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Questions and Answers
What does an increased blood urea nitrogen (BUN) level indicate?
Which medication is effectively used to suppress involuntary bladder contractions?
What is the primary cause of acute pyelonephritis?
Which condition would most likely present with severe flank pain and hematuria?
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What is the most common form of urinary incontinence?
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Which of the following is a common symptom of cystitis?
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What intervention is crucial for a patient with hydronephrosis?
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Which type of renal cancer is associated with paraneoplastic syndromes such as anemia and hypercalcemia?
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What dietary recommendation should be made for a patient with calcium oxalate stones?
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What is a major complication associated with nephrectomy?
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What condition is characterized by fluid-filled cysts developing in the nephrons?
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What diagnostic test is often used to confirm renal arteriography findings?
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Which symptom is NOT typical of urinary tract infections?
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When managing hydronephrosis, what test helps visualize the obstruction?
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What is one of the primary functions of the kidneys?
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What is normal urine output for an average adult per day?
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What does angiotensin II primarily do in the body?
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What is a common change in kidney function with aging?
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Which hormone is responsible for stimulating red blood cell production?
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What effect does aldosterone have on the kidneys?
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Which condition can result from poor kidney function?
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What is a primary role of tubular reabsorption in the kidneys?
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What can lead to increased blood pressure in the RAAS system?
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Which age-related change affects urinary sphincter function?
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What dietary recommendation is advised for maintaining kidney health?
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What does the glomerular filtration rate (GFR) measure?
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Which substance is NOT reabsorbed in the kidneys?
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Which risk factor can contribute to kidney disease?
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Study Notes
Kidney Functions
- Kidney function is key to filtering waste and maintaining body fluid volume, composition, blood pressure, and acid-base balance.
- Urine is created and excreted to remove waste, with a normal output of 1500-2000 mL daily or within 500 mL of fluid ingested.
- Specific gravity of urine provides insight into concentration levels, ranging from 1.005-1.030.
- Erythropoietin is produced to stimulate red blood cell synthesis.
- Vitamin D activation occurs in the kidneys, crucial for calcium absorption.
- Glucose reabsorption takes place in the kidneys, with any excess filtered out.
- Kidney issues can potentially be linked to recent respiratory problems, aches, heart disease, or gastrointestinal conditions.
Renin-Angiotensin-Aldosterone System (RAAS)
- RAAS is activated by low blood pressure, blood volume, sodium, oxygen levels, and high potassium.
- Juxtaglomerular (JG) cells in the kidney release renin when activated, which can be inhibited by renin inhibitors.
- Angiotensinogen, an inactive form secreted by the liver, is activated by renin to form angiotensin I, a process that can be blocked by ACE inhibitors.
- Angiotensin-converting enzyme (ACE), produced by the lungs, converts angiotensin I to angiotensin II, which can be inhibited by ARBs.
- Angiotensin II stimulates the adrenal cortex to release aldosterone, a process that can be blocked by aldosterone inhibitors.
- Aldosterone promotes sodium reabsorption and potassium excretion in the kidneys, ultimately increasing blood pressure and volume.
- Medications inhibiting RAAS (renin inhibitors, ACE inhibitors, ARBs, aldosterone inhibitors) lead to decreased blood pressure and volume, promoting sodium and water excretion.
Regulatory Functions of the Kidneys
- Fluid and electrolyte balance and acid-base balance are regulated through urine elimination.
- Glomerular filtration, tubular reabsorption, and tubular secretion are key processes involved in urine formation.
- Filtration, diffusion, active transport, and osmosis are mechanisms used by the kidneys.
- Glomerular filtration is the initial step in urine formation, filtering out waste and excess fluid.
- Large molecules, such as blood cells, albumin, and proteins, are too large to pass through the glomerular capillary wall.
- Normal glomerular filtration rate (GFR): 125 mL/min, approximately 180 L/day.
- Urine excretion: 1-3 L per day, with the remaining fluid reabsorbed back into the bloodstream.
- GFR control: selective constriction and dilation of afferent and efferent arterioles.
- Afferent constriction or efferent dilation decrease pressure on glomerular capillaries, leading to reduced filtration.
- Tubular reabsorption is the second process in urine formation, reabsorbing most of the filtered fluid (early urine) back into the system.
- Proximal convoluted tubule (PCT): responsible for reabsorbing majority of water, sodium, and chloride.
- Potassium, bicarbonate, calcium, and phosphate: primarily reabsorbed in the PCT.
- Bicarbonate reabsorption contributes to acid-base balance and blood pH maintenance.
- Ascending loop of Henle (thin and thick segments): impermeable to water.
- Distal convoluted tubule (DCT): permeable to water, with some water reabsorption occurring.
- Vasopressin (antidiuretic hormone) and aldosterone: enhance DCT water permeability, promoting reabsorption.
- Vasopressin: increases tubular permeability to water, allowing water reabsorption and affecting blood pressure through arteriole constriction.
- Aldosterone: promotes sodium reabsorption in the DCT.
- Urea reabsorption: approximately 50% is reabsorbed, while creatinine is not reabsorbed.
Hormonal Functions of the Kidneys
- Renin, prostaglandins, erythropoietin, and activated vitamin D: hormones produced by the kidneys.
- Renin release: triggered by decreased blood flow, blood volume, or blood pressure through renal arterioles, or low sodium levels in kidney blood.
- Renin: contributes to blood pressure control by stimulating angiotensin II production.
- Angiotensin II: increases systemic blood pressure through vasoconstriction and stimulates aldosterone release from the adrenal glands.
- Aldosterone: enhances sodium absorption in the distal tubule of the nephron, leading to increased water absorption, blood volume, and blood pressure.
- Prostaglandins: influence glomerular filtration, kidney vascular resistance, renin production, and contribute to water and sodium retention.
- Erythropoietin: produced and released in response to low oxygen levels in the kidneys, stimulating red blood cell production in the bone marrow.
- Kidney dysfunction: leads to decreased erythropoietin production and anemia.
- Vitamin D activation: occurs in the kidneys, crucial for calcium absorption in the intestinal tract and calcium balance regulation.
Kidney and Urinary Changes with Aging
- Kidney changes with aging: impact urine elimination, blood filtration, and waste excretion.
- Reduced blood flow to the kidney: leads to cortical tissue and nephron loss and kidney shrinkage.
- Medulla: remains unaffected by aging, with juxtamedullary nephrons preserved.
- Glomerular and tubular basement membrane thickening: hinders glucose, bicarbonate, and sodium absorption.
- Decreased number and surface area of glomeruli: affecting filtration capacity.
- Shorter tubule length: reduces urine concentration ability, potentially causing urgency or nocturnal polyuria.
- Blood flow decline: about 10% per decade, due to blood vessel thickening.
- Decreased GFR: approximately 65 mL/min at age 65, increasing the risk of fluid overload, dehydration, and hypernatremia.
- Reduced kidney mass, blood flow, and GFR: contribute to slower drug clearance, increasing the risk of drug reactions and kidney damage.
- Detrusor muscle elasticity decline: reduces bladder capacity and urinary retention.
- Urinary sphincter tone loss: leads to immediate bladder emptying with urgency.
- Weakened pelvic floor muscles: shorten the urethra, increasing incontinence risk in women.
- Enlarged prostate gland: makes urination difficult and can cause urinary retention.
- Sudden changes in pH and fluid load: require monitoring.
- Toxicity: potential risk, necessitating careful awareness.
Risk Factors for Kidney Disease
- Hypertension
- Diabetes mellitus
- Heart disease
- Contrast medium exposure
- Exposure to hydrocarbons, heavy metals, and gases
- Drug use: heroin, cocaine, meth, ecstasy, and inhalants
Assessment for Potential Kidney Issues
- Allergies
- Medications: including purpose and dosage
- Patterns
- Family history
- Over-the-counter medications: NSAIDs can contribute to protein in urine and acute kidney injury.
- Symptoms onset and frequency
- Nausea and vomiting
- Insurance
Diet Considerations and Implications
- Fluid intake: recommended at 2 L daily, with attention to caffeine content.
- High protein intake: can temporarily impact kidney function and contribute to kidney stone formation.
- Changes in appetite, taste, and thirst sensation: can occur due to buildup of nitrogenous waste products from kidney failure.
Diagnostic Tests
- Intravenous pyelogram (IVP): requires bowel preparation, NPO status, and contrast dye injection. Images are taken at intervals to evaluate kidney, ureter, and bladder size, shape, and location. Post-procedure, renal function monitoring, input and output assessment, and IV fluids are crucial to flush the kidneys.
- Cystography and cystourethrography: used for recurrent UTIs, obstructions, hematuria causes, enlarged prostate, post-trauma issues, and strictures.
Blood Tests
- Creatinine (0.6-1.2) - measures the end product of muscle and protein metabolism. Increased creatinine suggests a 50% loss of kidney function, indicating issues with the nephrons. ACE inhibitors are renal protective and should be given to patients with pre-existing kidney disease.
- BUN (8-25) - measures the renal clearance of urea nitrogen. Elevated BUN suggests renal disease and can be caused by red blood cell protein reabsorption, dehydration, and decreased renal perfusion.
- BUN:Creatinine Ratio - Normal range is 10:1-20:1. A ratio above 20 indicates a pre-renal issue, such as severe dehydration. A ratio below 10 suggests acute tubular necrosis, where the kidneys are not functioning properly.
- A decrease in GFR leads to an increase in BUN and creatinine levels.
Urinary Incontinence
- Most common type is stress incontinence which occurs with increased intra-abdominal pressure, caused by weak pelvic floor muscles or anatomic damage.
- Urge incontinence is involuntary urine loss caused by detrusor muscle overactivity, resulting in a strong urge to void.
- Mixed incontinence combines a weakened bladder outlet with detrusor muscle overactivity.
- Functional incontinence occurs when other illnesses or conditions contribute to incontinence, such as dementia, severe depression, disability, or sedation.
Urinary Incontinence Treatment
- Anticholinergics (tolterodine): Suppresses involuntary bladder contractions, increases urine volume, and increases bladder capacity.
- Antispasmodics (oxybutynin): relaxes bladder muscles
- SNRIs (Cymbalta):
- Tricyclic antidepressants (imipramine and nortriptyline): increase serotonin and norepinephrine levels, strengthen urinary sphincters, and have anticholinergic effects.
- Estrogen: enhances nerve conduction to the urinary tract, reduces tissue deterioration, and increases blood flow.
Cystitis
- Inflammation of the bladder, commonly caused by bacterial infection.
- Symptoms: Pelvic pain, urgency, frequency, malaise, fever, left shift in WBC due to infection, painful urination, and sometimes blood in urine.
- Treatment:
- Antiseptics (nitro): interfere with bacterial enzyme systems and bacterial wall formation.
- Antibiotics (bactrim): avoid sunlight and take on an empty stomach; drink fluids.
- Analgesics (phenazopyridine): relieves pain but turns urine orange.
- Antispasmodics (hyoscyamine): blocks acetylcholine, causing drowsiness, dry mouth, and blurred vision.
- Long-term antibiotic therapy, antifungal treatments, and diet therapy may be used in cases of complicated cystitis.
Cystitis Types
- Uncomplicated: All bladder functions are normal.
- Complicated: Factors like pregnancy, male gender, obstruction, diabetes, neurogenic bladder, CKD, and reduced immunity contribute to the diagnosis.
Acute Pyelonephritis
- Bacterial infection of the kidney, commonly caused by E. coli, Proteus, and Pseudomonas.
- Risk factors: Long-term diabetes, pregnancy, urinary obstruction, vesicoureteral reflux.
- Symptoms: Fever, malaise, tachycardia, tachypnea, nausea, vomiting, flank pain, frequency/urgency, chills, abdominal discomfort, nocturia, and fatigue.
- Interventions:
- Antibiotics: 2 weeks of treatment.
- Analgesics: for pain management.
- Aromatherapy: may provide relief.
- Testing for recurrence: IVP, voiding cystourethrography, labs (BUN/creat, WBC, CMP, UA), and surgery.
- Prevention: Educate patients to avoid abruptly stopping medications, increase fluid intake, and avoid caffeine and alcohol.
Chronic Pyelonephritis
- Causes: Recurrent infections, obstructive conditions, such as hypertension, vesicoureteral reflux, kidney stones, and chemotherapy.
- Symptoms: Early symptoms are similar to acute pyelonephritis. Hypertension and dysuria are common, and the condition can lead to renal failure.
- Diagnosis: Cystoscopy, ultrasound, and IVP.
- Interventions:
-Antibiotics: 2 weeks treatment
- Percutaneous ultrasonic pyelolithotomy: Removal of kidney stones.
- Increase fluids: 2 liters per day.
- Diet: Low protein, high carbohydrates.
- Pain Management: for discomfort.
- Urinary antiseptics
Urolitiasis (Kidney Stones)
- Calculi that usually originate in the kidneys and travel.
- Symptoms: Renal colic, flank pain, diaphoresis, severe sudden pain, symptoms of infection, hematuria, nausea, and vomiting.
- Interventions:
- Avoid caffeine, tea, alcohol, opioids, and NSAIDs.
- Toradol: is highly effective for pain relief.
- Spasmolytics: ditropan, propanthel
- Encourage walking to facilitate stone passage.
- Strain urine.
- Lithotripsy (shock wave therapy) to break up stones.
- High risk for infection due to fragments scraping the ureters.
- Pre-operative care: NPO, consent, topical anesthetics, heart monitoring, moderate sedation, baseline labs.
- Post-operative care: observe for flank bruising (normal), strain urine, hydrate.
Surgical Management of Kidney Stones
- Retrograde ureteroscopy under fluoroscopy: Radiocontrast is injected into the ureter.
- Stenting: Temporary placement to keep the ureter open and facilitate stone passage.
- Percutaneous ureterolithotomy: Removal of the stone through the abdomen into the ureter.
- Pyelolithotomy: Removal of the stone through the pelvis of the kidney, through the flank area.
- Nephrolithotomy: A cut into any part of the kidney through the flank area.
- Open procedure: May require catheter placement.
Post-Operative Management of Kidney Stones
- Monitor for signs of bleeding.
- Check urine output.
- Encourage increased fluid intake.
- Strain urine.
- Infection prevention: Start on broad spectrum antibiotics, such as gentamicin or keflex.
- Stone prevention : 2.5 L of fluids/day, sodium restriction, protein restriction.
### Kidney Stone Diet
- Maintain adequate calcium intake; it binds with oxalates in the intestines to aid in excretion.
- Increase fluids to 2 L/day.
- Moderate protein intake.
- Low sodium intake.
- Avoid high oxalate foods: spinach, rhubarb, beets, nuts, coffee, black tea, cola, chocolate, beer, strawberries.
- Limit vitamin C intake to 200 mg per day.
Medication Management of Kidney Stones
- Calcium/oxalate stones: Thiazides, phosphates can help decrease urine pH and urinary calcium excretion, maintain bone density, and increase fluid output.
- Uric acid stones: Allopurinol, potassium citrate can alter pH levels.
- Cystine stones: Sodium bicarbonate- Rare, genetic issue, autosomal recessive disorder that increases cystine excretion in the urine.
Hydronephrosis
- Obstruction causing the kidneys to swell due to backed-up urine, leading to potential kidney damage.
- Causes: Fibrosis, tumors, pregnancy, aortic aneurysm.
- Complications: Hypertension, loss of renal function, sepsis.
- Treatment:
- Ureteral stent
- Cystoscopy pyelogram
- Nephrostomy tube
- Open surgery
Hydroureter
- Obstruction causing the ureter to swell due to backed-up urine.
Nephrostomy Tube
- Pre-operative care : NPO, administration of antihypertensive medications, coagulation labs.
- Procedure : Numb the area, provide moderate sedation, position the patient prone, use fluoroscopy and guide wire to place a catheter in the renal pelvis. The catheter is connected to an external drainage bag.
- Post-operative care : Monitor drainage, watch for signs of infection. Hematuria is normal for 12-24 hours, but monitor for polyuria (over 3 L per day).
- Contraindications: Bleeding problems, uncontrolled hypertension.
Urothelial (Bladder) Cancer
- Risk factors:
- Smoking
- Male gender
- Age 50+
- Working with chemicals, rubber, or textiles industries
- Dyes
- Symptoms: Gross hematuria without pain, UTI symptoms, flank pain if tumor growth obstructs structures.
- Diagnostic assessment: Urinalysis (UA) showing hematuria without infection. Cystoscopy with tissue biopsy.
- Nonsurgical management:
- Prophylactic immunotherapy: Instillation of bacteria to induce a local immune response and reduce disease progression.
- Chemotherapy into the bladder.
- Radiation: Complications include burns.
- Surgical management:
- Cystectomy: Bladder removal with removal of surrounding muscle tissue - most effective treatment.
- Post-operative care: Monitor for infection, skin integrity.
Bladder Trauma
- Requires surgical repair.
- Fractures must be fixed before bladder repair.
- Complications: Hemorrhage, infection, wound dehiscence, urinary extravasation (urine accumulation in peritoneal or retroperitoneal spaces), small capacity bladder.
Polycystic Kidney Disease (PKD)
- Genetic condition in which fluid-filled cysts develop in the nephrons.
- A 60% risk of hemorrhage in the abdomen with even mild trauma.
- No cure.
- Autosomal dominant trait.
- Can affect other organs.
- Individuals are susceptible to traumatic injury.
- Average age of onset is 30-50 years old.
- Diagnosis: CT scan, ultrasound.
- Treatment goals: Prolong life, ease symptoms.
Assessment:
- Assess abdomen and flank for signs of infection, bleeding, and kidney stones.
- Monitor for hematuria.
- Watch for recurrent UTIs.
- Note nocturia.
- Interventions:
- Educate patients to avoid contact sports.
- Use heat pads.
- Administer stool softeners.
- Avoid NSAIDs and sodium.
- Control hypertension.
- Dialysis is required prior to kidney removal.
Acute Glomerulonephritis
- Causes:
- Streptococcal infection (usually 7-10 days after infection).
- Infective endocarditis.
- Pneumococcal pneumonia.
- Viral hepatitis.
- Mumps/measles.
- Symptoms: Proteinuria, oliguria, increased BUN and creatinine levels, hypertension, edema, ascites, elevated ESR, decreased hematocrit/hemoglobin due to fluid retention.
- Treatment: Manage underlying infection, administer diuretics.
- Prevention of complications :
- Diuretics
- Sodium, potassium, and protein restriction.
Chronic Glomerulonephritis
- Progressive kidney disease that takes 20-30 years to develop.
- Causes: Rapidly progressing glomerulonephritis, diabetic nephropathy, uncontrolled hypertension, lupus nephritis.
- Interventions: Diet, fluid adjustments, drug therapy, dialysis, kidney transplant.
- Goal: Slow disease progression and prevent further complications.
Renovascular Disease
- Reduced blood flow to renal tissue, leading to ischemia and atrophy of renal tissue.
- Risk factors:
- Smoking
- Obesity
- Diabetes
- Peripheral artery disease (PAD)
- Coronary artery disease (CAD)
- Symptoms: Sudden, uncontrolled hypertension resistant to medication, unexplained pulmonary edema, hypertension with elevated creatinine levels.
- Diagnosis: Ultrasound, MRA, renal arteriography, CT angiogram.
- Treatment:
- Antihypertensive medications
- Diuretics
- Angioplasty or stent placement in the renal artery.
Goals of Treatment for Renovascular Disease
- Control blood pressure: Systolic reduction by 20 mmHg, diastolic reduction by 8 mmHg.
- Reduce pulmonary edema.
- Prevent a decline in renal function.
Renal Arteriography
- To assess renal blood flow to the kidneys, diagnose renovascular hypertension, bleeding, aneurysms.
- Pre-operative care: Consent, bowel prep, moderate sedation, NPO, medication allergies, baseline labs.
- Post-operative care: Monitor for bleeding, vital signs, pressure at the injection site, bed rest for 4-6 hours with the affected leg kept straight. Encourage fluids, assess kidney function labs.
Renal Cell Carcinoma
- Renal cells release parathyroid hormone, causing decreased renal excretion of calcium and elevated serum calcium levels.
- The sedimentation rate is usually elevated.
- Paraneoplastic syndromes:
- Anemia
- Erythrocytosis
- Hypertension
- Hypercalcemia
- Liver dysfunction
- Hormonal effects (causing other complications)
- Nonsurgical management:
- Radiofrequency ablation (effectiveness is uncertain)
- Chemotherapy (limited effectiveness)
- Biological response modifiers and tumor necrosis factor (may prolong survival time)
Renal Biopsy
- Used to determine the status of a transplanted kidney, investigate the cause of poor kidney function, or check for cancer.
- Pre-operative care: Consent, NPO for 4 hours prior, coagulation tests, IV access, education about the procedure.
- Procedure: The right kidney is easier to access; patient is placed in a prone position with moderate sedation. The area is numbed with a local anesthetic, and a needle is inserted into the renal cortex. The needle depth is confirmed with a CT scan or ultrasound. To prevent diaphragmatic movement and interference with needle placement, the patient is asked to take a breath and hold it while the sample is taken.
- Follow-up: Monitor for bleeding for 24 hours, monitor for hematuria after 48 hours, bed rest for 2-6 hours to reduce the risk of bleeding, avoid strenuous exercise for 1-2 weeks.
- Complications: Infection at the biopsy site, hematoma, bruising, soreness, puncture of a major vessel, bleeding (which can cause hematuria), bleeding into the peritoneal cavity (monitor for back and flank pain), hypotension, decreased urine output.
Nephrectomy
- Removal of the kidney. The remaining kidney must perform the function of both kidneys.
- Pre-operative care: NPO, consent.
- Procedure: Kidney cells are highly vascular; significant bleeding during surgery is a significant concern.
- Post-operative care: Monitor for bleeding, hematocrit/hemoglobin, urine output, pain management (dilaudid, morphine), prevention of complications.
Renal Trauma
- Nonsurgical management: Platelets, blood products, dopamine to improve renal perfusion, vitamin K, plasma volume expanders (albumin or dextran) to prevent fluid shifts.
- Surgical management: Nephrectomy (removal of the kidney) or partial nephrectomy.
Pyridium Side Effects
- Turns urine orange/red.
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