chapter 18 Flashcards
Anatomy of the urinary system
Kidneys, ureters, urinary bladder, urethra
nephrons
Functional units of the kidneys
each kindey has how many nephrons
over 1 mil
Where does filtration take place?
Renal corpuscles
- large volume of fluid passes from glomeruler capillaries into the tubule (bowmans capsule)
What is filtered in the kidneys
wasters, nutrients, electrolytes, other dissolved substances
Reabsorption (kidneys): explain
reabsorption of essential nutrients, water and electrolytes into the peritubular capillaries
- control of pH and electrolytes
What are the transport mechanisms of reabsorption
Active transport
Co-transport
Osmosis (water)
Proximal convoluted tubules
h2o and glucose reabsorption
Antidiuretic hormone (ADH): secreted from what
posterior pituitary
ADH function
Reabsorption of water in distal convoluted tubules and collecting ducts
Aldosterone: secreted from what
adrenal cortex
Aldosterone function
sodium reabsorption in exchange for potassium of hydrogen
Atrial natriuretic hormone comes from where
from the heart
Atrial natriuretic hormone function
Reduced sodium and fluid reabsorption
Specialized pattern of the blood flow through the kidneys
- renal artery
- interlobular artery
- arcuate artery
- interlobular artery
- afferent arteriole
- glomeruler capillaries
- efferent arteriole
- peritubular capillaries
- interlobular vein
10 arcuate vein - interlobar vein
- renal vein
GFR: auto-regulation and hormones control pressure in the glomerular capillaries by what
- Vasoconstriction of afferent arteriole
- Dilation of afferent arteriole
- vasoconstriction of efferent arteriole
Pressure control in the glomerular capillaries: vasoconstriction of afferent arteriole
decreases glomerular pressure – decreases filtrate
Pressure control in the glomerular capillaries: Dilation of afferent arteriole
increased pressure in glomerulus – increases filtration
Pressure control in the glomerular capillaries: vasoconstriction of efferent arteriole
increases pressure in glomerulus – increases filtration
Control of arteriolar constriction is done by what 3 factors?
Autoregulation, SNS, renin
Control of arteriolar constriction: auto-regulation
local adjustments in diameter of arterioles made in response to changes in blood flow in kidneys
Control of arteriolar constriction: SNS
increases vasoconstriction in both arterioles
Control of arteriolar constriction: Renin
Secreted by juxtaglomerular cells when blood flow to afferent arterioles is reduced
(renin-angiotensin mechanism)
Enuresis
involuntary unination by child (or under 4 years)
- often related to developmental delay, sleep pattern, or psychological aspect
Stress incontinence
increased intra-abdominal pressure forces urine through sphincter (coughing, lifting, laughing)
more common in women especially those who had babies
Overflow incontinence
Incompetent bladder sphincter; weakened detrusor muscle may prevent complete emptying of bladder - frequency and incontinence
what may cause overflow incontinence
- age
- spinal cord injuries / brain damage
- neurological bladder
- interference with CNS and ANS voluntary control of the bladder
neurological bladder may be what
spastic or flaccid
Retention
inability to empty bladder
retention may be accompanied by what
overflow incontinence
what cause retention
spinal cord injury at sacral level blocks micturition reflex
may follow anesthesia (general or spinal)
incontinence
loss of voluntary control of the bladder
Urinalysis:
Straw colored with mild odor
- normal urine
what is the specific gravity of normal urine
1.010 to 1.050
Urinalysis: cloudy
may indicate presence of large amounts of protein, blood, bacteria and pus
Urinalysis: dark color
may indicate hematuria, excessive bilirubin, or highly concentrated urine
Urinalysis: unpleasant or unusual odor
infection or result from certain dietary components or medication
Urinalysis: small amounts of blood
Infection, inflammation or tumors or urinary tract
Urinalysis: large amounts of blood
Increase glomerular permeability or hemorrhage
Urinalysis: elevated protein level (proteinuria, albuminuria)
Leakage of albumin or mixed plasma proteins into filtrate
Urinalysis: bacteria (bacteruria)
Infection of urinary tract (UTI)
Urinalysis: urinary casts
Indicate inflammation of kidney tubules
specific gravity
Indicated ability of tubules to concentrate urine
Urinalysis: low specific gravity
Dilute urine (with normal hydration)
Urinalysis: high specific gravity
Concentrated urine (with normal hydration) - related to renal failure
Urinalysis: glucose and ketones
Found when diabetes is not well controlled
Blood tests: electrolytes
Depend on related fluid balance
Blood tests: antibody level
Antistreptolysin O or antistreptokinase titters
Used for diagnosis of poststreptococcal glomerulonephritis
Blood tests: elevated renin levels
Indicated kidney as a cause of hypertension
Blood tests: elevated serum urea and serum creatinine levels indicate what
Indicate failure to excrete nitrogen wastes
Elevated serum urea and serum creatinine levels: cause
Decrease GFR
Blood tests: metabolic acidosis
Indicates decreased GFR
Failure of tubules to control acid-base balance
Blood tests: anemia
Indicated decreased erythropoietin secretion and/or bone marrow depression
Culture and sensitivity studies on urine specimens
ID of causative organism of infection
Help select appropriate drug treatment
Radiologic tests
Used to visualize structures and possible abnormalities, flow patterns and filtration rates
Clearance tests
Used to assess GFR
Ex. Creatinine or insulin clearance
Cystoscopy
Visualizes lower urinary tract; may be used to perform biopsy or remove kidney stones
Biopsy
Used to acquire tissue specimens
Dialysis
Provides filtration and reabsorption
Two forms of dialysis
Hemodialysis
Peritoneal dialysis
How often does one need to go to dialysis
Usually requires 3x a week - each lasts about 3 to 4 hours
Potential complications of dialysis
- Shunt may become infected
- Blood clot formation
- Blood vessels involved in shunt may become sclerosed
- Patient has increase risk of infection with HBV, HCV or HIV of standard precautions are not followed
Describe the process of hemodialysis
Patients blood moves from an implanted shunt/catheter in an artery to machine
º exchange of wastes, fluids, and electrolytes
º semipermeable membrane between blood and dialysis fluid (diastlsate)
— blood cells and proteins remain in blood
º after exchange is completed, blood retuned to patients vein
Peritoneal dialysis
Peritoneal membranes serve as the semipermeable membrane
Catheter with entry and exit points is implanted into the peritoneal cavity
Dialyzing fluid is instilled into a cavity
Dialysate is drained from cavity via gravity into container
Peritoneal dialysis requires what
More time
Loose clothing to fit the fluid bag
May be done at night (during sleep) or while patient is ambulatory
Usually done at outpatient basis
Major complication of peritoneal dialysis
Infection resulting in peritonitis
Why Is caution required with drugs when doing either type of dialysis
Toxic level buildup can occur
Why are UTIs more common in women and older men
Women: short urethra, close to butthole
Older men: prostatic hypertrophy, urine retention
Common predisposing factors of UTI
Incontinence, retention, direct contamination with fecal matter
Is urine a good growth medium for bacteria?
Yes
Lower urinary tract infections are called
Cystitis
Urethritis
Upper UTI name
Pyelonephritis
Common causative UTI organisms
E. Coli
Cystitis and urethritis is inflammation of what
Cystitis = bladder wall Urethritis = urethra
Cystitis and Urethritis: cause
Hyperactive bladder and reduced capacity
Cystitis and Urethritis: common local signs
Pain in pelvic area Dysuria Urgency Frequency Nocturnal
Cystitis and Urethritis: systemic signs
Fever, malaise, nausea, leukocytosis
Cystitis and Urethritis: urine
Cloudy unusual odor
Cystitis and Urethritis: urinalysis indicated what
Bacteriurea, pyuria, microscopic hematuria
Pyelonephritis: what?
One or both kidneys involved - from ureter to kidney
Purple to exudate fills pelvis and calyces
Pyelonephritis: recurrent / chronic infection can lead to scar tissue formation - what results from this?
Loss of tubule function
Obstruction and collection of filtrate —> hydronephrosis
Eventual chronic renal failure is untreated
Pyelonephritis: signs of cystitis plus pain can be associated with renal disease - s/s of this
Dull, aching pain in lower back or flaunt area
Pyelonephritis: systemic signs
High tempuruate
Pyelonephritis: urinalysis indicates what
Similar to cystitis
Urinary casts are present - reflection of renal tubule involvement
Treatment of UTIs
Antibacterial
? There is a long list on slide 26, not sure if I need to know all of these ?
Inflammatory disorder (Glomerulonephritis): types
Many forms
Inflammatory disorder (Glomerulonephritis): presence of antistreptococcal (ASO) antibodies —— what does this do?
Formation of antigen-antibody complex
Activates compliment system
Inflammatory response in glomeruli
Increased capillary permeability
Inflammatory disorder (Glomerulonephritis): inflammatory response
Congestion and cell proliferation
Decreased GFR - retention of fluid and waste
Inflammatory disorder (Glomerulonephritis): urine
Dark and cloudy
Inflammatory disorder (Glomerulonephritis): edema
Starts with facial and periorbital edema - general edema follows
Inflammatory disorder (Glomerulonephritis): elevated BP why
Increased renin secretion and decreased GFR
Inflammatory disorder (Glomerulonephritis): flank or back pain, why
Edema and stretching of renal capsule
Inflammatory disorder (Glomerulonephritis): signs / symptoms
General signs of inflammation and decreased UOP
Inflammatory disorder (Glomerulonephritis): blood tests reveal what
Elevated serum urea and creatinine levels
Elevation of anti-DNase B, streptococcal antibodies, antistreptolysin, antistreptokinase
Complement levels decreased (use in renal inflammation)
Inflammatory disorder (Glomerulonephritis): how does it effect pH
Metabolic acidosis
Inflammatory disorder (Glomerulonephritis): urinalysis shows
Proteinuria, hematuria, erythrocyte casts
No evidence of infection
Inflammatory disorder (Glomerulonephritis): treatment
Na+ restriction
Protein and fluid intake decreased (if severe)
Glucocorticoids (lower inflammation)
Antihypertensives
Nephrotic syndrome
Abnormality in glomerular capillaries, increased permeability, large amounts of plasma proteins escape into filtrate
Nephrotic Syndrome: cause
May be idiopathic in children 2-6 years
Secondary to SLE
Exposure to nephrotoxins or drugs
Nephrotic Syndrome: patho
Hypoalbuminemia with decreased plasma osmotic pressure
º subsequent generalized edema
BP remains low or normal
ºmay be elevated depending on angiotensin II levels
Increased aldosterone secretion in response to reduced blood levels
º more edema
High blood cholesterol, lipoprotein in urine, lipiduria with milky appearance to urine
Nephrotic Syndrome: s/s
Proteinuria, lipiduria, cast
Massive edema
Sudden increase in girth
Nephrotic Syndrome: treatment
Glucocorticoids (lessen inflammation)
ACE inhibitors
Antihypertensives
Restrict Na+ intake
What are examples of urinary tract obstructions
Urolithiasis
Hydronephrosis
Tumors
Urolithiasis (Calculi)
Can develop anywhere in urinary tract
Kidney stones - small or large
Urolithiasis (Calculi): tends to form with
Excessive amounts of solutes in filtrate
Insufficient fluid intake
UTI
Urolithiasis (Calculi): manifestations only occur what?
With obstructed urine flow
- lead to infection
- hydronephrosis with dilation of calyces
- if located in kidney or ureter and atrophy of renal tissue
Urolithiasis (Calculi): calculi composed of calcium salts, meaning what
High urine calcium levels
Form readily with highly alkaline urine
Urolithiasis (Calculi): uric acid stones —> hyperuricemia
Gout, high-purine diets, cancer chemo
Especially with acidic urine
I think this is asking for what causes hyperuricemia
What are the types of Urolithiasis (Calculi)
Uric acid stones
Struvite stones
Cystine stones
Urolithiasis (Calculi): stone formation depends on what
Predisposing factor
Urolithiasis (Calculi): s/s of stones in kidney or bladder
Often asymptomatic
- frequent infection may lead to investigation
- flank pain possible causde by distention of renal capsule
Urolithiasis (Calculi): s/s —> renal colic
Caused by obstruction of ureter
- spasms and flank pain radiation into groin until the stone passes or is removed
N/v, cool moist skin, rapid pulse
Radiologic examination confirms location of calculi
Urolithiasis (Calculi): treatment
Small stones eventually pass Extracorporeal shock wave lithotripsy (ESWL) Laser lithotripsy Drugs to partial dissolve stones Surgery
Urolithiasis (Calculi): prevention
Treatment of underlying condition
Adjustment of urine pH through dietary modifications
Consistent increased fluid intake
Hydronephrosis: what
Secondary condition caused by:
- complication of calculi
- tumors, scar tissue in kidney / ureter
- untreated prostatic enlargement
Hydronephrosis: s/s
Asymptomatic in early stages
Hydronephrosis: diagnosis
Ultrasounds, radionucleotide imaging, ct or renal scan
Hydronephrosis: what happens is cause not removed
Chronic renal failure
Renal cell carcinoma: where
Tumor arising from tubule epithelium - more often in renal complex
Renal cell carcinoma: s/s
Symptomatic in early stages
Renal cell carcinoma: where does it metastasize
Liver, lung, bone or CNS at time of diagnosis
Renal cell carcinoma: population
Men and smokers
Renal cell carcinoma: treatment
Removal of kidney
Immunotherapy
Radioresistant and chemo is not used in most cases
Renal cell carcinoma: manifestations
Painless hematuria (gross or microscopic)
Dull, aching flank pain
Palpable mass
Weight loss
Anemia or erythrocytosis
Paraneoplastic syndromes (hypercalcemia or Cushing’s syndrome)
Bladder cancer: where
Most are malignant and commonly arise from transitional epithelium of bladder
- often develop as multiple tumors
Bladder cancer: diagnosis
Urine cytology and biopsy
Bladder cancer: early signs
Hematuria, dysuria
Infection
Bladder cancer: explain how these tumors are invasive through wall to adjacent structures
Metastasize to pelvic lymph nodes, liver and bone
Bladder cancer: predisposing factors
Working with chemicals (anilines, dyes, rubber, aluminum)
Cig smoking
Recurrent infections
Heavy intake of analgesics
Bladder cancer: treatment
Surgery removal of tumor
Chemo and radiation
Photoradiation in early cases
Vascular disorders (nephrosclerosis): involves what
Vascular changes in kidneys
- some occur normally with aging
Vascular disorders (nephrosclerosis): patho
Thickening and hardening of walls of arterioles and small arteries in kidneys
Vascular disorders (nephrosclerosis): narrowing of blood vessel lumen has what effects
- Loss of blood supply to kidneys
- Stimulation of renin
- Increased BP
- Ischemia
- Destruction of renal tissue
- Chronic renal failure
Vascular disorders (nephrosclerosis): can be primary or secondary, how?
Can be primary lesion developed in kidney
May be secondary to essential hypertension
Vascular disorders (nephrosclerosis): treatment
Antihypertensives agents
Diuretics
Beta blockers
Sodium intake should be reduced
Congenital kidney disorders: vesicoureteral reflux
Not in slides, look it up
Congenital kidney disorders: agenesis
Failure of one kidney to develop
Congenital kidney disorders: ectopic kidney
Kidney and ureter not in normal position
Congenital kidney disorders: “horseshoe” kidney
Fusion of 2 kidneys
Congenital kidney disorders: hypoplasia
Failure to develop to normal size
Adult polycystic kidney: what
Autosomal dominant gene on chromosome 16
- no indications in child and young adults
Adult polycystic kidney: when do manifestations begin
Around 40 years
Adult polycystic kidney: multiple cysts develop in both kidneys leading to what
Enlarged kidneys
Compression and destruction of kidney tissue
Chronic renal failure
Adult polycystic kidney: diagnosis
Abdominal CT or MRI
Wilms’ Tumor: what
Most common tumor in children
Defects in tumor suppressor genes on chromosome 11
- may occur WITH other congenital disorders
Wilms’ Tumor: usually what
Unilateral
- large encapsulated mass
Wilms’ Tumor: what may be present at diagnosis
Pulmonary metastasese
Acute renal failure: causes
- Acute bilateral kidney diseases
- circulatory shock or heart failure
- Nephrotoxins
- Mechanical obstruction
Acute renal failure: onset
Sudden
Hence “acute”
Acute renal failure: blood tests show what
Elevated serum urea nitrogen and creatinine levels
Metabolic acidosis
Hyperkalemia
Acute renal failure: treatment
Fix primary problem to minimize risk of necrosis and permanent damage
Dialysis to normalize body fluids and maintain homeostasis
Chronic renal failure: what
Gradual irreversible destruction of the kidneys over a long period of time
Chronic renal failure: s/s
Asymptomatic in early stages
Chronic renal failure: may result from
Chronic kidney disease
Congenital polycystic kidney disease
Systemic disorders
Low-level exposure to nephrotoxins over sustained period of time
Chronic renal failure: stages
Decreased renal reserve
Renal insufficiency
End-stage renal failure
Chronic renal failure: decreased renal reserve
- Decrease in GRF
- Higher than normal serum creatinine levels
- No apparent clinical symptoms
Chronic renal failure: Renal insufficiency
- Decreased GFR to about 20% of normal
- Significant retention of nitrogen wastes
- Excretion of large volumes of dilute urine
- Decreased erythropoiesis
- Elevated BP
Chronic renal failure: end-stage renal failure
- Negligible GFR
- Fluid, electrolytes and wastes retained in body
- Anemia’s
- All body effected
- Oliguria or Anuria
- Dialysis or kidney transplantation
Chronic renal failure early signs and complete failure
Slide 51
Chronic renal failure: diagnostic tests
Metabolic acidosis becomes decompensated
Azotemia
Anemia becomes severe
Serum electrolytes may vary depending on the amount of water retained in the body. Usually hyponatremia and hyperkalemia occur, as well as hypocalcemia and hyperphosphatemia
Chronic renal failure: treatment
Drugs to stimulate erythropoeisis Drugs to treat CV issues Fluid restriction Dialysis Transplant
