Kidney Function and Exercise

Role of Kidneys

• Homeostasis is maintained by balancing fluids and acids/bases, and excreting nitrogenous waste in the form of urea.
• Endocrine functions include producing erythropoietin (EPO) and 1,25-dihydroxycholecalciferol (Vitamin D).
• Blood pressure is regulated through the renin/angiotensin system.
• Kinins mediate inflammation.
• Renal tubules recover essential nutrients and fluids from blood filtrate, with the remaining fluid becoming urine.
• Normal urine concentrating ability ranges from 100-1200 mOsm/L, while normal serum is 290-296 mOsm/L.
• Daily urine volume typically falls between 400-4000ml.

Exercise Effects on Kidneys

• Renal blood flow is reduced by 75% during exercise.
• Glomerular Filtration Rate (GFR) at rest is 120-125ml/min, dropping to 60ml/min during exercise.
• Kidneys, characterized by high blood flow and metabolic activity, are susceptible to hypoxia.
• A tubular arrangement uses a countercurrent mechanism to concentrate urine.

Exercise Consequences

• Possible hypoxic damage to nephrons.
• Increased glomerular permeability leading to higher excretion of red blood cells (RBCs) and protein.
• Elevated aldosterone production enhances sodium reabsorption.
• Renal vasoconstriction limits blood flow.
• Increased filtration pressure occurs.
• Stasis of glomerular capillaries.

Exercise-Associated Renal Impairment

• This impairment is characterized by reduced renal blood flow and GFR, further exacerbated by dehydration and poor renal perfusion.
• Poor renal perfusion causes hypoxia and acute tubular necrosis (ATN).
• Impairment can be worsened by myoglobinuria and hemoglobinuria leading to Acute Renal Failure (ARF).
• Nephrotoxic drugs like NSAIDs inhibit prostaglandin, a renal vasodilator, worsening GFR.
• Manage oliguria with vigorous rehydration
• Oliguria occurs when urine is < 400ml/24hr, and anuria is defined as < 50ml/24hr.

Impairment Prevention

• Maintain adequate hydration, knowing individual "wet weight".
• Drink according to thirst, especially in the first hour or two post exercise.
• Avoid NSAIDs for 48 hours before prolonged, strenuous exercise.
• Seek medical attention if there is no urine output within 12 hours post-exercise.
• Acclimatize to hotter environments before exercise.

Considerations for Renal Impairment and Exercise

• Be mindful of the inability to excrete nitrogen, avoiding protein supplements.
• Note potential increased risk of hypertension (HTN)
• Note potential impact of less EPO production impacting fatigue.
• Avoid NSAIDs because of the role that they can play in reduced kidney function.
• Encourage regular exercise, while avoiding contact sports, for individuals with kidney transplants.

Dehydration and Renal Function

• Exercise-related fluid loss averages 1-2 liters per hour.
• Dehydration and concurrent hypovolemia cause reduced extracellular fluid (ECF).
• Reduced blood oncotic and glomerular capillary pressure leads to decreased GFR and sodium filtration.
• Volume control regulators: increased angiotensin II, aldosterone and ADH and reduced ANP.
• Severe dehydration consequences: decreased renal perfusion, hypoxia, and possible acute renal failure.

Electrolyte Abnormalities: Hyperkalemia

• Causes include renal impairment/failure, drugs like ACE-I, Spironolactone, NSAIDs, vigorous exercise (acute and mild, self-limiting, self-corrects after 5 minutes), hypoaldosteronism, and rhabdomyolysis.
• Presentation: > 7 is an emergency, muscle weakness, ECG changes (peaked T waves), and cardiac arrest.
• Treatment: I-stat machine for field diagnosis, insulin and glucose.
• Administer 10 units of novorapid IV and 50ml 50% glucose to push potassium into cells.
• Give calcium gluconate (10ml of 10%) if ECG changes.
• Consider sodium bicarbonate (8.4% 50ml) if there is metabolic acidosis.

Electrolyte Abnormalities: Hypokalemia

• Causes include diuretics (thiazides/loop diuretics), hyperaldosteronism, and GI losses (vomiting, diarrhea, disordered eating, laxative abuse).
• Presentation: usually asymptomatic, but severe cases involve muscle weakness, atrial and ventricular ectopics.
• Serious arrhythmias can occur, treat the underlying cause and administer IV or oral potassium as required.

Electrolyte Abnormalities: Hyponatremia

• Sodium levels are < 135mmol/L.
• It is associated with exercise
• Symptoms appear when sodium is < 130, which is related to the osmotic shift of water.
• Symptoms: bloating, nausea, and vomiting.
• More severe cases: headaches, altered mental state, seizures and respiratory distress caused by pulmonary edema.
• Causes: excess water/hypotonic fluid consumption, SIADH (tumors, CNS, pulmonary issues, SSRIs, NSAIDs), Addison's disease, hypothyroidism, and psychogenic polydipsia.
• Quick sodium correction can lead to central pontine demyelination.

Electrolyte Abnormalities: Hypernatremia

• Sodium levels are > 145mmol/L.
• Signs include thirst and severe when Na >157, presenting as lethargy, weakness, irritability, and neuromuscular excitability.
• Causes: dehydration/prolonged exercise and ADH deficiency (e.g., diabetes insipidus).

NSAIDs and Renal Function

• NSAIDs inhibit cyclooxygenase, preventing prostaglandin synthesis.
• Prostaglandins enhance renal perfusion through vascular dilatation, promoting diuresis and natriuresis.
• Basal renal vasoconstrictor tone is low in healthy subjects, so prostaglandin production is not essential for normal renal function.
• In diseased states, prostaglandins vasodilate the renal vascular bed, ensuring adequate renal blood supply.
• NSAID impact: NSAIDs reduce renal blood flow during exercise but do not significantly affect GFR in subjects exercising at 80% VO2 max for 30 minutes.
• Conflicting data exists about the impact of NSAIDs.
• Impacts creatinine increase vs non NSAID group.

Urinary Excretion Disorders: Hematuria

• Hematuria is the presence of red blood cells in the urine.

Hematuria - Intro

• Normal urine contains a small number of RBCs
• Dysmorphic RBCs indicate glomerular origin.
• Dipstick reacts to heme groups from: free Hb, free myoglobin, and intact RBCs.
• Other causes: beetroot and drugs (rifampicin, nitrofurantoin).
• Benign hematuria of an exercise related nature is common (20-25%)

Hematuria - History and Examination

• It is important to assess fever for UTI's
• Flank pain may suggest calculi.
• It is important to assess any trauma.
• A history of Streptococcal glomerulonephritis should be assessed
• During examination, assess patient's temperature, blood pressure, and check for edema.
• Perform abdominal palpation.

Hematuria - Investigations and Follow up

• Perform urine MCS and look for presence of whole RBCs, red cell casts.
• Ffollow-up in 48-72 hours if the initial unremarkable exam
• If benign cause then should be negative

Hematuria - Exercise Causes

• Heelstrike hemolysis: seen in endurance runners due to intravascular hemolysis from foot striking.
• Bladder wall abrasions: posterior wall vs trigone, from bladder bouncing up and down.
• Athletic pseudonephritis: Seen in 20% of marathon runners, presenting with casts and protein. Nephron ischemia and hypoxia cause transient increased glomerular permeability, resolves in 48 hours
• Perineal trauma: caused by cyclists

Hematuria - Other Causes

• May result from Drugs (anti-coags and NSAIDs)
• Past medical history of sickle cell, von-Willebrand's, renal and bladder tumors or calculi, and infection may lead to hematuria.
• Renal trauma also has to be kept in mind
• Additional Investigations should be performed if Hematuria is not resolving in 72 hours or has other clinical concerns
• Consider:
  • Imaging (CT scan)
  • Urine cytology/MCS
  • Referral to urologist or renal physician
• Microscopic haematuria can continue, macroscopic need to wait until clears

Proteinuria

• Increased Glomerular Filtration of albumin during exercise and after both contact and non-contact sport
• As intensity increases, tubular reabsorption of low MW proteins (B2 microglobulin declines
• Maximal protein loss lasts for 30 minutes post activity and ceases at 24 hrs
• The peak level is 3+ (300mg/24hr), which reduces with training
• Adolescent athletes may see peaks, but no routine urinalysis is needed.

Proteinuria - Investigation and Management

• Repeat testing after 48 hours is recommended
• If still abnormal then perform Upright and supine urinalysis for benign orthostatic
• If it is still proteinuria then suggest:
  • Perform Serum Ur and Cr, as well as 24hr urine for Cr, protein and urine protein electrophoresis
  • If >3g/day proteinuria, it may be suggestive of need to refer to assess suggestive renal disease
    • Predominantly B2-microglobulin = tubular disease (interstitial nephritis)
    • Predominantly albumin = glomerular disease (glomerulonephritis)

Myoglobinuria

• Found in muscle and normally bound to plasma globulins; it is maintained at <0.003mg/dl in serum.
• Coca cola urine
• Myoglobinuria occurs >1.5mg/dl due overwhelming tubular endocytosis rate and metabolism, excreted in the urine
• Test of choice for rhabdomyolysis as dipsticks reacts to Hb and Myoglobin
• Serum CK > 10,000 is most sensitive that indicates Elevated CK is common in distance runners in first 24 hours
• Only visible in urine if >100mg/dL
• Serum myoglobulin cleared rapidly - urine can be negative while CK still rising

Rhabdomyolysis

• Complex medical condition involving rapid dissolution of damaged or injured skeletal muscle that leads to direct release of intracellular products:
  • Myoglobin
  • CK
  • Aldolase, LDH and Electrolytes
• Due to disruption of ion channels that lead to Electrolytes into blood stream and extracellular space
• Ranges from Asymptomatic illness, with elevation in CK, to
• Life threatening condition that can cause:
  • High CK++ and Electrolyte imbalances
  • Acute renal failure (10-40% of patients with Rhabdomyolysis)
  • Disseminated intravascular coagulation

Rhabdomyolysis – Massive Necrosis

• Manifested as: Limb weakness, Myalgia, Swelling
• Look for Gross pigmenturia (Coca Cola, tea colored urine) without haematuria
• Common denominator of both traumatic and non traumatic includes: Greater than 50% do not complain initially of muscle pain or weakness)
• Need to suspect based on urine color

Rhabdomyolysis – Exercise Induced

• Breakdown of muscle leads to release from cells the that can cause:Hyperkalaemia, Hypocalcaemia, and ARF
• Risk includes Unaccustomed, and extreme exertion + Eccentric exercise = and "squat jump syndrome" in military and Crossfit
• Heat stress and Dehydration/hypovolaemia are important risk factors, as are recent Viral illness, and the use of drugs: Statins and Diuretics

Rhabdomyolysis - Dx

• Marked Tenderness, presence of Hypovolaemia, Altered GCS and Tachycardia and hypotension.
• Blood Test: -CK >10,000, and Myoglobinuria, Hyperkalaemia, Hypocalcemia and Hyperphosphataemia and Raised creatinine. -IV fluids (4-11L in first 24 hours)
• Other Supportive Actions" -Cation exchange resins,Diuresis alkalinization of urine. Phosphate binders. -Dialysis. -In severe field - Facilitate Transfer. -In the field monitor Hospital and Re-hydrate -Gradual Re-introducing (Slowly) -Avoid heavy exercise,
• Hydration. -Avoid Heat and review Medical history, and reduce Drugs and statins as needed. -Management with the Team.

Exercise associated Hyponatremia:

• Characterized by high Osmotic/Water shift with headache and the need for a high level of suspicion. -Can present with (tumors and the use of Pulmonary Drugs. -Diagnoses that there more often and a statement with the symptoms that result by Osmosis.

  • and more often due to 67% with Endurance.

• With a lower heart rates

Hemodynamic Support:

-Increase volume status And the use of other modalities to assist -and the reduction of pain(NSAIDS) due to exercise:

Exercise-associated Hyponatramia

• It is defined as Blood Na < 135mmol/L.
• Can occurs within 24 hours after a prolonged physical activity.
• EAH is a an increased volume of fluid of the high pressure of the water shifts high increase with a 2% increase of the pressure With Signs and Symptoms=Bloating
• General causes are due to the consumption of of hyptotonic fluids and pulmonary concerns with other medical concern such as Addison or hypto and or Psychiatric illnes
• To reduce correction, consider an increase sodium level to reduce the patient demyleination and the concern
• Can result From CNS pressure,Multiple tumors and pulmonary issues.
• And the reduction of (Drugs) to the medical history to the patient as more medical attention is more often.

Exercise-Associated Hyponatremia

• Is common among Long distance Athletes, with the diagnosis 67% will occur as the symptoms occurs. Hew - Increase the chance with volume , but is common if more frequent:

Reduce Symptoms

-Most high risk and lower Body Rates.

High Risk of increased volume -That includes more non Medical Issues. -Increased with lower volume

###Pathophysiology Includes --Non as medicinally(AVH) that results from Heat and Medical Issues -Which causes more concern and or pain. -Salty fluid that causes and increase IL 6 and results from other volume .The body does not want -This volume can also result in: and change the The Na in the System that causes change . 1 = more

• This change is related to overexertion of that patient with higher concentration levels.

###The body will be over Volume with no increase in: -Electrolytes due to the change result. -Will produce more Na in the system.

• The water will be more frequent and regular . The volume for that matter is based on different levels.

• The range from 125 or when the that more help in the management

• Assess for GCS volume

• Always has and IV saline to help with of fluid volume.

EAH Education

• Fluid intake must be determined according to thirst

UTI risk

• Prevalence increases in both men and women as they age
• Use of spermicide-coated condoms, diaphragms and spermicides can increase cystitis
• Comorbid conditions that can increase an individual's risk of developing UTI includes
  • Comorbid diabetes mellitus
  • Structural or functional urinary abnormalities

UTI Pathogenesis:

• Most common is by an ascending infection via the urethra and bladder
• Recent sexual Intercourse
• Other rare, via haematogenous spread can occur for organism: Staphylococcus aureus, Salmonella species, Mycobacterium tuberculosis

###UTI Infections are grouped by Organs: E Coli 70-90% Staphylococcus saprophyticus (5-10%)

• Are grouped into uncomplicated with : one (No concerns to the concerns)
• Or Complicated and can occurs due to Medical reasons or concerns
• One the most common Bacteria issues issues.

Factors Influencing the Risk of Developing UTI

Several factors contribute to an increased risk of urinary tract infections (UTIs):

• Thin, amenorrheic, or postmenopausal female athletes may have a reduced oestrogenic effect and thinner periurethral tissues, leading to increased UTI risk
• Athletes with active sex lives may have a higher exposure to postcoital UTIs

Sport specific risk for UTI

• Cyclists can experience: - Prostatitis -Traumatic urethritis.

For Women

-Female cycles develop cystitis and that is a risk factor

Diagnosis of a patients from the Exam Room.

• General complaints from the patient with other signs that cause a reason

• Urine

• Complaints

• General complaints

• More complaints

• Other medical concerns must be observed.

• Medical test for Nitrite/Leukocytes Other testing Includes.

• WCC/MID

• Bacteria Volume of the concerns:

UTI Bacterial Count

-A bacterial count equal to and greater than 105/ml with volume. Blood testing

• If Septic
• Unusual
• STI

UTI Treatment

• The use of specific treatment -Increase UTI -Increase for the Medical need.

• Can result in concerns of an infection and result for medical issues.

• And use may medical history

For patient with more testing required

• And most has be medically managed. -Other medications Medical history

Renal Trauma Statistics

• Rare, among trauma patients renal injury is detected in 0.3% to 3.25%.

• Kidneys commonly injury and the age group may vary.

• Patient the has been has kidney transplant

• Other reasons May injuries Falls Sports

Testicular Trauma

• Usually will report - The of pain and nausea

• Exam test, Inspect the testicle, and color to see if blood is still moving

• Color and assess the flow. Treat the pain. No the for concerns need medical.

• Wear a box. -May medical: high level.

Need healing and clearance by Doctor.

• May affect the women due to activities and their levels. -High impact to their lives.
• There a certain % for for individuals with the condition(Incontinence). -More issues must be well-developed
• -The body most also be very coordinated.