Renal PDF

Kidneys: ○ responsible for filtering water and removing waste from the bloodstream ○ help maintain body fluid volume and composition and create urine for waste elimination ○ help regulate blood pressure and acid-base balance ○ Produce erythropoietin for RBC synt...

Kidneys: ○ responsible for filtering water and removing waste from the bloodstream ○ help maintain body fluid volume and composition and create urine for waste elimination ○ help regulate blood pressure and acid-base balance ○ Produce erythropoietin for RBC synthesis ○ Convert vitamin D to active form ○ Reabsorb some of the glucose filtered from the blood ○ Recent upper respiratory problems, aches, heart disease, or gi conditions may be related to kidney problems ○ Normal urine output is 1500-2000 mL / day or within 500 mL of the volume of fluid ingested ○ Normal specific gravity- 1.005-1.030 RAAS: ○ Activated by: low BP, BV, Na, O2, high K ○ If any of these happen, the JG cells in the kidney are stimulated and excrete renin — renin inhibitors to stop ○ Liver secreting angiotensinogen (inactive form), renin activates it to angiotensin I— ACE Inhibitors to stop (pril) ○ Lungs produce ACE, changing angiotensin I to II. – ARBS (sartins) ○ angiotensin II goes to kidneys adrenal cortex which releases aldosterone — aldosterone inhibitor (spironolactone diuretic) ○ Aldosterone causes kidneys to excrete any excess K, and reabsorbs Na and H2O ○ This increases BP and BV ○ By bringing back homeostasis it inhibits renin, but if you give any of the meds ^ to stop the cycle, BP and BV will decrease so you will excrete the Na and H2O Kidney functions: ○ Regulatory- controls fluid and electrolyte balance and acid-base balance through urine elimination - Glomerular filtration, tubular reabsorption, tubular secretion - They use filtration, diffusion, active transport, and osmosis - Glomerular filtration is the first process in urine formation - Large molecules- blood cells, albumin, other proteins are too large to filter through the glomerular capillary wall - Normal GFR is 125 mL/min about 180 L/day - 1-3 L are excreted each day as urine, the rest is reabsorbed back into the blood - GFR is controlled by selectively constricting and dilating afferent and efferent arterioles - When afferent is constricted or efferent is dilated, pressure on glomerular capillaries falls and filtration decreases - Tubular reabsorption is the second process in urine formation  - Reabsorption of most of the filtrate ( early urine ) keeps normal urine output at 1-3 L /day and prevents dehydration - Most water, sodium, and chloride reabsorption occurs in the proximal convoluted tubule (PCT) - Potassium is mostly absorbed in the PCT and thick segment of the loop of henle - Bicarb, calcium, and phosphate are mostly reabsorbed in the PCT- bicarb reabsorption helps acid base balance and maintains normal blood ph - Thin and thick segments of the ascending loop of henle are not permeable to water - The distal convoluted tubule can be permeable to water and some water reabsorption occurs as the filtrate continues to flow through the tubule - DCT may be more permeable to water when vasopressin (antidiuretic hormone) and aldosterone are present - Vasopressin increases tubular permeability to water, allowing water to leave the tube and be reabsorbed into the capillaries, it also increases arteriole constriction which alters BP and affects the amount of fluid and particles that exit glomerular capillaries - Aldosterone promotes the reabsorption of sodium in the DCT - About 50% of all urea in the filtrate is reabsorbed, creatinine is not reabsorbed - ○ Hormonal- control RBC formation, BP, and vitamin D activation - Kidneys produce renin, prostaglandins, erythropoietin and activated vitamin D - Renin assists in bp control as it is formed and released when there is a decrease in blood flow, blood volume, or blood pressure through the renal arterioles or when too little sodium is present in kidney blood - Renin release causes the production of angiotensin II - Angiotensin II increases systemic bp with powerful blood vessel constricting effects and triggers the release of aldosterone from the adrenal glands - Aldosterone increases the absorption of sodium in the distal tube of the nephron- more water is absorbed- increase BV and BP - Prostaglandins are produced in the kidney to help glomerular filtration, kidney vascular resistance, and renin production, and increase water and sodium - Erythropoietin is produced and released in response to decreased oxygen supply in the kidneys, triggers rbc production in the bone marrow, when kidney function is poor, this production decreases and anemia results - Activated vitamin d happens in the kidney, it is needed to absorb calcium in the intestinal tract and regulate calcium balance  Kidney and Urinary Changes with Aging: ○ Changes in the kidney as a result of aging affect urine elimination, their ability to filter blood and excrete waste products ○ Kidneys lose cortical tissue and nephrons and get smaller as a result of reduced blood flow to the kidney ○ Medulla is not affected by aging and the juxtamedullary nephrons are preserved ○ Thickening glomerular and tubular basement membranes causing glucose, bicarb, and sodium to not be as readily absorbed ○ Number of glomeruli and their surface areas decrease ○ Tubule length decreases – decreases the ability to concentrate urine resulting in urgency or nocturnal polyuria ○ Blood flow to the kidney declines by 10% per decade as blood vessels thicken ○ GFR decreases with age, at 65 GFR is about 65mL per min – increased risk for fluid overload, dehydration and hypernatremia ○ Combination of reduced kidney mass, reduced blood flow, and decreased GFR contributes to reduced drug clearance, and greater risk for drug reactions and kidney damage to drugs and contrast ○ Changes in detrusor muscle elasticity leads to decreased bladder capacity and reduced ability to retain urine ○ Urinary sphincters lose tone- immediate bladder emptying with urge ○ Weakened pelvic floor muscles shorten the urethra and promote incontinence in women ○ Enlarged prostate glands make starting urine stream difficult and cause urinary retention ○ Sudden changes in pH, fluid load ○ Be aware of toxicity Risk Factors for Kidney Disease: ○ Hypertension ○ Diabetes mellitus ○ Heart disease ○ Contrast medium ○ Exposure to hydrocarbons, heavy metals, and gasses ○ Use of heroin, cocaine, meth, ecstasy, and inhalants Assessment: ○ Allergies ○ Medications and why ○ Patterns ○ Family hx ○ OTC meds - nsaids- protein in urine, acute kidney injury ○ Symptoms onset frequency ○ Nausea and vomiting ○ insurance  Diet: ○ Ask about fluid intake and caffeine content ○ 2 L of fluid daily is recommended ○ High protein intake can result in temporary kidney problems– caliculi formation ○ Change in appetite, taste, thirst sensation - can occur when theres a buildup of nitrogenous waste products from kidney failure Diagnostic Tests: ○ IVP- bowel prep, NPO, Contrast dye injected and pictures taken at intervals, looks at kidney ureter and bladder size shape location.Post procedure- look at renal function, I and O’s, IV fluids to flush the kidneys ○ Cystography, Cystourethrography- for recurring UTI, obstructions, causes of hematuria, enlarged prostate, problems with structures after trauma, strictures. needs consent, dye instilled into the bladder. Voiding- take pictures during for vesicoureteral reflux, make sure the urine isn't back flowing ○ Blood Tests- - creatinine (0.6-1.2) - end product of muscle and protein metabolism. Increased means 50% kidney function loss, nephrons are having problems. Give ACE inhibitors for patients with pre kidney or kidney disease bc they are renal protective - BUN (8-25)- measures the renal clearance of urea nitrogen. Increased bun suggests renal disease, can be caused by reabsorption of rbc protein, dehydration, and decreased renal perfusion - Ratio- 10:1-20:1. Above 20 is prerenal issue- severe dehydration. Below 10 is acute tubular necrosis, kidneys arent functioning properly - Decrease in GFR= increase in BUN and creatinine Conditions: ○ Urinary incontinence ○ Stress- most common, occurs coincidentally with intra abdominal pressure, caused by weak pelvic floor muscles or anatomic damage to urethral sphincter- sneezing ○ Urge- involuntary urine loss due to the detrusor muscle overactivity, strong urge to void, person cannot suppress the signal and leaks urine- UTI ○ Mixed- bladder outlet is weak and detrusor muscle overactive ○ Functional- other illness or disease results in incontinence- dementia, severely depressed, disabled, sedated ○ Dx- skin breakdown, infection, self esteem, falls ○ Treatments  ○ Anticholinergic (tolterodine)- suppresses involuntary bladder contractions, increase urine volume and bladder capacity ○ Antispasmodics (oxybutynin)- bladder muscle relaxation ○ SNRI (cymbalta) ○ Tricyclic antidepressants (imipramine and nortriptyline)- increases serotonin and norepinephrine levels, strengthens urinary sphincters, anticholinergic effects ○ Estrogen- enhances nerve conduction to urinary tract, reduce tissue deterioration and increase blood flow Cystitis- Inflammation of the bladder , usually caused by bacterial infection ○ S/S: ○ Pelvic pain ○ Urgency ○ Frequency ○ Malaise ○ Fever ○ Left shift WBC increase due to infection ○ Painful urination ○ Sometimes blood in urine ○ Treatments: ○ antiseptics (nitro)- interferes with bacterial enzyme system and bacterial wall formation ○ antibiotics (bactrim)- avoid sunlight take on empty stomach drink fluids, ○ analgesics (phenazopyridine)- relieves the pain but orange urine ○ Antispasmodics (hyoscyamine)- blocks acetylcholine- drowsiness dry mouth blurred vision ○ antifungal treatments long term antibiotic therapy, diet therapy ○ Uncomplicated- everything is functioning properly ○ Complicated- factors or conditions that contribute to diagnosis include pregnancy, male, obstruction, diabetes, neurogenic bladder, CKD, and reduced immunity Acute pyelonephritis ○ Bacterial infection in the kidney, usually e coli, proteus, pseudomonas ○ Risks: ○ Long term DM (bacteria loves sugar) ○ Pregnancy ○ Urinary obstruction ○ Vesicoureteral reflux ○ S/S: ○ Fever ○ Malaise ○ Tachycardia ○ Tachypnea  ○ n/v ○ Flank pain ○ frequency/urgency ○ Chills ○ Abdominal discomfort ○ Nocturia ○ Fatigue ○ Interventions ○ Antibiotic 2 weeks ○ Analgesics ○ Aroma therapy ○ Testing if recurrence: IVP, voiding cystourethrography, labs (BUN/creat, wbc, CMP UA), surgery ○ Prevention: ○ Educate patient on not abruptly stopping meds, increase fluid intake, avoid caffeine and alcohol Chronic Pyelonephritis: ○ Causes: ○ Recurrent infections ○ Obstructive conditions- HTN, vesicoureteral reflux, kidney stones, chemo ○ S/S: ○ Early same as acute htn, dysuria, can cause renal failure ○ Dx: ○ Cystoscopy, ultrasound, IVP ○ Interventions: ○ Antibiotics- 2 weeks ○ Percutaneous ultrasonic pyelolithotomy - kidney stone removal ○ Increase fluids 2 L per day ○ Low protein high carb ○ Pain management ○ Urinary antiseptics Urolitiasis: ○ Kidney stones- calculi ○ Usually originate in kidneys then travels ○ S/S: ○ Renal colic ○ Flank pain ○ Diaphoresis ○ Severe pain ○ Sudden ○ Infectious s/s ○ Hematuria  ○ n/v ○ Interventions: ○ Avoid caffeine tea alcohol opioids nsaids ○ toradol, very effective ○ Spasmolytics - ditropan, propanthel ○ Walk to facilitate passage of stone ○ Strain urine ○ Lithotripsy- shock to break up stones ○ High risk for infection bc fragments scrape the ureters ○ Pre op- NPO, consent, topical anesthetics , heart monitoring, moderate sedation, baseline labs ○ Post-op - observe for flank bruising (normal), strain urine, hydrate ○ Surgical management: ○ Retrograde ureteroscopy under fluoroscopy - radiocontrast into ureter ○ Stenting- usually temporary, opens to help pass stones ○ Percutaneous ureterolithotomy- removal of stone through abdomen into ureter ○ Pyelolithotmy - removal of stone through pelvis of kidney through the flank area ○ Nephrolithotomy- cut into any part of the kidney through flank area ○ Open procedure- may have to put catheter in ○ Post op- ○ Monitor for signs of bleeding ○ Check urine output ○ Increase fluid intake ○ Strain urine ○ Infection prevention- start on broad antibiotics- gentamicin/keflex ○ Stone prevention- 2.5 L of fluids/day, na restriction, protein restriction ○ Diet: ○ Still want calcium in diet bc it binds with oxalates in the intestines to get rid of it ○ Increase fluids 2L/day, moderate protein, low sodium, avoid high oxalate foods (spinach, rhubarb, beets, nuts, coffee, black tea, cola, chocolate, beer, strawberries), no more than 200 mg of vitamin C ○ Medications for types of stones- ○ Ca/oxalate- thiazides, phosphates help decrease ph and urinary ca excretion, maintain bone density, increase fluid output ○ Uric acid- allopurinol, potassium citrate- alters ph ○ Cystine- sodium bicarb- rare genetic issue, autosomal recessive disorder, increases urine cystine excretion Hydronephrosis: ○ Obstruction causing kidneys to become swollen from backed up urine ○ Prone to causing kidney damage ○ Causes- ○ Fibrosis ○ Tumors  ○ Pregnancy ○ Aortic aneurysm ○ Complications- ○ htn ○ Loss of renal function ○ Sepsis ○ Treatment- ○ Ureteral stent ○ Cystoscopy pyelogram ○ Nephrostomy tube ○ Open surgery Hydroureter: ○ Obstruction causing ureter to swell from backed up urine Nephrostomy tube: ○ Preop- NPO, give HTN meds, coag labs ○ Numb area, moderate sedation, prone position, fluoroscopy needle w guide wire- place catheter in renal pelvis- attached to external drainage bag ○ Post op- monitor drainage, monitor for infection, hematuria is normal 12-24 hrs after, monitor for polyuria for more than 3L/day ○ Contraindications- bleeding problems, uncontrolled htn Urothelial (bladder) cancer: ○ Risk factors- ○ Smoking ○ Male ○ 50+ ○ Work w chemicals, rubber or textile industries ○ Dyes ○ S/S- ○ Gross hematuria w no pain ○ UTI s/s ○ Flank pain if tumor growth obstructs structures ○ Diagnostic assessment- UA shows hematuria, no infection, cystoscopy w tissue biopsy ○ Nonsurgical management- ○ Prophylactic immunotherapy - instill bacterium which will induce local immune response to help decrease disease ○ Chemotherapy into bladder ○ Radiation- burns is a complication ○ Surgical management- ○ Cystectomy- bladder removal w removal of surrounding muscle tissue- most effective  ○ Post op- monitor for infection, skin integrity Bladder trauma: ○ Has to be surgically repaired ○ Fractures have to be fixed before bladder ○ Complications- hemorrhage, infection, wound dehiscence, urinary extravasation- urine accumulates in the peritoneal spaces or retroperitoneal spaces, small capacity bladder Polycystic kidney disease: ○ Genetic ○ Fluid filled cysts develop in the nephrons ○ Hemorrhage in ab 60% of individuals even w mild trauma ○ No cure ○ Dominant trait ○ Can affect other organs ○ Susceptible to traumatic injury ○ Average between 30-50 yr old ○ Diagnostic- ct, us ○ Treatment goals- prolong life, ease symptoms ○ Assessments- ○ Abd and flank for infection bleeding and kidney stones ○ Hematuria ○ Recurrent uti ○ Nocturia ○ Interventions- educate to avoid contact sports ○ Heating pad ○ Stool softener ○ Avoid nsaids and na ○ Control htn ○ Have to be put on dialysis before removing kidney Acute glomerulonephritis ○ Causes- ○ Strep- usually 7-10 days after ○ Infective endocarditis ○ Pneumococcal pneumonia ○ Viral hepatitis ○ mumps/measles ○ s/s- ○ Proteinuria, oliguria ○ Increase bun and creat ○ Htn ○ Edema  ○ Ascites ○ Esr ○ Decrease H/H from holding all the fluid ○ Treatment- manage infection, diuretics ○ Prevention of complications- ○ Diuretics ○ Reduce na , k , protein Chronic glomerulonephritis ○ Takes 20-30 yrs ○ Causes- ○ Rapid progressing glomerulonephritis ○ Diabetic nephropathy ○ Uncontrolled htn ○ Lupus nephritis ○ Interventions- diet, fluid intake, drug therapy, dialysis, kidney transplant ○ Goal- slow progression and prevent further complications Renovascular disease: ○ Decrease blood flow to renal tissue- ischemia and atrophy of renal tissue ○ Risk factors- ○ Smoking ○ Obesity ○ Diabetes ○ PAD ○ CAD ○ S/S- ○ Sudden uncontrolled htn - meds dont help ○ Pulmonary edema thats unexplained ○ Htn with increase creat ○ Dx - US MRA Renal arteriography CT angiogram ○ Treatment- ○ Htn meds ○ Diuretics ○ Angioplasty or stent to renal artery ○ Goals for tx- ○ Bp control- systolic decrease by 20, diastolic by 8 ○ Reduce pulmonary edema ○ Stop decrease of renal function Renal arteriography- ○ Reasons- ○ Assess renal blood flow to kidneys ○ Renovascular htn  ○ Bleeding ○ Aneurysms ○ Preop- consent, bowel prep, moderate sedation, NPO, meds allergies, baseline labs, iv fluids ○ Postop- monitor for bleeding, vitals, pressure on site, bed rest 4-6 hr w affected leg straight, encourage fluids, post op kidney function labs Renal cell carcinoma: ○ Tissues release parathyroid hormones, decrease renal excretion of ca and increase serum calcium concentration ○ Increase sedimentation rate ○ Paraneoplastic syndromes- ○ Anemia ○ Erythrocytosis ○ Htn ○ Hypercalcemia ○ Liver dysfunction ○ Hormonal effects ○ Nonsurgical management- ○ Radiofrequency ablation- effect is unknown ○ Chemotherapy- limited effect ○ Biological response modifiers and tumor necrosis factor- lengthen survival time Renal biopsy ○ To check on status of transplanted kidney, figure out why theres poor kidney function, check for cancer ○ Preop- consent, npo 4 hrs prior, coag tests, iv access, teach ab procedure, ○ Procedure- rt kidney is easier to access bc of position, prone position, moderate sedation, numb w local anesthetic, needle into the renal cortex- depth verified by ct or us,while sample is taken, pt is asked to breathe in and hold breath-preventing movement of diaphragm which can interfere w placement ○ Follow up- monitor for bleeding for 24 hrs, monitor for hematuria after 48hr, bedrest 2-6 hrs to reduce risk of bleeding, no strenuous exercise 1-2 weeks ○ Complications- infection at site of biopsy ○ hematoma ○ Can cause bruising or soreness ○ Puncture of major vessel ○ Bleeding - cause of hematuria ○ Cant see bleeding in peritoneal cavity- assess for flank and back pain ○ Hypotension ○ Decrease urine output ○ If these signs occur- significant blood loss occurred  Nephrectomy- ○ removal of the kidney- remaining kidney must perform function of both kidneys ○ Preop- npo, consent ○ Procedure- renal cells are very vascular, significant bleeding during surgery is a major concern ○ Postop- monitor for bleeding, h/h, urine output, pain management- dilaudid, morphine, prevention of complications Renal trauma- ○ Non surgical management- ○ Platelets ○ Blood products ○ Dopamine for renal perfusion ○ Vitamin k or plasma volume expanders like albumin or destran to reduce fluid shift ○ Surgical management- nephrectomy or partial nephrectomy ○ Pyridium side effects- turns urine orange/red