Alterations of Renal and Urinary Tract Function Chapter 36 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

2 Urinary Tract Obstruction  Blockage of urine flow within the urinary tract  Obstruction can be caused by an anatomic or functional defect Obstructive uropathy Obstructive uropathy  Severity based on: Location Location Completeness Completeness Involvement of one or both upper urinary tracts Involvement of one or both upper urinary tracts Duration Duration Cause Cause

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Urinary Tract Obstruction  Hydroureter  Hydronephrosis  Tubulointerstitial fibrosis  Apoptosis

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Urinary Tract Obstruction

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Urinary Tract Obstruction  Compensatory hypertrophy  Obligatory growth  Compensatory growth  Postobstructive diuresis  Low bladder wall compliance

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Kidney Stones  Other factors affecting stone formation  Crystal growth–inhibiting substances  Particle retention  Matrix  Stones  Calcium oxalate or calcium phosphate  Struvite stones  Cystinuric stones  Uric acid stones  Indinavir

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Kidney Stones  Manifestation  Renal colic  Evaluation  Stone analysis  Kidney-ureter-bladder (KUB)  Intravenous pyelogram  Spiral abdominal computed tomography (CT)  Treatment  Stone removal

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 8 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

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Kidney Stones: Calculi  Masses of crystals, protein, or other substances that form within and may obstruct urinary tract  Risk factors  Male  Age years  Inadequate fluid intake (biggest contributor)  Living in desert or tropical region Temperature, humidity, fluid, and dietary patterns Temperature, humidity, fluid, and dietary patterns

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Kidney Stones: Calculi  Composition of mineral salts  Calcium oxalate/phosphate (70%-80%)  Struvite (magnesium, ammonium, phosphate, 15%)  Uric acid (7%)

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Lower Urinary Tract Obstruction  Bladder neck dyssynergia  Prostate enlargement  Urethral stricture  Severe pelvic organ prolapse

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Lower Urinary Tract Obstruction  Neurogenic bladder  Neurogenic detrusor overactivity Detrusor sphincter dyssynergia Detrusor sphincter dyssynergia Overactive bladder syndrome Overactive bladder syndrome  Obstruction  Low bladder wall compliance

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Neurogenic Bladder

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Tumors  Renal tumors  Renal adenomas  Renal cell carcinoma  Bladder tumors  Papillary tumors  Nonpapillary tumors  Metastasis to lymph nodes, liver, bone, lungs

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Urinary Tract Infection (UTI)  Inflammation of the urinary epithelium following invasion and colonization by some pathogen within the urinary tract  Complicated UTI  Uncomplicated UTI  Persistent UTI  Interstitial cystitis

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Urinary Tract Infection (UTI)  Most common pathogens  Escherichia coli  Staphylococcus saprophyticus  Enterobacter spp  Virulence of uropathogens  Host defense mechanisms

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Urinary Tract Infection (UTI)  Cystitis  An inflammation of the bladder  Manifestations Frequency, dysuria, urgency, and lower abdominal and/or suprapubic pain Frequency, dysuria, urgency, and lower abdominal and/or suprapubic pain  Treatment Antimicrobial therapy, increased fluid intake, avoidance of bladder irritants, urinary analgesics Antimicrobial therapy, increased fluid intake, avoidance of bladder irritants, urinary analgesics

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 18Pyelonephritis  Acute pyelonephritis  Acute infection of the ureter, renal pelvis, and/or renal parenchyma  Contributing factors Cystitis Cystitis Urinary tract obstruction with reflux infection Urinary tract obstruction with reflux infection Women are 5 times more likely to develop pyelonephritis Women are 5 times more likely to develop pyelonephritis

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Pyelonephritis  Clinical manifestations  Flank pain  Fever  Chills  Costovertebral tenderness  Purulent urine  Treatment  Chronic pyelonephritis

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Glomerular Disorders  Glomerulopathies are disorders that directly affect the glomerulus  Urinary sediment changes  Nephrotic sediment  Nephritic sediment  Sediment of chronic glomerular disease

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Glomerular Disorders  Glomerular disease has sudden or insidious onset of hypertension, edema, and an elevated blood urea nitrogen (BUN)  Decreased glomerular filtration rate  Elevated plasma creatinine, urea, and reduced creatinine clearance  Glomerular damage causes decreased glomerular membrane surface area, glomerular capillary blood flow, blood hydrostatic pressure

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Glomerular Disorders  Increased glomerular capillary permeability and loss of negative ionic charge barrier result in passage of plasma proteins into the urine  Resulting hypoalbuminemia encourages plasma fluid to move into the interstitial spaces  Edema

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 23 Glomerular Disorders  Glomerulonephritis  Inflammation of the glomerulus Immunologic abnormalities (most common) Immunologic abnormalities (most common) Drugs or toxins Drugs or toxins Vascular disorders Vascular disorders Systemic diseases Systemic diseases Viral causes Viral causes

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 24 Acute Glomerulonephritis  Pathophysiology  Formation of immune complexes (antigen/antibody) in the circulation with subsequent deposition in glomerulus  Antibodies produced against the strep organism cross-react with the glomerular endothelial cells (may be related to inadequately treated strep)  Activation of complement  Recruitment/activation of immune cells and mediators

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 25 Glomerulonephritis

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 26 Glomerulonephritis  Acute poststreptococcal glomerulonephritis  IgA nephropathy (Berger disease)  Crescentic glomerulonephritis  Membraneous nephropathy  Membranoproliferative glomerulonephritis  Antiglomerular basement membrane disease (Goodpasture syndrome)  Chronic glomerulonephritis

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 27 Glomerulonephritis

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Acute Glomerulonephritis  Decreased GFR  Decreased glomerular perfusion (glomerular blood flow) due to inflammation  Glomerular sclerosis (scarring)  Thickening of the glomerular basement membrane (but increased permeability to proteins)

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 29 Clinical Manifestations of Acute Glomerulonephritis  Hematuria  Smoky, brown-tinged urine  Red blood cell casts  Proteinuria  Low serum albumin  Edema  Eventual oliguria  Oliguria: urine output <30 ml/hour or <400 ml/day

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 30 Nephrotic Syndrome  Excretion of 3.5 g or more of protein in the urine per day  Protein excretion is due to glomerular injury  Findings  Hypoalbuminemia, edema, hyperlipidemia, and lipiduria

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Causes of Nephrotic Syndrome  Glomerulonephritis  Genetic defects that alter the glomerular membrane  Systemic diseases (diabetes, SLE)  Drug/toxin injury  Infections (especially chronic and/or recurrent)

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 32 Nephrotic Syndrome

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Renal Dysfunction  Renal insufficiency  Renal failure  End-stage renal failure  Uremia  Azotemia

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 34 Renal Failure  Acute  Sudden and rapidly progressive within hours (often reversible); abrupt reduction in renal function  Chronic  Chronic, slowly progressing to end-stage renal failure over months or years

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Renal Failure  Azotemia: increased urea and frequently creatinine levels  Uremia: elevated urea and creatinine levels with fatigue, anorexia, nausea, vomiting, diarrhea, weight loss, pruritus, edema, neurologic changes (all related to retention of toxic wastes, deficiency states, and electrolyte disorders)

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 36 Prerenal ARF  Most common cause of ARF  Caused by impaired renal blood flow (sudden reduction of perfusion to the kidneys)  GFR declines due to the decrease in filtration pressure (results in oliguria)  Ischemia leads to hypoxic injury and acute tubular necrosis (ATN)

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 37 Intrarenal ARF  Damage to the renal parenchyma  ATN (most common cause) Postischemic Postischemic Nephrotoxic injury Nephrotoxic injury  Corticol necrosis  Acute glomerulonephritis  Vascular disease (i.e., malignant hypertension)  Toxic injury (drugs, such as antibiotics; nephrotoxins)

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 38 Postrenal ARF  Occurs with urinary tract obstructions that affect the kidneys bilaterally and increase the intraluminal pressure upstream (thus a fall in GFR)  Prostatic hypertrophy  Bladder outlet obstruction  Bilateral ureteral obstruction

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 39 Clinical Manifestations of ARF  Oliguria/anuria  Elevated BUN and creatinine  Hyperkalemia  Metabolic acidosis  Hypertension (volume overload)

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 40 Acute Renal Failure (ARF)  Initiation phase  Maintenance phase  Recovery phase

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 41 Chronic Renal Failure  The irreversible loss of renal function that affects nearly all organ systems  Progression  Reduced renal reserve  Renal insufficiency  Renal failure  End-stage renal disease

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 42 Chronic Renal Failure  Creatinine and urea clearance  Sodium and water balance  Phosphate and calcium balance  Potassium balance  Acid-base balance

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 43 Chronic Renal Failure  Skeletal and bone alterations  Cardiopulmonary system  Neural function  Endocrine and reproduction  Hematologic alterations

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 44 Chronic Renal Failure  Immunologic  Gastrointestinal  Integument  Alterations in proteins, carbohydrates, and lipids

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 45 Progression of Chronic Renal Failure  Decreasing renal function  Reduced renal reserve (GFR reduced to 50%)  Renal insufficiency (GFR declines to 25%)  Renal failure: significant loss of function (GFR <20% of normal)  End-stage renal failure (near absence of GFR)

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 46 Reduced Renal Reserve  GFR reduced to 50%  No clinical symptoms  BUN may be elevated

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 47 Renal Insufficiency  GFR reduced to 25%  Compensation of remaining nephrons  Mild clinical symptoms (mild uremia)  Increased BUN/creatinine  Mild anemia  Impaired renal function during stress

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 48 Renal Failure  GFR <20%  Increased BUN/creatinine  Oliguria  Metabolic acidosis  Electrolyte imbalances  Hyperkalemia, hypernatremia  Severe anemia  Increasing uremia and affects nonrenal organs

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 49 End-Stage Renal Disease (ESRD)  GFR = 0%  Severe uremia  Severe water, electrolyte, acid-base imbalances  Multiorgan/multisystem failures

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 50 Multiorgan/Multisystem Failures  Cardiovascular  Hypertension, congestive heart failure Volume overload, hyperactivity of renin system Volume overload, hyperactivity of renin system  Atherosclerosis, stroke, coronary artery disease Dyslipidemia Dyslipidemia  Hematologic  Anemia (lack of erythropoietin)  Platelet defects—bleeding disorders

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 51 Multiorgan/Multisystem Failures  Neurologic  Neuropathies  Encephalopathy  Gastrointestinal  Nausea, vomiting, anorexia  Uremic fetor

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 52 Multiorgan/Multisystem Failures  Endocrine  Insulin resistance  Decreased sex hormones  Metabolic  Altered protein, lipid, carbohydrate metabolism

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 53 Multiorgan/Multisystem Failures  Integumentary, bone, mineral  Hyperphosphatemia  Hypocalcemia  Hyperparathyroidism; brittle bones  Skin changes (bruises, itching, uremic frost, yellowing)  Immune dysfunction  Immunosuppression

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 54 Dialysis or Transplant?  Immediately life threatening: hyperkalemia  Severe uremia and multi-organ effects  Metabolic acidemia