

P: He is all swollen up.

D: How long has this been going on?

P: At least 2 months.

D: Have you noticed anything different about him before the swelling?

P: No, nothing special.

D: Please tell me more about the swelling in detail.

P: About two months ago, his cheeks and eyelids started to swell gradually I noticed his legs have also become swollen.The swellings are getting worse or more obvious.

D: Are there any other symptoms?

P: He urinates less, may be only a cup-full per day.His urine has also turned very dark, especially in the last 3 to 4 days.

D: Does he have pain when he urinates?

P: No.

D: Have you noticed any bright red blood in the urine?

P: No.

D: Did he have fever or sore throat before these symptoms?

P: No.

D: Has he had a rash or other symptoms like asthma or shortness of breath?

P: No.

D: Has he seen any doctor?

P: We have gone to the hospital in the vicinity of our home.

D: Good.What did the doctor say(or what was the diagnosis)?

P: The doctor said he has nephritis.His blood pressure was normal.There were protein in the urine, “+ +”and“+ + +”.I cannot remember other details.

D: What treatment has he received?

P: He took traditional Chinese medicine for half a month.He also took water tablets(diuretics)when the swelling was very bad, but it did not work.

D: How is his energy and appetite?

P: He looks tired all the time, he feels weak.His appetite is poor and feels nauseated.

D: How is his bowel motion?

P: Yes, as usually.

D: I am going to ask you a few questions relating to his growth and development, then I will examine him and arrange for blood and urine tests.I will then explain to you what is wrong and the treatment options, ok?