Disorders Of Renal Function

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Disorders of renal function

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--kidneys develop early in the 5th week of gestation and start to function 3 weeks later
--urine formation begins in the 0th-12th weeks of gestation
--urine is excreted into the amniotic cavity and is the main constituent of amniotic fluid

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Agenesis

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--complete failure of an organ develop
--unilateral renal agenesis is relatively common:1 of 1000 newborn infants
--boys more often than girls
--left kidney is usually the absent kidney
--does not cause symptoms
--total agenesis of both kidneys is incompatible with extrauterine life

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Polycystic kidney disease

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--one of the most common genetic diseases
--characterized by fluid-filled sacs or segments that have their origin in the tubular structures of the kidney
--cysts vary in size
--cysts can be found in the liver, pancreas and spleen
--loss of kidney function occurs by age 60 in 50% of patients

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PKD

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-defined as:
--fluid-filled in both kidneys
--autosomal dominant (adult polycystic disease) coomon, and autosomal recessive (rare)
--most common hereditary disorder in the US
--ACCOUNTS FOR 10% OF ALL CASES OF ckd THAT REQUIRED DIALYSIS OR TRANSPLANTATION

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PKD S/S

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-flank pain
-hematuria
-infection
-hypertension r/t compression of intrarenal blood vessels with stimultion of the renin-angiotensin mechanism
-Treatment: supportive and aimed at delaying progression of the disease

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Disorder of glomerular function

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- Glomerular disorders affect the semipermeable properties of the glomerular capillary membrane that allows water and small particles to move from the blood into the urine filtrate, while preventing blood cells and plasma proteins from leaving the blood

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Nephritic syndromes

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-produce a decrease in glomerular permeability
-caused by inflammatory processes that occlude the glomerular capilary lumen and damage the capillary wall, permitting red blood cells to escape into the urine
- causes a decrease in GFR

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Nephritic syndrome

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- clinical manifestations are related to:
-- decrease in GFR
- clinical manifestations:
-sudden onset of hematuria
-proteinuria
-decreased GFR
-oilguria
-edema
-HTN

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Acute postinfectious glomerulonephritis

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- post-streptococall glomerulonephritis:
--follows a streptococall infection by 7-12 days
-primary infection usually involved the pharynx
-First symptom: oliguria
-proteinuria and hematuria follow
-edema (especially of the face and hands)
-HTN
usually has an excellent prognosis and raely causes chronic kidney disease

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Nephrotic syndrome

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-not a specific glomerular disease, but a constellation of clinical findings that result from an increase in glomerular permeability
-any increase in permeability allows protein to escape from the plasma into the glomerular filtrate (urine)

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Nephrotic syndrome S/S

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-Massive proteinuria (>3.5)
-lipiduria: free-fat oval bodies, fat casts
-generlized edema : results from salt and water retention and a decrease in plasma colloidal osmotic (oncotic) pressure due to loss of albumin in the urine

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Nephrotic syndrome S/S

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-hypoalbuminemia (<3g/dl)
-hyperlipidemia (cholesterol >300)
- can develop as a primary disorder or secondary to changes caused by systemic diseases such as diabetes mellitus and SLE.

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Urinary tract infection

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- second most common bacterial disease
-escherichia coli (e.coli) is the most common pathogen
-upper UTI-involving the renal parenchyma, pelvis, and ureters
- lower UTI-confined to the lower urinary tract usually does not have systemic manifestations

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Classifying UTI's

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- Uncomplicated infections; those that occur in an otherwise normal urinary tract
-complicated infections
--include those with coexisting
---presence of obstruction
--- stones
--- catheters
--- existing diabetes
--- neurologic disease
--- recurrent infections
--- those with complicated infections are at risk for renal damage

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Pathophysiology of UTI's

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-urinary tract above the ureters is sterile
-an alteration in any of the defense mechanisms increases the risk of contracting a UTI
- normal defense mechanisms:
-- normal voiding with complete bladder emptying
-- antibacterial ability of the bladder mucosa and urine
-- ureterovesical junction competence
- peristaltic activity that propels urine toward bladder

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Predisposing facters to UTI

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- factors increasing urinary stasis
-- obstruction
-- retention
- foreign bodies
-- catherter
--stents
-- calculi
- anatomic factors
-- shorter female urethra
-factors compromising immune response
-- HIV, diabetes
-functional disorders
-- constipation

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Clinical manifestations of UTI

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-dysuria
-frequent urination (every 2 hours)
-urgency
-suprapubic discomfort or pressure
-gross hematuria
-sediment (cloudy appearance)
-flank pain
-chills
-fever indicates upper infection (pyleonephritis)

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Older adults and UTI's

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symptoms often absent
nonlocalized abdominal discomfort rather than dysuria and suprapbubic pain
may also have cognitive impairment
-less likely to have fever with infection of the upper urinary tract
-patient > 80 may have slight decline in temp.
-may have no s/s or nonspecific symptoms
--anorexia, fatigue

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Cystitis

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-inflammation of the bladder wall caused by ascending bacterial infection from urethra
-repeat the urine culture floowing a full course of antibiotics
-etiology
-- fecal contamination
-- instrumentation
-- cathererization
- clinical manifestations
-- pain in bladder
-- pressure
-- urinary frequency, uregency
-dysuria (burning pain)
-changes in urine: foul odor, purulent drainage, or WBC's

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Cystitis cont

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-non infectious agents also cause irritation to the bladder:
bladder tumor
intravesicular chemo
Pelvic radiation

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Cystitis

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Risk factors:
urinary stasis
Benign prostatic hypertrophy
sexual intercourse
pregnancy

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Pyelonephritis

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-inflammation of the renal pelvis and parenchyma
-often secondary to urine regurgitating into ureters or bacteria ascending from bladder
-can result in loss of nephrons due to chronic inflammation and scarring
-stone formation can occur
-hypertension and uremia may eventually occur if not treated

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Pyelonephritis

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Etiology
-ascending infection from bladder 9cystitis, strictures, stones)
-men with benign prostatic hypertrophy at risk

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Pyelonephritis

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-clinical manifestations
acute:
chills, fever, malaise, N&V, flank pain, dysuria, frequency and foul smelling urine
chronic:
bacteria invasion and repeated inflammation leads to scarring, fibrosis and tubular dilation
-may have symptoms of acute or asymptomatic

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Urinary tract Calculi

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-kidney stone disease: nephrolithiasis
-associated with UTI
-more common in men
-between 20-55 years old
-higher incidence in people with family history
-recurrent stones 50% of patients
- seasonal (more often in summer)

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Etiology and pathophysiology

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- a kidney stone is a hard mass developed from crystals that separate from the urine within the urinary tract
-crystals, when in concentrated form, unite to form stones
-kidney stones may contain various combinations of chemicals
-most common: calcium in combination with oxalate or phosphate
-obstruction with urinary stasis

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Metabolic

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-abnormalities that result in increased urine levels of:
-calcium
-oxaluric acid
-uric acid
-citric acid

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Climate

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- warm climats that cause fluid loss
-decreased urine volume
-increased solute concentration in urine
-history of diuretic use to control HTN

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Diet

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-large intake of dietary proteins that increase uric acid excretion
-excessive amounts of tea or fruit juices that increase urinary oxalate levels
-large intake of calcium and oxylate
- decreased fluid intake that increased urinary concentration (dehydration)

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Types of stones

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- calcium phosphate
- struvite (always assoc. with UTI's): give antimicrobial agents
-uric acid : give allopurinol, decrease dietary purines (meat, fish, organ meats)
- cystine: genetic defect, increase hydration, give k+ citrate to maintain alkaline urine

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Clinical manifestations

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-abdominal or flank pain (severe): r/t stone irritation
-hematuria and renal colic: major manifestation of descending kidney stone
-nausea and vomiting
-mild shock (when passing stone)

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Malignant tumors of the kidney

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- wilms tumor (nephroblastoma):
one of the most common primary neoplasms of young children
-usually presents between 3-5 years of age
-may occur in one or both kidneys
-solid renal tumor composed of immature cells

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Wilm's tumor

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- tumors grow to large size, distorting kidney structure
- presenting s/s
- large abdominal mass
asymptomatic
-vomiting
-hypertension
-10-25% present with hematuria (microscopic and gross)
- treatment: surgery, chemotherapy, RT

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Adult Kidney Cancer

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-affects men more than women
-incidence peaks btween 55-84 years of age
-renal cell carcinoma originates in the renal cortex (80% of tumors)
- occupational exposure to petroleum products, heavy metals, and asbestos
- smoking
-obesity

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Kidney Cancer

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-clinical manifestations
Hematuria
Renal mass
- treatment: radical nephrectomy

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Bladder Cancer

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-the most frequent form of urinary tract caner in the U.S
90% of bladder cancers are derived from the transitional cells that line the bladder
-Risk factors: cigarette smoking, exposure to dyes used in the rubber and cable industries
-Patients with chronic recurrent stones, chronic UTI's and chronic cystitis

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Clinical manifestations of bladder CA

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- the most common symtom in early bladder CA is gross, painless hematuria (chronic or intermittent)
- Bladder irritability
Dysuria
Frequency
Uregency
- presence of atypical cells in U/A
send urine specimen to cytology
Bladder cancer is confirmed by biopsy