Renal

1
Renal

• Complex

2
Kidneys

• Excretion of waste products
• Regulation of electrolytes
• Regulation of A/B balance
• Regulation of blood pressure
• Vit D synthesis
• Secretion of prostaglandins
• Erythropoietin production
• Renin production

3
Aging Changes

• 20-30 decrease in size and weight
• At age 70, 30-50 of glomeruli have lost function
  though homeostasis maintained unless disease
  process is encountered
• Renal blood flow is decreased
• Decreased Glomerular filtration rate (GFR) and
  creatinine clearance

4
Aging Changes

• Nocturia
• Decreased bladder capacity, muscle tone, and
  elasticity
• Weak urinary sphincter muscles shortened
  urethra--females
• Tendency to retain urine
• Enlarged prostate in males

5
Diagnostic Tests

• Serum Creatinine
• decreasedecreased muscle mass, advanced liver
  disease, long term steroid use, hyperthyroid
• increase any acute or chronic renal impairment

• Blood Urea Nitrogen (BUN)
• increase renal or liver disease, dehydration,
  infection, steroids, GI bleeding, increased
  catabolism
• decrease malnutrition or low protein diet, fluid
  volume excess, IV therapy severe liver damage

6
Diagnostic Tests

• Serum electrolytes
• BUN/Creatinine ratio
• Normal 101
• increase fluid volume deficit
• decrease fluid volume excess, malnutrition
• no change in ratio with increases in bothrenal
  impairment

7
Diagnostic Tests Urinalysis

• Culture Sensitivity (CS)
• Electrolytes
• Creatinine clearance
• Uric acid

• UA Types
• voided
• clean catch
• catheterized
• 24hr
• UA
• pH5.5--6
• normal, color, odor, turbidity
• Specific gravity 1.001-1.035
• Negative for bilirubin, blood, acetone, glucose,
  protein, bacteria
• Occasional epithelial cells, hyaline casts

8
Diagnostic Tests

• KUB
• kidneys, ureters, bladder
• IVP
• intravenous pyelogram
• Cystoscopy
• Ultrasound
• Biopsy

• MRI
• CT

9
Acute Renal Failure
10
ARF

• A sudden decrease in renal function sufficient
  enough to increase nitrogenous wastes (azotemia)
  and impair fluid and electrolyte balance
• Mortality rates 42 - 88 with no change over the
  last 50 years

11
ARF

• Azotemia
• Abnormally high blood levels of nitrogenous
  wastes
• Increased blood urea nitrogen, uric acid,
  creatinine
• Relates to decrease in GFR and inability to clear
  wastes made

12
Acute Renal Failure

• Three types
• Prerenal
• Intrarenal or Intrinsic
• Postrenal

13
ARF

• Prerenal failure
• Result of decreased perfusion to an otherwise
  normal kidney
• Impaired blood flow predisposes to acute tubular
  necrosis
• Reversible if cause can be corrected before cell
  damage occurs

14
ARF

• Causes of Prerenal Failure
• Hypovolemia
• Profound dehydration
• Loss of GI fluids
• Hemorrhage
• Cardiogenic shock

15
ARF

• Causes of Prerenal Failure
• Septic shock
• CHF
• Anaphylaxis
• Interruption of renal blood flow due to surgery
  or other causes

16
ARF

• Intrarenal Failure
• Results from primary damage to parenchymal cells
  of the kidney
• Three possible sites
• Tubular (most common)
• Interstitial
• Glomerulus

17
ARF

• Causes of Intrarenal Failure
• Ischemia associated with prerenal causes
• Toxic insult from medications or poisons
• Intratubular obstructions
• Acute pyelonephritis
• Glomerulonephritis
• Rhabdomyelosis

18
ARF

• Causes of Intrarenal Failure continued
• Infection
• Nephrotoxic drugs (antimicrobials, radiographic
  contrast media)
• Heavy metals (lead, barium, iron)
• Organic solvents
• NSAIDS (indomethacin, aspirin)
• ACE inhibitors

19
ARF

• Postrenal Failure
• Results from obstruction of urine out of the
  kidneys
• Can occur in ureter, bladder, or urethra
• Treatment is to treat underlying cause of
  obstruction

20
Acute Renal Failure

• Acute Tubular Necrosis (ATN)
• Causes
• Ischemia, Aminoglycosides, Radiocontrast media
• Oliguria
• Tubular obstruction theory
• Back Leak theory
• Alterations in RBF

21
ARF

• Acute Tubular Necrosis
• Caused by prolonged acute prerenal failure
• Four phases
• Initiating phase
• Oliguric phase
• Diuretic phase
• Recovery phase

22
ARF

• Initiating Phase
• From the time of initial injury to point of
  tubular injury
• The time from the start of ischemia to injury is
  variable in each patient

23
Acute Renal Failure

• Oliguria
• 1 day post hypotensive event
• 1-3 weeks
• Urine output varies BUN/Cr increase
• plasma creatinine inverse to GFR
• Diuresis
• renal function improves, monitor FE
• Recovery
• 3-12 mo, 30 do not reach pre failure levels

24
ARF

• Oliguric Phase
• Decrease U/O lt400 cc/day
• Lasts up to 10-14 days
• Results in hypervolemia
• Increased BUN, creatinine, and electrolyte
  imbalances

25
ARF

• Diuretic phase
• Starts a few days to 6 weeks after oliguric
• Nephrons are recovered enough to make urine
• Usually still unable to clear waste products

26
ARF

• Recovery Phase
• Function returns slowly
• GFR 70-80 within 1-2 years
• Residual mild to moderate renal failure

27
ARF

• Diagnosis
• Assessment of patients at risk
• Preexisting renal insufficiency
• Diabetes
• Shock states
• Blood tests
• BUN
• Creatinine
• Electrolytes

28
ARF

• Diagnosis continued
• Careful U/O observation
• Urine tests
• Urine osmolarity
• Urine sodium
• Proteinuria
• Hemoglobinuria

29
ARF

• Diagnosis continued
• Other tests
• Imaging studies to determine kidney size, renal
  blow flow, renal perfusion/function to
  differentiate between ARF and Chronic Renal
  Failure

30
ARF

• Treatment
• Identify and remove the cause
• Improve renal blood flow
• Remove obstruction
• Discontinue toxic drugs
• Focus on prevention
• Maintain renal function

31
ARF

• Treatment continued
• Goal is to minimize or prevent permanent damage
  while maintaining fluid and electrolyte balance
• Regulate fluids
• Maintain normal fluid volume
• Maintain electrolyte balance
• Adequate nutrition
• Prevent and treat infections

32
ARF

• Treatment continued
• Adjust medications related to renal impairment
  and impaired excretion
• Manage and prevent complications
• Monitor I/O
• Monitor electrolytes
• Monitor LOC
• Peritoneal or hemodialysis
• CRRT (continuous renal replacement)

33
ARF

• Caring for patient and family
• Teaching
• Importance of maintaining strict intake and
  output measurements
• Importance of family understanding for the need
  to limit fluids
• Family assist with movement and turning of
  patient with edema

34
ARF

• Teaching continued
• Understanding of laboratory values and how they
  are associated with recovery of the renal
  function
• Nutritional support and needs even after discharge

35
ARF

• Caring for patient and family
• Provide psychosocial support as this is a life
  threatening event
• Remain vigilant for changes in lab values, I/O,
  and patient condition to be able to intervene
  quickly
• Provide spiritual support as needed

36
Chronic Renal Failure

• Cause
• Progressive, irreversible loss of nephrons
• Normal
• Regulates fluid volume
• Solute concentration dilution
• Acid-base balance
• Excretion of waste
• Secretion of hormones that control rbc prod
• B/P calcium metabolism

37
Chronic Renal Failure

• Effects on body systems
• Fluid electrolyte status
• Metabolic
• infection
• Neurologic
• Encephalopathy, peripheral neuropathy, loss of
  motor control

• Cardiopulmonary
• HTN, pericarditis, pulmonary edema, Kussmaul
  respirations
• Dermatologic
• Uremic skin, pigmentation changes, pruritis

38
Chronic Renal Failure

• Effects on Body Systems
• GI
• Anorexia, N-V, ulcers,
• uremic fetor, GI bleeding,
• ulcers
• Musculoskeletal
• Bone inflammation demineralization, factures,
  osteomalacia

• Hematologic
• Anemia, platelet disorders
• Reproductive
• Sexual dysfunction, infertility

39
Chronic Renal Failure

• Treatment
• Goal is to minimize or prevent further damage
  while maintaining fluid and electrolyte balance
• Regulate fluids
• Maintain normal fluid volume
• Maintain electrolyte balance
• Adequate nutrition
• Prevent and treat infections

40
Chronic Renal Failure

• Treatment continued
• Adjust medications related to renal impairment
  and impaired excretion
• Manage and prevent complications
• Monitor I/O
• Monitor electrolytes
• Monitor LOC
• Hemodialysis
• CRRT (continuous renal replacement)

41
Glomerulonephritis

• An inflammatory disorder involving the glomerulus

42
Glomerulonephritis

• Types
• Acute, post-streptococcal
• 7-10 d post infection
• s/s 10-21 d hematuria, rbc, protein, decreased
  GFR, oliguria, edema, HTN
• Rapidly progressive
• adults, 50s-60s
• renal insuff progresses to failure
• Chronic
• DM, r/t glomerulosclerosis

43
Glomerulonephritis

• Lesions
• 2 types of immune damage
• deposition of antigen-antibody complexes
• antibodies (anti-glomerular basement membrane)
• Etiology
• Inflammatory Rx
• Altered membrane permeability
• Loss of negative electrical charge
• Platelet aggregation

44
Glomerulonephritis

• Pathophysiology
• antigen-antibody complex formed
• complex deposited in glomerulus
• inflammation and activation of chemical mediators
• chemical mediators attack glomerular basement
  membrane

45
Glomerulonephritis

• Manifestations
• hematuria
• brown-tinged, smoky
• proteinuria
• albumin
• decreased GFR
• oliguria
• edema
• hypertension
• 10-20 yearsgtgtgtNephrotic Syndrome

46
Glomerulonephritis

• Pathophysiology
• alteration of membrane permeability
• abnormal filtration
• development of acute or chronic renal failure

47
Nephrotic Syndrome
48
Nephrotic Syndrome

• Types of Nephrotic Syndrome
• Congenital
• Rare
• Primary
• Caused by infectious process to
  the kidneys such as acute post-infectious
  glomerulonephritis (APIGN) or minimal change
  nephrotic syndrome (MCNS)

49
Nephrotic Syndrome

• Types continued
• Secondary
• Results from the multi-system effects from
  another disease such as sickle cell anemia,
  diabetes, or systemic lupus erythematous

50
Uremia

• Results in
• edema
• metabolic acidosis
• increased concentration of urea, creatinine and
  uric acid
• increased concentration of sulfates, phosphates
  and potassium

51
Nephrotic Syndrome

• Clinical state characterized by edema, massive
  proteinuria, hypoalbuminemia, and altered
  immunity
• Clinical state results from increased glomerular
  permeability to the plasma proteins
• Initiating event causes a derangement in the
  glomerular membrane

52
Nephrotic Syndrome

• Excretion of more than 3.5g of protein/day
• Characteristic of glomerular injury
• More common in Peds
• Secondary d/t other diseases, drugs
• DM, SLE(Lupus)
• Treatment Normal protein, low fat diet, Na
  restriction, diuretics, steroids, Dietary protein
  supplements essential

53
Urolithiasis

• Location Types
• Typically occur over narrowings in the ureter
• Calcium Oxalate, Uric Acid, etc.
• Treatment
• Diet adjustment depending on type of stone
• Pain control
• Surgical procedures
• STRAIN URINE!!

54
Urolithiasis - Urinary Tract Stones

• Clinical Manifestations
• Ureteral obstruction (colic) - pain, nausea,
  vomiting
• Bleeding
• Pyelonephritis

55
Urinary Tract Stones - Types

• 1. Calcium Oxalate (non-pH)
• 2. Uric Acid
• 3. Struvite (Magnesium Ammonium Phosphate)
• 4. Cystine

56
Urinary Tract Stones

• Risk factors in developing stones
• Dehydration
• Hypercalcemia or hypercalciuria
• Hyperuricemia or hyperuricosuria
• Infection with urea splitting bacteria
• Other

57
Medical Management

• Hemodialysis
• Peritoneal dialysis
• Antibiotics
• Antihypertensive Drug therapy
• Cystoscopy
• Extracorporeal shock wave lithotripsy
• Percutaneous lithotripsy

• Partial or total nephrectomy
• Renal transplant

58
Pharmacologic Therapy

• Urinary Tract antiseptics
• Sulfonamides
• Cholinergic agents
• Antispasmodics
• Urinary analgesics

• Hematopoietic Growth factor
• Immunosuppressants used to prevent Organ Rejection

59
Urinary Incontinence

• Scope of the Problem
• gt13 million Americans
• 15-30 non-institutionalized
• 19 male 39 female
• In nursing facilities 50-70
• Prevalence
• Increases with age, BUT, NOT normal aging!
• Second leading cause of institutionalization

60
Urinary Incontinence

• Costs
• Community dwelling costs over 7 billion annually
• LTC costs 3.3 billion
• Psychological and Social Impact
• Depression, social isolation

61
Risk Factors

• Immobility
• Impaired cognition
• Medications
• Obesity
• Smoking
• Fecal Impaction
• Delirium
• Childhood nocturnal enuresis

• Low fluid intake
• Environmental barriers
• High-impact physical activities
• Diabetes Mellitus
• Stroke
• Estrogen depletion
• Pelvic muscle weakness

62
Acute Reversible Incontinence

• D--Delirium
• R--Retention, Restricted mobility
• I--Inflammation, infection impaction
• P--Polyuria, pharmacy

63
Chronic or Persistent Incontinence

• Stress
• Urge
• Overflow
• Functional
• Reflex

64
Stress Urinary Incontinence (SUI)

• Loss of relatively small amounts of urine
• Associated with increases in intra-abdominal
  pressure
• laughing
• coughing
• sneezing
• No associated urge to void.

65
Urge Urinary Incontinence (UI)

• Loss of moderate amounts of urine
• Precipitated by a strong urge to void
• Associated with Involuntary Detrusor Contractions
  
• bladder instability
• unstable bladder
• Key in the lock syndrome

66
Reflex Urinary Incontinence

• Loss of moderate to large amounts of urine
• No precipitating urge to void
• No sensation in lower urinary tract
• Associated with some level of Detrusor External
  Sphincter Dsynergia (DESD)
• Some level of uncoordinated voiding

67
Overflow Urinary Incontinence

• Occurs when symptoms of dribbling or leakage are
  caused by an inability to effectively empty the
  bladder
• Complains of incomplete emptying
• urinary retention
• incomplete bladder emptying