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Chapter 13: Haematuria and other urinary symptoms

CHRIS MILNE; PAUL BLAZEY

INTRODUCTION

The doctors told me I would never run again, [but] I’m back running. They told me I would be on dialysis for the rest of my life, but I’m not. I had a kidney transplant, it was successful and I’m back doing what I love. So, if you just stay positive and stay focused on something you really want to achieve, you will do amazing things.

Aries Merritt, 110-metre hurdles world record holder

The kidneys are important but often neglected organs. Exercise can have significant effects on renal function. The most serious renal problem associated with exercise is rhabdomyolysis. Other common renal problems include post-exercise protein/haemoglobinuria and non-steroidal anti-inflammatory drug (NSAID)–induced renal dysfunction. Renal trauma may also be the result of a sports-related abdominal injury or trauma. There have been some well-documented cases of renal disease in athletes at the very top of their professions, including Jonah Lomu, the New Zealand rugby union star, and Aries Merritt, the US 2012 Olympic gold medallist in the 110-metre hurdles. Their stories are considered in case studies later in this chapter.

CLINICAL ANATOMY AND PHYSIOLOGY

Ordinarily, the kidneys are paired organs that lie under well-developed flank muscles.1, 2 Kidneys receive high blood flow (approximately 20% of the total cardiac output at rest) and are composed of metabolically active cells. These cells are susceptible to hypoxia and tolerate this poorly. The tubular arrangement within the kidney uses a countercurrent mechanism to produce hypertonic urine.

The four major functions of kidneys are:

  • to maintain salt and water balance

  • to excrete nitrogen, mainly as urea

  • to produce erythropoeitin and the vitamin D metabolite 1,25-dihydroxycholecalciferol

  • to regulate blood pressure via the renin-angiotensin-aldosterone system.

Normal values for renal function at rest and with exercise are listed in Table 13.1.

Table 13.1Renal function—normal values
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Table 13.1 Renal function—normal values
  At rest During exercise
Renal blood flow mL/min 1200 300
Glomerular filtration rate (GFR) mL/min 120 60
Concentrating ability:

  • Urine osmolality 100–1200 mOsmol/kg water

  • Serum osmolality 280–295 mOsmol/kg water

  • Daily urine volume 400–4000 mL

  • Obligatory water loss 840 mL*

*Assumptions:

  • For each 3 g of protein ingested, about 1 g of urea will be produced.

  • 1 g of urea equals approximately 17 mmol.

  • Urine osmolality can be up to three times that of plasma.

It follows that 120 g of protein ingested per day provides 40 g of urea for excretion. This is about 680 mmol. At a urine osmolality three times that of plasma, 840 mL of obligatory water loss per day is required to excrete that nitrogen.

During exercise, physiological changes that have been observed are:

  • increased glomerular permeability

  • increased excretion of red blood cells and protein into the ...

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