Kidney & Bladder.pdf

Kidney Diseases  Kidneys  Ureters  Bladder  Urethra Genitourinary Tract  Sit at the level of T 12 – L 3 with the left slightly higher than the right  Between 11 -15 cm long and weigh 150 grams  Receives 15 -20 % of cardiac output  Capped by the adrenal glands Kidney Kidney Ana...

Kidney Diseases  Kidneys  Ureters  Bladder  Urethra Genitourinary Tract  Sit at the level of T 12 – L 3 with the left slightly higher than the right  Between 11 -15 cm long and weigh 150 grams  Receives 15 -20 % of cardiac output  Capped by the adrenal glands Kidney Kidney Anatomy/Physiology Kidney Anatomy/Physiology Stage GFR ( mL /min/1.73m 2) 1 (Normal) >90 2 60 -89 3 30 -59 4 15 -29 5 <15  Glomerular Filtration Rate (GFR)  The best overall measure of kidney function  The volume of blood filtered through the kidney per minute expressed in mL/min/1.73m 2  Functions:  Maintain proper balance of water and minerals  Filtration and excretion of waste products  Regulate blood pressure and secrete certain hormones  Kidney function requires these processes to be carried out within a range of normal  Failure of both kidneys to do so will result in death within a few days without medical intervention Kidney  Acute Renal Failure  Chronic Kidney Disease  Nephrolithiasis  Renal Neoplasm Conditions Acute Renal Failure -Defined as a rapid decrease in renal function occurring over days to weeks  Often a result of major trauma, illness or surgery  Leads to accumulation of nitrogenous products in the blood (azotemia) which is not compatible with life  Treatment must be immediate and the underlying cause must be found Acute Renal Failure  3 types: 1. Prerenal: inadequate perfusion e.g. cardiovascular disease 2. Renal: intrinsic renal disease or injury 3. Postrenal: due to obstruction of the collecting and voiding parts of the renal/urinary tract No matter the type the end result is build - up of creatinine and urea and electrolyte/fluid imbalance Acute Renal Failure  S/S of underlying illness  Weight gain and peripheral oedema may be the only initial findings  Uraemia:  Nausea/vomiting  Myoclonic jerks  Hyper -reflexia  Confusion  Seizures  Coma Signs & Symptoms  Uremic pericarditis:  Friction rub  Chest pain  Tamponade – muffled heart sounds, jugular distention and hypotension  Dyspnea  Crackles on auscultation  Costo -vertebral angle may be tender Signs & Symptoms  Suspected when urine output decreases or serum BUN and creatinine rise  Blood tests  CBC, BUN, Creatinine, Calcium, Phosphate, Sodium etc.  Rising creatinine over progressive days  Normochromic -normocytic anemia Diagnosis  Overall survival rate ~ 50 %  Most cases of acute renal failure have significantly life threatening underlying causes  If the underlying cause is found early, the renal failure may be fully reversed Prognosis  Critical care unit for emergency treatment to preserve life  Haemodialysis  Treatment of underlying cause  Adjustment of drug regimen  Dietary changes:  Water/fluid intake restriction  Sodium and potassium intake restriction Medical Treatment  Medical emergency if suspected Chiropractic Management Chronic Kidney Disease - Long standing progressive deterioration of renal function - Defined by a GFR <60mL/min/1.73m 2 for > 3 months  Results from any cause of renal dysfunction of sufficient magnitude  The MC cause is diabetic nephropathy and hypertension  Leads to glomerular hypertension and progressive decline in GFR  Initially as renal tissue loses function the rest of the tissue increases in function to compensate  A 75% loss of renal function only drops the GFR by 50% Chronic Kidney Disease  Water retention due to a loss of GFR leading to sodium and fluid retention  Fluid accumulation causes pulmonary edema  Anemia  Inability of the kidneys to secrete potassium in the urine  Damaged kidneys fail to excrete phosphate → hyperphosphatemia → hypocalcemia → secondary hyperparathyroidism Chronic Kidney Disease  Asymptomatic until very late in the disease  Lab testing may pick it up as elevated BUN and creatinine with nocturia  Fatigue and lassitude are early signs of uraemia  Muscular twitches/cramps  Peripheral neuropathies with sensory and motor findings  Hyper -reflexia  Convulsions  Lassitude Signs & Symptoms  Uremic frost  Hypertension  Fluid retention  Pericarditis  Congestive heart failure Signs & Symptoms  GI manifestations:  Nausea  Vomiting  Anorexia  Unpleasant taste in the mouth  GI ulceration and bleeding  Tissue wasting as a result of malnutrition  Pruritus Signs & Symptoms  Elevated  BUN  Creatinine  Acidosis  Hyperphosphatemia  Decreased  Hypocalcemia  Urinalysis  Anemia - normochromic -normocytic Lab Findings  Depends on underlying condition  Complications may decrease life length  If all other organs are fine then dialysis and transplant improve the life expectancy Prognosis  Dietary management!!!!!!!  Fluid intake restriction  Phosphate binders  Sodium bicarbonate to reduce acidity  Diuretics  Dialysis  Transplant Medical Treatment  Dietary management /referral!!!!!!!!!!!!!!!  Water/fluid intake restriction  Sodium and potassium intake restriction  Post -surgical consideration  Check and adjust to patient tolerance Chiropractic Management Nephrolithiasis -Aka Renal Stones  Can occur anywhere in the urinary tract  Found in 1% of all autopsies  1/1000 adults are hospitalised each year for stones  Vary in size from microscopic to several cm’s  Staghorn calculi  80% calcium; 10% uric acid; 3% magnesium ammonium phosphate; 2% cystine Nephrolithiasis  Larger calculi are more likely to be lodged  Common areas:  Ureteropelvic junction  Ureterovesical junction  Distal ureter (at the level of the iliac crest)  Even large calculi remaining in the renal pelvis are usually asymptomatic unless they cause obstruction and/or infection  Renal colic pain when obstruction occurs  Excruciating and intermittent (cyclically, lasting 20 -60 minutes)  Patient may be unable to lie still and may pace, or constantly shift positions  Pain may radiate to flank or back or across the abdomen following the course of the ureter Signs & Symptoms & Physical Examination  On examination, patients may be in obvious extreme discomfort, often diaphoretic  Abdomen may be somewhat tender on the affected side  But lacking peritoneal signs – no involuntary guarding or rebound tenderness  Nausea/vomiting  Chills/fever  Haematuria – may be first symptom  Increased urinary frequency/urgency Signs & Symptoms & Physical Examination  Clinical differential diagnosis!  Peritonitis – e.g. due to appendicitis – pain is usually constant and patients lie still because movements worsen pain. Rebound tenderness and rigidity is usually positive  Cholecystitis – may cause colicky pain, but usually in epigastrium or RUQ often with Murphy’s sign +ve  Signs/symptoms!  Urinalysis and Imaging studies – x -ray/CT  Haematuria? Pyuria? Diagnosis  Antibiotics for infection  Painkillers for relief  Ultrasound ablation to break down stones  Calculus dissolution  Surgical removal – if not passed within 6 -8 weeks  If patient has an infection – surgery is done ASAP Medical Treatment  Prevention strategies:  Hydration  Dietary referral  Check and adjust to patient tolerance  Postsurgical consideration if relevant Chiropractic Management Renal Neoplasm -Accounts for 1 -2% of all adult cancers with most being malignant  Twice as common in males than females  Renal parenchyma can be invaded by leukaemia, lymphosarcoma, melanoma, lung, breast, stomach, intestine and female reproductive cancers  Extensive changes to kidneys however function remains unaltered for a long time Renal Neoplasm  May be completely asymptomatic until metastasized or become very large  Haematuria is the MC presentation  Flank pain  Weight loss  Fever of unknown origin  Palpable mass – rarely Signs & Symptoms  Picked up increasingly as an incidental finding on abdominal US and CT  If suspecting kidney cancer based on symptoms – they use CT/MRI to confirm the diagnosis  Chest x -ray for pulmonary metastasis  Blood tests – RBC may be increased or decreased Diagnosis  Prognosis is good if the lesion is localised and without metastasis  Complete surgical resection of kidney and lymph nodes Prognosis & Treatment  Post surgical considerations  Check and adjust to patient tolerance  If metastasised to bone = contraindication! Chiropractic Management Bladder Diseases  Kidneys  Ureters  Bladder  Urethra Genitourinary Tract  Hollow elastic organ  Collects urine excreted by the kidneys  3 openings: 2x ureters and 1x urethra  Holds 300 -350ml urine  Expansion triggers contraction of detrusor muscle to expel urine Bladder  Neurogenic Bladder  Bladder Calculi  Urinary Tract Infection  Bladder Cancer Conditions Neurogenic Bladder -Bladder dysfunction caused by neurologic damage  Can be caused by any condition that causes signalling changes to the bladder or bladder outlet  Stroke  Spinal injury  ALS  Diabetic neuropathy  Alcoholic neuropathy  Herniated disc  Parkinson’s disease  MS  Syphilis Neurogenic Bladder  Can be flaccid or spastic and bot  Spastic: low volume high pressure  Flaccid: high volume low pressure  Mixed  Both result in overflow incontinence Neurogenic Bladder  Overflow incontinence  Almost constant overflow dribbling  Erectile dysfunction  Frequency  Nocturia Signs & Symptoms  Recurrent UTIs  Urinary calculi  Vesicoureteral reflux and hydronephrosis  Nephropathy Complications  Based on clinical suspicion  X -ray with contrast  Post -void residual volume measured  Renal US to detect hydronephrosis  Serum creatinine and BUN to asses renal function Diagnosis  Good outcome if the underlying cause is diagnosed and treated before kidney damage ensues  Renal function monitoring, control/prevention of UTI’s and urinary calculi  Early ambulation after surgery, frequent changes in position, dietary restriction to reduce stone formation Prognosis  Catheterisation  Stimulation of voiding  Pressure on suprapubic area  Scratching thighs  Sacral nerve stimulation  Surgery Medical Treatment  Check and adjust to patient tolerance  Catheter consideration  Bladder training:  Voiding diary – amount of fluid intake, times of urination and episodes of leakage  Kegel exercises – strengthen pelvic muscles Chiropractic Management Bladder Calculi  Stones can vary from microscopic to several cm’s  Form due to urinary stasis in the bladder  Typically seen in paraplegics/quadriplegics and those with bladder emptying deficits  Can start from a renal stone that has passed into the bladder  Main concern is secondary infection Urinary Calculi  Most are asymptomatic  Low back & abdominal pain  Urinary frequency  Nocturia  Haematuria  Fever  Keep in mind paraplegics may not have these symptoms Signs & Symptoms  Often discovered incidentally on plain film  US can be used  Cystoscopy – painful! Diagnosis  Increased fluid intake  Break down of large stones via US or lithotripsy  Open cystotomy  Infection is a risk and will be managed as it develops Treatment  Check and adjust to patient tolerance  Post -surgical consideration of applicable  Encourage them to stay hydrated! Chiropractic Management Urinary Tract Infection -Infection of all or part of the urinary tract  Can be upper or lower  Upper : Kidneys  Lower : Ureter, bladder, urethra, prostate  Differentiating between the site can be difficult or impossible  Infection commonly spreads  MC = bacterial : E . coli  Otherwise look for STD, mycobacteria, fungi and parasites Urinary Tract Infection  Symptoms may be absent, but this is not typical  Once infection has reached the kidneys → systemic symptoms or sepsis can occur  50 x more common in women than men under the age of 50  Very common in young girls due to improper hygiene  Important to teach girls proper hygiene early  Ratio evens out after 50 due to increase in prostate disorders Urinary Tract Infection  May be asymptomatic – unlikely though  Flank pain  Urinary frequency, urgency  Small volume voiding  Burning pain on urination  Suprapubic and low back pain  Cloudy or turbid urine  Pneumaturia  Nausea & vomiting  Fever  +ve tenderness for costovertebral percussion on the involved side Signs & Symptoms  Clinical symptoms  Urine collection for bacterial culture or STD check Diagnosis  Antibiotics  Alkaline drinks to neutralise urine acidity  Increased fluid intake  Hygiene advice  Cotton underwear Medical Treatment  Check and adjust to patient tolerance  Hygiene advice  Taking showers rather than baths  Wear the right underwear – cotton  Urinate often  Clean from front to back  Wash before and after having sex  Alkaline drinks to neutralise urine acidity  Increased fluid intake Chiropractic Management Bladder Cancer  Usually transitional cell carcinoma  >60 000 new cases and 12 700 deaths per year  4 th MC cancer in men; less common in women  M:F 3:1  High chance of recurrence  Smoking is a risk factor as is analgesic abuse, chronic irritation, and chemical exposure (dye, rubber, electric, cable, paint)  Tends to metastasise to lymph nodes, lung, liver and bone Bladder Cancer  Unexplained haematuria  Anaemia  Voiding symptoms: dysuria, burning, frequency, pyuria  Pelvic pain (advanced)  Possible palpable pelvic mass Signs & Symptoms  Suspected clinically  Intravenous urography/pyelography  Cystoscopy with biopsy  CT and chest x -ray to check for metastasis Diagnosis  Good  Even with invasive cancer the 5 -year survival averages 50%  Though progressive or recurrent cancer gives a poor outcome Prognosis  Surgical resection  Repeated bladder instillations of chemotherapeutic drugs reduce risk of recurrence  Radical cystectomy  A team of chemo and radio can be used if surgery is contraindicated and can give good results in 20 -40% of patients  Monitored every 3 -6months Medical Treatment  Check and adjust to patient tolerance  If metastasis to bone – contraindication! Chiropractic Management