Caring For Clients with Disorders of the Kidneys and Ureters

Urologic Disorders General Overview

• The most frequent types of urologic disorders encountered are those involving infectious and inflammatory processes.

• Disorders affecting the kidneys are classified as extremely dangerous because damage to the nephrons can lead to permanent renal dysfunction.

• Upper urinary tract disorders, including kidney stones, ureteral stones, and tumors, carry similar risks for serious consequences.

• Potential outcomes of these conditions include the development of either acute kidney injury or chronic kidney disease.

Gerontologic Considerations for Renal Care

• Causes and Prevalence:

  • Urinary obstruction stands as the most frequent cause of pyelonephritis among older adults.

  • Acute glomerulonephritis in this population typically presents in individuals with preexisting chronic cases, often triggered by streptococcus or gram-negative bacteria.

  • Glomerulonephritis may arise as an immunologic reaction to systemic diseases such as lupus (lupus erythematosus), as immunity declines with age, or due to unknown etiologies.

• Symptomatology:

  • Symptoms in older adults are often subtle and nonspecific, which may lead to the condition going undetected.

  • Key clinical signs include nausea, malaise, arthralgia, and the exacerbation of preexisting illnesses.

  • The initial presentation may also be accompanied by symptoms of heart failure or renal failure.

• Clinical Management and Prognosis:

  • Thorough documentation is essential to monitor for subtle changes in the status of older adults.

  • Older adults face a high risk for acute kidney injury (AKI) due to a natural decline in the glomerular filtration rate ($GFR$), loss of nephrons, and a reduction in the number of glomeruli.

  • The prognosis for AKI in older adults is generally favorable, and treatment protocols do not differ from those used for younger adults.

  • Continuous ambulatory peritoneal dialysis (CAPD) is an appropriate treatment for older clients who are not eligible for kidney transplantation.

  • Care planning must involve the family and caregivers to monitor for sudden or subtle subjective changes indicative of complications.

Acute and Chronic Pyelonephritis

• Definition: Pyelonephritis is a bacterial infection (either acute or chronic) affecting the kidney and the lining of the kidney pelvis.

• Acute Pyelonephritis:

  • Presents with moderate-to-severe symptoms typically lasting $1$ to $2$ weeks.

  • Infections are caused by bacteria ascending through the bladder and urethra.

  • Common pathogens (normal fecal flora) include: Escherichia coli (accounts for approximately $85\%$ of infections), Klebsiella pneumoniae, Proteus mirabilis, Streptococcus fecalis, Pseudomonas aeruginosa, and Staphylococcus aureus.

• Chronic Pyelonephritis: Occurs when treatment for the acute form is unsuccessful and the infection recurs. It is associated with long-term urinary obstruction and reflux.

• Risk Factors for Acute Pyelonephritis:

  • Instrumentation: Urethral and bladder procedures (catheterization, cystoscopy, urologic surgery).

  • Urinary Issues: Inability to empty the bladder, urinary stasis, and obstructions (tumors, strictures, calculi, prostatic hypertrophy).

  • Medical History: Diabetes mellitus, polycystic kidney disease (PKD), and pregnancy.

  • Neurogenic Bladder: Conditions like stroke, multiple sclerosis, or spinal cord injury.

  • Lifestyle (Women): Increased sexual activity, use of diaphragms or spermicides, failure to void after intercourse, and history of recent infections.

  • Lifestyle/Health (Men): Anal intercourse and infection with HIV.

• Risk Factors for Chronic Pyelonephritis:

  • Recurrent episodes of acute infection.

  • Chronic obstructions such as strictures and stones.

  • Reflux disorders where urine flows backward up the ureters.

Assessment and Diagnosis of Pyelonephritis

• Clinical Symptoms:

  • Acute: Flank pain/tenderness, chills, fever, malaise. Frequency and burning occur if cystitis is also present.

  • Chronic: May be asymptomatic or present with low-grade fever and vague GI complaints.

  • Urinary Changes: Polyuria and nocturia occur when tubules fail to reabsorb water; urine may be foul-smelling, cloudy, bloody ($hematuria$), or contain pus ($pyuria$).

• Diagnostic Procedures:

  • Urinalysis: Identifies abnormalities such as pyuria.

  • Urine Culture: Identifies the specific causative microorganism.

  • Ultrasound or CT Scan: Used by primary providers to check for obstructions.

  • Voiding Cystourethrogram (VCUG): X-ray with contrast taken while the bladder is full and during voiding to check for structural abnormalities.

  • KUB X-ray: Views the kidneys, ureters, and bladder for calculi, cysts, or tumors.

  • DMSA Scintigraphy: Uses a small amount of radioactive material to identify infection or scarring as it passes through the kidneys.

  • Lab Tests: Elevated Serum Creatinine and Blood Urea Nitrogen (BUN) indicate impaired function.

• Urinalysis Results Comparison:

  • Acute Findings: Increased leukocytes, bacteria, and bacterial casts; leukocytes, granular, and renal tubular casts; few red blood cells; slightly alkaline pH; minimal to mild proteinuria; colony count >100,000\,\text{organisms/mm}.

  • Chronic Findings: Absent/minimal proteinuria; casts present in early stages but absent in late; low specific gravity.

Medical and Nursing Management of Pyelonephritis

• Pharmacologic Treatment:

  • Antimicrobials: Trimethoprim-sulfamethoxazole (TMP-SMZ, Septra), gentamycin (with or without ampicillin), cephalosporins, or ciprofloxacin (Cipro) for $14$ days.

  • Long-term therapy: Relapsing infections may require $4$ to $6$ weeks of drug therapy.

  • Symptomatic relief: Antispasmodics and anticholinergics like oxybutynin (Ditropan) and propantheline (Pro-Banthine) to relax smooth muscles and increase bladder capacity.

• Follow-up: Repeat urine cultures at $2$ weeks and $3$ months post-treatment.

• Patient Teaching:

  • Complete the entire antibiotic regimen. Drink large volumes of fluids.

  • Avoid alcohol and caffeine if bladder spasms occur.

  • Women: Wipe front to back; wear cotton underwear; void every $2$ to $3$ hours, and before/after intercourse; avoid feminine hygiene products.

Acute Glomerulonephritis

• Definition: Inflammation of the glomeruli caused by bacterial infection.

  • Primary: Independent of other conditions, usually an acute post-infectious process (often Group A Beta-Hemolytic Streptococcus).

  • Secondary: Results from conditions like lupus erythematosus or diabetes.

• Pathophysiology:

  • An antigen-antibody complex from a recent infection deposits in the glomerulus.

  • This causes increased production of epithelial cells and leukocyte infiltration, leading to thickening and scarring of the glomerular filtration membrane.

  • The result is a decreased glomerular filtration rate ($GFR$).

• Assessment Findings:

  • Sudden onset: Fever, nausea, malaise, headache.

  • Edema: Generalized, periorbital (puffiness around eyes), or in the hands/abdomen/feet.

  • Urinary Changes: Pink or cola-colored urine (hematuria); foamy urine (proteinuria/excess albumin).

  • Signs: Hypertension, fatigue related to anemia or kidney failure, and flank tenderness.

• Diagnostic Findings:

  • Elevated antistreptolysin O (ASO) titer; decreased hemoglobin; slightly elevated BUN and creatinine; elevated ESR.

  • Electrolyte shifts in renal insufficiency: Hyperkalemia, hypermagnesemia, hypocalcemia, and dilutional hyponatremia.

  • Percutaneous renal biopsy reveals characteristic antigen-antibody response changes.

• Medical Management:

  • Goals: Preserving function and preventing complications. No specific cure exists.

  • Treatment: Bed rest, sodium-restricted diet, penicillin (to clear remaining strep), diuretics (for edema), and antihypertensives.

  • Advanced cases: Corticosteroids, immunosuppressants, or dialysis for aggressive cases.

  • Cure status: Clear protein and RBCs from urine for $6$ months.

Chronic Glomerulonephritis

• Definition: Slowly progressive inflammation causing irreversible damage to nephrons, eventually leading to kidney reduction and fibrosis.

• Etiology: Familial links, repeated acute episodes, or autoimmune disorders (Lupus, Goodpasture syndrome).

• Clinical Presentation:

  • Anasarca (generalized edema).

  • Azotemia: Accumulation of nitrogen waste (elevated BUN, creatinine, and uric acid).

  • Symptoms: Fatigue, headache, dizziness, hypertension, dyspnea, visual disturbances, weight loss, digestive issues, and nocturia.

• Management: Controlling hypertension (sodium restriction/medication), correcting electrolyte imbalances, managing heart failure, and potentially dialysis or transplantation.

Polycystic Renal Disease (PKD)

• Genetics: Inherited as autosomal dominant or autosomal recessive.

• Forms:

  • Infantile: Rare; causes fetal/neonatal death or childhood renal failure.

  • Adult: Onset between $30$ and $40$ years; progresses to renal insufficiency. Usually fatal within $4$ years of renal failure onset without dialysis/transplant.

• Pathophysiology: Multiple bilateral fluid-filled cysts enlarge the kidneys from fist-size to football-size. This compresses vessels, causes chronic hypertension, and leads to renal failure.

• Assessment and Diagnosis:

  • Symptoms: Hypertension ($75\%$ of clients at diagnosis), flank pain (retroperitoneal bleeding), lumbar discomfort, increased abdominal girth, and colic (if stones/clots pass).

  • Tests: Urinalysis (proteinuria, hematuria, pyuria). CBC (may show increased RBCs due to accelerated erythropoietin). Imaging (Ultrasound, CT, MRI, IVP) shows cysts.

• Management: No cure. Hypertension control, prompt UTI antibiotics, iron/Epogen for anemia. Avoid NSAIDs and cephalosporins at all costs.

Kidney and Ureteral Calculi (Urolithiasis)

• Composition: Mineral salt precipitates. Mostly calcium oxalate or calcium phosphate. Others include uric acid, cystine, and struvite (magnesium ammonium phosphate).

• Predisposing Factors:

  • Calciuria (excess calcium in urine) from hyperparathyroidism or high Vitamin D intake.

  • Dehydration and urinary stasis.

  • Metabolic disorders like gout; bone demineralization (osteoporosis); diets high in protein, sodium, or sugar.

• Clinical Signs: Sudden, sharp, severe flank pain radiating to the suprapubic area, inguinal ring, thighs, or genitalia (renal/ureteral colic). Nausea, vomiting, and shock may occur.

• Medical and Surgical Treatment:

  • Hydration and drug therapy.

  • Extracorporeal Shock Wave Lithotripsy (ESWL) and laser lithotripsy.

  • Procedures: Nephrostomy, Ureterolithotomy, Pyelolithotomy, Nephrolithotomy.

Ureteral Strictures and Kidney Tumors

• Strictures:

  • Causes: Chronic stones, repeat ureteroscopies, radiation, or congenital anomalies.

  • Signs: Flank pain/discomfort at the costovertebral angle.

  • Surgery: Balloon dilation, endoureterotomy (surgical or laser).

• Kidney Tumors:

  • Renal cell carcinoma is the most common ($9$ of $10$ adults). Transitional cell cancer is the second type.

  • Risk factors: Age (>60), male gender, tobacco, industrial chemicals (cadmium, asbestos), and obesity.

  • Classical Triad/Symptoms: Painless hematuria, persistent low back pain, and a palpable mass or lump.

  • Management: Radical nephrectomy (removal of tumor, adrenal gland, fat, and fascia), nephroureterectomy (including cuff of bladder), radiation, or chemotherapy.

Classifications and Stages of Renal Failure

• Acute Kidney Failure (AKF/AKI) Categories:

  • Prerenal: Disrupted blood flow to nephrons (e.g., hemorrhage, sepsis, MI).

  • Intrarenal: Conditions within the kidney itself.

  • Postrenal: Obstructive issues below the kidney.

• RIFLE Classifications: Risk, Injury, Failure, Loss, End-stage Kidney Disease.

• Phases of AKF:

  1. Initiation (Acute tubular necrosis).

  2. Oliguric (Reduced urine volume).

  3. Diuretic (Nephrons recovering).

  4. Recovery (May take $1$ year or more).

• Chronic Kidney Disease (CKD) Stages based on GFR:

  • Stage I: Normal function, GFR >90\,\text{mL/hr}.

  • Stage II: Mild damage, $60\text{-}89\,\text{mL/hr}$. HTN symptoms; rising creatinine/urea.

  • Stage III: Moderate damage, $30\text{-}59\,\text{mL/hr}$.

  • Stage IV: Severe damage, $15\text{-}29\,\text{mL/hr}$. Anemia (EPO deficiency), high phosphorus, metabolic acid/base changes.

  • Stage V: End-Stage, GFR <15\,\text{mL/hr}. Life-threatening.

AKI and CKD Assessment and Biomarkers

• Diagnostic Biomarkers:

  • NGAL (Neutrophil gelatinase-associated lipocalin): Rises $24$ to $48$ hours before creatinine increases due to poor perfusion.

  • Cystatin C: Serum/urine levels predict AKI mortality.

  • TIMP-2: Appears in urine within $12$ hours of tubular injury.

  • GFR: Best real-time biomarker reflected in urine output volume.

• General Assessment: Elevated BP, weight gain, puffy facial features, pale skin, GI bleeding, pruritus, and characteristic urine odor on breath/body.

Dialysis and Transplantation

• Hemodialysis: Extracorporeal filtering using a dialyzer. Requires vascular access (AV Fistula, AV Graft, or Catheter).

• Peritoneal Dialysis (PD): Uses the peritoneal membrane as a filter.

  • Dextrose concentrations pull fluid ($1.5\%$, $2.5\%$, and $4.25\%$ strengths).

  • Types: Continuous Ambulatory (CAPD - gravity-based) and Automated (APD - machine-based).

• Kidney Transplantation:

  • Can be preemptive (before dialysis).

  • Requires induction and maintenance with immunosuppressive (antirejection) drugs.