Renal

Care of the Patient with Genitourinary/Renal Conditions

Chronic Kidney Disease

  • Definition: Progressive, irreversible loss of kidney function.

  • Also Known As: Chronic renal failure.

  • Prevalence: Affects approximately 1 in 10 adults; over 1 million Americans are receiving treatment for end-stage renal disease (ESRD). CKD is much more common than acute kidney injury (AKI).

Risk Factors for Chronic Kidney Disease (CKD)

  • Diabetes

  • Hypertension

  • Age: ≥ 60 years

  • Cardiovascular Disease

  • Family History of CKD

  • Exposure to Nephrotoxic Drugs

  • Proteinuria

  • Ethnicity: 3x more common in African Americans

Clinical Manifestations of CKD

  • Asymptomatic until Glomerular Filtration Rate (GFR) is 20-50% below normal.

  • Uremia Symptoms: Appear when GFR is 15-20% below normal.

  • Severity of Symptoms: Depends on causes, level of impairment, comorbidities, age, and adherence to treatment.

  • Signs/Symptoms (s/s) resulting from retained substances:

    • Elevated Creatinine: > 1.2 mg/dL

    • Retained Hormones, Electrolytes (↑ K), Water, Urea, Acid

Genitourinary System Symptoms in CKD

  • Early stages: No change

  • Later stages: Progressive fluid retention; reproductive issues

Cardiovascular System Symptoms in CKD

  • Leading cause of death in CKD patients is cardiovascular disease.

  • Traditional cardiovascular risk factors include hypertension, which is both a cause and consequence of CKD.

  • Can lead to cardiomyopathy and heart failure.

Neurological System Symptoms in CKD

  • Central Nervous System (CNS) depression

  • Peripheral neuropathy

  • Seizures

  • Restless Leg Syndrome.

Gastrointestinal (GI) System Symptoms in CKD

  • Anorexia, Nausea and Vomiting (N/V), Uremic fector, Metallic taste

Immune System Symptoms in CKD

  • Decreased B- and T-cell function

  • Decreased phagocytosis

Hematologic System Symptoms in CKD

  • Anemia

  • Prolonged bleeding times

Integumentary System Symptoms in CKD

  • Pruritus

  • Gray-bronze skin color

  • Ecchymosis/Purpura

  • Dry, flaky skin

  • Brittle nails

  • Thinning hair

Musculoskeletal System Symptoms in CKD

  • Cramps

  • Weakness

  • Bone pain/fractures

Diagnostics for CKD

  • History and physical examination

  • Urine dipstick for protein (1+ protein on two or more occasions in a 3-month period indicates need for further assessment)

  • Comprehensive urinalysis

  • Renal ultrasound or biopsy

  • Assess GFR

Goals of Care for CKD

  • Preserve existing kidney function

  • Reduce risks of cardiovascular disease

  • Prevent complications

  • Provide patient comfort

Interventions for CKD

Medications

  • Phosphate-binding agents

  • Calcium supplements

  • Antihypertensive and cardiac agents

  • Anticonvulsants

  • Erythropoietin

  • Vitamin/mineral supplements

Dietary Interventions

  • Protein restriction (varies depending on dialysis type)

  • Fluid restrictions

  • Sodium restrictions

  • Potassium restrictions

  • Phosphorous restrictions

  • Peritoneal dialysis patients may not need as strict restrictions as hemodialysis patients.

Medication Concerns in CKD

  • CKD can lead to decreased elimination, increasing the potential for drug toxicity.

  • Doses and frequency should be adjusted based on the severity of disease.

  • Increased sensitivity in tissues and blood can occur, affecting how patients respond to medications, including:

    • Digoxin

    • Diabetic agents (e.g., Metformin)

    • Antibiotics (e.g., Vancomycin, Gentamicin)

    • Opioids

Nursing Management for CKD

  • Educate patient on dietary and fluid restrictions.

  • Promote self-care independence and coping strategies.

  • Monitor blood pressure.

  • Encourage adherence to treatment regimens.

  • Educate patients on when to contact healthcare providers for new or worsening symptoms such as N/V, changes in urine output (UO), ammonia or urine odor on breath, muscle weakness, diarrhea, and abdominal cramps.

Renal Replacement Therapy

  • Three categories:

    1. Hemodialysis: Blood passes through a semipermeable membrane filter outside the body.

    2. Peritoneal Dialysis: Blood passes through peritoneum surrounding the abdominal cavity as the dialyzing membrane.

    3. Kidney Transplant: Organ transplant of a kidney.

Dialysis

  • Definition: Diffusion of solute molecules across a semipermeable membrane from an area of high concentration to one of lower concentration, used to remove excess fluid and wastes.

  • Early dialysis can reduce complications.

  • Dialysis relies on three principles:

    • Diffusion: Movement of solutes from high to low concentration

    • Osmosis: Movement of fluid from low solute to high solute concentration

    • Ultrafiltration: Movement of water and solutes from high to low hydrostatic pressure.

Hemodialysis

  • Blood is taken from the patient via a vascular access site, pumped to the dialyzer.

  • The dialyzer has a porous membrane allowing small molecules to pass through.

  • Electrolytes can be added back as needed.

  • Frequency: performed for 3-5 hours per session, 3-4 sessions weekly.

  • Not used if the patient is hemodynamically unstable (e.g., hypotension, low cardiac output).

Vascular Access Sites for Hemodialysis

  • Access site is the patient’s lifeline to remove and return blood during dialysis.

  • Acute/Temporary Vascular Access: Double-lumen catheter placed in subclavian, jugular, or femoral vein.

Longer-Term Vascular Access

  • Arteriovenous (AV) Fistula: Direct connection between an artery and vein created by surgical anastomosis.

    • Considered the best access method

    • Characterized by palpable pulsation and bruit on auscultation

  • Arteriovenous (AV) Graft: Indirect connection using a synthetic tube.

    • Can be internal or external

    • Higher risk for infection and clotting.

    • Protect the access arm: no blood pressure or blood draws; daily inspections needed for thrill and signs of complications (redness, swelling, bleeding, drainage, heat, pain).

Hemodialysis Complications

  • Most frequent: Hypotension

  • Other complications: Muscle cramps, bleeding, dysrhythmias, air embolism, infection.

Peritoneal Dialysis

  • Uses the peritoneum surrounding the abdominal cavity as the dialyzing membrane.

    • Includes processes of inserting and draining dialysate that absorbs waste products through a semi-permeable membrane into the peritoneal space.

Types of Peritoneal Dialysis

  1. Continuous Ambulatory Peritoneal Dialysis (CAPD):

    • 4-hour dwell time with 3-5 exchanges per day.

  2. Automated Peritoneal Dialysis (APD):

    • Machine mediates exchanges performed overnight with 4+ exchanges each taking 1-2 hours.

  • Aseptic technique is critical to avoid peritonitis.

Complications of Peritoneal Dialysis

  • Peritonitis: Inflammation of the abdominal lining, often infectious.

    • Diagnosis: Fluid sample shows >100 WBC/mm³, 50% neutrophils, or positive gram stain.

    • Treatment: Antimicrobial therapy (IV or via dialysate).

  • Leakage: Dialysate leaks around the catheter.

    • May heal spontaneously if dialysis is withheld or require surgical intervention.

  • Bleeding: Can occur and needs monitoring.

  • Incomplete Fluid Recovery: Can improve with repositioning or bowel emptying, but never reposition the catheter.

  • Abdominal Hernia: Persistent pressure increases with PD can cause hernias.

Pros and Cons of Peritoneal Dialysis

Pros

  • Easier fluid control

  • Fewer restrictions on diet

  • Fewer medications required

  • Greater freedom for patients

Cons

  • Risk for peritonitis

  • Contraindicated for morbidly obese patients or those with prior abdominal surgeries

  • Requires reliable caregiver or self-management capabilities

  • Slow rate may not be optimal for AKI

Kidney Transplant

  • Major advances in: procurement, preservation, surgery, matching, and rejection prevention.

  • Less than 4% of ESRD patients receive transplants.

  • Over 100,000 patients on waiting lists, with fewer than 18,000 transplants performed annually.

  • Successful transplants have >90% 1-year graft survival rates. Transplantation can reverse pathophysiologic changes related to renal disease.

Recipient Selection Criteria

  • Exclusions: Smoking and morbid obesity.

  • Contraindications: Advanced cancer, refractory heart disease, chronic respiratory failure, ongoing infection, non-adherence.

  • Donor Sources: Includes deceased donors and living donors (known and unknown).

  • Compatibility Studies:

    • Blood typing (ABO group)

    • Histocompatibility studies (human leukocyte antigen [HLA] testing, cross-matching).

Nursing Role in Transplant

  • Preoperative Care: Includes physical preparation (EKG, chest X-ray, labs, dialysis), infection screening, and patient education about procedures.

  • Postoperative Care:

    • Focus on fluid/electrolyte balance.

    • Monitor for acute tubular necrosis and sudden decrease in urine output (U/O).

    • Educate on signs/symptoms of complications, post-op appointments, and medication regimens.

Transplant Complications

  • Rejection: Major concern post-transplant.

    • Hyperacute: Rapid destruction of blood vessels by pre-existing antibodies; no treatment available, organ must be removed.

    • Acute: Cell-mediated immune response; treat with immunosuppressive therapy.

    • Chronic: Long-term immune injury leads to organ fibrosis; supportive therapy is required; no definitive treatment.

  • To Prevent Rejection: Administration of immunosuppressants for life, including corticosteroids and agents like cyclosporine and tacrolimus, often in combination.

Other Transplant Complications

  • Infection

  • Cardiovascular disease

  • Cancer

  • Recurrence of original disease

  • Complications related to corticosteroids.

Nephrolithiasis/Urolithiasis

  • Calculus: A stone.

  • Lithiasis: Stone formation.

  • Supersaturation: Common conditions leading to stone formation include high levels of calcium oxalate, calcium phosphate, and uric acid.

  • Occurrence in ~9% of the US population; stone recurrence is 50%.

  • Higher frequency in males, especially aged 40s-70s, often with a family history of renal tubular acidosis.

  • Increased risk factors: high protein and salt diets, low calcium intake, dehydration, obesity, metabolic issues (like diabetes, hyperparathyroidism, or gout).

Manifestations and Diagnostics in Nephrolithiasis

  • Symptoms: Sudden, severe flank pain, N/V due to pain, restlessness, hematuria, and signs of urinary tract infection (UTI) including dysuria and fever.

  • Diagnostics:

    • Imaging (X-Ray, CT scan, ultrasound)

    • Urinalysis

    • Serum studies (calcium, phosphorus, sodium, potassium, bicarbonate, uric acid, BUN, and creatinine)

    • 24-hour urine collection

Types of Urinary Stones

  1. Calcium Stones (~75%)

    • Predisposing factors: hypercalcemia, hyperparathyroidism, renal tubular acidosis, excessive vitamin D, low fluid intake.

    • Treatment: Hydration, dietary changes to lower oxalate and sodium, thiazide diuretics, ammonium chloride.

  2. Struvite Stones (~15%)

    • Caused by alkaline, ammonia-rich urine due to bacteria.

    • Treatment: Antimicrobials, measures to acidify urine, increased fluid intake.

  3. Uric Acid Stones (~5-10%)

    • Associated with gout and acidic urine.

    • Treatment: Urine alkalinization with potassium citrate or sodium bicarbonate, allopurinol, dietary purine reduction.

  4. Cystine Stones (~1-2%)

    • Rare; caused by an inherited defect in renal absorption of cysteine.

    • Treatment: Hydration, medications to prevent crystallization, dietary protein reduction.

Treatment of All Types of Stones

  • General Measures:

    • Encourage hydration, even at night.

    • Avoid medications that exacerbate stone formation (like antacids and loop diuretics).

    • Reduce sodium intake.

    • Avoid foods high in oxalate and prevent dehydration especially during high-intensity activities.

    • Treat UTIs promptly.

  • Goals: Eradicate stones, prevent nephron damage, and manage pain effectively.

Nutritional Therapy for Stones

  • Low-Purine Diet for Gout: Focus on increasing fruits, vegetables, and whole grains while reducing shellfish, organ meats, alcohol, and soft drinks.

Procedural Treatments for Stones

  • Ureteroscopy: Scope is inserted into ureter to remove stones or fragment them, may involve stent placement.

  • Lithotripsy: Stones are shattered using shock waves, ultrasound, or laser energy.

  • Surgical Options: Nephrolithotomy, pyelolithotomy, ureterolithotomy, cystotomy.

  • Post-procedural Care: Hematuria is common; emphasize increased fluid intake; watch for complications like infection and retained fragments.

Urinary Tract Infections (UTI)

  • Overview: Most common bacterial infection in ambulatory care settings and second most common reason for health care visits.

    • Common Pathogens: Escherichia coli is most common; Candida albicans is the second most common.

Natural Defense Mechanisms Against UTI

  • Voiding with complete bladder emptying.

  • Competence of ureterovesical junction.

  • Ureteral peristalsis.

  • Acidic urine pH and high urea concentrations.

  • Presence of glycoproteins.

Classification of UTI

  1. Upper UTI: Pyelonephritis.

  2. Lower UTI: Cystitis, urethritis, prostatitis, urosepsis.

  3. Uncomplicated UTI: Occurs in healthy individuals with a normal urinary tract and is typically community-acquired.

  4. Complicated UTI: Occurs with structural or functional problems in the urinary tract often resistant to treatment.

Risk Factors for UTI

  • Anatomical abnormalities

  • Compromised immune systems

  • Urinary stasis

  • Foreign instrumentation

  • Functional disorders

  • Poor hygiene, delay of urination, pregnancy, menopause, multiple sexual partners, and use of spermicidal agents.

Manifestations of UTI

  1. Lower UTI Symptoms:

    • Dysuria

    • Burning

    • Hesitancy

    • Post-void dribbling

    • Increased frequency

    • Urgency

    • Incontinence

    • Nocturia

  2. Upper UTI Symptoms:

    • Systemic symptoms including fever, chills, tachycardia, tachypnea, anorexia, fatigue, and flank pain.

  3. Older Adults Symptoms: May present as non-localized symptoms such as abdominal discomfort and cognitive impairments.

Diagnosis and Treatment of UTI

  • Diagnosis: History, physical assessment, urinalysis with positive nitrites and leukocyte esterase, urine culture and sensitivity, blood culture if bacteremia is suspected, imaging studies if necessary (CT, ultrasound, cystoscopy).

  • Management: Includes antibiotics, increased fluid intake, avoiding irritants, encouraging regular voiding (every 2-3 hours), voiding before and after sexual intercourse, preventing catheter-associated UTI (CAUTI), and use of urinary analgesics like phenazopyridine.

  • Complications: Chronic infection can lead to kidney failure.

Adult Voiding Dysfunction

Overactive Bladder

  • Characterized by increased urgency, frequency, and nocturia, with or without urinary incontinence.

  • Normal void frequency is 7 times/day and 1 nocturnal void.

  • Significant impact on quality of life (QOL).

  • Management:

    • Avoid caffeine, alcohol, and spicy foods.

    • Weight loss for overweight individuals.

    • Kegel pelvic floor exercises and bladder training.

    • Medications: Anticholinergics (e.g., oxybutynin), beta-3 agonists (e.g., mirabegron), and antidepressants like amitriptyline.

Urinary Incontinence

  • Definition: Involuntary loss of urine, often underdiagnosed and underreported.

  • Risk Factors:

    • Age

    • Menopause

    • Pregnancy

    • Genitourinary surgeries

    • High-impact exercise

    • Diabetes Mellitus (DM)

    • Stroke

    • Morbid obesity

    • Cognitive/neurogenic disturbances

    • Medications

    • Lack of assistance or facility to toilet.

Types of Urinary Incontinence

  1. Stress Incontinence: Leakage due to pressure from sneezing, coughing, or changing positions; commonly seen in females postpartum and post-menopause; males after radical prostatectomy.

  2. Urgency Incontinence: Inability to reach the toilet in time, often linked with overactive bladder and uninhibited bladder contractions.

  3. Reflex Incontinence: Overflow from over distention of the bladder due to obstructions like tumors or BPH.

  4. Functional Incontinence: Inability to identify the need to void or reach the toilet on time due to external factors.

  5. Iatrogenic: Resulting from medications.

Diagnosing Incontinence

  • Comprehensive history and physical assessment including medication history, a voiding history, and potentially urodynamic tests.

Management of Urinary Incontinence

  • Medical Management:

    • Anticholinergics (e.g., oxybutynin)

    • Hormone therapy

    • Urethral slings, periurethral bulking procedures

    • Artificial sphincters, prostate resections.

  • Patient Education:

    • Awareness of fluid intake timing

    • Scheduled timing for diuretic use

    • Avoidance of bladder irritants and constipation

    • Education on regular voiding patterns and pelvic floor exercises

    • Smoking cessation

    • Weight management.

Urinary Retention

  • Definition: Inability to empty the bladder completely.

  • Men Risk Factors: Obstruction from BPH or acute prostatitis, anesthesia effects.

  • Women Risk Factors: Less common aside from anesthesia effects or organ prolapse.

  • General Risk Factors:

    • Diabetes

    • Prostate enlargement

    • Urethral blockages (overt or occult)

    • Pelvic injuries or pregnancy

    • Neurologic/myogenic disorders

    • Medications increasing bladder outlet resistance or inhibiting bladder contractility.

Manifestations of Urinary Retention

  • Often overlooked: tools to inquire include last voiding time and amount, frequency of ei and dribbling, discomfort in lower abdomen, abdominal distention, dullness on percussion, restlessness or agitation.

  • Utilizing a post-void ultrasound can clarify residual urine levels.

Diagnosis of Urinary Retention

  • Urodynamic tests, histories, and voiding diaries assist in diagnosis. A post-void residual of over 100 mL suggests retention issues.

Management of Urinary Retention

  • Catheterization: Caution in cases of previous radical prostatectomy or urethral reconstruction due to risks of hematuria and hypotension.

  • Encourage normal voiding patterns amidst comforting conditions (e.g., privacy and warmth).

  • Home modifications may include removing obstacles, utilizing support bars, and ensuring adequate lighting in bathrooms.

  • Goals: Prevent overflow and treat underlying causes.

Complications of Urinary Retention

  • Can lead to chronic retention and overflow incontinence, infection, pyelonephritis/sepsis, renal calculi, and acute/chronic renal failure.

Acute Kidney Injury (AKI)

  • Also referred to as Acute Renal Failure (ARF).

  • Defined as a rapid decline in renal function occurring in hours to days with manifestations of azotemia and fluid/electrolyte imbalances.

Categories of Acute Kidney Injury

  1. Prerenal AKI (50-60% of cases): Results from conditions that disrupt renal blood flow and perfusion. Typically reversible with restored blood flow. Common causes include:

    • Hypovolemia (hemorrhage, dehydration)

    • Low cardiac output (heart failure, myocardial infarction)

    • Decreased peripheral vascular resistance (anaphylaxis, shock, antihypertensive medications)

    • Decreased renovascular blood flow (thrombosis, embolism).

  2. Intrinsic/Intrarenal AKI (25-40% of cases): Occurs due to direct damage to the functional kidney tissue. Major causes include glomerular/microvascular injury, trauma (leading to rhabdomyolysis and myoglobinuria), infections (including glomerulonephritis and pyelonephritis), and nephrotoxic agents.

  3. Postrenal AKI (<10% of cases): Results from conditions that obstruct urine excretion such as BPH, urinary calculi, or tumors.

Acute Tubular Necrosis (ATN)

  • Defined as destruction to tubular epithelial cells resulting in renal function decline.

  • Accounts for 90% of intrarenal AKI and is the most prevalent cause in hospitalized patients, stemming from ischemia, nephrotoxins, or sepsis.

Risk Factors for AKI

  • Major trauma or surgery

  • Infections

  • Hemorrhage

  • Heart failure

  • Severe liver disease

  • Lower urinary tract obstructions

  • Medications, especially nephrotoxins.

Aging and AKI

  • Older adults may present with diminished renal mass, fewer nephrons, and a decreased GFR.

  • This population commonly experiences AKI due to higher incidence of serious illnesses.

Phases of Acute Kidney Injury

  1. Initiation Phase: Where cellular injury occurs.

  2. Oliguric Phase: Characterized by urine output <400 mL/24 hours; significant fluid overload occurs.

  3. Diuretic Phase: Daily urine output may spike (1-3 L/day); risk of fluid volume deficits arises.

  4. Recovery Phase: Tubule cell repair takes place, and GFR gradually returns to normal; full recovery can take up to a year for some.

Course and Manifestations in AKI

  • Oliguric Phase: Significant drop in GFR and tubular necrosis prevents efficient waste excretion leading to azotemia (↑ BUN, Cr), fluid retention, electrolyte imbalances (↑ K, Mg, Ph), metabolic acidosis, and anemia due to suppressed erythropoietin secretion.

  • Diuretic Phase: Characterized by osmotic diuresis and the kidneys regaining ability to excrete wastes, leading to hypovolemia and dehydration.

  • Recovery Phase: Gradual return of electrolyte levels to baseline; some patients never regain full function and may progress to CKD or ESRD.

Diagnostics for AKI

  • Lab tests including urinalysis, serum creatinine, BUN, serum electrolytes, arterial blood gases, complete blood count (CBC), and imaging studies (renal ultrasound, CT/MRI, kidney biopsy).

Medications for AKI

  • Treatment goals include elimination of causes, symptom management, and complication prevention.

  • Treatment may involve IV fluids, blood volume expanders, nephrotoxin removal, Kayexalate, IV insulin, sodium bicarbonate, diuretics, and removal of obstructions.

Nursing Care for AKI

  • Focus on prevention and early recognition; ensure adequate hydration and prompt treatment of hypotension/shock.

  • Monitoring urine output and labs closely; infection management and prompt intervention for trauma.

  • During AKI, monitor daily weight and maintain fluid/electrolyte balance, adjust diets, and education on nephrotoxic medicines.

Conclusion

  • Comprehensive care and management of the genitourinary and renal conditions are vital in promoting health and preventing complications.