Renal 321

What is the function of the glomerulus?

* Creates urine formation by filtering blood
* Rate of 125 ml/min

What is the tubular function?

1. Reabsorption and secretion
2. Eliminate unnecessary substances
3. Acid Base balance, electrolytes

What are other functions of the kidneys?

* RBC formation → Erythropoietin
* BP regulation → Renin
* Vitamin D activation for metabolism and calcium balance
* Prostaglandin synthesis
* Acid base, electrolyte, water balance

How much does the bladder hold and how much will it cause urge to pee?

* 600-1000 mls
* 200-250 mls

Kidneys will decrease in function due to what?

* Age
* Size
* Renal blood flow due to artherosclerosis
* Decreased ability to concentrate urine
* Enlarged prostate
* Loss of elasticity and muscle tone

What is polycystic kidney disease?

* Genetic disease that causes large cysts

Where does polycystic kidney disease occur?

* In the cortex and medulla of both kidneys

What are clinical manifestations of polycystic kidney disease?

* Hypertension
* Headaches
* Hematuria
* Pain
* Symptoms of UTI or Renal Calculi
* Enlarged kidneys

How to diagnose Polycystic Kidney Disease?

* Family history of PKD
* Ultrasound, CT scan, MRI of abdomen
* Monitor BUN and Creatinine, UA and C/S

How to manage Polycystic Kidney Disease?

* Treat and prevent urinary infections
* HTN and pain management
* Diet modifications and fluid restrictions
* Genetic counseling; patient and family support

How would you treat end stage Kidney Disease?

* Dialysis
* Nephrectomy
* Kidney transplant

What is glomerulonephritis?

* Immune related antibody induced response
* Inflammation of glomeruli and blood vessels
* Destruction of renal tissue

What are risk factors of glomerulonephritis?

* Infections
* Immune diseases
* Vasculitis
* Diabetic nephropathy
* Hypertension
* Amyloidosis
* Drug use

What is Acute Poststreptococcal Glomerulonephritis (APSGN)?

* Glomerulonephritis that occurs after a strep infection

What are clinical manifestations of Acute Poststreptococcal Glomerulonephritis (APSGN)?

* Hypertension
* Oliguria
* Hematuria w rusty or smoky appearance
* Abdominal or flank pain
* Edema

How would you diagnose Acute Poststreptococcal Glomerulonephritis (APSGN)?

* ASO titers
* UA and Urine sediment microscopy
* Shows presence of **erythrocyte casts and proteinuria**, serum BUN and creatinine

How to manage Acute Poststreptococcal Glomerulonephritis (APSGN)?

* Symptom relief (anti HTN, dietary restrictions)
* Adequate rest
* Antibiotics → PCN

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Most fully recover but can lead to chronic glomerulonephritis or end-stage renal disease

What is renal trauma?

* Trauma to the abdomen, pelvis, back, or kidneys
* Blunt force trauma or penetrating trauma

What group of people is most common for renal trauma?

Men less than 30 yrs old

What are clinical manifestations of renal trauma?

* Pain in abdomen, back or flank
* Hematuria
* Ecchymosis
* Trauma at kidneys

What diagnostic studies would you use for renal trauma?

* Urinalysis
* CT scan
* MRI
* Renal arteriography

How would you treat renal trauma?

* Stabilize the patient
* Depends on the patient
* Rest
* Pain control
* Fluids
* Surgery (Kidney repair or nephrectomy)

What would you monitor w renal trauma?

* Vital signs
* Cardiac status
* Renal status
* Hemodynamic status
* Patient monitoring

What are risk factors of renal tumors (cancer)?

* Smoking
* Family history of renal cancer
* Obesity
* HTN
* Environmental exposure to asbestos
* Cystic kidney disease

What are early clinical manifestations of renal tumors?

No symptoms

What are clinical manifestations of renal tumors?

* **Hematuria**
* **Flank Pain**
* **Palpable mass in abdomen or flank**
* Hypertension
* Weight loss
* Anemia

How would you diagnose renal cancer?

* CT scan
* Renal ultrasound
* MRI
* Biopsy → to stage disease

What are treatments for renal cancer?

* Surgery (partial or radical nephrectomy)
* Immunotherapy or targeted biologic therapies
* Emotional support
* Symptom management

Where do lower UTI infections affect and what can they turn to?

* Bladder or Urethra
* Urethritis (caused by STDs)
* Cystitis (inflammation of bladder)

Where do upper UTI infections affect and what can they turn to?

* Renal parenchyma, pelvis, ureters
* Acute pyelonephritis
* Begins in renal medulla and spreads to cortex
* Chronic pyelonephritis
* Loss of kidney functions can occur due to scarring

What can UTIs lead to?

Urosepsis (severe reaction to infection)

What are uncomplicated UTI’s?

* Urinary tract infection involving only the bladder
* Occurs in a normal urinary tract
* Ex. Single UTI

What are complicated UTI’s?

* UTI that occurs with:
* Obstruction, stones, or catheter
* Neurological Diseases, Diabetes, Kidney disease
* Pregnancy induced changes
* Recurrent infection
* At risk for pyelonephritis, renal damage, and urosepsis

What can cause UTI’s?

* Bacteria: E coli most common
* HAUTI, CAUTI
* Fungal or parasite (less common; associated w immunosuppression)

What are risk factors for UTI’s?

* Female
* Urinary Stasis
* Foreign Bodies → Catheter, calculi, instrument
* Anatomical Factors → Congenital defects, obesity, fistula
* Compromised immune response → aging/HIV/DM
* Functional disorders→ voiding dysfunction, constipation
* Pregnancy, menopause, sex, poor hygiene, holding piss, use of diaphragm or spermicidal agents

What are clinical manifestations of lower UTI’s?

* Dysuria
* Frequent urination
* Urgency
* Suprapubic pressure
* Hematuria
* Cloudy urine
* Sediment in urine

What are clinical manifestations of Upper UTI’s?

* Lower UTI symptoms
* Flank pain
* Nausea and vomiting
* Fever
* Chills

What are clinical manifestations of UTI’s in older adults?

* Generalized abdominal discomfort
* Change in mental status, cognitive impairment, or clinical deterioration

How would you diagnose UTI’s?

* Urinalysis and Urine culture
* CBC
* Costovertebral tenderness
* Intravenous pyelogram, CT scan or renal ultrasound

What are drug therapies for UTI’s?

* Pyridium: Urinary analgesic for pee pain
* Bactrim for uncomplicated UTI’s
* Fluoroquinolones for complicated UTI’s
* Preventative dosing of bactrim

What are nursing interventions for UTI’s?

* Adequate fluids/hydration (PO, IV)
* Localized heat
* Patient teaching
* Avoid caffeine, alcohol, citrus fruit, chocolate, spicy foods
* Watch for changes in patient

How to prevent UTI’s?

* Proper emptyting
* Normal bowel movements
* Proper oral fluid intake
* Proper handwashing
* Sterile technique
* Perineal hygiene

What are the causes of nephrolithiasis/urolithiasis?

* Metabolic factors
* Warm climates
* Low fluid intake/dehydration
* Sedentary lifestyles/Immobility
* UTIs
* Diet
* Genetics

What are clinical manifestations of nephrolithiasis/urolithiasis?

* Sharp pain of abdomen/flank
* Nausea and vomiting
* Hematuria
* Fevers
* Chills

What diagnostic studies are used for nephrolithiasis/urolithiasis?

* Urinalysis and C/S
* Serum BUN
* Creatinine
* Electrolytes
* CT scan or Ultrasound
* Analysis of calculi

What are treatments for nephrolithiasis/urolithiasis?

1. Treat symptoms, infection, and obstruction
2. Treat the cause and prevent recurrence
3. Endourologic procedures

What are types of Urinary tract calculi?

* **Calcium oxalate**
* **Calcium phosphate**
* Uric acid
* Cystine
* Struvite (magnesium ammonia phosphate)

What are nursing interventions for Urinary Tract Calculi?

* Encourage fluid intake
* Drug therapy or dietary restriction based on composition of the calculi

What food to avoid with purine (uric acid) calculi?

* High: Sardines, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads
* Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham

What food to avoid with Calcium calculi?

* Milk, cheese, ice cream, yogurt, sauces w milk, ovaltine
* All beans (except green), lentils
* Fish w fine bones (sardines, kippers, herring, salmon)
* Dried fruits, nuts, chocolate, cocoa

What food to avoid with oxalate calculi?

* Dark roughage (fiber), spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, runner beans
* Chocolate, cocoa, instant coffee, ovaltine, tea, worcestershire sauce

What is lithotripsy?

* Shockwave that shocks calculi to become smaller

What is Percutaneous nephrolithotomy?

Procedure to remove kidney stones through the skin.

What are ureteral strictures?

* Narrowing of the lumen of the ureter from scarring or adhesions from surgery/tumor or cysts

What are clinical manifestations of ureteral strictures?

* Mild to moderate colicky pain
* Decreased output
* Signs and symptoms of infection if stent/nephrostomy is obstructed

How would you diagnose ureteral strictures?

* Intravenous pyelogram or renal ultrasound

What is treatment for ureteral strictures?

* Dilation or stent placement
* Nephrostomy tube
* Ureteral surgery

What are urethral strictures?

* Narrowing of the lumen of urethra
* Results from fibrosis or inflammation

What causes urethral strictures?

* Trauma
* Infection
* Congenital defect
* Repeated catheterizations
* Meatal stenosis

What are clinical manifestations of urethral strictures?

* Decreased stream of urine
* Straining to urinate
* Spraying stream of urine
* Dribbling of urine after voiding
* Incomplete emptying
* Frequency

What are nephrostomy tubes?

Drainage tube inserted directly into the kidney

For removal of urine

How to care for nephrostomy tubes and other tubes?

* Ensure unobstructed drainage
* Irrigate as ordered
* Skin care to insertion site

Who are at risk for bladder tumors?

* Men (60-70)
* **Smoking**
* Exposure to dyes (in rubber)
* Women treated with cervical radiation
* Chronic renal calculi and UTI’s

What are clinical manifestations of bladder tumors?

* **Hematuria**
* Bladder irritation
* Dysuria
* Frequency and urgency

What are diagnostic studies of bladder tumors?

* Urine specimen (epithelial cells)
* Ultrasound
* CT scan
* MRI
* Cystoscopy w biopsy

How to treat bladder tumors?

Surgery (TURBT or cystectomy)

Urinary Diversion

Radiation

Chemotherapy and intravesical therapy

What is incontinent urinary diversion?

* Urinary diversion comes to the skin via a stoma or small opening
* Ileal conduit is most common

What are ileal conduits?

* most common urinary diversion
* Part of ileum made into a piss channel
* Non reversible

What are continent urinary diversions?

* Part of bowel made into reservoir
* Patient or RN must catheterize every 4-6 hrs
* Ex. Kock, Mainz, Indiana, Florida Pouches

What is Orthotopic Neobladder?

* Creation of new bladder from bowel
* Eliminates urine via urethra

What are disadvantages of Orthotopic Neobladder?

* Incontinence at times
* Need to self cath

What is acute kidney injury?

* Rapid loss of kidney function
* Occurs within hours to days
* Slight deterioration in kidney function to severe impairment with azotemia

How will the labs be with acute kidney injury?

* Increased:
* BUN
* Creatinine
* Potassium
* Reduces urine output (oliguria)

How does acute kidney injury occur?

* Occurs after severe, prolonged hypotension, hypovolemia, or exposure to nephrotoxic medications
* Prerenal, Intrarenal, Postrenal

What can cause acute prerenal kidney injury?

* Factors **external** to the kidney which decreases blood flow to or within the kidneys
* MI, Heart failure, decreased cardiac output
* Hypovolemia, Severe dehydration, hemorrhage, or burns
* Anaphylaxis, thrombosis

What can prerenal acute kidney injury do?

* Decrease Glomerular filtration rate
* Prerenal oliguria → no damage to kidneys
* Caused by decrease in circulating blood volume
* Autoregulatory mechanisms attempt to preserve blood flow to essential organs

What is Intrarenal (intrinsic) acute kidney injury caused by?

* Caused by conditions that cause direct damage to kidney tissue, resulting in impaired function of nephrons

What are symptoms of intrarenal acute kidney damage?

* Acute Tubular Necrosis (ATN) → Most common
* Results from ischemia, nephrotoxins, acute glomerulonephritis
* Prolonged ischemia, nephrotoxins, acute glomerulonephritis, hemoglobin from hemolyzed RBCs, or myoglobin released from necrotic muscle tissue
* IV contrast dye

What causes postrenal acute kidney injury?

* Caused by mechanical obstructions which block the flow of urine out of the kidney
* BPH
* Prostate Cancer
* Renal calculi
* Extrarenal tumors
* Trauma
* Complication of urinary obstruction → hydronephrosis

What are phases of kidney injury?

1. Initiating phase
2. Oliguric phase
3. Diuretic phase
4. Recovery phase

What is the initiating phase of acute kidney injury?

1st phase: Kidney injury

What is the oliguric phase of acute kidney injury?

* 2nd Phase
* Presence of oliguria → Decreased urine output

What is the diuretic phase of acute kidney injury?

* 3rd phase of acute kidney injury
* Increased urine output (but nephrons not fully functional yet)
* May last 1-3 weeks

What is the recovery phase of acute kidney injury?

* 4th phase of acute kidney injury
* GFR increases but allows BUN/Creatinine to stabilize and then decrease
* May take up 1 year for kidney function to fully stabilize
* Can progress to CKD

What are diagnostic studies for acute kidney injury?

* Urinalysis, urine osmolality, urine sodium, urine specific gravity
* BUN and creatinine
* Serum electrolytes
* ABGs
* Renal ultrasound; CT scan or MRI
* Renal biopsy if intrarenal lesions

How would you treat AKI?

* Manage s/s of metabolic acidosis, hyperkalemia, and hypervolemia
* Monitor intravascular volume
* Monitor I&Os
* Nutritional Therapy
* Determine indications for dialysis
* Daily weights
* Prevent infection
* Skin and mouth care
* ID high risk meds, treat hypovolemia, and hypotension immediately

What is chronic kidney disease (CKD)?

* Progressive, irreversible loss of kidney function
* Presence of kidney damage
* Decreased GFR (and increased BUN/Creatinine)

What is stage 4 and 5 of chtonic kiney disease?

Stage 4: 15-29 Prepare for dialysis

Stage 5:

What are some other causes of end-stage kidney disease (ESKD) and chronic kidney disease?

* Nephrosclerosis
* Diabetic nephropathy

What is nephrosclerosis?

* Cause of End-stage kidney disease (ESKD)/Chronic renal disease)’
* Sclerosis of small arteries and arterioles of the kidney
* Results in decreased renal blood flow
* Causes ischemia and necrosis

What are risk factors of nephrosclerosis?

* Hypertension
* Atherosclerosis

How would you treat and diagnose nephrosclerosis?

* Diagnosis: Hypertension screening
* Treatment: Control of hypertension

What are complications of nephrosclerosis?

Renal insufficiency/Renal failure

Death

What is diabetic nephropathy?

* Damage of small blood vessels which supply the glomeruli

What are risk factors of diabetic nephropathy?

* Hypertension, smoking, and controlled DM or chronically high blood sugars

What are diagnosis and treatements for diabetic nephropathy?

* Diagnosis: Urine for albumin and creatinine; serum creatinine
* Treatment: glucose and hypertension control
* Accu Checks (4 times a day)
* ACE inhibitor and losartan (Cozaar)

What are clinical manifestations of CKD?

* Decreased urine output
* Waste product accumulation
* Altered blood sugars
* Fluid overload
* Metabolic acidosis
* Anemia
* Bleeding tendencies
* Infection
* Wt. loss/malnutrition
* CKD mineral and bone disorder
* Infertility
* Psychological changes
* CV disease: Elevated Triglycerides, HTN, dysrhythmias, effusions, pericardititis

How to treat chronic kidney disease?

* Prevention: Early identification of CKD to slow progression
* Treatment:
* **Preserve existing renal function, decrease CV risks, and provide comfort**
* Treat CV disease
* Prevent complications by treating symptoms
* Dialysis
* Kidney transplant if appropriate

What are drug therapies for chronic kidney disease?

* Drugs for:
* Hyperkalemia
* Hypertension
* CKD-MBD (osteodystrophy)
* Anemia
* Dyslipidemia
* Fluid overload

What are nutritional therapies for chronic kidney disease?

* Concern w protein
* Normal protein often allowed w avoidance of high protein diets/supplements
* Fluid restrictions
* Gain no more than 1-3kg between dialysis treatements
* Monitor weights
* Sodium and potassium restrictions
* Phosphate restrictions
* Can also give phosphate binder with meals sevelamer