Genitourinary: Renal Failure and Bladder Cancer

Overview of Renal Failure and Acute Kidney Injury (AKI)

• Definition of Renal Failure: An emerging term that refers to varying degrees of renal impairment. It involves the inability of the nephrons in the kidneys to perform essential functions, including:

  • Maintaining fluid, electrolyte, and acid-base balances.

  • Removing nitrogenous waste products from the blood.

  • Performing regulatory functions.

• Classification of Renal Failure: There are two primary types:

  • Acute Renal Failure (ARF): Also known as Acute Kidney Injury (AKI).

  • Chronic Renal Failure (CRF): Long-term, progressive loss of function.

• General Etiology: Renal failure develops as a consequence of factors such as:

  • Decreased blood flow to the kidneys.

  • Conditions that directly damage the nephrons.

  • Obstructive disorders that hinder urine outflow.

Acute Renal Failure (ARF/AKI)

• Nature of the Disorder: A complex disorder with numerous etiological factors and variant clinical manifestations.

• Causes and Classifications:

  • Prerenal (Reduced Perfusion): Caused by systemic circulation issues, such as hypovolemic shock or sepsis.

  • Intrarenal (Kidney Tissue Damage): Direct damage to the organ, such as nephrotoxicity or systemic diseases like Lupus.

  • Postrenal (Obstruction to Urine Flow): Obstructions occurring after the kidney, such as an enlarged prostate or kidney stones.

• Biochemical Markers: Rapid accumulation of toxic wastes occurs as the kidneys fail.

  • Serum Urea (BUN): Blood Urea Nitrogen level rises through the breakdown of proteins.

  • Creatinine (CR): A waste product of muscles. Serum creatinine is considered a superior indicator of kidney function compared to BUN.

• Clinical Presentation: The client typically becomes oliguric. Treatment is focused on correcting the underlying cause and preventing permanent damage to the organ.

Four Phases of Acute Renal Failure

• 1. Initiation (Onset): Occurs immediately after the acute injury. Signs and symptoms appear within hours or days. Manifestations include decreased urine output ($U/O$) and alterations in electrolytes.

• 2. Oliguric-Anuric: Characterized by significantly reduced blood flow to the kidneys.

  • Pathophysiology: May lead to Acute Tubular Necrosis (ATN), which is the death of cells in the collecting tubules of the nephrons.

  • Lab Changes: Increased levels of Creatinine ($CR$), Urea ($UR$), Potassium ($K$), and Magnesium ($MG$).

• 3. Diuresis: A phase marked by a gradual increase in urine output as glomerular filtration begins to recover.

  • Clinical Note: The client remains uremic because the kidneys are not yet able to concentrate urine effectively, leading to a continued buildup of waste products in the blood despite high fluid loss.

• 4. Recovery: The return of normal renal function. This phase can take anywhere from $3-12\,months$.

Medical and Surgical Management of ARF

• Preventative Measures:

  • Ensure adequate hydration.

  • Promptly treat shock and hypotension.

  • Promptly treat infections.

• Medical Interventions:

  • Treat the primary cause to limit damage and ensure perfusion of the renal arteries.

  • IV Therapy: Fluid management using intravenous fluids.

  • Dialysis: Utilization of Hemodialysis or Peritoneal dialysis.

  • Dietary Restrictions: Individualized based on dialysis use. Includes low or high protein depending on needs, low Sodium ($Na$), low Potassium ($K$), low Phosphorus, increased Calcium ($Ca$), and decreased fat if hyperlipidemia is present.

  • Anemia Correction: Supplementation with iron and vitamins.

• Surgical Management: Kidney Transplantation.

Potential Nursing Diagnoses and Interventions

• Excess Fluid Volume: Monitor intake and output ($I\&O$), daily weight, and lung sounds. Administer prescribed diuretics and antihypertensives.

• Imbalanced Nutrition: Assess nutritional and fluid status. Provide small, frequent meals and supplements (iron, calcium, Vitamin D). Reinforce dietary restrictions.

• Risk for Impaired Skin Integrity: Maintain skin and mucous membrane integrity. Provide frequent mouth care (post-meals and every $4\,hours$). Limit bathing to $30\,minutes$ using lukewarm water. Use emollients and advise against scratching.

• Activity Intolerance: Schedule rest periods between activities.

• Risk for Infection: Monitor vital signs every $4\,hours$. Monitor for signs/symptoms of infection. Restrict contact with infectious individuals. Perform catheter and perineal care every shift.

• Risk for Electrolyte Imbalances: Monitor cardiac rhythm and electrolyte levels. Assess for signs and symptoms of specific imbalances.

• Risk for Ineffective Coping: Provide emotional support and counseling.

Chronic Renal Failure (CRF/CKD)

• Definition: Severe, permanent damage where kidneys can no longer adequately remove protein by-products and electrolytes, maintain acid-base balance, maintain bone calcification, or produce erythropoietin (essential for Red Blood Cell production).

• Pathophysiology: As nephrons are destroyed, remaining undamaged nephrons increase their work capacity to compensate. Clients may show no signs/symptoms until $50\%$ of nephron function is lost.

• Stages of CKD:

  • Renal Insufficiency: Occurs when $75\%$ of nephron function is lost.

  • End-Stage Renal Disease (ESRD): Level 5 CKD, occurring when $85-90\%$ of nephrons are destroyed.

• Causes: Diabetes Mellitus ($DM$), hypertension, glomerulonephritis, polycystic kidney disease, autoimmune diseases, and drug-induced damage.

• Labs in CKD: Elevated BUN and Creatinine, Hyponatremia (low sodium), Hyperkalemia (high potassium), Hypocalcemia (low calcium), and metabolic acidosis.

CKD Classification by GFR and Function

• Stage 1: Kidney damage with normal function; $GFR \ge 90$ ($90-100\%$ function).

• Stage 2: Kidney damage with mild loss of function; $GFR = 89-60$ ($89-60\%$ function).

• Stage 3a: Mild to moderate loss of function; $GFR = 59-45$ ($59-45\%$ function).

• Stage 3b: Moderate to severe loss of function; $GFR = 44-30$ ($44-30\%$ function).

• Stage 4: Severe loss of function; $GFR = 29-15$ ($29-15\%$ function).

• Stage 5: Kidney failure; GFR < 15 (<15\% function).

Systemic Assessment Findings in CKD

• Integumentary: Uremia leads to "uremic frost" as the skin becomes an excretory organ; pruritus (itching) caused by calcium-phosphate deposits.

• Hematological: Anemia, bleeding tendencies, higher risk of infection and cancer.

• Cardiovascular (CV): Cardiovascular disease is the leading cause of death. Complications include hypertension, fluid overload, Congestive Heart Failure ($CHF$), and Left Ventricular Hypertrophy ($LVH$).

• Urinary: Patterns vary from polyuria to oliguria and eventually anuria.

• Respiratory: Dyspnea and pulmonary edema.

• Gastrointestinal (GI): Ulcerations, stomatitis, and uremic fetor (breath smelling of urine).

• Neurological: CNS depression, lethargy, fatigue, apathy, irritability, and altered mental ability.

• Musculoskeletal: Bone disorders, bone pain, and muscle cramps.

• Reproductive: Infertility, decreased libido, and impotence.

• Endocrine: Hypothyroidism is common.

Dialysis Procedures

• Definition: A procedure that filters and cleans the blood, substituting for lost kidney function.

• Hemodialysis:

  • Involves transporting blood through a machine containing a dialyzer (semipermeable membrane filter).

  • Vascular Access: Requires Arteriovenous fistulas ($AVFs$), grafts ($AVGs$), or central venous catheters (internal jugular or subclavian).

  • AVF: Preferred method; a surgical connection between an artery and vein in the forearm. Created $3-4\,months$ before use to allow the vein to become larger/muscular.

  • Duration: Typically $3-5\,hours$ per treatment, at least $3\times/week$.

  • Complications: Hypotension, muscle cramps, blood loss, hepatitis, sepsis, and Disequilibrium Syndrome (monitored via Level of Consciousness/$LOC$).

• Peritoneal Dialysis:

  • Uses the peritoneum (lining of the abdomen) as the semipermeable membrane.

  • Procedure: A catheter is inserted into the peritoneal cavity and filled with commercial dialysis solution (dialysate).

  • Exchange Phases: Inflow, Dwell, and Drain. One cycle is an "exchange" ($4-6\,times/day$).

  • Complications: Exit-site infections, peritonitis, abdominal pain, hernias (umbilical/inguinal), outflow issues, lower back problems, bleeding, pulmonary complications, and protein loss.

Nursing Care During Dialysis

• Assessment: Check weight, Blood Pressure ($BP$), peripheral edema, heart sounds, and lung sounds.

• Monitoring: Vital signs every $30-60\,minutes$. Monitor the condition of the vascular access.

• Interventions: Provide blankets if the patient is cold. If hypotension occurs, elevate the patient's feet and slow the dialysis rate.

Glossary of Urinary Assessment Abnormalities

• Anuria: Technically no urination; output is <100\,mL in $24\,hours$. Related to ARF, ESRD, or bilateral obstruction.

• Dysuria: Painful or difficult urination.

• Oliguria: Diminished urine amount; output is $100-400\,mL$ in $24\,hours$. Related to dehydration, shock, or kidney disease.

• Polyuria: Large volumes of urine in a given time. Related to Diabetes Mellitus, Chronic Renal Failure (early stages), or diuretics.

• Hematuria: Blood in the urine. Potential sign of cancer, stones, trauma, or UTI.

• Retention: Inability to urinate despite the bladder being full.

• Nocturia: Frequency of urination at night.

• Urgency: Strong desire to urinate immediately.

• Pneumaturia: Passage of urine containing gas; indicates fistula between bowel and bladder.

Bladder Cancer

• Pathology: Most common malignant tumor is transitional cell carcinoma.

• Risk Factors: Cigarette smoking (primary), environmental carcinogens, recurrent UTIs, stones, high urinary pH, high cholesterol, and pelvic radiation.

• Clinical Manifestations:

  • Visible but painless hematuria (most common).

  • Bladder irritability (dysuria, frequency, urgency).

  • Change in urinary patterns.

  • Pelvic or back pain (signals metastasis).

• Diagnosis: Urine cytology, confirmed with cystoscopy and biopsy.

• Management:

  • Surgical: Transurethral resection, cystoscopy.

  • Pharmacologic: Opioid analgesics, stool softeners.

  • Therapy: Chemotherapy (Methotrexate, BCG), Radiation.

• Nursing Notes: Address fears, monitor urine color post-op, encourage smoking cessation, and recommend sitz baths ($15-20\,minutes$ several times daily) for muscle relaxation.

Urinary Diversion Devices

• Urinary Catheter: Requires keeping the bag lower than the bladder and using proper lubrication to prevent trauma.

• Suprapubic Catheter: Inserted through the abdominal wall into the bladder; clamped to test voiding ability once an obstruction is resolved.

• Nephrostomy Tube: A tube inserted from the kidney pelvicals directly to the outside of the abdomen.

• Ileoconduit: Ureters are implanted into a $12\,cm$ loop of the ileum, which is brought to the abdominal surface as a urostomy. Stents are used initially to prevent occlusion.

• Indiana Pouch: A segment of ileum and cecum is used to create a reservoir; urine is drained by inserting a catheter into the stoma.

• Kock Pouch: A continent ileal urinary diversion using an isolated segment of small bowel with a valve mechanism. Can be modified in males to attach to the urethra.

• Ureterosigmoidostomy: Ureters are introduced into the sigmoid colon, allowing urine to flow out via the rectum.

• Vesicostomy: The bladder is sutured to the abdominal wall, creating a stoma for drainage.