Professor Email mareh@herzing.edu Phone: 404 816-4533 EX: 15141 Dr. Moreen Areh RN, MSN, FNP, DNP Email mareh@herzing.edu Phone: 404 816-4533 EX: 15141

Alterations of Renal and Urinary Tract Function Chapter 30 Alterations of Renal and Urinary Tract Function Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved.

Urinary Tract Obstruction Severity based on: Location Completeness Involvement of ureters and/or kidneys Duration Cause Urinary tract obstruction is an interference with the flow of urine at any site along the urinary tract The obstruction can be caused by an anatomic or functional defect Obstructive uropathy Copyright © 2017, Elsevier Inc. All rights reserved.

Upper Urinary Tract Obstruction Hydroureter Accumulation of urine in the ureter Hydronephrosis Enlargement of the renal pelvis and calyces Ureterohydronephrosis Dilation of both the ureter and the pelvicaliceal system

Upper Urinary Tract Obstruction Kidney stones Calculi or urinary stones Masses of crystals, protein, or other substances that form within and may obstruct the urinary tract(Formation of renal calculi) Risk factors Gender and age Race Geographic location Seasonal factors Fluid intake Diet Occupation Kidney stones are classified according to the minerals that make up the stone Compensatory hypertrophy and hyper-function Obligatory growth Compensatory growth Post-obstructive diuresis Nephrogenic diabetes insipidus

Kidney Stone Formation Supersaturation of one or more salts Presence of a salt in a higher concentration than the volume able to dissolve the salt Precipitation of a salt from liquid to solid state Temperature and pH Growth into a stone via crystallization or aggregation Other factors affecting stone formation Crystal growth- inhibiting substances Particle retention Matrix Stones Calcium oxalate or calcium phosphate Struvite stones Uric acid stones

Kidney Stones Manifestation Renal colic Evaluation Imaging studies 24-hour urinalysis Treatment High fluid intake Decreasing dietary intake of stone- forming substances Stone removal

Lower Urinary Tract Obstruction Neurogenic bladder Dyssynergia Detrusor hyperreflexiad--- overactive Detrusor areflexia---underactive Overactive bladder syndrome (OBS) Frequency, urgency, nocturia Obstruction Urethral stricture, prostate enlargement, pelvic organ prolapse Partial obstruction of bladder outlet or urethra Low bladder wall compliance Tumors Renal tumors Renal adenomas Renal cell carcinoma (RCC) Bladder tumors Transitional cell carcinoma (most common) Gross, painless hematuria Most common in males older than 60 years and smokers

Urinary Tract Infection (UTI) UTI is inflammation of the urinary epithelium caused by bacteria Acute cystitis Painful bladder syndrome/interstitial cystitis Acute and chronic pyelonephritis Most common pathogens Escherichia coli Virulence of uro- pathogens Host defense mechanisms

Urinary Tract Infection (UTI) (Cont.) Acute cystitis Cystitis is an inflammation of the bladder Manifestations Frequency Dysuria Urgency Lower abdominal and/or supra-pubic pain, low back pain Treatment Antimicrobial therapy Increased fluid intake Avoidance of bladder irritants Urinary analgesics Painful bladder syndrome/Interstitial cystitis Nonbacterial infectious cystitis; noninfectious Manifestations Most common in women 20 to 30 years old Bladder fullness, frequency, small urine volume, chronic pelvic pain Treatment No single treatment effective, symptom relief

Urinary Tract Infection (UTI) (Cont.) Pyelonephritis Acute pyelonephritis Acute infection of the ureter, renal pelvis, interstitium Vesicoureteral reflux, E. coli, Proteus, Pseudomonas Chronic pyelonephritis Persistent or recurring episodes of acute pyelonephritis that lead to scarring Risk of chronic pyelonephritis increases in individuals with renal infections and some type of obstructive pathologic condition Copyright © 2017, Elsevier Inc. All rights reserved.

Glomerular Disorders Mechanisms of injury Glomerulonephritis Deposition of circulating soluble antigen-antibody complexes, often with complement fragments (type III hypersensitivity) Antibodies reacting in situ against planted antigens within the glomerulus (type II hypersensitivity– cytotoxic) Nonimmune (drugs, toxins, ischemia) Glomerulonephritis Inflammation of the glomerulus Immunologic abnormalities (most common) Drugs or toxins Vascular disorders Systemic diseases (secondary) Viral causes Manifestations Two major symptoms if severe Hematuria with red blood cell casts Proteinuria exceeding 3 to 5 g/day with albumin (macro-albuminuria) as the major protein Oliguria Hypertension Edema Nephrotic sediment Nephritic sediment

Glomerulonephritis (Cont.) Types Membranous nephropathy/glomerulonephritis Rapidly progressing glomerulonephritis Antiglomerular basement membrane disease (Goodpasture syndrome) Chronic glomerulonephritis Copyright © 2017, Elsevier Inc. All rights reserved.

Nephrotic Syndrome Excretion of 3.5 g or more of protein in the urine per day The protein excretion is caused by glomerular injury Findings Hypoalbuminemia Edema Hyperlipidemia and lipiduria Vitamin D deficiency Membranous glomerulonephritis Focal segmental glomerulosclerosis Minimal change nephropathy (lipoid nephrosis) Nephritic syndrome Common Symptom is Hematuria with RBC casts Mild proteinuria Immune injury

Acute Kidney Injury (AKI) Renal insufficiency Renal failure End-stage renal failure (ESRF) Prerenal Most common cause of ARF Caused by impaired renal blood flow GFR declines because of the decrease in filtration pressure Intrarenal Acute tubular necrosis (ATN) is the most common cause of intrarenal renal failure Post-ischemic or nephrotoxic Oliguria Post-renal Occurs with urinary tract obstructions that affect the kidneys bilaterally

Acute Kidney Injury (AKI) (Cont.) Initiation phase Kidney injury is evolving Prevention of injury is possible Maintenance (oliguric) phase Established kidney injury and dysfunction Urine output is lowest during this phase, and serum creatinine and blood urea nitrogen both increase Recovery (polyuric) phase Injury repaired and normal renal function reestablished Diuresis common Decline in serum creatinine and urea Increase in creatinine clearance

Chronic Kidney Disease (CKD) Progressive loss of renal function that affects nearly all organ systems Associated with HTN, diabetes, intrinsic kidney disease Stages: Normal (GFR >90 mL/min) Mild (GFR 60-89 mL/min) Moderate (GFR 30-59 mL/min) Severe (GFR 15-29 mL/min) End stage (GFR less than 15)

Chronic Kidney Disease (CKD) (Cont.) Proteinuria and uremia Due to glomerular hyperfiltration Damages interstitial tissue of kidney via inflammation Creatinine and urea clearance GFR falls Plasma creatinine increases Fluid and electrolyte balance Sodium and water balance Sodium excretion increases with obligatory water excretion leading to sodium deficit and volume loss Concentration and dilution ability diminishes Potassium balance Tubular secretion increases early Once oliguria sets in, potassium retained Acid-base balance Metabolic acidosis when GFR 30%-40%

Chronic Kidney Disease (CKD) (Cont.) Fluid and electrolyte balance (Cont.) Calcium, phosphate, bone Reduced renal phosphate excretion, decreased renal synthesis of 1,25-(OH)2 vitamin D3 and hypocalcemia Fractures Protein, carbohydrate, fat metabolism Anemia Lethargy, dizziness, and low hematocrit are common Alterations seen in following systems Cardiovascular Pulmonary Hematologic Immune Neurologic Gastrointestinal Endocrine and reproduction Integumentary

Signs and Symptoms of Kidney Failure From Goldman L, Schafer AI: Goldman’s Cecil medicine, ed 24, Philadelphia, 2012, Saunders; redrawn from Forbes CD, Jackson WF: Color atlas and text of clinical medicine, ed 3, London, 2003, Mosby.

Question/Case Study Which of the following is a risk factor for post-obstructive diuresis? Dehydration Hypertension. Unilateral obstruction Neurogenic diabetes insipidus Correct Answer: B Postobstructive diuresis is the rapid elimination of fluid after an obstruction is removed. The risk factors include bilateral obstruction, nephrogenic diabetes insipidus, hypertension, edema, congestive heart failure, and uremic encephalopathy. Neurogenic diabetes insipidus is caused by insufficient amounts of antidiuretic hormone (ADH). Rapid postobstructive diuresis causes dehydration and fluid and electrolyte imbalances.

Acute tubular necrosis Prerenal acute renal failure A patient presents with flank pain and anuria followed by polyuria after undergoing catheterization of the ureters. What is the most likely cause of this condition? Acute tubular necrosis Prerenal acute renal failure Postrenal acute renal failure. Intrarenal acute renal failure Correct Answer: C Postrenal acute renal failure occurs with urinary tract obstruction caused by diagnostic catheterization of the ureters. Prerenal acute renal failure is caused by impaired blood flow. Intrarenal acute renal failure results from acute tubular necrosis that is caused by ischemia, usually after surgery.

Question/Case Study Which of the following is a symptom of chronic renal failure? Hypotension Hypokalemia Hypocalcemia. Hypernatremia Correct Answer: C Chronic renal failure produces hypocalcemia secondary to impaired renal synthesis of vitamin D. Hypertension occurs in chronic renal failure, not hypotension. In chronic renal failure sodium is lost in the urine, producing hyponatremia and potassium is retained, producing hyperkalemia.