Exam 18 - Disorders of the Kidney

Renal Tumors

• Etiology/Pathophysiology: Malignant adenocarcinomas (renal cell carcinomas) are most common. They often develop unilaterally and are large when detected. Develop in proximal convoluted tubules.
• Increased Risk Factors: Smoking, obesity, genetics/heredity (especially conditions like hypertension and horseshoe kidney), and specific multi-organ syndromes (like von Hippel-Lindau disease).
• Clinical Manifestations (late signs): Painless, intermittent hematuria; palpable flank mass; dull flank pain.
• Clinical Manifestations (early signs): Hypercalcemia, fever, anemia, weakness, erythrocytosis, gross hematuria (rare until advanced).
• Clinical Manifestations (metastatic): Respiratory distress, bone pain.
• Assessment (subjective): Hematuria (without pain), weight loss, fatigue, dull flank pain.
• Assessment (objective): Palpable flank mass, hematuria (check for anticoagulant use), signs of metastasis.
• Diagnostics: Urinalysis (hematuria), cystoscopy with IVP/tomography (detect mass), CT scan (with/without contrast), chest X-ray, bone scan (staging). Biopsies are uncommon.
• Medical Management: Radical nephrectomy (with lymph nodes) for localized disease. Partial nephrectomy for solitary kidney or renal insufficiency. Radiation and chemotherapy are not usually very effective.
• Nursing Interventions: Post-operative care for nephrectomy; encourage patient expression of fears and concerns regarding poor prognosis; teach coping skills; support realistic hope; answer questions honestly.

Polycystic Kidney Disease (PKD)

• Etiology/Pathophysiology: Fluid-filled sacs (cysts) on kidneys, increase with age; Many are discovered through imaging tests.
• Increased Risk Factors for Cancer:
  • Common in patients with chronic renal failure
  • Causes are unknown but may be related to compensatory hyperplasia.
• Diagnosis: More than 4 cysts per kidney, visible during ultrasound or CT scans.
• Clinical Manifestations: Cysts on renal structures, frequently in collecting ducts (urine/blood fill the cysts).
• Bosniak Classification: Used to classify cysts, with classes I-IV; Class I are benign; Class II are minimally complicated; Class III have irregular thickened walls and need investigation; Class IV are malignant and require nephrectomy
• Assessment (subjective): Abdominal/flank pain, headache, GI issues, voiding problems, history of recurrent UTIs.
• Assessment (objective): Hypertension, hematuria.
• Diagnostics: Family history, physical exam, IVP and sonogram, renal function panel (BUN, creatinine).
• Medical Management: No specific treatment exists, pain management (heat/analgesics), maintaining blood pressure control (antihypertensives, diuretics, dietary modifications), managing infections. Dialysis/transplant may be needed.
• Nursing Interventions: Manage patient symptoms and severity; provide genetic counseling; address emotional concerns; monitor renal function; strict I&O.

Nephrotic Syndrome

• Etiology/Pathophysiology: Characterized by the following: marked proteinuria, hyperlipidemia, hypoalbuminemia (low albumin levels), and edema; this occurs due to glomerulus damage interfering with its permeability.
• Etiology/Pathophysiology (cont.): Protein loss reduces serum osmotic pressure, allowing fluid to enter interstitial spaces causing edema and decreased intravascular volume; immune responses (humoral and cellular) are suppressed, increasing risk of infection.
• Clinical Manifestations: Severe generalized edema (anasarca), anorexia, weight loss, activity intolerance, fatigue, foamy urine (proteinuria).
• Assessment (subjective): Anorexia, fatigue, foamy urine, decreased urine output (oliguria).
• Assessment (objective): May include electrolyte imbalances like decreased bicarbonate and magnesium, and increased potassium, sodium, and phosphatase.
• Diagnostics: Kidney function studies; blood tests.
• Medical Management: Primary goal is to conserve renal function, initiate dialysis, prepare for transplant; drug therapies include anticonvulsants, anti-anemics, vitamin supplements, antiemetics, anti-pruritics, biological response modifiers such as epoietin alfa (but iron replacement may be necessary first).
• Nursing Interventions: Maintaining fluid & electrolyte balance (strict I&Os, weights, hydration monitoring); nutritional therapy (high calories, high fat, protein, potassium restriction); addressing emotional support, safety; maintaining asepsis, documentation and reporting.

Dialysis

• Definition: Removing wastes, drugs, electrolytes, and controlling water balance by utilizing a semipermeable membrane.

• Hemodialysis: For acute/irreversible renal failure and fluid/electrolyte imbalances. Blood is circulated through an artificial kidney (dialyzer) to remove wastes while returning cleaned blood. Requires vascular access (temporary or permanent).

• Vascular Access (temporary): Quinton catheter (subclavian or femoral), two ports.

• Vascular Access (permanent): AV fistula (preferred, artery/vein sewn together), or AV graft (synthetic tube between artery/vein).

• Procedure: Patient connected to dialysis machine via AV fistula or graft; performed by trained technician; treatments are scheduled multiple time per week.

• Complications: Cardiovascular issues (heart failure, stroke), hypotension, muscle cramps, dysrhythmias, headaches, nausea/vomiting, rapid changes in electrolytes.

• Medical Management: Monitor drug levels; adjust medications to avoid toxicity; instruct patients to not take OTC medications without approval; monitor GFR, dialysis, vomiting, and missed medications.

• Peritoneal Dialysis: Utilizes the peritoneum as a semi-permeable membrane to remove waste and excess fluids. Types include CAPD (continuous ambulatory), CCPD (continuous cycling), and NIPD (nocturnal intermittent).

• Peritoneal Dialysis Considerations: Patient preference; less rapid treatment needed; no need for blood vessel access; more freedom for the patient, severe cardiovascular issues. 

• Complications (Peritoneal): Peritonitis, hypotension, pain, and hemorrhage.

• Patient Teaching: Explain procedure, signs of complications, diet/fluid restrictions, medication scheduling.

Nephrectomy

• Procedure: Removal of all or part of a kidney.
• Types: Partial (diseased tissue), Radical (kidney, ureter, adrenal gland, and surrounding fatty tissue).
• Post-op Management: Monitor vital signs, look for bleeding, identify GI problems (nausea, vomiting, distention), record I&O. Keep drainage tubes clear. Monitor output, change dressings. 
• Patient Teaching: Avoid heavy lifting, drink sufficient fluids (unless contraindicated), monitor output, avoid alcohol, infections, and hazardous activities (that could hurt the remaining kidney).

Nephrostomy

• Procedure: Surgical insertion of a catheter into the renal pelvis for urine drainage.
• Post-op Management: Maintain catheter patency; prevent hemorrhage, monitor I&O; careful skin care. Irrigate catheter as prescribed, avoiding catheter displacement. Note drainage, observe for obstruction. Change dressings regularly. Maintain drainage below the kidney.

Kidney Transplantation

• Recipient Selection: Based on medical, immunological, and psychosocial evaluation of the patient's status. General guideline based on age.

This quiz covers the etiology, pathophysiology, and clinical manifestations of renal tumors, focusing on renal cell carcinomas. It explores risk factors, diagnostic criteria, and assessment techniques associated with the condition. Perfect for medical students and healthcare professionals looking to enhance their knowledge of renal tumors.