8 renal disease Flashcards
Localized manifestations of renal disease
Flank pain Dysuria Colic (spasmodic pain) Polyuria Oliguria Anuria
Oliguria definition
<30ml/hr or 400ml/day
Localized
Proteinuria
Glucosuria
Hematuria
Pyuria - pus in the urine
Systemic manifestations (vary depending on etiology)
Bacterial infection - fever, chills, general malaise
Renal failure - Uremia + other S&S of chronic renal failure
Hyperkalemia, hypercalcemia
Anemia
Uremia defintion
Blood excess of: Urea (BUN) Creatinine Other metabolic end products Chronic uremia can cause neuro changes and CNS depression
Renal insufficiency
25% of normal or GFR 25-30ml/min
Typically has mildly elevated BUN and creatinine
End stage renal failure
Less than 10% function
Renal failure
Inability of kidney to maintain normal function
Symptoms of uremia
Elevated creatinine and BUN
Fatigue, anorexia, N/V, pruritus and neuro changes
Pruritus
Severe itching of the skin as a symptom of various ailments
Oliguria
Reduced urine output
Acute renal failure
Abrupt reduction in renal function with uremia
Usually oliguria (can be normal or increased)
Both kidneys
Reversible if treated early
Extra systemic waste, less stuff normally kept by kidneys
Three classifications of acute renal failure
Pre, intra and post renal
Prerenal ARF
Most common cause of ARF
Decreased blood flow, which drops GFR because of inadequate filtration pressure
Causes of prerenal failure
Hypovolemia - trauma, GI bleed, childbirth, burns, peritonitis, water and lytes loss (vomiting/diarrhea/bowel obstruction/beeties/diuretics)
Hypotension - Sepsis, cardiac, PE, renal artery stenosis, vasoconstriction (PIH, hepatorenal syndrome)
Three types of intrarenal ARF
Acute tubular necrosis (ATN)
Acute glomerulonephritis
Acute pyelonephritis
Acute tubular necrosis (ATN)
Destruction of tubular epithelial cells by:
Iscehmia, nephrotoxins, intratubular obstruction, acute renal diseases
Usually multifactoral, lead to necrosis through a combination of the above causes
Least reversible as cell death is present
Ischemia in ARF
Surgery, sepsis, hypovolemia, trauma, burns
ATN from trauma and burns is multifactoral and can involve nephrotoxins and obstruction
Nephrotoxins (ATN)
Carbon tetrachloride, NSAIDS, tylenol, aminoglycoside, antibiotics (gentamycin, garamycin)
Radiocontract medium
Hemoglobin, myoglobin
Bacterial endotoxins (E.coli)
Intratubular obstruction (ATN)
Rhabdomyolsis or
Hemoglobinuria from anemia’s and transfusion reactions
Acute glomerulonephritis intrarenal ARF
Inflammation of glomeruli, often from immune or autoimmune
Type 2HR (strep A)
Type 3 HR (SLE)
HTN
Diabetes
Eventually inflammation causes tissue damage and decreased function
Clinic manifestations of glomerulonephritis
NephrItic syndome (IN) Decreased GFR due to inflammatory occlusion - Hematuria/oliguria/ edema/HTN NephrOtic syndrome (things go OUT) Increased GFR due to inflammatory perm Proteinuria Hypoalbuinema Hyperlipidema Edema Clotting disorders
Acute pylonephritis intrarenal ARF
UTI affecting renal pelvis and renal parenchyma
More common in women and especially preggos
Urinary catheterization, immunosuppression, the beeties, anything that obstructs flow, improper hygiene, systemic infections
Acute pylonephritis patho
Begins in urethra, travels to kidneys
Must affect both kidneys to be ARF
Purulent exudate fills renal pelvis and begins to obstruct surrounding structures
Abscess formation and inflamm causes tissue necrosis
Clinical manifestations of acute pylonephritis
Dull achy lower back/flank pain which is reproducible with palp to costoverterbral angle Dysuria with urgency and frequency Malaise N/V Fever Urinalysis shows infection
Postrenal ARF
Rarest cause of ARF Ureteral destruction (edema, tumors, stones, clots) Bladder neck obstruction (enlarged prostate)
Three phases of ARF
Oliguria, Diuresis, Recovery
Phase 1 manifestations of ARF
Oliguria - other manifestations depend on underlying cause
Elevated BUN makes pt prone to hyperK+
Edema from fluid retention
N/V, fatigue, lyte issues
Delayed wound healing/increased risk of infection
Increased BUN and creatinine
Phase 2 of ARF
Diuresis
Progressive increase in urine volume as function improves. Tubular damage is still present and reabsoprtion may not recover as fast as glomerular filtration
Na+ and K+ loss - risk of hypo K+
Volume depletion may occur
Phase 1 of ARF
Back leak and obstruction of tubules causes lack of urine, occurs one day after hypotensive event
Lasts 1-2 weeks depending on severity
Can become anuria
Phase 3 of ARF
Recovery, may take 3-12 months
Chronic renal failure (CRF)
AKA CRD A slow progressive loss of nephrons Changes not evident until 25% of normal From ARF (chronic pyelonephritis) or congenital polycystic kidney disease or HTN/beeties
CRF classifications in GFR mL/mn/1.73m2
Normal,mild,moderation,severe and failure >90 60-90 30-60 15-30 <15
Clinical manifestations of CRF
Accumulation of nitrogenous wastes High BUN and creatinine Moves from azotemia to uremia Fluid/lyte/pH disorders Bone disorders Hematologic disorders - anemia, coagulopathies (bleeding disorders and thrombotic)
Azotemia
Accumulation of N2 wastes
Chronic Renal Failure presentation
HTN, HD, pericarditis Anorexia, n/v, ulcers Uremic encephalopathy, decreased sensory and motor Risk of infection Abnormal pigment, terry nails ED Impaired drug elimination
Terry’s Nails
Most of the plate turns white (not from being detached)
A sign of decreased blood supply (anemia)
Myoglobinuria
Life threatening - from severe muscle trauma
Renal threshold is low (0.5mg/100mL)
Released from sarcolemma membrane, along with CK and massive amounts of other serum enzymes. Prerenal ARF
UTIs - Cystitis
Inflammation of the bladder, usually from retrograde bacteria
Hemorrhage, suppuration, ulceration, gangrene
UTIs cystitis
10-20% more common in women
Frequency, urgency dysuria and suprapubic/low back pain
Hematuria and flank pain
Can be asymptomatic
Cystitis patho
Sexually active females
Pregnancy
Indwelling caths
Beeties, neurogenic bladder, poor hygiene and UT obstruction
Neurogenic bladder
Dysfunction from neuro damage (spastic or flaccid)
Incontinence, frequency, urgency, urge incontinence, retention.
Suppuration
The process of pus forming
Renal Calculi
Renal stones from metabolic disorders, common cause of UT obstruction
Renal Colic
Spasms of ureter, can be induced by passage of renal calculi
Renal Calculi - stone types
Calcium salts, often associate with hypersecretion of calcium - forms 70-80%
Struvite - magnesium ammonia phosphate (10%)
Uric acid (5-10%) related to gout
Cysteine (<1%) from errors of amino acid metabolism
Patho of renal calculi
Stones usually grow on papillae or, renal tubules, calcyces, renal pelvis
Mostly <3-5mm diamater
More common in men
5% of all adults
Clinical manifestations of renal calculi
Pain
Usually asymptomatic above ureters unless infection or obstruction occurs, or until migrates to ureter and obstructs lumen
Colicky pain occurs as ureter contracts to attempt to advance the stone
Distension and spasm follow when urine builds
Pain of Renal calculi
Flank pain at costovertebral angle (last rib and lumbar)
Radiation to groin if lower in ureter
N/V hematuria
